Room sharing but not bed sharing is recommend in the first six months of life for safe sleep and avoiding accidental death in infants. However, for some parents, this may result in unsafe sleep practices. Here’s what you need to know.
In June of 2022, the American Academy of Pediatrics (AAP) updated their safe sleep recommendations . This statement reinforced much of what we already knew about how babies should sleep to reduce the risk of sudden infant death syndrome(SIDS) and addressed other causes of death in infancy— specifically accidental suffocation.
According to the AAP, The best way for your infant to sleep is:
- On a flat firm surface
- On his back
- Without any soft covers or blankets (including no crib bumpers or crib blankets
- In a room with mother or caregiver
Other ways to reduce the risk of SIDS include:
- Avoidance of exposure to tobacco smoke during pregnancy and afterwards
- Avoidance of exposure to alcohol or drugs
- Routine immunizations
- Use of a pacifier
- Continued breastfeeding.
All of these are excellent recommendations. There is one recommendation from the 2016 guidelines (continued in the current edition of the guidelines. the new recommendation that parents room share but not bed share for AT LEAST six months, and ideally up to one year of age, claiming that this could reduce the risk of babies dying in their sleep by “up to 50%”. This got my attention when it was initially published.
Here is the full text of the recommendation:
It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for at least the first 6 months. There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%. In addition, this arrangement is most likely to prevent suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.From Moon, R.Y., Carlin, R.F., Hand, I., THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN, 2022. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics 150, e2022057990. https://doi.org/10.1542/peds.2022-057990
What’s good about room sharing
Certainly, room sharing can facilitate closeness with your baby and works well for many families worldwide. In many parts of the world, where families sleep with multiple family members in a room, SIDS rates are very low.
Room sharing make it easier to breastfeed, and to continue breastfeeding, which we know is healthy for both mother and child. (And breastfeeding itself reduces the risk of SIDS). If it is working well for your family, there is no reason to stop it. Long term, room sharing in infancy does not seem to be associated with any sleep or behavioral issues in later childhood. A study of 6, 7, and 8 year olds showed no evidence of problems after room sharing in infancy, and some improvement in pro-social behaviors, although the sample size and effect sizes were small.
However, if you and your baby are struggling to sleep, and you are wondering if it is truly necessary, read on. At first I was a bit skeptical of the science but I have since come around.
The Evidence for the Room Sharing Recommendation
Dr. Moon and Dr. Hauck (Dr. Moon is an author of the current guidelines and 2016, Dr. Hauck on the 2016 guidelines only), describe the evidence in a commentary on the Paul study (which I discuss below on the potential risks of room sharing).
“The AAP’s room-sharing without bed-sharing recommendation is based on case-control studies in England, New Zealand, and Scotland, which have demonstrated that room-sharing decreases the risk of SIDS compared with solitary sleeping. Blair et al31 found an adjusted odds ratio of death of 10.49 (95% confidence interval [CI] 4.26–25.81) for infants who slept in a separate room compared with those who slept in the parents’ room. The New Zealand Cot Death study reported an adjusted odds ratio of death for infants who room-shared during the last sleep of 0.35 (95% CI 0.26–0.49) compared with solitary-sleeping infants.32 Tappin et al33 reported an adjusted odds ratio of 3.26 (95% CI 1.03–10.35) for solitary-sleeping infants compared with room-sharing infants. Although these authors found this reduction in risk to be present only when the parent was a smoker, Blair found this reduction to be present for both smoking and nonsmoking parents (P. Blair, PhD, personal communication, 2016). More recent, unpublished data from the New Zealand Sudden and Unexplained Death in Infancy study show similar protection from room-sharing, with an adjusted odds ratio of 0.36 (95% CI, 0.19–0.71) for room-sharing infants compared with solitary-sleeping infants (E. Mitchell, MBBS, personal communication, 2016). Because none of these studies stratified the risk by infant age in months, it is difficult to determine the optimal end point for room-sharing.”Moon, R.Y., Hauck, F.R., 2017. Are There Long-term Consequences of Room-Sharing During Infancy? Pediatrics 140, e20171323. https://doi.org/10.1542/peds.2017-1323
To put this in plain language. The odds ratio quantifies the strength of the association between two different events or conditions in case-control studies. So, for example, when the odds ration of death for sleeping in a separate room was 10.49, it means that infants sleeping in a room by themselves were 10.49 times more likely to die than infants that slept in the parents room IN THIS PARTICULAR SET OF PATIENTS. (For more on odds ratios you can read this article). In the Blair study, above, this was the largest effect size seen of the three studies.
