Association Between Infant Sleep Location and Breastfeeding

Abstract

Objective:

Studies have shown that mothers sleeping with their babies have longer breastfeeding duration. Bedsharing (BS) is thought to be a risk factor for Sudden Infant Death Syndrome. The aim was to investigate the frequency of BS and roomsharing (RS) and the effect of those on breastfeeding during the first 2 years of life. Also to evaluate risk-bearing situations regarding sleep environment.

Methods and Study Design:

This is a cross-sectional study, with retrospective cohort features for the evaluation of some data. The setting was a Well-Child Clinic at Bakırköy Research and Training Hospital. The children were followed from the first month until survey. Feeding history was collected retrospectively from child health records. Parents were surveyed concerning sleeping location and sleeping arrangements with a questionnaire. The study encompassed 351 children and their families.

Results:

The rate of exclusive breastfeeding was found to be 50.2% for the first 6 months of life and BS increased in exclusively breastfed infants. When breastfeeding continued after 6 months, the trend of increased BS through months was observed. RS, BS, and breastsleeping rates were 80.6%, 22.8%, 56.1%, respectively, in the whole cohort. Working mothers and mothers >35 years of age were significantly more likely to bedshare. Cigarette smoking in BS parents was identified as a child health risk. Unsafe sleep environment was found in 72.4% of the group.

Conclusions:

BS increases breastfeeding for the first 6 months. Families need guidance on safe sleeping practices and should be advised regarding avoidable risks and unsafe situations in BS. Parents should be counseled to make informed decisions.

Introduction

Research has shown that the period of breastfeeding and frequency of feeds in mothers who share their beds with their babies is increased.^1,2 The sleeping location of babies has become a medical issue since it ultimately has an effect on breastfeeding. In contrast, evidence supports proximate parent–infant sleep combined with lactation represents a complex set of adaptations that constitute the human evolutionary norm.³ Experts working on the context of infant sleep recommend studies that reflect the cultural identity of the target group.⁴ Although parents sharing a room with their babies is a common Turkish tradition, there is little information about bedsharing (BS) frequency and its effect on breastfeeding.

Roomsharing (RS) is defined as parents sleeping with the baby in the same room but on different surfaces, whereas BS is defined as an infant sharing a bed with an adult (caregiver) for sleep.⁵ The American Academy of Pediatrics recommends that to prevent Sudden Infant Death Syndrome (SIDS) as safe sleep practice, parents should sleep close to the baby but on a different surface and room-share for at least 6 months, and ideally for 1 year.⁶ The British National Institute for Health and Care Excellence (NICE) states that safe BS practices should be discussed with all parents. Also NICE emphasizes the association between BS and breastfeeding.⁷ Safe BS is possible and the existing evidence does not support the conclusion that BS among breastfeeding infants causes SIDS in the absence of known hazards.⁵

Cultural differences such as beliefs and rituals play an important role in child rearing practices.^4,8 The message “mothers and babies should not sleep in the same bed” may decrease breastfeeding and have an adverse effect on maternal and child health.^9,10 In addition an associated decrease in breastfeeding may lead to an increase in SIDS cases.^2,11 Despite recommendations, BS is a common practice among parents worldwide.¹² Health professionals can counsel BS parents concerning certain risks to avoid. These include parental smoking, high level of tiredness, alcohol and of sedative drug use, parental obesity, other children also trying to share the bed, low birth weight or preterm babies, sleeping on a surface other than a bed, such as a sofa or a couch, sleeping on a soft surface such as water bed, other furniture or walls close to the bed that may present a crushing risk to the baby, and the baby sleeping face down.^5,6 There are few studies that evaluated risky behavior and safe sleep practices of Turkish mothers but no statistical data exist about national SIDS prevalence.^13,14

