AP 101: Principle 5, Ensuring safe sleep, physically and emotionally

I've been pondering this post since I first began my attachment parenting series on this blog, knowing how controversial issues related to infant sleep can be. I'm going to first lay out the resources I've used in preparing this entry. These books, articles, and websites are invaluable stores of scientific research and hands-on information for parents who want to be more informed about infant sleep.

• Attached at the Heart, by Barbara Nicholson and Lysa Parker, founders of Attachment Parenting International
• Sleeping With Your Baby: A Parent's Guide to Cosleeping, by James McKenna, Director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame
• Good Nights: The Happy Parents' Guide to the Family Bed by Jay Gordon, MD, and Maria Goodavage
• The Baby Book, by William Sears, MD, and Martha Sears, RN
• The No Cry Sleep Solution, by Elizabeth Pantley
• http://www.nd.edu/~jmckenn1/lab/faq.html
• http://www.dur.ac.uk/sleep.lab/
• http://mothering.com/sleep

I share these sources in part to show that there is ample scientific evidence to back up the things I am going to write. The approach to infant sleep that we've chosen to adopt in our family is not merely the result of naive or coddling parents who are either blissfully ignoring "danger" or setting up their children for years of dependence. It is an approach that has been shown to benefit infants and parents, an approach that is normal to the vast majority of families across the world.

In my previous posts, I've touched on several important needs of babies, in particular, sensitive and consistent responsiveness from caregivers as well as plenty of physical contact. Neither of these needs suddenly go out the window when it gets dark outside and it's time for bed! Yet many parents wish they would and even try to make them do so. It's understandable that the extreme sleep deprivation many of us experience during those first weeks and months of parenthood drives us to seek out ways to make babies sleep more like adults than babies. But we're operating under the influence of far more than just sleep deprivation. We're following subtle but strong messages that have been ingrained in our culture for several generations, even though these messages are unheard of in other cultures, in fact, most cultures the world over.

First of all, how are babies really meant to sleep?

James McKenna, professor at Notre Dame, says this:

"The reality is, no babies need to sleep through the night. That is completely a cultural construct. It is usually not the babies who have the sleep problems--they can sleep where and when they need--but it is the parents who have the sleep problems. These are usually induced by the notions of the baby being separate from the parent. It is not that the baby can't sleep, they just can't sleep how the parents want it, when they want it, and in a solitary environment. Biologically speaking, this is unnatural for them, and their emotions rightly tell them so."

• Babies need frequent feeding and skin-to-skin nurturing in order to grow and be healthy; their sleep patterns mirror this, as they sleep in shorter stints partly to be able to eat more frequently.
• Babies and adults differ in the amount of time they spend in deep and light (REM) sleep. Babies have much more REM sleep and much less deep sleep. Some researchers believe that REM sleep helps stimulate the brain and aids its development and that it is both healthy and important for babies to spent plenty of time in that lighter sleep for this reason.
• Naturally, lighter sleep means more wakefulness. Transitions from light sleep to deep sleep happen about every 90 minutes, and these are prime times for the baby to awaken.
• Some researchers feel that this time spent in light sleep is also a safety mechanism for young infants. Spending too much time in deep sleep could increase a baby's risk of SIDS, which may be linked to an infant's inability to awaken herself in the event of a breathing problem. (This is one reason why we are told to put infants to sleep on their backs--back sleeping means lighter sleeping!)

So the typical advice to encourage a baby to sleep through the night as soon as possible goes completely counter to the way young babies are actually designed! Nature designed them to sleep in ways that not only protect them physically but also nourish them physically, emotionally, and intellectually. Yet our society focuses instead of training them to develop "good" sleep habits that will make life easier for the adults around them.

From Attached at the Heart: "Infants' sleep patterns gradually adjust to adultlike sleep patterns beginning around the ages of two and three years."

Two and three years! Not two and three months.

Now, I've lived with two newborns, and I know how hard it is as a parent to deal with nightwaking. Having a new baby in the house is exhausting and overwhelming, no doubt about it. I'm sure there isn't a parent around (me included) who hasn't wished for a baby to sleep longer, sooner. It's a perfectly natural desire. But it's not natural for the baby. When seeking solutions, we need to keep baby's needs foremost in our minds and find ways to make life easier for all of us that don't require babies to adapt to adult patterns that are not appropriate for their tiny bodies and brains.

