Helen L. Ball

The prevalence and characteristics associated with parent–infant bed-sharing in England

Aims: To investigate the characteristics of parent–infant bed-sharing prevalence in England. Methods: Data on night-time sleeping practices from a two year, local, longitudinal study and a three-year, national, cross-sectional study were obtained. A total of 261 infants in North Tees were followed up at 1 and 3 months of age, as were 1095 infants aged 1 week to 1 year from five English health regions. Results: Data from both studies found that almost half of all neonates bed-shared at some time with their parents (local = 47%, 95% CI 41 to 54; national = 46%, 95% CI 34 to 58), and on any one night in the first month over a quarter of parents slept with their baby (local = 27%, 95% CI 22 to 33; national = 30%, 95% CI 20 to 42). Bed-sharing was not related to younger mothers, single mothers, or larger families, and was not more common in the colder months, at weekends, or among the more socially deprived families; in fact bed-sharing was more common among the least deprived in the first months of life. Breast feeding was strongly associated with bed-sharing, both at birth and at 3 months. Bed-sharing prevalence was uniform with infant age from 3 to 12 months; on any one night over a fifth of parents (national = 21%, 95% CI 18 to 24) slept with their infants. Conclusion: Bed-sharing is a relatively common practice in England, not specific to class, but strongly related to breast feeding.

Randomised trial of infant sleep location on the postnatal ward

Objective: To determine whether postnatal mother–infant sleep proximity affects breastfeeding initiation and infant safety. Design: Randomised non-blinded trial analysed by intention to treat. Setting: Postnatal wards of the Royal Victoria Hospital (RVI), Newcastle upon Tyne, UK. Participants: 64 newly delivered mother–infant dyads with a prenatal intention to breastfeed (vaginal deliveries, no intramuscular or intravenous opiate analgesics taken in the preceding 24 h). Intervention: Infants were randomly allocated to one of three sleep conditions: baby in mother’s bed with cot-side; baby in side-car crib attached to mother’s bed; and baby in stand-alone cot adjacent to mother’s bed. Main outcome measures: Breastfeeding frequency and infant safety observed via night-time video recordings. Results: During standardised 4-h observation periods, bed and side-car crib infants breastfed more frequently than stand-alone cot infants (mean difference (95% confidence interval (CI)): bed v stand-alone cot = 2.56 (0.72 to 4.41); side-car crib v stand-alone cot = 2.52 (0.87 to 4.17); bed v side-car crib = 0.04 (−2.10 to 2.18)). No infant experienced adverse events; however, bed infants were more frequently considered to be in potentially adverse situations (mean difference (95% CI): bed v stand-alone cot = 0.13 (0.03 to 0.23); side-car crib v stand-alone cot = 0.04 (−0.03 to 0.12); bed v side-car crib = 0.09 (−0.03–0.21)). No differences were observed in duration of maternal or infant sleep, frequency or duration of assistance provided by staff, or maternal rating of postnatal satisfaction. Conclusion: Suckling frequency in the early postpartum period is a well-known predictor of successful breastfeeding initiation. Newborn babies sleeping in close proximity to their mothers (bedding-in) facilitates frequent feeding in comparison with rooming-in. None of the three sleep conditions was associated with adverse events, although infrequent, potential risks may have occurred in the bed group. Side-car cribs are effective in enhancing breastfeeding initiation and preserving infant safety in the postnatal ward.

Parent-infant bed-sharing behavior : Effects of feeding type and presence of father.

