Is Room Sharing in Infancy Necessary for Safe Sleep?

Last year, 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

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 was one major change, however, that got my attention: 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%”.

Let that sink in for a minute. The American Academy of Pediatrics said that if you have your baby in his own room, he is twice as likely to die. Does that freak you out? It would freak me out.

The Problems with Room Sharing

Anyone who’s shared a room with their infant knows that infants make a lot of noise when they sleep. They snort, cough, cry out, and move.

Now imagine you have just been told by the AAP that it is merely your presence in the room that reduces your child’s risk of dying. You literally have been told that you actively need to keep your child alive all night.

How do you think you are going to sleep at night?

We know that parents who room share sleep less, have more interrupted sleep, and may have less closeness with their partners. Let’s be frank here— having a newborn baby in the room is not going to put you in the mood.

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.

What’s good about room sharing

Certainly, room sharing can facilitate closeness with your baby and works well for many families worldwide. It does 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. There are some important limitations of the science behind this recommendation.

The Problems with the Room Sharing Recommendation

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.

1. 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).
2. 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.
3. These studies were performed in Europe where room sharing is much more common than in the US. Again, this makes it harder to generalize.

Room sharing may be associated with decreased sleep and increased risk to babies

A recent study just examined 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:

1. “Early independent sleepers” who were sleeping in different rooms from the parents at 4 months of age (62%).
2. “Late independent sleepers” who started sleeping independently between ages 4 and 9 months (27%).
3. Infants still room sharing at 9 months of age (11%).

The authors examined both sleep habits and safe sleep practices. They found:

1. 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.
2. 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.
3. 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.

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.

Some parents sleep better knowing their children are in the same room as them. Some children may sleep better as well. That’s fine. Other families don’t have an extra room for their children. That’s fine as well.

Some parents, however, are really struggling because their babies are sleeping poorly, and so are they. I’m worried about the mental state of frazzled parents who feel that they have to literally sacrifice their sleep to keep their children alive by constant vigilance, without a clear biological mechanism explaining why this may be beneficial.

I believe that having your infant sleep on her back, avoiding soft materials in the crib, and continuing to breastfeed are MUCH more important for safe sleep, especially as they have clear mechanisms to explain why they keep babies safe.

The peak of SIDS risk is between 1-4 months, and the risk is low after six months of age. Indeed, in Canada, the UK, the Netherlands, and New Zealand, the room sharing recommendation ends at six months of age, although Australia, like the US, ends at 12 months.

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. 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. Please talk with your pediatrician about how to keep your infant safe.

I would love to know what you think about this very fraught topic. Leave a comment below.