Some thoughts from a favorite book, Everyday Blessings: the Inner Work of Mindful Parenting, by Jon and Myla Kabat-Zinn:

"....new parents are often asked: 'Is the baby sleeping through the night yet?' We may notice, as we listen carefully to the intent behind this question, that it has more to do with how much sleep the parents are or aren't getting than it does concern for the baby. It is predicated on the supposition that babies are supposed to sleep all night long. The unspoken assumption is that the parents' needs should take priority. ....If we look closely at this, we may see that... the focus is predominantly on the parents' well-being rather than on the child's. Babies are seen as tough and resilient, while the parents are seen as vulnerable and in need of protection. Of course new parents do need to take care of themselves, and do need the loving care and support of others during this intense period of adjustment, when all sorts of new demands are being placed upon them. But it is important that in the process, the baby's needs are not minimized or lost sight of. If we can act with some degree of awareness, our choices in taking care of ourselves will not be at the expense of our baby's well-being."

One way that this goal can be accomplished is through any of the various forms of co-sleeping. Here's where we get contoversial! In fact, sharing sleep is probably the most misunderstood and contentious issue around when it comes to parenting infants.

Let's understand that this controversy really only exists in the United States and other western countries. As James McKenna stated in an above quote, our western ideal of solitary sleep and "sleeping through the night" is a cultural contstruct not shared by the vast majority of parents in this world. Throughout most of the world, co-sleeping IS the norm, and solitary sleeping the "strange" practice. Even in our western world, co-sleeping was the norm prior to the last 100 years or so for most people. Having babies sleep alone in cribs in separate rooms is really a very recent phenomenon in the history of the world!

Now, let's define the term "co-sleeping". To most people, it means sharing a bed with one's baby. But in reality, is merely means sleeping in close proximity to one another. You can have your baby in a bassinet or cradle next to your bed, and you are still "co-sleeping". It simply means that you honor your baby's need for your presence, and you create an environment where you can quickly and easily respond to your baby during the night. Now, many people do choose to share a bed, and it is a very common form of co-sleeping throughout the world. But bedsharing is not the only way to co-sleep!

Co-sleeping has immense benefits for both baby and parents! Parents who sleep near their babies are in a much better position to monitor and mediate anything that might happen during the night, whether baby has a breathing issue, begins to run a fever, awakens hungry and crying, etc. Parents can hear their child more easily and don't have to wait for baby to actually cry before becoming aware of a problem.

Babies who co-sleep experience more periods of light sleep, which stabilize heart rates and breathing patterns and decrease the risk of SIDS. (Attached at the Heart, p. 155)

Dr. Jay Gordon, in his book Good Nights, states:

"It's intriguing that the rate of SIDS is highest in industrialized societies where infant sleep separately from their parents. In societies where babies routinely sleep with their parents, the rate of SIDS is considerably lower. It would be convenient to argue that the increased SIDS cases in modern societies stem from pollution, parents who smoke, or any of the environmental drawbacks of living in a 'developed' culture. But Japan is the fly in that theory's ointment. Japan, where babies routinely sleep with their parents, boasts low SIDS figures more typical of non-industrialized countries."

Co-sleeping can help parents get more sleep, even as their babies wake at normal intervals. Co-sleeping parents don't have to get up and go to another room to feed the baby. Nursing mothers can easily breastfeed and put the baby right back to sleep. Bottlefeeding parents, if a convenient "station" is set up next to the bed beforehand, can easily prepare a bottle and feed their infant without having to go to the kitchen. Baby can get his needs met quickly without having to wake wake and go into a full-blown cry, which will in turn help him go back to sleep more quickly.

Now that we've discussed co-sleeping in general, I am going to be focusing this post mainly on bedsharing, aka the family bed. I'm doing so because that's what I'm familiar with as a parent and also because that's where there is the greatest need for education and breaking down of myth and misunderstanding.

Why bedshare? Well, in addition to the benefits of co-sleeping mentioned above, all of which apply to family-bedders, babies get the physical and emotional benefits of touch.

