Bedsharing Promotes Breastfeeding

James J. McKenna, PhD*; Sarah S. Mosko, PhD‡; and Christopher A. Richard, PhD‡

ABSTRACT. Objective. Because breastfeeding is majority of the world’s societies.4,5 Only in the last
thought to be protective against sudden infant death 100 to 200 years, and mostly in western industrial-
syndrome (SIDS), environmental or child care factors ized societies, has nocturnal breastfeeding been dis-
that promote breastfeeding might reduce infant vulner- associated from the co-sleeping environment within
ability to SIDS. The effect of mother-infant bedsharing which it evolved.
on nocturnal breastfeeding behavior was studied in 20
routinely bedsharing and 15 routinely solitary sleeping
The potential impact of this relatively sudden
Latino mother-infant pairs when the infants were 3 to 4 change in child care on infant development and sur-
months old. vival and on maternal reproductive physiology has
Methodology. All pairs were healthy and exclusively not yet been addressed. Understandably, the need
breastfeeding at night. The videotape portion of all-night for privacy after retiring for bed makes collection of
laboratory polysomnographic studies was used for the reliable data on nocturnal breastfeeding particularly
analyses. For each pair, an adaptation night was followed difficult, regardless of the type of sleeping arrange-
by one night each of bedsharing and solitary sleeping. ment. In fact, most breastfeeding data collected in
Results. The most important finding is that when both diverse nonwestern and western ethnographic
tested in their usual sleeping conditions, routinely bed-
sharing infants breastfed approximately three times
settings emerge from either diurnal observations or
longer during the night than infants who routinely slept from structured interviews or daily feeding diaries
separately: this reflected a two-fold increase in the num- that rely on maternal recall.6 – 8 Unfortunately, mater-
ber of breastfeeding episodes and 39% longer episodes. nal recall has not proven to be very reliable.9 For
Breastfeeding was also facilitated on the bedsharing example, Vitzthum’s8 field studies of breastfeeding
night relative to the solitary night within the routinely among Peruvian women found that mothers signif-
bedsharing group: the number and total duration of icantly underestimated the frequency of breastfeed-
breastfeeding episodes were significantly larger on the ing while consistently overestimating its duration,
bedsharing night. compared with the researcher’s direct observations.
Conclusions. We suggest that, by increasing breast-
Because there exists near universal agreement that
feeding, bedsharing might be protective against SIDS, at
least in some contexts. Furthermore, maternal reproduc- increased breastfeeding reduces infant morbidity
tive physiology could be impacted because nursing fre- and mortality worldwide,10 –12 including in some
quency affects ovulation. This is the first study to di- populations the infant’s chances of dying of sudden
rectly measure nocturnal breastfeeding behavior in any infant death syndrome (SIDS),13–15 it is unfortunate
cultural group. Pediatrics 1997;100:214 –219; bedsharing, that clinical, experimental, and ethnographic studies
co-sleeping, breastfeeding, SIDS. have not addressed the role that sleeping arrange-
ments play in either promoting or inhibiting this
ABBREVIATIONS. SIDS, sudden infant death syndrome; RB, rou- practice. The absence of research in this area may be
tinely bedsharing; RS, routinely solitary sleeping; BN, bedsharing explained partially by the cultural context within
night; SN, solitary sleeping night. which pediatric research unfolds. Western cultural
values clearly favor early weaning and solitary infant
sleeping arrangements believed to help promote in-

