Sharing a sleep surface with a baby can increase the risk of Sudden Unexpected Death in Infancy (SUDI), including Sudden Infant Death Syndrome (SIDS) and fatal sleep accidents.
The safest place to sleep a baby is in their own safe sleeping place in the same room as an adult care-giver.
Sharing a sleep surface with your baby can increase the risk of Sudden Unexpected Death in Infancy (SUDI), including Sudden Infant Death Syndrome (SIDS) and fatal sleep accidents.
For the purpose of this statement the term ‘sharing a sleep surface’ is used to include bed-sharing and other co-sleeping practices.
- Bed-sharing refers to bringing the baby onto a shared surface where co-sleeping is possible, whether co-sleeping is intended or not.
- Co-sleeping is defined as a parent or caregiver, their partner, the infant’s siblings or any other person being asleep on the same sleep surface as the baby.
A considerable proportion of Sudden and Unexpected Deaths in Infancy occur on a shared sleeping surface. An analysis of infant deaths in the CDC (USA) Sudden Unexpected Infant Death Case Registry found that 14% of 1812 deaths between 2011 and 2014 were classified as suffocation. Importantly 50% of these infants were sharing a sleeping surface with adults or other children. The most common links in the sleep environment were soft bedding (69%), and 48% of these infants sharing a sleep surface. Overlay occurred in (19%) and 71% of these infants died when sharing a sleep surface. Wedging accounted for 12% and 45% of those infants were sharing a sleep surface33.
Sharing a sleep surface is especially high-risk if:
- The baby is less than three months of age, was born pre-term or was born small for gestational age,
- Parents sharing the sleep surface are smokers
- Parents sharing the sleep surface while under the influence of alcohol, sedating medications or illicit drugs
- Parents fall asleep with their infant on a sofa or couch
There is no increased risk of SUDI whilst sharing a sleep surface with a baby during feeding, cuddling and playing providing the baby is returned to its own safe sleeping surface before the parent goes to sleep 1.
Increased research has shown that there are differences in characteristics between different co-sleeping groups that impact the associated risk for infant death21.
Red Nose recommends sleeping a baby in their own safe sleep space next to the parent or caregivers’ bed for the first six months of life as this has been shown to lower the risk of SUDI 2–4.
Why do parents and caregivers share a sleep surface with their infant?
A large-scale review of infant care practices 5 revealed that across research studies in different populations, the main reasons that parents co-sleep or share a sleep surface remain consistent. The reasons given are that it improves sleep quality or sleep duration for the mother and/or the infant, it facilitates breastfeeding, parents perceive improved safety through closer monitoring of the infant, and there are cultural norms that encourage sharing sleep surfaces through ideals around comfort and closeness. In particular, for many cultural groups including Australian First Nations families, sharing the sleep surface with a caregiver is a culturally valued practice 6. Non-reactive co-sleeping refers to parents who intentionally bed-share as part of their parenting approach (Heron, 1994). It is also important to acknowledge that in some vulnerable families shared sleeping may be unavoidable due to insufficient space for, or the unavailability of a cot, or another sleep area to keep infants safe6.
How common is it for parents and caregivers to share a sleep surface with their infant?
A 2018 survey of mothers attending Victorian maternal-child health services at 8 weeks postpartum, found that almost half (n=503, 44.7%) of the mothers indicated that their infants had bed-shared at some time since birth. Of these mothers, 390 (77.5%) reported that they had not planned to bed-share, whilst 108 (21.5%) reported that bed-sharing was planned 7.
Potential benefits of sharing a sleep surface
Improved breastfeeding outcomes
A prospective review of the relationship between sharing a sleep surface and breastfeeding found that bed-sharing helps prolong the total duration of breastfeeding, especially in women with fewer socio-economic resources who are at high risk of early cessation of breastfeeding 8. These findings were supported by Australian research that found that Infants who shared a sleep surface were more likely to be exclusively breastfed at 6 months and longer total breastfeeding duration than infants who slept in their own sleep space9.
Improved maternal sleep
Sleeping with a baby has been reported to make nocturnal breastfeeding less disruptive for the mother. Mothers who bed-share and breastfeed report that they get more sleep compared to mothers who breastfeed and sleep separately from their baby, and compared to mothers who bottle-feed 10–12.
Enhanced maternal bonding and protective behaviours
Bed-sharing and co-sleeping are practices associated with enhanced maternal-infant bonding and maternal responsiveness 13,14. Parents report that sleeping with their baby improves their bond with their baby and permits close monitoring of their babies throughout the night so they can respond if their baby adopts a non-recommended sleep position or becomes ill 15.
Observation shows that breastfeeding mothers physically orient so that they face towards their baby, are often in physical contact, and position themselves so the baby cannot be rolled onto, or baby cannot move up or down the sleeping surface under bedding 16–18. Unfortunately, mothers of infants who have higher risk of SUDI (e.g., Indigenous, single, young, smokers, preterm delivery) were more likely to bed-share.