James McKenna states, "As a developmental extension of the skin-to-skin experience, parent-infant bedsharing, when practiced safely, can be a warm and snuggly experience that many parents enjoy. However, it is much more than that--it is a biologically-driven process whereby the baby's body temperature is regulated and steady breathing is promoted in part by the sounds of mother's breathing and by the infant feeling the mother's rhythmic chest movements. In many biological studies these cues are shown to act as 'hidden' stimuli by which the young of other mamals time their next breath!"

"During skin-to-skin contact, the infant body stimulates just the right brain cells to be nurtured and connected to each other. In a sense, nighttime co-sleeping can be said to extend the needed micro-environment that during the day also fosters a variety of social, communicative, and emotional skills whilt the baby is being monitored and protected. A mother is certainly more than a service provider; she is the entity around which the human infant was designed not just to be awake, but to sleep." (Sleeping with your Baby, p. 41)

Bedsharing has many benefits for breastfeeding mothers and babies, and it is in the context of nursing that bedsharing has developed and flourished over the millenia. Bedsharing makes nighttime nursing highly conventient, and the more-frequent breastfeeding also helps to stimulate the mother's milk supply. In a future post, I will specifically address issues related to bottlefeeding parents.

As an adoptive mother, I feel that the family bed has been the single best thing we've done to help hasten bonding between our children and ourselves! Though it has at times been a challenge, many of my fondest memories of parenthood revolve around our family bed. There is nothing quite like being woken up in the morning by a sweet little person climbing on your head!

As I mentioned, bedsharing has been a controversial issue in our American society, no thanks to a couple of equally controversial "studies" that have been widely circulated in the media. For further detailed information on these studies and for rebuttals from sleepfamily bed experts, see the above-listed resources. Suffice it to say that there are flaws in these studies that the general public can't always see. For example, the most prominent study was done by the Consumer Product Safety Commission with support from the Juvenile Products Manufacturers Association. Ok, that last group mentioned? Those are the guys that make cribs and cradles and bassinets and pack-n-plays! Those are the guys that stand to lose a lot of money if the family bed becomes the norm in our society. And while it's far from the norm, it has been quickly gaining in popularity. The threat to their business is real. At any rate, in my opinion, their involvement taints the study from the beginning because they have a vested financial interest in the outcome.

The biggest criticism of these studies, however, comes not because of their sponsors but because of their methodology. The main issue is that when they look at bedsharing deaths, they don't look at other safety issues that may have been at play. If a child died while in a parent's bed, they automatically blame it on the fact that the child was in the parent's bed. In reality, the child may have been in bed with a parent who was drunk or under the influence of drugs or medicines. The parent may have been a heavy sleeper. The child may have become trapped under a comforter that was too thick or become wedged between the bed and the wall because there was a too-large gap there. The baby may have suffocated under a pillow that was unsafe. The child may have been sleeping with a parent on a couch or a waterbed, both of which are environments that are known to be unsafe. In one study I read about--I think it was the CPSC one--some 20% of the deaths actually occurred on waterbeds. In another study I came across recently, I think it's one that's been in the news lately, I believe 80% of the deaths happened in waterbeds. But instead of telling parents not to have their baby in a waterbed (which is like a "duh!" situation to me), or to keep thick quilts off the bed, or to make sure the bed is flush with the wall and can't be moved, or to make sure they never sleep with their baby while under the influence of anything--they tell parents that bedsharing in and of itself is inherently unsafe.

Well, tell that to the millions of parents around the world who share their beds with their babies--safely. I do like that James McKenna points out in one of his articles on his website that most of the bedsharing parents in the world live in different situations than we cushy Americans do. They are not going to bed each night on soft, thick pillowtop mattresses with king-sized pillows and huge down comforters. We do need to keep this in mind as we prepare safe sleeping environments for our babies! But it can be done. It can be done!

