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Cradle of Doubt

The Internet is awash in parents who endorse co-sleeping. And public health agencies are largely silent.

Government officials can be quick to punish parents whose babies die while sleeping with them, but slow to craft a safety message that resonates with today’s parents

Bed-sharing parents endorse practice online
Social media is filled with accounts from parents who endorse co-sleeping. Many see positive reasons for bed-sharing and see risks as exaggerated if precautions taken. (Olivia Yarvis/Globe Staff)

Public health authorities paint a dire picture: Mothers who sleep in the same bed as their babies put their infants at an increased risk of a tragic sleep death — perhaps, they say, three times higher. And the death is often attributed to the mother herself, sometimes moving in her sleep onto the child.

It is a horror beyond imagination. How many loving parents would take this chance?

Most of them.

Surveys show that some 60 percent of mothers acknowledge they have shared their bed with their baby at some point, and those may be just the ones honest enough to admit it. Their abundant thoughts on social media — some defiant, others confessional — offer a spirited counterpoint to the strict messages from top public health agencies and pediatricians’ groups. These parents believe the bed-sharing risks are exaggerated and can be mitigated, and they see positive reasons to co-sleep.

“Co-sleeping with my baby is THE BEST. Sorry not sorry,” one mother posted on TikTok with photos of her cozying up to her infant in her adult bed, a message that garnered 30,000 likes.

“Co-sleeping made me a better Mom. Why? Because I get adequate sleep!” one mom posted on Instagram.

“Breastfeeding and co-sleeping is like a match made in heaven,” another mother posted with a video of her baby lying next to her in bed.

Facebook, Instagram, TikTok, and YouTube are awash in carefully crafted videos of mothers co-sleeping in the same beds with their infants.

The flurry of postings is a reminder of the issues that consume parents at this stage of life. Sudden unexplained sleep death is relatively rare — roughly 1 in 1,000 births a year — but it is tragedy that has haunted mothers and fathers for generations.

The Globe’s review, extensive but hardly comprehensive, found on Facebook alone more than a dozen active private communities and support groups specifically dedicated to bed-sharing — some with memberships in the tens of thousands to more than 200,000. TikTok videos on co-sleeping have been viewed millions of times. And countless infant sleep consultants’ websites and blogs on the subject can be found with a simple internet search; most of them send a message at odds with government warnings.

And how have the medical establishment and government officials responded to this flood of posts, articles, videos, and blogs that flout their warnings?

With little energy and even less creativity.

Hospitals, public health agencies, and doctors’ groups commonly offer dull brochures or brief video tutorials warning about all kinds of “unsafe sleep.” And some of the leading experts, who insist co-sleeping is unsafe under all conditions, are barely engaged online, where much of the vibrant parent discussion is happening.

Instructional posters created by the American Academy of Pediatrics warn against co-sleeping.

Even the federal government’s lead agency on safe sleep has posted only two direct warnings against co-sleeping on its Instagram page this past year. Nor are there any new attempts by government agencies to craft a more savvy and nuanced message — perhaps allowing that bed-sharing under some limited circumstances can be low risk and may have some emotional and pragmatic benefits for some parents.

“Parents are tuning out,” said Alison Jacobson, executive director of the nonprofit First Candle, which educates parents on safe sleep practices.

The government’s attempt to rein in co-sleeping also has a punitive dimension, as the Globe previously reported, which is often hidden from public view.

Medical examiners, state police, district attorney’s offices, and child protective services track the incidence of infant sleep deaths and punish parents — sometimes prosecute them — when their infants die while co-sleeping. These actions have fallen hardest on low-income parents, whose babies more often die of unexplained sleep deaths, data show. Parents facing such sanctions are often made to feel like criminals even as they are wracked with grief over their tragic loss.

The Centers for Disease Control estimates close to one out of three sudden unexpected deaths can be attributed to accidental suffocation through unsafe sleep conditions, even though research shows this data may offer an incomplete picture of the frequency and dangers of co-sleeping. Some cases are often based on circumstantial evidence such as a parental admission of co-sleeping or pillows and blankets found in the shared bed. Autopsies almost never can distinguish between suffocation and a SIDS death.

