Big ol’ list of links about CIO – Part II

As promised, here’s a huge pile o’ links to studies that show that CIO has beneficial effects on children, parents and families in general, and some related topics I thought you might find interesting. Keep in mind this is not a recommendation to CIO if you don’t want to – if whatever you’re doing works for you, more power to you. However, if you find your infant’s (preferably>6months) waking at night is causing you grief, you don’t need to feel shamed by the sanctimommies who inhabit certain parenting-messageboards-which-shall-not-be-named , nor certain alarmist parenting “experts”. I’ve tried to link to the full-text articles when available free online.

First of all, it’s been shown in several studies that the one recurring factor for young babies not learning to sleep for stretches (by this I don’t necessarily mean the 9-12 hours straight we might expect of an older baby, but one 4-6 hour stretch by 2-3 months) and not learning self-soothing behavior is falling asleep with a parent present:

Night Waking, Sleep-Wake Organization, and Self-Soothing in the First Year of Life:”Consistent with previous research, this study found that infants who were consistently put into the crib awake were more likely to be self-soothers than infants who were consistently put into the crib asleep. Infants who required parental assistance to fall asleep at the beginning of each night were more likely to require parental assistance upon awakening in the middle of the night.”

Factors Associated With Fragmented Sleep at Night Across Early Childhood:”Parental presence until sleep onset was the factor most strongly associated with not sleeping at least 6 consecutive hours per night at 17 months and 29 months of age.”

Sleeping through the night: a developmental perspective:“By 3 months of age, infants who were put into the crib awake at bedtime and allowed to fall asleep on their own were more likely to return to sleep on their own after awakenings later in the night. In contrast, infants who were put into the crib already asleep at the beginning of the night were significantly more likely to be removed from the crib following a subsequent nighttime awakening…This association was present at 8 months as well.”

Some more interesting factors:”More time awake at night was related to separation distress, frequent daytime crying, dysregulation, co-sleeping with parents, breast feeding, and being put to bed asleep. More frequent waking was related to separation distress, frequent daytime crying, co-sleeping, and breast feeding.”

Lack of sleep (for the baby and his family) has a detrimental effect upon the family as a whole, and on maternal mood and functioning in particular:

Early infant crying and sleeping problems: a pilot study of impact on parental well-being and parent-endorsed strategies for management.:”Problem infant behaviours are associated with poor parental mental health.”

Maternal depression can have adverse effects on infant and stunt their psychological growth:”Postpartum depression at 4 months measured by the Edinburgh Postnatal Depression Scale was found to be strongly associated with toddlers’ fear score/behavioral inhibition at 14 months. Maternal depressive symptoms assessed by the revised 90-item Symptom Checklist at 6 weeks , 4 and 14 months were found to be related to child inhibition as well. Conclusions: Even maternal depression not reaching the level of clinical diagnosis and treatment has an impact on child behavioral development.”

Hmmm…maybe it’s not all that great to run mothers ragged “for the good of the baby”.

However, help is at hand – behavioral modification techniques, including CIO in various forms and impressing even on a small infant that it’s sleep time, not feeding or play time, can be very effective in both improving infants’ sleep quality and Mom’s depressive symptoms. I’ll not that some of these interventions were done on infants significantly younger than the 6-12 months normally recommended for CIO; however, the expectation here was to enable even these small babies to sleep for decent stretches of time (4-6 hours in one period during the night), not the usual “sleeping through the night” we expect of older infants. When your baby is 2 months old and has been waking 10 times a night since birth, even a 4-hour episode of unbroken sleep can seem like sheer heaven.

Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood:”Behavioural intervention significantly reduces infant sleep problems at two but not four months. Maternal report of symptoms of depression decreased significantly at two months, and this was sustained at four months for mothers with high depression scores.”

Early infant crying and sleeping problems: a pilot study of impact on parental well-being and parent-endorsed strategies for management.