F
rom an evolutionary perspective, breastfeeding
and parent-infant co-sleeping constituted an in- fant autonomy as early in life as possible.16,17 For
tegrated system throughout human history in example, Pinilla and Birch18 devised a behavioral
which both the mother’s and infant’s sleep physiol- strategy by which starting early in infancy mothers
ogy were entwined in adaptive ways. These child can reduce or eliminate nocturnal feeds, thereby
care practices were probably designed by natural minimizing the need for nighttime parental interven-
selection to maximize the chances of infant survival tions. Moreover, research in the area of infant sleep-
and parental reproductive success,1–3 and even today ing arrangements has focused on child care strategies
they remain inseparable and inevitable for the vast that accord with parental work schedules and pref-
erences, without scientific determination of whether
decreased nocturnal parent-infant contact represents
From the *University of Notre Dame, Notre Dame, Indiana; the Department any disadvantages for infants.19 Solitary infant sleep-
of Neurology, University of California, Irvine, Orange, California; and the ing and early weaning presumably improve the
‡Department of Neurology, University of California, Irvine, California. mother’s sleep, but possible biological trade-offs for
Received for publication Feb 12, 1996; accepted Jun 7, 1996. the infant, whose social and biological interests are
Reprint requests to (J.J.M.) Department of Anthropology, University of
Notre Dame, Notre Dame, IN 46556.
different from the mother’s, remain unexplored.
PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad- With the unprecedented worldwide declines in
emy of Pediatrics. SIDS rates after recent public campaigns against the