McKenna points out in Sleeping with your Baby:

"In Western industrialized society, cosleeping has never been discussed on what anyone could even remotely consider a level playing field. ....Unlike problems associated with getting babies to sleep alone, and unlike efforts made toward solving the safety issues of babies sleeping in cribs, any possible problems associated with cosleeping are deemed not worth solving, or impossible to solve. These are social judgments, not science. In magazine articles and books that take a negative stance on various forms of cosleeping, each infant death is used as 'proof' of the dangers of bedsharing, and the whole practice is condemned. But each one of the thousands of infants that have died in cribs is NOT used as proof that crib sleeping needs to be eliminated. Because the true causes of almost all bedsharing deaths reported publicly are omitted, it is easy to understand how many of our citizens fail to realize that this 'proof' is actually just a bias that the writer of the article or book has, and that it is not proper scientific proof that bedsharing is invariably dangerous and cannot be made safe."

So, let's list some of the safety precautions for parents who choose to share sleep with their babies! Here are a few things that most family bed books recommend:

• Obviously, do not bring your baby into your bed if you are under the influence of alcohol, drugs, or medications that cause excessive drowsiness such as cold medicines, or if you smoke.
• Avoid too-soft or sagging mattresses or too-thick pillowtops.
• Never sleep with a baby on a sofa, in a chair, on a beanbag, or in a waterbed.
• Make sure that there are no gaps between the mattress and the wall or headboard where a baby could become trapped. The very safest thing to do is to remove the mattress and box springs and put them directly on the floor, then move the mattress far away from the wall. Rolled towels or foam can also be placed in gaps, but parents must make sure to check it each night to be sure it is absolutely immoveable.
• If you are a heavy sleeper, it may not be wise to have your baby in bed with you.
• Likewise, if you are very obese, you may want to rethink bedsharing, as the weight distribution can cause "wells" in the mattress where baby could become trapped or, you might have a hard time "feeling" the babies presence.
• Make sure you only have thin blankets on the bed, no heavy quilts or fluffy comforters. If you are cold at night, wear more clothing rather than using more bedding.
• Use caution with pillows. Make sure no pillows are near baby's head. Some books recommend having firm, square pillows that will not shift easily during the night. I slept on a small travel pillow for several months, though now I think my memory foam pillow would be quite safe because it doesn't move.
• Some books recommend having baby sleep next to the mother only, not in between the parents. The idea is that mothers tend to be more responsive than fathers. (I felt like James was very responsive, and we always had our babies in the middle with no problems. But each family should assess their own sitaution.) Of course, if baby is not in the middle of the bed, make sure you have a guard rail at the side, and make sure there are no gaps between the mattress and the rail.
• Make sure the room is cool enough and that baby is not dressed in heavy clothing. More bodies in the bed create more heat, and you must be careful that baby does not get overheated. Blanket sleepers are definitely not needed in a family bed!
• Do not put baby in a bed where other children or pets could enter the bed.
• Make sure that each adult in the bed knows where the baby is at all times. For example, if James went to bed early and I came in later with the baby, I would wake him and tell him that baby was in bed with us. Each adult must be willing to take full responsibility for the baby's presence in the bed.
• Of course, make sure to put the baby to sleep on her back (that's true of crib sleeping as well!)
• I would also make sure that the blankets did not come higher than the baby's waist.

I can say that in many months of sharing our bed with two babies, we never had a close call. I take safety very seriously and was perhaps a bit paranoid about it, but I think that's a good thing!

If a parent chooses not to share a bed, they can still give their baby many great benefits by keeping baby's crib or bassinet close by and making it a priority to respond consistently to baby's nighttime needs just as they would in the daytime.

My main purpose here is not really to convince everyone that they should bedshare (though I do highly recommend it!). I mostly want people to understand why we have chosen this route and that it is not inherently dangerous when practiced with precautions. Could something happen? Of course, no sleep situation is foolproof! The death of a baby would always be a huge tragedy, yet it could happen in a crib just as easily as in a safe family bed situation. The difference would be that in a crib, no one would blame the parents, while in the family bed, all fingers would point to the parents simply because of our society's negative connotations concerning sharing sleep. That is not fair.

As I said before, we have seen tremendous benefits for both our children and ourselves because of the way we've approached sleep. It has not always been easy! One of our children in particular has consistently woken at night longer than what is the cultural norm (though entirely normal from a biological point of view). I know some people probably think we're crazy for not handling the issue in a culturally normal way (e.g making her cry herself back to sleep), yet we're committed to finding solutions that fit our parenting values and respect her emotional needs.