Additionally, in my literature review, I found another article from the Netherlands showing that the risk of death in infants sharing a room with parents had an adjusted odds ration of 0.3– so babies were 70% less likely to die from SUID.
If those numbers seem scary, it is important to recognize that, fortunately, these events still remain very rare– it is difficult to say how rare. In the AAP statement, the authors estimate that room sharing results in a 50% risk reduction of infant death. I’m unclear how they arrived at that calculation.
A new 2022 study provides more evidence on the safety benefits of room sharing
The most recent study (Parks, S.E., DeSisto, C.L., Kortsmit, K., Bombard, J.M., Shapiro-Mendoza, C.K., 2023. Risk Factors for Suffocation and Unexplained Causes of Infant Deaths. Pediatrics 151, e2022057771. https://doi.org/10.1542/peds.2022-057771) on this topic showed the strongest evidence yet that room sharing prevents both unexplained deaths (a category that that includes SIDS) and deaths related to accidental suffocation.
The authors were comparing 112 infants who died via accidental suffocation and 300 infants who died due to unexplained reasons. They compared each infant with four separate healthy controls matched for age and region. This is a pretty rigorous study design. Their studies were striking. They demonstrated an odds ratio of 18.7 for suffocation and 7.6 for unexplained death. This means that infants exposed to the condition of NOT sharing a room with a mother or caregiver increased their chance of suffocation death over 18 times and unexpected death by 7.6 times. This study also confirm the risk of other identified risk factors (such as non-supine positioning, bed sharing, and soft materials in the baby’s sleep environment), but the odds ratios were not as large.
There are some limitations to this study. To me the most prominent one is “social desirability” bias– the idea that parents of healthy infants are more likely to answer affirmatively to questions about safe sleep when surveyed. On balance, however, this study is pretty convincing to me. It presents “modern” (post Back to Sleep) data. It also teased out suffocation related deaths which earlier studies do not do.
Why does room sharing reduce the risk of SIDS?
It is not well understood. Babies and parents who room share seem to sleep less soundly. If babies wake up more easily, this may reduce the risk of SIDS. Additionally, room sharing infants are more likely to breast feed more frequently (which has also been shown to reduce this risk of SIDS).
In the 2022 study, the room sharing effect was most prominent in reducing the risk of accidental suffocation. I suspect that mothers are more likely to notice unsafe sleeping conditions if they share a room– say, if a grandparent has put a blanket on a baby when babysitting.
Room Sharing Pitfalls
Room sharing is also potentially dangerous as tired parents don’t always make good decisions about, say, falling asleep next to their child which increases the risk of suffocation (more on this below). Tired parents also may be prone to health issues, and are more likely to get into car accidents. Maternal sleep deprivation is associated with a higher risk of post-partum depression, which is not good for children either.
The Problems with the Room Sharing Recommendation in 2016
Dr. Aaron E. Carroll examined the evidence sited by the AAP, which was comprised of three studies and an out of print book. He noted a few issues with these studies.
- These are “case-control” studies. The issue with these types of studies (which match children with SIDS with similar children in terms of age and gender) is that they may prove a relationship, but cannot prove causation. (Note that SIDS is fortunately rare. Because of this, however, this type of study is really only the way to study this problem).
- These studies were performed in the 1990s. Since the 1990s, there has been a marked decline in the rate of SIDS worldwide, due to education about “back to sleep” and other safe sleep practices. Since the risk of SIDS is much lower now, it is unclear if room sharing is still protective.
- These studies were performed in Europe where room sharing is much more common than in the US. Again, this makes it harder to generalize.
He also brought attention to the following study (Paul, I.M., Hohman, E.E., Loken, E., Savage, J.S., Anzman-Frasca, S., Carper, P., Marini, M.E., Birch, L.L., 2017. Mother-Infant Room-Sharing and Sleep Outcomes in the INSIGHT Study. Pediatrics 140, e20170122. https://doi.org/10.1542/peds.2017-0122)
Room sharing may be associated with decreased sleep and increased risk to babies
The study by Paul et al looked at the relationships between mother-infant room sharing and sleep. It examined the sleep of infants in 259 families. The authors compared the sleep of children at four and nine months of age. They compared three groups of infants:
- “Early independent sleepers” who were sleeping in different rooms from the parents at 4 months of age (62%).
- “Late independent sleepers” who started sleeping independently between ages 4 and 9 months (27%).
- Infants still room sharing at 9 months of age (11%).