214 PEDIATRICS Vol. 100 No. from

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prone sleeping position, infant care practices, includ- were 11 boys and 9 girls, aged 13.0 6 1.3 weeks when sleep testing
ing breastfeeding and bedsharing, are being scruti- was performed; RS infants were 4 boys and 11 girls and were
12.9 6 1.3 weeks old.
nized in ways not previously anticipated. However,
the complexity of infant care practices and the diver- Procedure and Data Analysis
sity of approaches used to study them have led to Mother-infant pairs underwent 3 consecutive nights of labora-
inconsistent and/or contradictory perspectives and tory study: an initial adaptation night matching the routine home
findings. For example, not every epidemiologic sleeping arrangement followed by a bedsharing night (BN) and a
study shows that breastfeeding provides increased solitary sleeping night (SN) in randomly assigned order. Sleep
studies were performed in the University Medical Center Sleep
protection from SIDS,20 but a serious problem in Disorders Center, a facility accredited by the American Sleep
comparing findings is that the type, frequency, and Disorders Association. For solitary sleeping, infants slept in a
duration of breastfeeding are not always differenti- standard crib in the room adjacent to the mother’s (in hearing
ated or categorized in the same way.21,22 Also, results range) with the doors between them ajar. On the bedsharing
from an epidemiologic study from New Zealand night(s), mother-infant pairs shared the same twin-size bed used
by the mother for solitary sleeping. Infants were maintained on
suggest that in some populations bedsharing in con- their usual feeding and sleeping schedules, with mothers perform-
junction with maternal smoking increases SIDS ing all care taker interventions ad lib. Mothers were blind to all
risk.23 In contrast, we have argued from an evolu- experimental hypotheses and instructed only to prepare and re-
tionary perspective that, under otherwise safe condi- spond to their infants as they would at home. Mothers also retired
at their usual times, and monitoring was terminated after mother
tions, bedsharing and other forms of co-sleeping may and infant had awakened the next morning at their usual times.
offer infants an adaptive advantage and be protec- Monitoring each night in infants and mothers included contin-
tive against SIDS.24,25 The apparent diversity of co- uous infrared audiovisual recordings as well as the standard,
sleeping environments, within as well as between noninvasive polysomnographic measures required by the larger
cultures, makes comparisons between existing stud- ongoing study (including electroencephalograms, electrooculo-
grams, and surface chin electromyogram for determination of
ies challenging at best. sleep-wake stages26). A large digital clock placed in the camera
As a beginning step toward disentangling some of field allowed calculation of breastfeeding data to the nearest
these complex issues, the present study was de- minute.
signed to quantify nocturnal breastfeeding behavior Breastfeeding was defined as nipple attachment, which was
usually verifiable through observation of the video recordings.
in routinely bedsharing (RB) and routinely solitary Therefore, identification of breastfeeding did not rely on infant
sleeping (RS) Latino mother-infant pairs, in both sucking behavior, with the exception of the few occasions when
bedsharing and solitary sleeping laboratory environ- the infant’s head was obscured by blankets; in those instances the
ments. This is the first study to directly measure sucking artifact, which is readily seen on the chin electromyo-
nocturnal breastfeeding in any cultural group. gram, was used to identify breastfeeding.
Breastfeeding behavior was quantified as breastfeeding epi-
sodes. Breastfeeding episodes began and ended with nipple at-
METHODS tachment and detachment, respectively, but also included very
Subjects short interruptions during which the mother switched from one
breast to the other. These interruptions were a matter of seconds
Results are presented for the first 35 mother-infant pairs in an and were below the 1-minute resolution of the digital clock. All
ongoing behavioral and polysomnographic study. Twenty were breastfeeding episodes were initiated by the mother placing her
RB and 15 were RS since birth. RB was defined as bedsharing with nipple in the infant’s mouth and defined to capture a single,
the mother for at least 4 hours per night, on at least 5 days per intentional, and continuous act of breastfeeding on the mother’s
week; RS was defined as bedsharing no more than 1 night per part. A new breastfeeding episode was scored if breastfeeding was
week for any part of the night. Two-week daily sleep logs were interrupted by maternal behaviors that indicated an apparent
completed at home just before the sleep recordings to confirm attempt by the mother to terminate feeding (ie, by closing her bra
maternal reports of the infants’ usual sleep environment. For the or nightgown, by attempting to leave the room, or by attempting
33 pairs who completed all 14 nights of the log, the mean (6SD) to return to sleep) but the infant’s subsequent refusal to settle
number of bedsharing nights was 13.7 6 .5 for the RB group prompted the mother to reinitiate feeding.
versus .6 6 .9 for the RS group. Fathers were excluded from the Three breastfeeding variables were computed each night: num-
study protocol, regardless of whether or not they participated in ber, mean duration, and total duration (sum) of breastfeeding
infant bedsharing, to isolate the influence of maternal-infant bed- episodes. Analyses were restricted to the time the infants were in
sharing on breastfeeding. bed each night, ie, from lights out to final morning awakening.
Subjects were recruited from the Birthing Center at the Univer- Within-group comparisons of the BN and SN were performed
sity of California Irvine Medical Center. All mother-infant pairs using the Wilcoxon matched-pairs signed rank test. The Mann-
visiting the Birthing Center for postpartum follow-up who met Whitney U test was used for between group (RB versus RS)
our inclusion criteria were asked to participate. Inclusion criteria comparisons. Significance was assigned when P , .05.
for mothers were that they: be Latino; be ,38 years old; be This protocol was approved by the University’s Human Sub-
exclusively or predominantly breastfeeding (no more than two jects Review Committee, and mothers were remunerated for their
4-ounce bottles of formula per day and none after 3 pm); have had participation.
prenatal care; have no present or past history of drug or alcohol
abuse; have no history of smoking, alcohol, or illicit drug use
during pregnancy; have had uncomplicated pregnancies, labors, TABLE. Breastfeeding Behavior
and deliveries; be in good health and free of sleep disorders; be
taking no medications known to affect sleep pattern; and have Group BN SN
chosen sleeping practice for reasons other than infant tempera- No. of breastfeeding episodes RB 4.7 6 0.6* 3.3 6 0.4
ment (eg, response to a fussy infant). A physician trained in sleep RS 3.8 6 0.7 2.3 6 0.3
medicine performed the sleep histories. RB mothers were 27.0 6 Total duration of episodes (min) RB 55.9 6 7.7 26.4 6 2.6
5.9 (SD) years of age, and RS mothers were aged 24.3 6 8.5 years. RS 35.3 6 7.1 19.8 6 2.6
Inclusion criteria for infants were that they: be 11 to 15 weeks Mean duration of episodes (min) RB 12.4 6 1.3 9.5 6 1.1
old at the time of the sleep studies; be in good health, with normal RS 9.4 6 0.9 8.9 6 0.3
growth and development; weighed .2500 g and were .37 weeks’
gestational age at delivery; had a 5-minute Apgar score $8; have Abbreviations: BN, bedsharing night; SN, solitary sleeping night;
no history of SIDS in first degree relatives; and no history of RB, routinely bedsharing; RS, routinely solitary sleeping.
prolonged apnea or an apparent life-threatening event. RB infants * Table entries reflect means 6SD.