Does CIO harm the baby and cause him to cry incessantly, thereby permanently damaging his delicate psyche? It appears not:

A systematic review of treatments for settling problems and night waking in young children:”The most controversial aspect of behaviour modification studies is recommending that families leave their infants to cry while “learning” to fall asleep alone. This study found no differences in mean hours of crying between the intervention and control groups.”

Changes in infant sleep problems after a family-centered intervention. : “The intervention was based on correction of day-sleep rhythm, support of self-comforting capabilities of the infant, and education of parents in regard to the infants’ characteristics and developmental status. Changes in day naps and infant irritability over daytime also improved significantly.”

Help me make it through the night: behavioral entrainment of breast-fed infants’ sleep patterns. : “By 3 weeks, treatment infants showed significantly longer sleep episodes at night. By 8 weeks 100% of treatment infants were sleeping through the night compared to 23% of control infants. Treatment infants were feeding less frequently at night but compensated for the relatively long nighttime interval without a feed by consuming more milk in the early morning. Milk intake for 24-hour periods did not differ between groups. Treatment infants were rated as more predictable on Bates’ Infant Characteristics Questionnaire. It is concluded that parents can have a powerful influence on the development of their infants’ sleep patterns. Frequent night waking in breast-fed infants often results in early termination of lactation. Parents can teach their breast-fed infants to lengthen their nighttime sleep bouts, making the continuation of breast-feeding easier for the new mother.” (Ooooh, that last sentence might catch the eye of an APer, won’t it?).

Treatment of sleep problems in families with young children: effects of treatment on family well-being:”Before intervention, the sleep-disturbed children were rated as more insecure than a matched comparison group with unknown sleep behaviour. This difference was eliminated after the interventions. The more anxious the children were rated before intervention, the more they tended to benefit from it.”

Behavior characteristics and security in sleep-disturbed infants treated with extinction :There was no evidence of detrimental effects on the treated infants whose security, emotionality/tension, and likeability scores improved.

I’ll be adding more links that attest to the efficacy and safety of CIO as I find them; feel free to suggest your own.

Added May 9th, 2008: long but thorough review by Dr. Jodi Mindell, et al, about behavioral methods of sleep training.

Added October 22, 2008: See here.

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Big ol’ list of links about CIO, part I

Egrrrl in the comments pointed me towards this list of anti-CIO links posted at MotheringDotCommune. While the overwhelming majority of the links are to opinion pieces, including the notorious “Harvard study” I’d referred to in the thread the comment was on – par for the course for AP/NP “evidence”, and many have references that do not relate to cosleeping but to routine abuse and neglect, there was one link to a position paper on controlled crying (.pdf document). I’m linking to the original position paper and not the transcribed HTML link, as it looks clearer to read and has some intresting points. It’s written by one Pam Linke, a parenting book author and the national president of the Australian Association for Infant Mental Health, Inc. (AAIMHI). I can’t tell if she has any other relevant credentials (such as a degree in child psychology), but she comes out very supportive of cosleeping and against CIO. The sources she uses to bolster her position paper with, however, are…shall we say, interesting. The policy statement was first written in 2002, and revised Novmeber 2004.

Linke asserts that “Crying is a signal of distress or discomfort from an infant or young child. Although controlled crying can stop children from crying, it may teach children not to seek or expect support when distressed.” Unfortunately for her, there is no proof of this, and in fact, there is even no direct evidence that babies who undergo controlled crying suffer undue or lasting stress, as she states later on:”There have been no studies such as sleep laboratory studies, to our knowledge, that assess the physiological stress levels of infants who undergo controlled crying, or its emotional or psychological impact on the developing child.”

Actually, there have been studies which assessed the “emotional or psychological impact on the developing child” of controlled crying; one was written back in 1992, and the other was published in January 2004 ( a full 10 months before Linke revised her policy statement); Needless to say, they do not support Linke’s baseless assertions…quite the contrary. There is no evidence that infants who are left to cry for short periods of time are traumatized in the manner of neglected children in Romanian orphanages are, no matter how much some parenting experts may wish it or hypothesize about it. In fact, when the babies learned how to sleep for long stretches, it did them (and their families) only good.