McKenna and Gettler proposed the term “breastsleeping” to reflect the physiological, evolutionary, and cultural connections between breastfeeding and infant sleep. Their intention was to emphasize and distinguish the dynamics of breastfeeding and BS in mother–infant pairs.¹⁵ In the literature, breastfeeding and BS have been reported to have a positive relation. The relationship may be bidirectional; breastfeeding mothers decide to bedshare to facilitate night feeding and thus achieve easier and better quality sleep.^16,17 Also infant sleep location can be determined by the interaction between the infant's temperament, parental social, and relational experiences.^8,18

The aim of this study was to investigate the association between infant sleep location, breastfeeding, and feeding practices during the first 2 years of life. The frequency of BS or RS with parents and the frequency of exclusive breastfeeding (EBF) and breastfeeding continuity were investigated. Family demographics were recorded and behavior and risks to safe sleep practices were also assessed.

Methods and Study Design

This study was cross-sectional in design although data were also collected retrospectively. Retrospectively collected data included monthly feeding patterns that were extracted from children's medical records and sleep data collected by asking parents to recall what happened at each age. A survey was conducted to collect the information about sleeping location and sleep arrangements of children and to explore the changes in sleep location from the first month of life until the time of study, if the children had not reached their second birthday or until 24 months of age.

The study was carried out in a Well-Child Unit, from October 1, 2015 to February 26, 2016. During this period 525 children, aged up to 24 months came for routine child health checkups. In the unit, children were followed from the first month of life. At each routine visit a detailed physical examination was carried out and findings were recorded in the medical records of the children. At these visits nutritional guidance including breastfeeding consultancy, safe sleep, and safety recommendations were given to every parent at every visit, advice being appropriate to the child's age.

Children between 0 and 24 months of age, born at term, and with no known chronic illness were eligible for inclusion in the study. In total, 370 parents volunteered to participate and of these 351 mother–infant pairs fulfilling the stated conditions were included in the study. Feeding history of participant children were gathered from files and information about sleeping location and sleep arrangements of children was obtained by survey. The surveys were completed by a pediatrician or a nurse in face-to-face interviews with either the mother alone or both parents.

For feeding patterns, data were classified into three groups: EBF for EBF; mixed feeding (MF) for mixed, for those both breastfed and consuming complementary feeding (CF) and/or any additional food including formula; and CF for those who consumed only CF without breast milk. Sleep patterns were also grouped into three: BS, RS, and sleeping in separate rooms (SRs). Age groups were formed as follows: the first 6 months with monthly changes in any relevant parameter being noted; from 7 to 18 months with bimonthly changes recorded; then one group when the child was between 19 and 24 months. For these groups, until the child's current age, retrospective feeding and sleeping pattern data were collected.

Sleep location and RS were questioned as “Where and in which room does your child sleep?” To investigate the prevalence of BS, parents were asked “Do you frequently sleep with your baby in the same bed?” If the answer was “yes” then they were categorized as “bedsharing.” To estimate prevalence of breastsleeping mother–infant pairs, the question “Do you sleep together in your bed while breastfeeding?” was asked. Safe sleep practice was defined as baby sleeping on their back on a firm surface, without loose bedding and blanket. Use of alcohol and of sedative drugs and smoking habits were questioned.

To determine the rates of obesity among parents, the body mass index (BMI) of parents was calculated and parental BMI was categorized into four groups according to the conventional WHO classification.¹⁹ Ethical approval for this study was obtained from Bakırköy Research and Training Hospital Ethics Committee (March 3, 2015 number: 2015/61).

The Number Cruncher Statistical System 2007 (Kaysville, UT, USA) program was used for statistical analysis. In analysis, descriptive statistical methods such as mean, standard deviation, median, frequency, and ratio were used. Normality of data distribution was assessed using the Kolmogorov–Smirnov test and boxplot charts. Group comparison between groups parameters with non-normal distribution was assessed using Kruskal–Wallis test and Mann–Whitney U test. Spearman's correlation analysis was implemented for correlations between variables. Pearson's chi-squared test and Fisher Freeman Halton test were employed for comparison of qualitative data. Findings were assessed with 95% confidence interval, with p < 0.05 level of significance.