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 RESULTS above findings by partitioning the three main vari-
The group means (6SD) for the three breastfeed- ables by sex: frequency, mean, and total duration of
ing variables each night are given in the Table. For breastfeeding. For both the BN and SN, no significant
the RB group, both the number (P 5 .006) and total differences were found for any variable between
duration of breastfeeding episodes (P , .001) were male and female infants in either RB or RS groups.
significantly greater on the BN than the SN. The This was also true when the two groups were com-
mean duration of breastfeeding episodes was also bined.
larger on the BN but the difference just failed to The nightly distributions of number of breastfeed-
reach statistical significance (P 5 .050). Because no ing episodes is graphed in the Figure for the two
significant differences were found in either the in- groups separately. The distributions show striking
fants’ time in bed (mean 6 SD 5 544.2 6 40.0 min- shifts to the left associated with both routine solitary
utes on BN vs 545.2 6 39.3 minutes on SN) or total sleeping (horizontal comparisons of RB-BN to RS-
sleep time (461.0 6 38.9 minutes on BN vs 442.5 6 BN, and RB-SN to RS-SN) and with solitary sleeping
52.9 minutes on SN) on the two nights (P , .05), the on a given night (vertical comparisons of RB-BN to
differences in breastfeeding could not be attributed RB-SN, and RS-BN to RS-SN). The medians reflect
to different length sampling periods. The net result these leftward shifts: median 5 4.5 for RB-BN, 3.0 for
was that RB infants spent more than twice as long RB-SN, 3.0 for RS-BN, and 2.0 for RS-SN. Single
breastfeeding on the BN than on the SN. breastfeeds during the night were most common for
All three breastfeeding variables were also larger RS infants on the SN (5 of 15 infants) and least
in the RS group on the BN than on the SN, but none common for RB infants on the BN (only 1 of 20
of the differences reached significance. Similarly, infants). Because computation of intervals of non-
comparing the two groups on the BN, the three breastfeeding time between breastfeeding episodes
breastfeeding variables were all larger in the RB requires at least two episodes, the occurrence of sin-
group than in the RS group; however, only the dif- gle breastfeeds prevented group comparisons of
ference in total duration of breastfeeding episodes those intervals. However, the differences noted in
was significant (P 5 .028). the mean and median number and mean duration of
The largest differences found in breastfeeding breastfeeding episodes and in the pattern of occur-
were consistently between the two groups in their rence of single breastfeeding episodes indicate that
routine conditions. Comparing the RB group on the both routine and occasional bedsharing are associ-
BN to the RS group on the SN, the number of breast- ated with shorter intervals between feeds.
feeding episodes was doubled (P , .001), the total The number of self-reported nocturnal breastfeed-
duration of breastfeeding episodes was nearly three ing episodes was also derived from the 2-week home
times as great (P , .001), and the mean duration of sleep logs. RB pairs averaged 2.4 6 .9 feeds per night
breastfeeding episodes was 39% greater (P 5 .039) in compared with 1.6 6 .7 per night in RS pairs, a
the RB group. A modestly (6%) longer total bed time significant difference (P 5 .009).
(P 5 .039) in RB infants on the BN (544.2 6 40.0
minutes) than for RS infants on the SN (512.7 6 49.4 DISCUSSION
minutes) was insufficient to explain the large differ- The most important finding of this study is that
ences seen in breastfeeding. infants who bedshared routinely at home breastfed
We examined any possible role of infant sex in the three times longer during the night than infants who

Figure. Frequency distributions of the

total number of breastfeeding episodes
are graphed separately for each group on
the BN and the SN.