Linke also claims that “If controlled crying is to be used it would be most appropriate after the child has an understanding of the meaning of the parent’s words, to know that the
parent will be coming back and to be able to feel safe without the parent’s presence. Developmentally this takes about three years. ”

Three years?! I think Linke needs a refresher course in child development. Children develop a sense of object permanence as young as 8 months old, some say even earlier. That’s how a baby knows Mommy doesn’t disappear into thin air when she’s out of sight, and is the source of the infant developing stranger anxiety. As for understanding what is said to them, even if they haven’t developed the linguistic capacity by age 3 to understand the meaning of the words “I’ll be back soon” (and I know precious few children that age who haven’t), the nonverbal concept of Mommy coming back can, and is, learned much earlier…by Mommy coming back night after night, morning after morning. Even tiny babies can learn to anticipate regular events.

Linke’s bibliography is, per her own admission, not particularly supportive of her statements:

“The list below is not specifically for studies on the impact of controlled crying on infants because there are no records of such studies. The list has sources of general background information related to sleep and to understanding children and stress.”

So we’ve got a mishmash of basic attachment theory research by Bowlby, Ainsworth and Bell (yes, children whose cries are constantly ignored for a long time go on to develop attachment sidorders); yet again, the Commons and Miller claptrap; and James McKenna’s factoids about cosleeping dyads which prove nothing aboust its safety. She also exhorts you to look into the works of Michel Odent, and further adds that “A wide range of articles for parents can be found on:
http://www.naturalchild.com or http://www.askdrsears.com”. I’ve already touched upon the subject of the quality of Dr. Sears’ “evidence” about cosleeping; his “evidence” regarding CIO is of similar…er, scientific rigor. And yeah, let’s send ususpecting mothers over to The Natural Child website, so they can learn how women who use formula, cribs and C-sections are fake mothers, among other things. Eek.

Next post, we’ll be looking at a big ol’ list of links to actual studies about CIO and its effects. Maybe it’ll be of help to those wishing to confront that other “big ol’ list of links” that pretends to be convincing proof that CIO will permanently damage your baby and turn him into a quivering, depressed lump of obedience and fear…and I promise it won’t contain any opinion pieces :-).

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To VBAC or not to VBAC?

Karen commented on my previous post about VBAC vs. ERCS:

…[I]n the majority of cases, a vbac will be safer for mom and baby, and the recovery is generally so much easier…

Overall, it’s true that most women – most studies I’ve found claim between 60-82% – of women given a trial of labor after one previous cesarean section will be able to successfully deliver their baby vaginally. That doesn’t mean, however, that “VBAC will be safer for Mom and baby”, as compared to the alternative, elective repeat CS. The reason for this is that CS’s are a relatively safe operation, especially if done under regional (epidural or spinal) analgesia and in a non-emergent fashion, and the 18-40% (on average) of women who are unsuccessful in their trial of labor and end up having a repeat emergency CS are subject to a high rate of morbidity, as are their babies. In fact, all things being equal, the odds slightly favor ERCS over VBAC. This has also been shown in practice in large studies. Most of the excess risk (as opposed to ERCS) is on the baby when a trial of labor fails, though there is also increased maternal morbidity in such cases. An comparison (.pdf file) based upon a few studies shows that ERCS is slightly more risky for the mother, whereas VBAC is slightly more risky for the baby:

Luckily for us (or unluckily, depending on who you are), not all things are created equal. The chance of VBAC success in any individual woman may be different from that of the cohort in general. In fact, in the past few years, different scoring systems based on risk factor profile have been suggested as a way to help predict the likelihood of any individual woman to undergo a successful VBAC. If such a scoring system is found reliable and universally accepted, this can be a wonderful guide for both pregnant women and their healthcare practitioners to making a decision to choose VBAC or ERCS based upon the woman’s specific situation. It should go without saying (though given human nature, it doesn’t) that in any case, the place to VBAC is where there is an appropriate obstetrics and anesthesia ‘safety net’ to deal with complications and perform a CS should it be necessary. It’s also a good idea to enable the staff to diagnose and treat complications that may arise ASAP – hence the recommendation for continuous EFM and venous access (heplock or IV).