Some parents, researchers, and breast-feeding advocates say that the public health community needs to figure out a safe-sleep strategy that is less punitive and simplistic in tone — perhaps something like the compromise message that is becoming more popular in Europe. There also has to be a way, they say, to tap the vibrant online world where mom influencers and celebrities hold sway — and many parents listen.

“I would love Rihanna, I would love to recruit anybody like that,” Jacobson said about the singer and fashion mogul who recently launched a line of breast-feeding bras. “She’s the one who’s getting listened to.”

Degrees of risk

Developing the right message to change human behavior has never been an easy task; the uphill battles against smoking and for bike helmets and seat belt use make that plain.

The American Academy of Pediatrics believes the latest research justifies its rigid approach: The group points to the risk of outright suffocation, when a sleeping parent rolls over and blocks the baby’s breathing. And there is the possibility that even a brief blockage or compromise of the infant’s breathing could set off of a chain reaction of symptoms in some vulnerable infants that becomes fatal.

Some leading researchers contend that most healthy babies can safely endure that kind of fleeting stressor but some babies can’t, perhaps because of undetected brain stem or neurological abnormalities. Why some babies are vulnerable to this life-threatening trigger is the focus of intense research. At Boston Children’s Hospital, researchers are also exploring the possibility that genetic components explain some deaths.

Because of the risks, Dr. Rachel Moon, the chair of the American Academy of Pediatrics task force on sudden infant death syndrome, or SIDS, said the group opposes co-sleeping under all circumstances. But she acknowledges that parents often make compromises on safe sleep measures because they are juggling multiple responsibilities, such as jobs and other children, and may not have adequate support systems.

“Safe sleep is hard,” she said.

What to know about SIDS

Much remains unknown about what causes sudden infant death syndrome (SIDS), but top pediatricians are largely guided by the Triple Risk Model. Under this theory, an infant is at higher risk of a SIDS death when these multiple factors interact simultaneously.

  • The baby is at a critical stage of development - usually the first six months of life.
  • The baby has an underlying vulnerability, such as brainstem abnormality or other disease that cannot be detected at birth.
  • The baby is exposed to an outside triggering event that may compromise their airways, even briefly, such as a parent’s body or a stuffed animal, or an overbundled infant in heat stress.
SOURCE: Dr. Hannah Kinney, who helped come up with the Triple Risk Model, and the American Academy of Pediatrics.

Still, some say this message of strict prohibition rarely addresses the benefits that many parents say they derive from co-sleeping, including the extra bonding time with babies, the convenience of checking on infants without getting out of bed, and more consistent breast-feeding, which research suggests boosts infant health in many ways and protects a baby from SIDS.

Parents these days are encouraged to act in ways that often make co-sleeping nearly impossible to avoid, such as encouraging frequent skin-to-skin contact with their newborns to better relax the baby. And they are also told that sometimes babies sleep best when they can hear the heartbeat of their mother.

“Saying, ‘Just don’t do it,’ isn’t stopping people,” said Katherine Bailey, 38, a mom from Sharon who started co-sleeping with her baby more than a month after he was born. “Maybe, we need to be able to have some more honest conversations.”

Some say public health officials should gain inspiration from the campaign to reduce teen pregnancy and sexually transmitted diseases. When teens ignored the abstinence-only sex education message, some state governments shifted their black-and-white message. They focused on recommending that teens delay sex, but if they did engage in it, use contraceptives, including condoms.

But health care specialists say a nuanced message around co-sleeping - acknowledging that the practice is a reality for many families, but important precautions must be taken - may be fraught with legal hazards. Pediatricians could be sued if they endorsed bed-sharing, against the advice of public health agencies and pediatrician groups, and a baby died in that situation.

“People are afraid to have an open and honest conversation because they are afraid of the legal ramifications,” said Dr. Lori Feldman-Winter, a pediatrics professor at Cooper Medical School of Rowan University.

Parents are also often aware of the legal issues. Bailey, the Sharon mother whose son is now over a year old, often felt like she was hiding a secret from her pediatrician when it came to his early sleeping habits. She knew the legal stakes are high in discussing the life of a newborn.