Co-sleeping with a baby has been associated with childcare practices that reduce risk of SUDI including breastfeeding, supine sleep position and responsiveness to infant behaviours 19,20.
Improved infant settling and decreased infant stress
Bed-sharing and co-sleeping are associated with improved infant settling, and reduced startling and crying 16,19. Startling and crying releases adrenaline, which increases heart rate and blood pressure, interferes with restful sleep and may lead to long-term sleep anxiety. Together, breastfeeding and co-sleeping have been associated with positive cortisol regulation in infancy, suggested as important for reducing the risk of maladaptive stress responses in later life 22. In contrast, persistent bedsharing across the first two years of life has been associated with sleep problems at two years of age including increased snoring and shorter night-time sleep duration than those that had not bed-shared 23.
Rates of SUDI associated with sharing a sleep surface
The degree to which sharing a sleep surface increases SUDI risk, independently of other risk factors, is difficult to ascertain. A meta-analysis of 11 studies24 found that the odd-ratio for bed-sharing and SIDS was 2.89 (95% CI, 1.99-4.18), meaning that across studies the risk of SIDS was around three times higher in infants who were sharing a sleep surface that those that were not.
However, the study also highlights the potential contribution of other risk factors to outcomes associated with co-sleeping. The study used a case-control design in the UK 25, and compared the last sleep for 80 infants who had died as a result of SUDI with the last sleep for two control groups (one randomly selected and one group of infants at increased risk for SUDI). Fifty-four percent of SUDI deaths occurred while sharing a sleep surface, while only 20% infants in the control group had shared a sleep surface at their last sleep. Importantly, variations between the reference and the control groups covered a range of other risk factors and infants who died as a result of SUDI were more often exposed to cigarette smoke before or after birth, be under three months of age, have soft items in the bed space, have co-slept on a sofa or couch, and to have a parent who had recently used alcohol or other drugs.
When is sharing a sleep surface especially high-risk?
Several studies highlight that young infant age increases the risk of death when co-sleeping and that the relationship with age persists even with adjustment for other known risk factors. Younger infants may be more vulnerable because they lack the motor coordination and strength to move their head or reposition themselves in an unsafe situation such as overlaying or head covering28.
Carpenter et al. (2013) analysed five large case-control datasets with a total of 1472 SIDS cases and 4679 controls. They found an 8-fold increase in the risk of SUDI if the infant is sharing a sleep surface at two weeks of age, and that the relationship remained significant until 3 months of age26. Another study by Venneman et al. (2012) found that the risk of SUDI was 10 times higher in infants younger than 12 weeks, while the risk for older infants was not elevated. Ruys et al. (2007) the risk of SUDI while sharing a sleep surface at 1 month of age was approximately nine times higher compared to not bed-sharing, after adjusting for smoking by one or both parents27.
Parent and caregiver characteristics
Mitchell et al. (2017) conducted a three-year prospective case-controlled study in New Zealand and reported that infants born to mothers who smoked during pregnancy and were bedsharing had a dramatically increased risk of SUDI compared to infants not exposed to maternal smoking or bedsharing29. Similarly, a study in the Netherlands30 found that the risk for SUDI associated with bed-sharing was markedly increased when the mother currently smoked or had smoked during pregnancy (aOR=17.7 and aOR=10.8 respectively). A meta-analysis examining the relationship between maternal smoking and SIDS also found that maternal smoking before or after birth increased SIDS risk, and that this risk was magnified if infants shared a sleep surface with their mother who smoked 31.
Sharing a sleep surface with an adult who has consumed alcohol has also been shown to significantly increase SUDI risk. For example, an analysis of 400 SUDI deaths and 1386 controls found that the “multivariable risk of SIDS for infants who were bedsharing with an adult on a sofa or chair, or with an adult who had consumed more than two units of alcohol was 18 times greater than for those infants who those who were not bedsharing”32. It is likely that exposure to alcohol or other sedating agents lessen the parent’s response to infant cues in the sleep environment and make it more difficult for the parent to identify and rectify head covering, overlying or other hazards.
Unsafe sleep environment
Adult sleeping environments are not designed with infant safety in mind and may contain hazards that are fatal for infants. These hazards include overlaying of the infant by another individual; entrapment or wedging between the mattress and another object such as a wall; head entrapment in bed railings, and suffocation from pillows and blankets.
Soft, bulky or loose bedding, or items in an infant’s sleeping space increase the risk of SUDI through inadvertent occlusion of the infant’s airway 34. Ball et al. (2009) conducted sleep studies in a laboratory and compared parent-infant triads on one night of bed-sharing and one night where the infant slept in their own sleep space35. They found that 14/20 (70%) infants spent some time with their airway covered with adult bedding while sharing a sleep surface while only 2/14 (14%) experienced airway covering when sleeping independently. Infants are more likely to experience rebreathing of carbon dioxide (hypercapnia) during sleep when sharing a sleep surface due to head covering by adult bedding 14. While some infants may be able to cope with environmental stressors like hypercapnia, a key concept in SIDS research is that infants with an underlying vulnerability die because they have less capacity to deal with such stressors.