Factors predictive of successful VBAC:

*Previous vaginal birth (either before or after the CS) – the more, the better

*One previous CS (the rates of uterine rupture are comparable with 2 CS’s, however major morbidity is greater than with 1 CS and as compared with a 3rd elective CS)

*Horizontal surgical incision on the lower segment of the uterus – it’s important to get the operative report of the CS, as a horizontal ‘bikini cut’ doesn’t necessarily mean the uterus was cut in the same manner.

* Delivery at least 19 months after the previous CS delivery

* Reason for the precious CS was a reason not likely to recur or that isn’t recurring in the current pregnancy (breech, fetal distress, placenta previa – as opposed to shoulder dystocia or cephalopelvic disproportion)

* Singleton birth in current pregnancy

*Labor begins naturally and does not require augmentation

*Mother is not obese

VBAC guidelines from the Royal College of Obstetricians, UK

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The VBAC/ERCS dilemma: is it vain to VBAC?

Kathie asked a very good question in the comments to my previous post:

Are VBAC moms minimizing the risks in order to have a more pleasant birth experience? Or are repeat c-section moms overestimating the risks of trying for a vaginal birth? (in general, I’m speaking to situations where there is a choice…not medically indicated repeat c-sections).

At the risk of boring you to pieces, let me tell you about my first two births. I’m not trying to hold myself up as some kind of role model necessarily, but to illustrate my thought processes that led me to my decision and the limits I put on the decision-making process.

My eldest son was born in December 1997 at a large university hospital in Jerusalem. My pregnancy had been uneventful, and I was considered a low obstetric risk (though a moderate general medical risk for non-OB related conditions). I’d gotten an epidural at 4-5cms dilation for pain relief, and was dilated to 9cm when the EFM tracing started showing late decelerations, diving deeper and wider. The midwife called the OB, who took one look at the monitor (which showed a fetal heart rate of 60 beats per minute by then) and asked her: “Does she have blood units ready?”.

To make a long story short, my epidural was topped up, I signed the consent form, we rushed to the OR down a short hallway, and 10 minutes later, I met my beautiful boy. It turned out he’d managed to wrap his umbilical cord around both his shoulders, clamping it in two places as he attempted to descend into the birth canal. He’s a bright, engaging child, though he can be very stubborn at times – and then I tell him that his orneriness manifested itself even in utero. 😀

My second son was born in March 2000. I’d decided rather early on that I wanted a VBAC, though to be honest, recovery from the C-section wasn’t all that bad. In fact, compared to the non-OB related abdominal (and non-emergency) surgery I’d gone through 13 months previous to the CS, it was a piece of cake: out of bed and walking around by the next morning (the CS occurred at 10:22 PM), the incision didn’t hurt, I had a bit of referred pain in one of my shoulders due to, most probably, air bubbles under my diaphragm that was easily alleviated with dipyrone. I was still wishing I’d gotten to push my eldest out, though. And since the reason for my CS was not likely to recur, I had the operative report which documented a transverse lower segment uterine scar, and otherwise had an uneventful pregnancy, I convinced my OB that this was a reasonable course of action. I also went on a tour of all 5 hospitals in Jerusalem and asked about their VBAC success rates, and decided to go to a slightly smaller and “crunchier” maternity hospital that had a 24/7 OB and anesthesiology staff, plus a small but decent NICU – but which had the highest VBAC success rates. I requested a low-dose “walking” epidural at 6cms, which had worn off by the second stage, and had continuous EFM and an IV line. I squatted to deliver my son like a good lil’ birther, though an episiotomy was, I believe, necessary (I was on my way to developing a rather large tear “up” into my clitoris and urethra). My son is almost 8, also a wonderful, healthy boy, though not quite as stubborn (you can see an old picture of them both in the title bar of this blog).