Results

In the study, the mean ± standard deviation age of the children was 12.0 ± 6.2 (median 11.0, range 0–24) months. Table 1 shows the distribution of ages in months and the number of children in each group during study follow-up.

Table 1.

Childrens' Monthly Feeding and Sleeping Data Distribution

Duration of available health records (months)	No. of children for whom data were collected (n)	No. of children in this age group at time of study (n)	Feeding patterns						Sleeping patterns
			Exclusive breastfeeding		Breast milk+CF (mixed feeding)		CF only		Bedsharing		Roomsharing		Separate rooms
			n	%	n	%	n	%	n	%	n	%	n	%
1	351	9	325	92.6	22	6.3	4	1.1	15	4.2	273	77.8	63	18.0
2	342	13	297	86.8	37	10.8	8	2.4	21	6.2	260	76.0	61	17.8
3	329	12	273	82.9	44	13.4	12	3.7	29	8.8	240	73.0	60	18.2
4	317	7	251	79.2	55	17.3	11	3.5	35	11.0	225	71.0	57	18.0
5	310	15	202	65.2	88	28.4	20	6.4	42	13.5	216	69.7	52	16.8
6	295	16	148	50.2	121	41.0	26	8.8	42	14.2	202	68.5	51	17.3
7–9	279	51	0	—	241	86.4	38	13.6	41	14.7	191	68.4	47	16.9
10–12	228	81	0	—	179	78.5	49	21.5	54	23.7	136	59.6	38	16.7
13–15	147	49	0	—	100	68.0	47	32.0	41	27.9	80	54.4	26	17.7
16–18	98	41	0	—	60	61.2	38	38.8	31	31.6	49	50.0	18	18.4
19–24	57	57	0	—	32	56.1	25	43.9	16	28.1	30	52.6	11	19.3

CF, complementary feeding.

The frequency of babies being breastfed at any time point in the duration of the study was 74.3%. When data were evaluated with respect to EBF for the first 6 months, EBF rate in the first month was 92.6%, decreasing gradually to 50.2% in the sixth month. All babies had started CF from the sixth month onward. The frequency of babies still having some breastfeeding at the 10th to 12th month was 78.5%, which decreased to 56.1% for by the ages of 19–24 months. The rate of babies being fed with exclusive CF was 1.1% in the first month, increasing gradually to 8.8% by the sixth month. In the age group 19–24 months, 43.9% of a total of 57 children were receiving no breast milk intake (Table 1).

Despite the fact that all children in the study had separate beds, 77.2% did not have SRs. The BS ratio was 22.8% and RS ratio was 80.6%. The mean age of start of BS was 5.4 ± 4.1 months. Rate of BS was 4.2% in the first month, increasing gradually to a peak of 31.6% at 16–18 months. The rate of RS was 77.8% in the first month, decreasing gradually to 52.6% by months 19–24. Although the rate of sleeping in an SR remained quite constant over the months, the lowest frequency was seen in the age group 10–12 months and the highest was in the age group 19–24 months (Table 1).

No SIDS case was occurred during follow-up in the group. Back sleep position was observed in 59.7% of infants during the first 6 months and 64.4% between 6 and 12 months. Sleeping on a soft surface was reported for 54.7% of infants. The frequency of a safe sleep environment defined by the study was found in only 27.6%. Pillow use increased by age. The breastsleeping rate was 56.1% in entire group (Table 2).

Table 2.