An evolutionarily informed perspective on parent-infant sleep contact challenges recommendations regarding appropriate parent-infant sleep practices based on large epidemiological studies. In this study regularly bed-sharing parents and infants participated in an in-home video study of bed-sharing behavior. Ten formula-feeding and ten breast-feeding families were filmed for 3 nights (adjustment, dyadic, and triadic nights) for 8 hours per night. For breast-fed infants, mother-infant orientation, sleep position, frequency of feeding, arousal, and synchronous arousal were all consistent with previous sleep-lab studies of mother-infant bed-sharing behavior, but significant differences were found between formula and breast-fed infants. While breast-feeding mothers shared a bed with their infants in a characteristic manner that provided several safety benefits, formula-feeding mothers shared a bed in a more variable manner with consequences for infant safety. Paternal bed-sharing behavior introduced further variability. Epidemiological case-control studies examining bed-sharing risks and benefits do not normally control for behavioral variables that an evolutionary viewpoint would deem crucial. This study demonstrates how parental behavior affects the bed-sharing experience and indicates that cases and controls in epidemiological studies should be matched for behavioral, as well as sociodemographic, variables.

Nighttime parenting strategies and sleep-related risks to infants.

A large social science and public health literature addresses infant sleep safety, with implications for infant mortality in the context of accidental deaths and Sudden Infant Death Syndrome (SIDS). As part of risk reduction campaigns in the USA, parents are encouraged to place infants supine and to alter infant bedding and elements of the sleep environment, and are discouraged from allowing infants to sleep unsupervised, from bed-sharing either at all or under specific circumstances, or from sofa-sharing. These recommendations are based on findings from large-scale epidemiological studies that generate odds ratios or relative risk statistics for various practices; however, detailed behavioural data on nighttime parenting and infant sleep environments are limited. To address this issue, this paper presents and discusses the implications of four case studies based on overnight observations conducted with first-time mothers and their four-month old infants. These case studies were collected at the Mother-Baby Behavioral Sleep Lab at the University of Notre Dame USA between September 2002 and June 2004. Each case study provides a detailed description based on video analysis of sleep-related risks observed while mother-infant dyads spent the night in a sleep lab. The case studies provide examples of mothers engaged in the strategic management of nighttime parenting for whom sleep-related risks to infants arose as a result of these strategies. Although risk reduction guidelines focus on eliminating potentially risky infant sleep practices as if the probability of death from each were equal, the majority of instances in which these occur are unlikely to result in infant mortality. Therefore, we hypothesise that mothers assess potential costs and benefits within margins of risk which are not acknowledged by risk-reduction campaigns. Exploring why mothers might choose to manage sleep and nighttime parenting in ways that appear to increase potential risks to infants may help illuminate how risks occur for individual infants.

Sleeping like a baby: Attitudes and experiences of bedsharing in Northeast England

This paper reports findings from a study that investigated infant care practices in a small population of Northeast England in order to determine whether parent‐infant bedsharing is common parenting behavior. In a year‐long prospective study we examined the opinions and practices of parents with regard to their infants’ nighttime sleeping strategies before and after the birth of their babies. Results confirm that parents pursue a heterogeneous array of nighttime parenting strategies and that 65 percent of the sample had actually bedshared. Parents with no previous intention to do so slept with their babies for a variety of reasons. One of this studys most important findings is that babies were being brought into bed with both parents. Ninety five percent of the bedsharing infants slept with both mother and father. This study has shown that bedsharing is a relatively common parenting practice. Despite initial worries and fears, mainly concerning overlaying, some parents found bedsharing an effective option yet were covert in their practices, fearing the disapproval of health professionals and relatives.

Infant care practices related to sudden infant death syndrome in South Asian and White British families in the UK.