The authors examined both sleep habits and safe sleep practices. They found:
- Children who were sleeping independently by 9 months of age were sleeping 45 minutes more than room sharers at 30 months of age. Interestingly, there was no difference at 9 months of age. Room sharers were more likely to have night time awakenings and feedings, and to be fed back to sleep.
- Early independent sleepers were almost more than twice as likely as room sharers to have a consistent bedtime routine and go to bed prior to 8 pm.
- Room sharing infants were twice as likely to have an unapproved soft object on their sleep surface. Moreover, infants who room shared at 4 and 9 months of age were four times more likely to bring their infant into their bed at night. It’s important to remember that co-sleeping is not safe for young infants.
This study had some significant limitations— it was a secondary analysis, meaning that the original study was not designed to assess these particular findings. And, like the studies above, the study was designed in such a way that it shows correlation but not causation.
However, this does suggest that babies (and their parents) who room share sleep less— even close to three years of age. It also suggests that the parents who have infants in their room are more likely to perform risky sleep practices at night.
This is of course, one study. But the authors echo Dr. Carroll’s concerns about the new AAP recommendations. They state in their conclusion:
While substantial progress has been made over the past several decades to improve the safety of infant sleep, the AAP recommendation that parents room-share with their infants until the age of 1 year is not supported by data, is inconsistent with the epidemiology of SIDS, is incongruent with our understanding of socioemotional development in the second half of the first year, and has the potential for unintended consequences for infants and families. Our findings showing poorer sleep-related outcomes and more unsafe sleep practices among dyads who room-share beyond early infancy suggest that the AAP should reconsider and revise the recommendation pending evidence to support room-sharing through the age of 1 year.
Two of the authors of the AAP Recommendation wrote a commentary on the study referenced above. They note that
. . .when the data are examined, the significant differences in the groups at 4 months of age are not the number of night awakenings but consistent bedtime routines, early bedtimes, the numbers of night feedings, and being fed back to sleep. Bedtime routines can be difficult for all families to establish, and there may be additional challenges for families who are room-sharing.
It’s definitely possible that working on bedtime routines may help reduce the burden of room sharing. Perhaps the effects on parental sleep can be reduced by better education about sleep.
How long should you share a room with your infant?
Based on the AAP guidelines, I would suggest six months if you can do so safely (see below).
Are there long term consequences for room sharing?
The literature does not suggest that there are long term benefits or downsides to room sharing with your infant. In the short term, babies who room share tend to sleep a bit less.
What about room sharing with other children?
The new AAP guidelines recommend that infants do not share sleeping spaces with other children. So avoid having multiple infants sharing a sleep surface.
As for room sharing with an infant and toddler, this is likely safe provided (and this is CRITICAL that the infant have a separate safe and secure sleeping surface.
Can my baby sleep in a swing or car seat?
In short, there is a risk of suffocation if your child is routinely sleeping in a swing, or in a car seat when not in the car. Here’s more on this.
So what the heck are you supposed to do?
My children were born prior to this very strong recommendation. Room sharing had a soft recommendation. We found that my wife and I slept better in with the children in separate rooms. The children slept better as well.
My thinking on this topic has evolved. I was not initially convinced of the benefits in the past. With time, however, it has become clear that room sharing likely confers reduced risk for accidental suffocation as well as unexplained death or SIDS.
If you have an infant less than six months of age, I think it is appropriate to follow the room sharing (but not bed sharing) recommendation IF you are able to adhere to safe sleep practices.
The caveat is for parents who find themselves in unsafe sleeping situations (e.g. ded sharing or falling asleep in a chair or couch because their baby is waking them up so frequently).
I believe that having your infant sleep on her back, avoiding soft materials in the crib, and continuing to breastfeed are also important for safe sleep.
The peak of SIDS risk is between 1-4 months, and the risk is low after six months of age. The 2022 guidelines were updated to suggest that the primary safety benefits of room sharing end after six months of age, in line with the recommendations in Canada, the UK, the Netherlands, and New Zealand.
I’m not the only to struggle with this. Dr. Claire McCarthy wrote about the trade offs that the room sharing recommendation have caused on the Harvard Health blog.
Obviously, this is a really complicated decision which has to take into account your baby’s health, your mental health, and the sleeping places available in your home. In 2023, the balance of evidence clearly suggests that room sharing with your infant is the safest practice. If you are room sharing and it is going well, terrific! However, if you are sleeping poorly, depressed, or resorting to unsafe sleep practices to make it through the night, you may want to consider moving your child out of your room if the option is available, with the recognition that this may impose some risk. Please talk with your pediatrician about how to keep your infant safe.