A data analyst who had internalized all the warnings about never sharing a bed with an infant, Bailey never expected to break the rules. But after exhausting days of constantly nursing and pumping and sleepless nights with a crying newborn, she fell asleep accidentally with her son one night. She decided after that to continue co-sleeping, following important precautions.

When she was ever asked where her son slept, she didn’t lie, but she often simply replied that there were no issues.

“It’s sort of a don’t ask, don’t tell situation,” Bailey said. “There’s no room for discussion. There’s no space to have a dialogue around it.”

Defending the current messaging

The Eunice Kennedy Shriver National Institute of Child Health and Human Development, part of the National Institutes of Health and the lead federal agency on safe sleep messaging, has defended its work. The institute shares evidence-based safe sleep messages in many ways, including social media, said Robert Bock, a spokesperson for the institute. He pointed to the agency’s recently revamped safe sleep website with interactive functions and its Instagram posts, though co-sleeping is only intermittently discussed.

Massachusetts public health officials say they are committed to safe sleep efforts and highlight that the state has one of the lowest rates of sudden unexpected infant death in the country — some 30 babies die here suddenly and unexpectedly every year.

Yet, in Massachusetts, the last major Department of Public Health campaign to promote safe sleep took place over a few months in 2018. That campaign included social media outreach, but its scope was limited. The state public health Facebook page, Infant Safe Sleep Massachusetts, only had 10 posts between October and December 2018, and gained a paltry 45 followers. One Facebook group for parents that promotes co-sleeping, Biologically Normal Infant & Toddler Sleep, routinely has robust activity and more than 208,000 members.

The government’s comparative absence online is, to many clinicians, a squandered educational opportunity: One study found close to 70 percent of parents sought child health and development information on social media, with “sleep” being the most common topic searched, and that parents of children under the age of 5 check online daily or multiple times a week.

“Moms are seeking health information on social media ... it’s an effective form of health communication, and we know that,” said Kelly Pretorius, a nurse and postdoctoral fellow at Indiana University, who has researched infant safe sleep messaging and social media.

But on the topic of infant safe sleep, Pretorius found, there’s “an almost complete lack of public health agency presence on social media.”

Beyond the United States

Cambridge mom Sandra Skjaervoe, 34, a scientific journal editor originally from Norway, said she wanted to sleep with her newborn close by as mothers had been doing for eons.

“I don’t have any guilt at all about bed-sharing,” Skjaervoe said on an afternoon this past summer as she watched her now toddler son pad around a local restaurant greeting diners. “I trust human nature. … When babies cry, they are clearly asking to be close to someone.”

Skjaervoe said she finds comfort in hearing her son breathing next to her and it helps her relax.

Sandra Skjaervoe, who believes in the benefits of co-sleeping, nursed her 1 year old son at her home in Cambridge. She is part of a group of mothers who support each other in their ideas about how to best raise children, including the role of bed-sharing. Craig F. Walker/Globe Staff

Skjaervoe is among a small group of local mothers who connected on social media and are now part of an online chat community, where they discuss issues about co-sleeping, naps, and other practices around child rearing.

“I am trying to find that village,” Skjaervoe said, referring to being with similarly minded parents.

Skjaervoe and other mothers who co-sleep point to countries, such as Japan and India, where it is the norm, studies show.

Reliable infant fatality data is inconsistent from country to country, so it is difficult to say if other nations’ rates of unexplained infant deaths are different from that of the United States. Safe sleep advocates also point out that mattresses may be firmer in other countries and maternal health and family support systems more robust, which could affect infant sleep death rates.

In the United States, Native American, Black, Asian, and Hispanic mothers are more likely to share a bed with their infants at some point than white mothers, although a majority of mothers of all races have said they have done so, according to a 2015 government survey. A 2020 study out of the University of Virginia found that while nearly 60 percent of mothers said they intended to follow safe sleep guidelines, only 45 percent actually did in practice.

Black and Native American mothers, in particular, report some of the highest bed-sharing rates, but they are also less likely to breast-feed, a disparity that researchers fear could play some role in the higher rate of infant sleep deaths, as babies don’t receive any of the protective benefits of breast-feeding that are linked to lower SIDS rates.