In the UK, infants of South Asian parents have a lower rate of sudden infant death syndrome (SIDS) than White British infants. Infant care and life style behaviours are strongly associated with SIDS risk. This paper describes and explores variability in infant care between White British and South Asian families (of Bangladeshi, Indian or Pakistani origin) in Bradford, UK (the vast majority of which were Pakistani) and identifies areas for targeted SIDS intervention. A cross-sectional telephone interview study was conducted involving 2560 families with 2- to 4-month-old singleton infants enrolled in the Born in Bradford cohort study. Outcome measures were prevalence of self-reported practices in infant sleeping environment, sharing sleep surfaces, breast feeding, use of dummy or pacifier, and life style behaviours. We found that, compared with White British infants, Pakistani infants were more likely to: sleep in an adult bed (OR = 8.48 [95% CI 2.92, 24.63]); be positioned on their side for sleep (OR = 4.42 [2.85, 6.86]); have a pillow in their sleep environment (OR = 9.85 [6.39, 15.19]); sleep under a duvet (OR = 3.24 [2.39, 4.40]); be swaddled for sleep (OR = 1.49 [1.13, 1.97]); ever bed-share (OR = 2.13 [1.59, 2.86]); regularly bed-share (OR = 3.57 [2.23, 5.72]); ever been breast-fed (OR = 2.00 [1.58, 2.53]); and breast-fed for 8+ weeks (OR = 1.65 [1.31, 2.07]). Additionally, Pakistani infants were less likely to: sleep in a room alone (OR = 0.05 [0.03, 0.09]); use feet-to-foot position (OR = 0.36 [0.26, 0.50]); sleep with a soft toy (OR = 0.52 [0.40, 0.68]); use an infant sleeping bag (OR = 0.20 [0.16, 0.26]); ever sofa-share (OR = 0.22 [0.15, 0.34]); be receiving solid foods (OR = 0.22 [0.17, 0.30]); or use a dummy at night (OR = 0.40 [0.33, 0.50]). Pakistani infants were also less likely to be exposed to maternal smoking (OR = 0.07 [0.04, 0.12]) and to alcohol consumption by either parent. No difference was found in the prevalence of prone sleeping (OR = 1.04 [0.53, 2.01]). Night-time infant care therefore differed significantly between South Asian and White British families. South Asian infant care practices were more likely to protect infants from the most important SIDS risks such as smoking, alcohol consumption, sofa-sharing and solitary sleep. These differences may explain the lower rate of SIDS in this population.

Association between Length of Exclusive Breastfeeding and Subsequent Breastfeeding Continuation

Background: Although breastfeeding initiation rates have improved, later prevalence is very low in the United Kingdom, and Northeast England is the region with the lowest rates. Objective: This study aimed to investigate novel in addition to well-established risk factors for cessation of breastfeeding among women in this region. Methods: Participants were 870 women considering breastfeeding prior to birth who were enrolled in the postnatal ward North East Cot trial at a tertiary hospital in Northeast England from 2008 to 2010. They provided weekly data on feeding and sleeping practices for 26 weeks postpartum using an automated telephone system with reminder postcards and contact by telephone, letter, or email if necessary. Cox proportional hazards regression was used to investigate factors associated with terminating any and exclusive breastfeeding in this period. Results: Ninety-four percent of women started any breastfeeding and 66% initiated exclusive breastfeeding. By 26 weeks postpartum, 47% were still breastfeeding, but < 1% were breastfeeding exclusively. Multivariate analysis showed that women who exclusively breastfed for at least 4 weeks breastfed for significantly longer after supplementation started (P < .001). Bed-sharing at home during the first 13 weeks was a significant predictor of both any and exclusive breastfeeding, as well as any breastfeeding after supplementation (P < .001). We also confirmed some recognized socio-demographic predictors of breastfeeding cessation in this location. Conclusion: We found that exclusive breastfeeding for at least 4 weeks was significantly associated with longer breastfeeding continuation after supplementation, and bed-sharing at home was associated with longer breastfeeding regardless of the definition used.