216 BEDSHARING PROMOTES BREASTFEEDING

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routinely slept separately, when tested in their rou- room, only by frank crying can the infant elicit ma-
tine conditions. This largely reflected a two-fold in- ternal attention and feeding in the solitary condition.
crease in the number of breastfeeding episodes al- That bedsharing promotes increased breastfeeding
though the duration of individual episodes was, on could have important implications for infant health.
average, also longer by 39%. These differences are The most visible effect might be on weight gain (not
only partly explained by acute or immediate effects measured in our study). Relatedly, Uvnas-Moberg et
of bedsharing because total breastfeeding time was al31 reported that increased stimulation of the in-
significantly larger in the RB group than the RS traoral cavity of the newborn leads to an increased
group on the BN. This suggests that routine bedshar- release of glucose and gastrointestinal food absorp-
ing promotes more nocturnal breastfeeding through tion hormones in newborns, and presumably in
additional factors not present during occasional bed- older infants too. In addition, Barr et al32 showed that
sharing. Because diurnal breastfeeding was not mea- more frequent infant feedings, especially those con-
sured in this study, we do not know if daytime taining sugar nutrients (as opposed to water), reduce
feeding pattern is also affected by routine bedsharing crying duration, thereby contributing to energy con-
at night. Available data on diurnal breastfeeding, servation and calm wakefulness presumably through
however, provide no evidence that daytime feeding both preabsorptive (orotactile and orogustatory) and
is diminished by breastfeeding at night.7,27 Further- postabsorptive mechanisms. Consistent with the lat-
more, how the results might be modified when a ter, we observed that on the BN infants rarely cried
father or other family member is also present during to elicit a maternal response leading to a breastfeed-
bedsharing with the mother and infant is unknown. ing episode, whereas they almost always did so to
Consistent with the laboratory findings, the sleep elicit a feed on the SN (J. J. McKenna, unpublished
logs revealed that RB pairs were also breastfeeding observation, 1996).
more often than RS pairs at night at home. This An increased daily infusion of maternal antibodies
indicates that the laboratory findings are, in general, at a time when their own immunological systems are
representative of behavior in the natural environ- least efficient may provide bedsharing/breastfeed-
ment. However, the number of breast feeds reported ing infants with increased protection from infectious
at home was approximately half that measured in the diseases, some potentially related to SIDS. According
laboratory. Although this could reflect that infants to Arnon,33 breastfeeding is important for protection
against infant botulism that may be misdiagnosed as
actually fed more often in the laboratory, the more
SIDS approximately 5% of the time. Bacterial infec-
likely explanations are that mothers used a different
tions also have been hypothesized by Blackwell et
criterion for defining a single feeding episode or that
al34 to interact with a range of infantile deficits to
they underestimated the true frequency. Regarding
cause some SIDS deaths, and these too might be
the latter, there is other evidence that mothers un-
reduced by the increased breastfeeding associated
derestimate the frequency of breastfeeding, com-
with bedsharing. Arnon33 suggests that the degree of
pared with researcher observations.8,9 Whatever the protection from SIDS provided by mother’s milk de-
reason(s) for the discrepancy, it serves to emphasize pends on the baby receiving greater amounts of se-
the need for objective measures in quantifying cretory immunoglobulin A. If one assumes that
breastfeeding behavior. longer total duration of breastfeeding equates with
Although the mechanisms through which routine more milk intake, then the additional intake (how-
bedsharing promotes breastfeeding have yet to be ever small) might help compensate for the natural
determined, there is evidence that olfactory cues variability of titers of antibodies that distinguish the
could be important. By 2 weeks of age, breastfed content of one mother’s milk from another’s.33
infants preferentially orient (by head turning) to- Two recent epidemiologic studies suggest that
ward odors from their mother’s breast and axillary breastfeeding lowers the risks of SIDS,14,15 and two
regions during sleep as well as waking.28,29 Consis- others suggest that the extent of protection may be
tent with some sort of sensory bridge between bed- dose-related.13,35 Whereas a protective effect has not
sharing infants and their mothers, we have found been found in every study,20 many international
that bedsharing infants remain oriented toward their SIDS prevention campaigns, including in the United
mothers for large portions of the night, up to 100%.30 States, recommend breastfeeding as a way to reduce
Inherent to bedsharing, the infant’s proximity to the risk for SIDS. That bedsharing is associated with
mother’s breast would enhance the infant’s exposure increased breastfeeding raises the possibility that
to olfactory and any other relevant sensory cues from bedsharing is a factor in the relatively lower rates of
the mother that might facilitate breastfeeding. One SIDS among the population from which our subjects
can further speculate that exposure to the mother’s were drawn. Our Latino mothers and infants repre-
odors during bedsharing might have the effect of sent a cultural group living in the Western and
lowering the infant’s arousal/hunger threshold. Bed- Southwestern United States for which their low
sharing might also promote breastfeeding by permit- socioeconomic and recent immigrant status suggest
ting mothers to sense their infant’s more subtle increased SIDS risk. Yet, similar to recent Asian im-
sounds and movements that increase in both fre- migrants in Great Britain,36 the most recent epidemi-
quency and intensity as breastfeeding episodes are ologic data show that California Latino infants of
approached (J. J. McKenna, unpublished observa- Mexican-born mothers are at lower risk (.8/1000 live
tion, 1996). Because this kind of maternal responsive- births) compared with Anglos (1/1000);37 and for
ness is not possible when infants sleep in a separate infants weighing more than 2500 g, this is also true