Looking back on my emotional state at the time, I think I did “minimize the risks in order to have a more pleasant birth experience” somewhat, but not to the point where I flat-out endangered myself or my baby. My decision to VBAC was based upon my risk factors for needing another CS (an indication for the CS that wasn’t likely to recur, a favorable uterine incision, my wish for more children after #2, overall decent health, a healthy current pregnancy with vertex presentation), along with providing for access to a surgical delivery just in case something went wrong anyway. I had also decided ahead of time that despite being emotionally invested in a VBAC, if an induction or augmentation of labor were deemed necessary, I’d forgo my VBAC plans and ask for a CS due to the increased incidence of uterine rupture.

So the answer to Kathie’s question, like a lot of things in life, is “it depends”. If a woman has access to all the medical information about her own condition and the facts about VBACs vs. repeat CS’s in general, she can make an informed decision (possibly along with her healthcare provider) to have either an elective repeat CS or a VBAC. Both have their advantages and their risks, and the equasion is not the same for every woman. That isn’t “minimizing the risks”, it’s recognizing the risks and benefits of both types of birth and how they relate to your personal situation.

I would, however, make an exception for women who choose to VBAC at home. Though uterine rupture is a relatively rare event, it still is more likely to happen in the context of a VBAC, and when it happens, you need that OB and neonatal team to pounce right on you and save you and your baby both. Dr Amy makes a very good case for homebirth carrying an excess risk of neonatal mortality even under the best of circumstances; all the more so when a woman has a VBAC, because such a woman is, even under the best of circumstances, no longer low-risk. In this, I tend to agree with the ACOG’s most recent statement about homebirth. A woman who denies this kind of risk is, in my opinion, elevating her birth experience over the baby’s (and her own) health, and is “minimizing the risks of VBAC”.

By the way, lest you think it’s just us evil mainstream people who think this way about VBACs, here’s one of the high priests of VBAC advocacy, Dr. Bruce Flamm, who thinks that even birth centers are too risky for VBAC and these women should all be referred to hospital:

Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery.

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Misperception of risk

A common thread runs though much of NP advocacy: the “normative” way of life (mainstream parenting, diet, values) is rife with risk, in a way the NP isn’t. Refraining from action towards the normative way of life will prevent dangerous outcomes, and if a bad thing happens, well, that’s what nature intended…”Nature’s will be done”.

The problem is that we humans are not all that good at objectively assessing risk. We also often have preconceived notions which often bias us towards a certain result. Everyone is prone to this; all of us have our biases, though scientific training and development of critical thinking skills can sometimes assist in identifying when we are biased. Hence the importance of peer-reviewed research and replicability of scientific results by different teams of researchers.

Psychology Today has a great article about how humans commonly misperceive risk. Or as my doctor used to say, “You’re afraid of all the wrong things”. Instead of fearing real, permanent damage that may happen during a birth gone wrong, many have a greater fear that some doctor might speak to them in a tone they don’t like, or – heaven forfend! – that a nurse might ask them if they want an epidural. Instead of worrying about the real, catastrophic results of contracting an infectious disease, some worry about the much smaller risk of a bad vaccine reaction (or the more common, but not severe or permanent, risk of a mild complication). It doesn’t help that there is a plethora of websites willing to stoke the fires of their fear by magnifying small (or hypothetical or nonexistent) risks and minimizing real and larger ones.

It reminds me a bit of an online conversation I had with a lactofanatic, who asserted that it’s important to breastfeed because a meteor might hit the Earth and as a result, thre will be no ready formula. No, I am not making this up.

An item in the article that especially “speaks” to this issue:

We Love Sunlight But Fear Nuclear Power

Why “natural” risks are easier to accept.