Changing how infants sleep was far simpler in the early 1990s, when the public health community pushed a “Back to Sleep” campaign after finding that fewer babies died of unexplained sleep deaths if they slept on their backs, not their stomachs, as had been a common practice.

That “Back to Sleep” campaign was effective: From 1994 to about 2000, infant sleep deaths dropped by half.

In the 20 years since, however, the death rate has been virtually unchanged, a troubling pattern that mystifies health officials.

La Leche League, a long-running international breast-feeding support organization, has tried to follow a middle way with its advice on co-sleeping.

The league tells mothers that sharing a bed with a baby is a “shared instinct as old as humankind,” but points to data showing its dangers can be severely lowered by taking some precaution. It supports co-sleeping for healthy babies but instructs parents to follow the Safe Sleep 7′s,which include these: mothers should be nonsmokers, breast-feed if possible, eschew drugs and alcohol to avoid nighttime impairment, and put the sleeping babies on their backs on a firm surface.

Some special bassinets are being pitched as ways to accommodate some type of co-sleeping, such as bedside sleepers or “sidecars,” which can be attached to a mattress. The American Academy of Pediatrics has said that these sleepers, which give parents easier access to their babies but reduce the risk of rolling over onto them, may provide a solution for some parents if they meet federal government safety standards.

The United Kingdom and Spain still encourage parents to put their babies alone in a bassinet or crib, but in the past decade they have stopped warning parents against co-sleeping in all situations, especially when the risk is low, according to advice given by their top health groups. A British SIDS awareness group’s animated video post on how to co-sleep safely now has about 48,000 views since it went up this past April on YouTube.

Some co-sleeping and breast-feeding advocates say that the United States should adopt a similar, more nuanced message. In 2022, when the American Academy of Pediatrics updated its safe sleep guidelines and remained firmly against sharing a bed with an infant, two sets of researchers sent dissenting letters arguing that the organization’s message was too hardline.

Dr. Melissa Bartick, an assistant professor of medicine at Harvard Medical School whose research focuses on breast-feeding and public health, was among the dissenters. She told the Globe that this country’s current approach is not working and often leads to more dangerous behavior, such as sleeping with a child on the sofa, which can be more risky due to cracks and lumps on the cushions.

“People will be bed-sharing no matter what,” said Bartick. “We have to change the message.”

Dr. Melissa Bartick, an assistant professor at Harvard Medical School, focuses much of her research on bed-sharing, breast-feeding, and economic justice issues. Bartick, shown at Mt. Auburn Hospital, where she also works, believes strict messaging against co-sleeping is counter-productive. Pat Greenhouse/Globe Staff

In the absence of an innovative national campaign on the issue, there have been isolated local efforts, often after a cluster of sudden deaths.

In 2011, Milwaukee’s Health Department took perhaps the most extreme approach. It took out ads showing babies sleeping in an adult bed with a butcher knife tucked under a pillow, meant to illustrate how dangerous it can be for a mother to share a bed with a newborn. The campaign outraged co-sleeping advocates and shocked many who worried that it would erode trust between families and public health workers.

Earlier this year, emergency room workers at the Cook Children’s Medical Center in Fort Worth, Texas, noticed that 30 babies had died in the span of 15 months, and they linked these deaths to unsafe sleep conditions, mostly co-sleeping. The hospital posted videos of bed-sharing risks and photos of safe sleep positions on its website to educate parents.

“The parent has a right to make the decision, but I want to make sure that they know the numbers and they know the risks,” said Sharon Evans, the trauma injury prevention coordinator at Cook Children’s. “It’s heartbreaking to hear a family say, ‘I never thought this could happen.’”

Read the rest of this three-part series about the government’s questionable approaches to curbing co-sleeping and SIDS: Part one and Part three.

Tips and feedback can be sent to reporter Deirdre Fernandes at deirdre.fernandes@globe.com. Or they can be sent to the Boston Globe Spotlight Team at spotlight@globe.com, or by calling 617-929-7483. Mail can be sent to Spotlight Team, the Boston Globe, 1 Exchange Place, Suite 201, Boston, MA. 02109-2132.

Deirdre Fernandes can be reached at deirdre.fernandes@globe.com. Follow her @fernandesglobe.