Bed- and Sofa-Sharing Practices in a UK Biethnic Population

OBJECTIVE: To describe the prevalence and associations of bed- and sofa-sharing in a biethnic UK birth cohort. METHODS: We surveyed 3082 participants in the Born in Bradford birth cohort study by using a telephone interview when infants were aged 2 to 4 months. We asked families about sleep surface sharing behaviors, and other sudden unexpected death in infancy (SUDI)-related behaviors. RESULTS: There were 15.5% of families that had ever bed-shared, 7.2% of families regularly bed-shared, and 9.4% of families had ever sofa-shared with their infants; 1.4% reported both. Regular bed-sharers were more commonly Pakistani (adjusted odds ratio [aOR] = 3.02, 95% confidence interval [CI] 1.96–4.66), had further or higher educational qualifications (aOR = 1.62, 95% CI 1.03–2.57), or breastfed for at least 8 weeks (aOR = 3.06, 95% CI 2.00–4.66). The association between breastfeeding and bed-sharing was greater among white British than Pakistani families. Sofa-sharing occurred in association with smoking (aOR = 1.79, 95% CI 1.14–2.80) and breastfeeding for more than 8 weeks (aOR = 1.76, 95% CI 1.19–2.58), and was less likely in Pakistani families (aOR = 0.21, 95% CI 0.14–0.31), or single-parent families (aOR = 0.50, 95% CI 0.29–0.87). CONCLUSIONS: The data confirm that bed-sharing and sofa-sharing are distinct practices, which should not be combined in studies of unexpected infant deaths as a single exposure. The determinants of sleep-surface sharing differ between the UK Pakistani and UK majority communities, and from those of US minority communities. Caution is needed in generalizing SUDI/SIDS risk factors across populations with differing risk factor profiles, and care should be taken in adopting SUDI/SIDS reduction guidelines from other contexts.

Postnatal Unit Bassinet Types When Rooming-In after Cesarean Birth: Implications for Breastfeeding and Infant Safety

Background: Postnatal unit rooming-in promotes breastfeeding. Previous research indicates that side-cars (3-sided bassinets that lock onto the maternal bed frame) facilitate breastfeeding after vaginal birth more than stand-alone bassinets (standard rooming-in). No study has previously investigated side-car bassinet use after cesarean, despite the constraints on maternal-infant interactions that are inherent in recovery from this birth mode. Objective: To test the effect of the side-car bassinet on postnatal unit breastfeeding frequency and other maternal-infant behaviors compared to a stand-alone bassinet following cesarean birth. Methods: Participants were recruited and prenatally randomized to receive the side-car or stand-alone bassinet for their postnatal unit stay between January 2007 and March 2009 in northeastern England. Mother-infant interactions were filmed over the second postpartum night. Participants completed face-to-face interviews before and after filming. The main outcome measures were infant location, bassinet acceptability, and breastfeeding frequency. Other outcomes assessed were breastfeeding effort, maternal-infant contact, sleep states, midwife presence, and infant risk. Results: Differences in breastfeeding frequency, maternal-infant sleep overlap, and midwife presence were not statistically significant. The 20 dyads allocated to side-car bassinets breastfed a median of 0.6 bouts/ hour compared to 0.4 bouts/hour for the 15 stand-alone bassinet dyads. Participants expressed overwhelming preference for the side-car bassinets. Bed sharing was equivalent between the groups, although the motivation for this practice may have differed. Infant handling was compromised with stand-alone bassinet use, including infants positioned on pillows while bed sharing with their sleeping mothers. Conclusions: Women preferred the side-car, but differences in breastfeeding frequency were not statistically significant. More infant risks were observed with stand-alone bassinet use.

Trade-offs underlying maternal breastfeeding decisions: a conceptual model.

This paper presents a new conceptual model that generates predictions about breastfeeding decisions and identifies interactions that affect outcomes. We offer a contextual approach to infant feeding that models multi-directional influences by expanding on the evolutionary parent-offspring conflict and situation-specific breastfeeding theories. The main hypothesis generated from our framework suggests that simultaneously addressing breastfeeding costs and benefits, in relation to how they are interpreted by mothers, will be most effective. Our approach focuses on contributors to the attitudes and commitment underlying breastfeeding outcomes, beginning in the prenatal period. We conclude that some maternal-offspring conflict is inherent with the dynamic infant feeding relationship. Guidance that anticipates and addresses family trade-offs over time can be incorporated into breastfeeding support for families.