The word radiation stirs thoughts of nuclear power, X-rays, and danger, so we shudder at the thought of erecting nuclear power plants in our neighborhoods. But every day we’re bathed in radiation that has killed many more people than nuclear reactors: sunlight. It’s hard for us to grasp the danger because sunlight feels so familiar and natural.

Our built-in bias for the natural led a California town to choose a toxic poison made from chrysanthemums over a milder artificial chemical to fight mosquitoes: People felt more comfortable with a plant-based product. We see what’s “natural” as safe—and regard the new and “unnatural” as frightening.

Any sort of novelty—including new and unpronounceable chemicals—evokes a low-level stress response, says Bruce Perry, a child psychiatrist at ChildTrauma Academy. When a case report suggested that lavender and tea-tree oil products caused abnormal breast development in boys, the media shrugged and activists were silent. If these had been artificial chemicals, there likely would have been calls for a ban, but because they are natural plant products, no outrage resulted. “Nature has a good reputation,” says Slovic. “We think of natural as benign and safe. But malaria’s natural and so are deadly mushrooms.”

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It’s nice to have company…

I did a bit more poking on the subject of the scientific evidence regarding cosleeping and the slightly raised risk of SIDS, especially in young babies. I found 2 very interesting Powerpoint slideshows online from two other doctors, who looked at the literature, reveiwed the studies better than I could (given that not all studies are available full-text online) and came up with conclusions very similar to mine. The second one, especially, is by a noted British authority on the subject, and contains information not readily available elsewhere.

Oh, to have been a fly on the wall when the lectures these slideshows accompanied were given!

The first one is a lecture given by Dr. Judy Straton from the Department of Public Health at the University of Western Australia . She lends somewhat more credence to the supposed qualitative benefits of cosleeping than I do, but her scientific conclusions are as follows:

Straton uses the first few slides to describe the scientific methods used in the various studies and on various definitions, which are extremely valuable in understanding the science behind them. It must have been one hell of a lecture, and I highly recommend studying all 21 slides of it.

The second slideshow (you may have to download this to your own computer’s Powerpoint) is by George Haycock, a professor of pediatric nephrology in Guys Hospital, London, who serves as the scientific advisor of the British Foundation for the Study of Infant Deaths. His conclusions:

The slideshow contains two further bits of information that are not readily available elsewhere:

* Additional infromation regarding the analysis of what apperas to be the dataset used here: “A further, so far unpublished, analysis was performed on an expanded data set (1994-2001) in which sofa sleepers were excluded. A significant risk was found for babies of non-smoking mothers aged under 16 weeks, OR 6.2: CI 1.88-20.61 (McGarvey C, personal communication).” This information still doesn’t seem to have been published, though.

* More, detailed information on the study which asserted that cosleeping babies show sleep patterns which indicate stress. I’m still not convinced this is necessarily true of all cosleeping babies, though it may explain the many anecdotes you read about and hear from people who try sleep-training methods:”I thought my baby was high-needs and fussy…it turned out he was just overtired from all the slinging and cosleeping! Once we Ferberized/Weissbluthed/Hoag’ed him, he became the happiest, most laid-back baby you ever saw”.

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Cosleeping myths vs. research realities, Part II

In Part I, we discussed various claims made about cosleeping (by which I mean sharing a bed with your baby) and its supposed benefits, and what the reasearch actually shows (or, more often, doesn’t show). This installment discusses major studies which checked the connection between cosleeping and the risk of SIDS, what are the conditions for safe cosleeping (and how well AP/NP websites communicate these risks), and how can they best be implemented.

A few large studies have shown that young, small infants – particularly those under 8-20 weeks of age, or small-for-dates babies – have an X1-2 elevated risk for SIDS when cosleeping. For older babies in non-smoking environments, the association between bedsharing and SIDS did not reach statistical significance, unless they were sharing a bed with siblings as well as a parent (Hauck et al, 2003). This risk is greatly increased if either of the parents, but especially the mother, smoked during the baby’s pregnancy. Evidence for older babies’ risk of SIDS being elevated is mainly in the presence of a smoking parent. A good illustration of this can be found in a study that examined SIDS cases in 20 European locales (Carpenter et al, 2004):

A recent systematic review of 40 studies on the subject came to similar conclusions.