Sleep Practice and Sleep Environment by Child Age Group

		0–6 months (n: 72) n (%)	6–12 months (n: 132) n (%)	12–24 months (n: 147) n (%)	Whole cohort (n: 351) n (%)
Breastsleeping	Yes	43 (59.7)	72 (54.5)	82 (55.8)	197 (56.1)
Does child has separate room?	Yes	12 (16.7)	27 (20.5)	41 (27.9)	80 (22.8)
Does child has separate room?	No	60 (83.3)	105 (79.5)	106 (72.1)	271 (77.2)
Roomsharing	Yes	62 (86.1)	108 (81.8)	113 (76.9)	283 (80.6)
Roomsharing	No	10 (13.9)	24 (18.2)	34 (23.1)	68 (19.4)
Bedsharing	Yes	13 (18.1)	23 (17.4)	44 (29.9)	80 (22.8)
Sleep position	Back	43 (59.7)	85 (64.4)	—	—
	Side	25 (34.7)	36 (27.3)	—	—
	Facedown	4 (5.6)	11 (8.3)	—	—
Pillow use	Yes	45 (62.5)	94 (71.2)	116 (78.9)	255 (72.6)
Mattress softness	Firm	37 (51.4)	64 (48.5)	58 (39.5)	159 (45.3)
Mattress softness	Soft	35 (48.6)	68 (51.5)	89 (60.5)	192 (54.7)

None of the parents admitted the use of alcohol and sedative drugs. Obesity rate among mothers and fathers were 12.8% and 10.8%, respectively. Although the rate of household smoking was 7.4%, parents who smoke and bedshare is found statistically significant (p = 0.03, Table 3).

Table 3.

Comparison of Parental Demographics by Bedsharing

	Non-bedsharing (n = 271)	Bedsharing (n = 80)	p
	n (%)	n (%)	p
Parents smoking status
Nonsmoker	257 (94.8)	68 (85.0)	0.003^*
Smoker	14 (5.2)	12 (15.0)	0.003^*
Maternal BMI
Underweight	8 (3.0)	0 (0)	0.222
Normal weight	144 (53.1)	39 (48.7)
Overweight	88 (32.5)	27 (33.8)
Obese	31 (11.4)	14 (17.5)
Paternal BMI
Normal weight	113 (41.7)	32 (40.0)	0.632
Overweight	131 (48.3)	37 (46.3)
Obese	27 (10.0)	11 (13.7)

Pearson's chi-squared test.

p < 0.01.

BMI, body mass index.

Monthly variation in feeding patterns and sleep location for children of all ages were examined. Three different sleep location changes, in line with the three different types of feeding, were compared. Variation between EBF and increase in BS and decrease in RS was statistically significant (p < 0.01). In the first 6 months, 44% of non-BS children were exclusively breastfed, whereas this rate was 68% among BS children. There is a statistically significant variation between EBF and BS for the first 6 months (p < 0.01) (Fig. 1).

FIG. 1.

Monthly variation in sleep location for children who were exclusively breastfed.

Upon examination of the patterns of sleep location among children having MF over the age range 1–24 months, it was found that the trend of increased BS over the months was statistically significant (p = 0.001). In the same group, the tendency for RS approached statistical significance (p = 0.05). There was an increase up to the sixth month and a decreasing trend thereafter. There was a statistically significant decrease in sleeping in SRs over the months in children in MF group (p = 0.001) (Fig. 2).

FIG. 2.

Monthly variation in sleep location for children who were Mixed fed.

In the group of exclusively complementary-fed children, there was no statistically significant variation between BS, RS, and sleeping in SRs over the age range of 1–24 months (p > 0.05).

Discussion

Our study reinforces the general global finding that breastfeeding is increased among BS mother–baby pairs.^9,20 RS and BS appears to be a common practice among parents in Turkey. This suggests that there should be sufficient parental counseling regarding a safe sleep environment and BS safety.