One particular environment where there is a very high risk of infant death, especially due to fatal sleeping accidents, is when a baby shares a sofa or couch with an adult during sleep. Several studies have found that sharing a couch or sofa for sleep increases the risk of SUDI by 50 times or more 36,37. Often parents and caregivers will fall asleep unintentionally on a sofa or couch and there is a very high risk of a sleeping accident in this situation as the baby may become wedged into cushions or the back of the sofa 38
Supine (back) sleeping has been found to be protective against SUDI, compared to prone and side sleeping. The prone (on the tummy) position places infants at high risk for SIDS (odds ratio [OR], 2.3–13.1) 36,39–41. Side sleeping is inherently unstable, and especially increases the risk of SUDI because infants who are settled on their side are more likely to roll onto their front than those settled on their back 39, 42. Baddock et al. (2006) observed 40 bed-sharing infants and 40 matched cot-sleeping controls and found that infants sharing a sleep surface spent most of their sleeping hours in the side position (66% of sleep time) compared with cot-sleeping infants who most commonly slept supine (on their back)43.
Sleeping an infant prone on the parent’s chest, especially skin to skin, is an excellent strategy for settling an infant when the parent or another adult caregiver is awake and able to monitor the baby. But if a parent falls asleep with an infant prone on the parent’s chest and unobserved the risks include prone positioning of the infant, and obstruction of the infant’s airway which can become obstructed by clothing, by the parent’s body or breast, or by the infant becoming positioned with his/her chin to chest.
Portable sleep spaces as an alternative to sharing a sleep surface
The safety of side-car cribs is yet to be determined, and currently, no Australian standard exists for either sidecar or standalone bassinets. In a maternity unit, following a caesarean section, parents preferred the sidecar crib (also known as a co-sleeper bassinet) to a stand-alone bassinet, although differences in breastfeeding frequency were not statistically significant 44. Another, randomised trial of 870 parents found that the use of sidecar cribs for mothers and infants did not improve the duration of any or exclusive breastfeeding, nor change the frequency of bed-sharing at home when compared with a stand-alone cot 45.
Wahakura and Pepi-pods
Wahakura (baskets woven from flax) and Pepi-Pods (made of plastic) are two alternative infant sleep surfaces specifically designed to provide the infant with their own sleep space within the parent bed. Studies comparing Wahakura, Pepi-Pods and traditional bassinets have found no differences between key outcomes such as oxygen saturation, skin temperature, non-prone positioning or head covering 46,47 although one study demonstrated an increased heart rate for infants slept in the Pepi-Pod (Tipene-Leach et al., 2018). As with bassinets, no safety standard currently exists in Australia for either Wahakura or Pepi-Pods.
Red Nose supports a risk minimisation approach
Red Nose promotes a risk minimisation approach that is based on the best available research and helps to facilitate informed choice to suit a family’s cultural beliefs and environmental circumstances. Risk minimisation approaches that provide practical strategies for creating safer shared sleeping environments relevant to family values and circumstances are more likely to engage caregivers than risk elimination messages that advise that caregivers should never bed-share 6,34. As described by Pease et al., 2021, it is critical to acknowledge that decisions around infant care are complex, and to support parents to create a safe sleep environment for every sleep48.
To summarise, evidence shows that sharing a sleep surface with a baby can increase the risk of SUDI and fatal sleeping accidents in some circumstances. Strategies can be used to reduce the risk of infant death associated with shared sleep environments for all parents; those who choose to bed-share or co-sleep, those who unintentionally fall asleep with their baby and those who may have no other option. These include:
- The safest place to sleep baby is in a cot that meets the current AS/NZS Mandatory Standard.
- Place baby to sleep on their back (not on their tummy or side).
- Make sure the mattress is clean and firm.
- Make sure that bedding and sheets cannot cover baby’s face.
- Keep pillows and adult bedding away from baby
- Use a safe sleep bag with a fitted neck, arms holes but no hood – do not wrap or swaddle baby as this restricts arm and leg movement and will lead to overheating
- Place the baby at the side of one parent - not in between two parents, which increases the likelihood of the baby becoming covered or slipping underneath adult bedding as well as overheating
- Ensure the baby is not too close to the edge of the bed where he/she can fall off. Do not place pillows at the side of the baby to prevent rolling off. A safer alternative is to place the adult mattress on the floor.
- Avoid pushing the bed up against the wall. Babies have died after becoming trapped between the bed and the wall.
- Tie up long hair and remove jewellery including teething necklaces, to prevent infant entanglement around the infant’s neck.
- Ensure the baby is never left unattended on a sofa or bed.
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Suggested Citation: Red Nose. National Scientific Advisory Group (NSAG). (2023). Information Statement: Sharing a Sleep Surface with a baby. Melbourne, Red Nose. This information statement was first posted in February 2006 and updated in May 2015 and December 2019.
Last modified: 27/6/23