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among Latinos living in the Chicago area where the include the bedsharing environment. The discovery
SIDS rates range from 1.0/1000 for Latino infants to that bedsharing promotes breastfeeding has impor-
1.2/1000 for white middle-class infants.38 That tant implications both for infant and maternal health.
breastfeeding and bedsharing are more commonly Perhaps most important is that bedsharing might
practiced among recent Latino immigrants than in reduce the risk of SIDS because breastfeeding is
white American families may explain some of this thought to be protective against SIDS for some pop-
discrepancy. Eighty-four percent of Mexican-born ulations. However, given that bedsharing may in-
mothers in the United States initiate breastfeeding in crease SIDS risk when practiced in combination with
contrast to 58.5% of white American mothers (Demo- maternal smoking,23 the potential benefits of bed-
graphic and Health Surveys, 1991, unpublished data, sharing cannot be considered independently of the
Institute for Resource Development, Westinghouse specific social and physical circumstances within
Corporation).39 Moreover, the incidence of all night which bedsharing occurs. The potential for overlying
bedsharing was found to be 21% among Latino fam- or falling out of bed should be considered, in addi-
ilies in east Harlem, New York City, significantly tion to the potential dangers associated with modern
higher than the 6% reported for a representative sleeping surfaces such as waterbeds, soft, fibrous, or
sample of white, middle-class urban infants matched bean mattresses, or loose bedding.48,49 In older infants
for age and sex.40 That maternal smoking, a known who continue to breastfeed, the possibility of pro-
risk factor for SIDS,41 may be relatively uncommon in moting dental caries should also be considered.
Latino women may also be contributory. Further- Finally, our study has important implications for
more, we found that bedsharing minimized use of appreciating the potentially important effects that
the prone sleep position in our Latino subjects,30 cultural choice of infant care practice has on the
which could also be a factor in the low SIDS rates mother-infant relationship in general and on mater-
reported for southern California Latinos because nal and infant biology in particular. The differences
prone sleeping is a known risk factor for SIDS.42 we report between RB and RS mother-infant pairs
Although bedsharing is most often considered in underscore the need to reconceptualize normal
terms of impact on infants, maternal reproductive mother-infant behavior, not in cultural terms alone,
physiology, particularly ability to reestablish ovula- but also in biological terms. These findings reinforce
tion, may also be affected. Suppression of ovulation the idea that mother and infant breastfeeding behav-
contributes to increased iron status by delaying iors are highly sensitive to the environment within
blood loss associated with menstruation and also which they find expression and that expression is
extends the recuperative period between pregnan- maximized when in the co-sleeping environment
cies, permitting the mother’s body to replenish fat within which breastfeeding evolved.
and nutrient stores required by herself as well as
future offspring.21,43 Recent studies suggest that fre- ACKNOWLEDGMENTS
quent nipple contact or sucking and relatively short This research was funded by National Institute of Child Health
intervals between breast feeds (rather than simply and Human Development grant R01 27482.
The authors wish to express their appreciation to Sean
breastfeeding versus not breastfeeding) are required Drummond and Naz Kajani for their excellent technical assistance.
to sustain the high levels of circulating prolactin
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 Bedsharing Promotes Breastfeeding
James J. McKenna, Sarah S. Mosko and Christopher A. Richard
Pediatrics 1997;100;214
DOI: 10.1542/peds.100.2.214

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 Bedsharing Promotes Breastfeeding
James J. McKenna, Sarah S. Mosko and Christopher A. Richard
Pediatrics 1997;100;214
DOI: 10.1542/peds.100.2.214

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