One of the significant findings in our study was that EBF was increased among BS mother–baby pairs. In the study of Moon et al.²¹ conducted with 1,194 mothers, it was shown that compared with non-BS babies, BS and BS-last-night babies were exclusively breastfed by 1.04 times (95% CI 1.02–1.06) and 1.05 times (95% CI 1.03–1.07), respectively, both of which were significant. In the study carried out by Ball et al.²² in 2016, 870 babies were followed up for 26 weeks after birth with respect to feeding and BS behavior. EBF among mothers BS “frequently” is found to be statistically significantly higher than those BS “sometimes/rarely/never.” In her 2003 study, Ball indicated a statistically significant correlation between BS in the first month and breastfeeding for at least 16 weeks.⁹ In systematic review about breastfeeding and BS showed a threefold increase in BS during the neonatal period in those who were breastfed compared with those who were not.²³

Our results showed that more than half of the mother–baby pairs were breastsleeping. In a recent study, Hirai et al.²⁴ stated that currently breastfeeding mothers and babies were 22% less likely to use separate sleeping surfaces. Currently, it is not possible to clarify the exact relationship between BS and breastfeeding although sleeping with the baby would make night-time care easier, and help mothers to monitor the baby, provide comfort when required, and obtain better quality sleep themselves.^10,17,25 We believe that to achieve better breastfeeding results, as stated in the ABM Protocol no. 6, “ending stigma around bedsharing and supporting the practice of breastsleeping the safest form of bedsharing in the context of breastfeeding in absence of all other known hazards” is needed.⁵

SIDS prevalence of infants in Turkey is still limited. In the studies from different regions, the rates were between 1.2% and 2.5%.^13,26 It has been documented that RS lowers the risk of SIDS.^6,17 Frequency of RS ranged from 66% to 90% in the studies from different areas of Turkey.^13,27 In our study, it was 80.6% during the first 2 years of life. Taken together, this evidence suggests that RS is common in Turkish families.

In the study, BS ratio was 22.8% in the whole cohort and the rate of BS was higher among smoking parents. Smoking is common in Turkey, where the prevalence is around 30%.²⁸ None of the parents admitted use of alcohol in the study. According World Health Organization, the average annual pure alcohol consumption per person in Turkey is 1.4 L, which is significantly behind as compared with other countries.²⁹ Less alcohol may decrease the typical risk factors, whereas smoking constitutes a problem in safe BS.

Unfortunately, safe sleep practices were followed in only 27.7% of the children in the study. Common unsafe sleep practices found in Turkish families are placing infants in nonsupine position, and using a pillow and soft mattress.^13,26 Sleeping on a soft surface is five times and sleeping prone on a soft surface is 21 times more risky in terms of SIDS than sleeping face-up on a hard surface.³⁰ In the literature, of the objects implicated in suffocation in SIDS 24.5% are pillows and 13.1% are blankets.³¹ Despite repeated and routine safe sleeping counseling at the Well Child Unit, a disappointingly low proportion of families had adopted optimal safe sleeping practice. In a review that re-evaluated the literature on safe sleep interventions for the past 25 years commented that creative methods for measuring adherence to safe sleep recommendations, beyond just self-report of behaviors, are needed.²⁵ Aligned with this, we suggest additional interventions to be developed to ensure safety.

Our study has certain constraints. We did not gather information about how frequently parents bedshare and the duration of BS per night. Information about the timing of initiation of BS, based on parents' memory, may cause recall bias. The number of children having no breast milk since birth and taking exclusive complementary feeds since birth is low in our sample, which meant that we were unable to identify statistical significance in the change of sleep location with respect to exclusive CF. Use of alcohol and sedative drugs among parents was not reported which, we believe, is unlikely.

Conclusions

Breastfeeding must be promoted to safeguard children's health and decrease childhood mortality, a view supported by a large body of evidence. It should be kept in mind that families do not have the same sleeping arrangement every night and BS might occur. Conversations with BS families should be nonjudgmental. RS in the first 2 years is a common practice in Turkey. There is evidence from this study that despite repeated counseling, safe sleeping practice is only present in less than a quarter of families in our cohort. We, therefore, believe that new strategies should be sought to emphasize these messages.

Footnotes

Authors' Contributions

B.K. contributed to the conception and design, acquisition, analysis, and interpretation of data, as well as with the drafting and critical revising of this article, and then approving the final version submitted for publication. G.G. contributed to the conception and design, interpretation of data, the drafting and revising of this article, and then approving the final version submitted for publication.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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