The presumptive reason for bedsharing children to die in an adult bed is suffocation. It’s important to state that we don’t really know what causes SIDS, but there is no way to reliably differentiate between SIDS and suffocation deaths. Some researchers refer to them collectively as SUDI (Sudden unexpected death of an infant). It’s been noted that bedsharing babies who die of SIDS/SUDI tend to die younger than those who crib-sleep.

A bedsharing infant can be smothered by the people cosleeping with him (parents or siblings), or alternatively, by the bedding or nooks and crannies in a bed which isn’t specifically designed for infant use. Accordingly, it’s been found that at-risk infants are those cosleeping with people other than Mom (in addition to Mom, not instead of her), if Mom is obese (over 79.5kg or 175lbs. – Carroll-Pinkerton et al, 2001), on sleeping pills, alcohol or just overly fatigued, if the bed has a soft mattress, thick pillows or duvet covers on it, or if the bed is a waterbed or a sofa.

To their credit (or at least, in response to the CPSC’s and AAP’s warnings about sharing a bed with one’s baby), various AP/NP sites started posting guidelines for safe cosleeping. However, the issue of not sleeping with very small babies, or if a parent smokes, is often absent – see Doc Sears or Attatchment Parenting International on the subject. Are they afraid that not enough parents will bedshare as a result of an honest warning?

Let’s look at some of the other warnings against bedsharing that are mentioned in those websites and elsewhere:

Never leave an infant or toddler unattended on an adult bed. Sounds great in rpinciple, until you remember that small infants sleep up to 16 hours a day. Most parents don’t. I suppose some of those sleep hours could be spent sleeping in a crib or a sling, but if there is no crib and you need to put the infant down to drink something hot or attend to another child…it could very well happen that an infant is left alone on a bed.

Never let another sibling sleep next to your baby. Realistically, older children in bed with you (and I speak from experience 😉 ) are all over the place when they sleep, including climbing over you to your other side. Unless you banish your older child(ren) from your bed where the newborn is, it’s very hard to prevent all contact between them, especially when there’s more than one older child in your bed.

Avoid using thick comforters or blankets near your sleeping baby. I wonder how feasible this is in most of North America in January. I doubt most cosleeping parents shun pillows, duvets or blankets.

To sum up, I think some parenting ‘experts’, in their zeal to promote cosleeping for largely unproven benefits, tend to understate the real risks of the practice. Is it really worth the warm fuzzies you get from cosleeping, or even the (maybe) increased breastfeeding, if your baby ends up dead as a result?

I think it would be far more honest to promote, instead, a sleeping arrangement that would allow parents to both have their cake and eat it, so to speak – that of encouraging use of a sidecar arrangement, or a separate sleeping surface within the bed, such as this one, for the first few months. It may not be “natural”, but surely infant survival is more important?

Let’s recap the oft not-mentioned sleeping advice that IMO should be given:

Despite what others may tell you, there is no proof sharing a bed prevents SIDS.And in certain cases, it may even be a risk factor for it.

Roomsharing should be encouraged in the first few months. There is ample evidence that roomsharing can reduce SIDS by as much as 50% (some of the studies linked above relate to this).

Bedsharing should be discouraged in the first 8 weeks of life (at least) or very small infants, obese parents, or when other siblings are in the bed. There is also the issue of “overly fatigued parents” – which is probably fairly universal among mothers of very small babies.

Don’t share a bed if you or your partner smoke…no matter what any AP advocate may tell you.

A good way to both share sleep and keep your baby safe is to provide a separate, but adjacent, sleeping surface for her, with separate, lightweight bedding.

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