When it comes to safe sleep for infants, parents find themselves navigating a sea of conflicting advice. The American Academy of Pediatrics (AAP), the World Health Organization (WHO), La Leche League (LLL), and the Academy of Breastfeeding Medicine (ABM) each offer guidelines rooted in extensive research and observation. In addition, sleep training books and programs further complicate things. However, the approaches of these organizations differ significantly, leading to confusion among parents striving to make the best decisions for their families.
The American Academy of Pediatrics (AAP) Guidelines
The AAP’s stance on safe sleep is clear and unwavering: infants should sleep on their backs, in their own cribs or bassinets, with no soft bedding or toys. In addition, they recommend room sharing, but not bed sharing, for the first 6 months to 1 year of life. The AAP's recommendations are designed to eliminating the risks of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths. This approach is akin to an abstinence-only model, focusing on eliminating risks by avoiding certain practices altogether, particularly bed-sharing.
The World Health Organization (WHO) Guidelines
The WHO’s stance on safe sleep emphasizes practices that support and protect breastfeeding, which indirectly impacts safe sleeping practices. They recognize the diversity of cultural practices and socioeconomic conditions worldwide. Their recommendations closely align with the AAP, except they don’t condemn bed sharing completely. WHO advises against bed-sharing in specific situations, such as when parents are smokers, under the influence of alcohol or drugs, or extremely tired. Additionally, they caution against bed-sharing in cases where the infant is premature or low-birth-weight, as these babies are more vulnerable.
La Leche League’s Safe Sleep Seven
La Leche League (LLL) acknowledges the AAP's guidelines but also recognizes that bed-sharing occurs for various reasons, including ease of breastfeeding. The Safe Sleep Seven is a set of criteria that aim to make bed-sharing safer for those who choose to do so. These guidelines include ensuring that both parents are non-smokers, the baby is breastfed, and the mother has not consumed alcohol or drugs, among other conditions. Furthermore, they recommend against swaddling and encourage appropriate clothing to avoid overheating during sleep. LLL’s approach is more about risk mitigation, providing guidance for safer bed-sharing when it happens.
Academy of Breastfeeding Medicine Protocol #37
ABM’s Protocol #37 on physiological infant care offers a comprehensive view, emphasizing the importance of proximity between the mother and the infant for breastfeeding success and bonding. The protocol acknowledges that while separate sleep surfaces are recommended, bed-sharing is a common practice in many cultures and can be done more safely with proper education and adherence to certain guidelines. The protocol also acknowledges that while bed-sharing can have benefits for breastfeeding, it needs to be approached with safety in mind. The ABM provides many recommendations and many of which align with other recommendations we have previously discussed. However, they go on to discuss the specific position mom and baby should be sleeping in, known as the cuddle-curl as well as lots of recommendations to improve sleep such as using red lights at night to avoid over waking and avoiding non-physiological interruptions to sleep such as night time pumping, bottle feeding, and having the baby sleep outside of the parent’s reach.
Sleep Training Books and Programs Like Baby Wise or Taking Cara Babies
Sleep training books and programs are not only detrimental to breastfeeding, they also go against several of the recommendations of the major health organizations listed above. In addition, none of the major health organizations recommend training your baby to sleep. Sleep training programs often encourage you to place your baby in a separate room to sleep very early which is against the AAP guidelines and does not facilitate ease of breastfeeding. They also instruct parents to use immobilization devices such as swaddles, sleep sacks, the merlin sleep suit, and more which increase the risk of overheating and plagiocephaly, or the development of flat spots on the skull. They often encourage parents to stop responding to their baby’s needs which can be detrimental to social-emotional development. Furthermore, these books and programs facilitates very long sleep periods of 6-12 hours which is detrimental to the milk supply of the vast majority of breastfeeding mothers.
Abstinence-Only Education vs. Risk Mitigation for SIDS Prevention
The debate between an abstinence-only approach and risk mitigation strategies in safe sleep is reminiscent of similar debates in other areas of public health. While abstinence-only models focus on eliminating risks by avoiding certain behaviors, risk mitigation strategies provide guidelines for safer practices, recognizing that these behaviors may still occur.
Research suggests that risk mitigation education might be more effective in ensuring parental compliance and safety. Parents are more likely to adhere to safe sleep practices when they feel their lifestyle and choices are understood and accommodated, rather than dismissed or ignored. This is particularly relevant in the context of bed-sharing, which, while not recommended, is a reality for many families, often driven by a need for convenience in breastfeeding and comfort.
Making Informed Choices
Ultimately, the decision about where and how an infant sleeps is deeply personal and can be influenced by various factors, including cultural practices, family needs, and individual circumstances. Parents should be empowered with comprehensive, unbiased information to make informed choices that best suit their family’s needs.
It’s crucial for health care providers and lactation consultants to engage in open, non-judgmental conversations with families, providing them with information on all sleep options. This includes discussing the benefits of room-sharing without bed-sharing, as recommended by the AAP, and offering guidance on safer bed-sharing practices for those who choose this option or in cases where bed sharing occurs accidentally - which is very common.
In conclusion, navigating infant sleep practices requires balancing different perspectives, understanding the nuances of each approach, and making informed choices that align with one’s family dynamics and values. Whether choosing a separate sleep surface or bed-sharing under safe conditions, what matters most is creating a sleep environment that ensures the safety, health, and well-being of the infant and facilitates sleep and rest for the parent.
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Sources:
American Academy of Pediatrics. 2023. HealthyChildren.org Safe Sleep Articles. https://www.aap.org/en/patient-care/safe-sleep/healthy-children-safe-sleep-articles/
La Leche League International. 2018. The Safe Sleep Seven. https://llli.org/news/the-safe-sleep-seven/
Academy of Breastfeeding Medicine. (2023). ABM Clinical Protocol #37: Physiological Infant Care-Managing Nighttime Breastfeeding In Young Infants. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/Physiologic%20Infant%20Care%20Protocol%2037.pdf
World Health Organization. Making sure newborns and children under 5 years sleep safely. https://www.who.int/tools/your-life-your-health/life-phase/newborns-and-children-under-5-years/making-sure-newborns-and-children-under-5-years-sleep-safely