Science AMA Series: I’m Dr. Barbara Ostfeld, I’m talking about bed-sharing as a risk factor for sudden unexpected infant deaths. AMA!



Is suffocation the main concern with co-sleeping? What else can cause SIDS? How much longer are premature babies suggested to only sleep by themselves? Thanks for your time!


For your first question, suffocation is a concern with bed-sharing. For your second question, by definition, SIDS is defined as a death for which no cause has been identified despite the thorough investigation consisting of a complete autopsy, a review of all medical records and a death scene investigation. Sadly, the diagnosis provides no answer to the most basic question every parent asks, "Why?" However, and this is very important, while SIDS deaths remain unexplained, we do know the risk factors that elevate their likelihood. Those risks and how to reduce them are at the core of the evidence-based guidelines of the AAP. They work. The rate has been cut by more than half since the onset of such recommendations as back to sleep, which has been called one of the seven most significant pediatric research findings of the past 40 years. Thousands of lives have been saved because of the application of these recommendations, and the added value is that not only do they reduce the risk of SIDS but, for completely different reasons, these same recommendations also create an environment that reduces the risk of suffocation. With knowledge of these guidelines, parents move from fear to empowerment. With respect to your third question, prematurity elevates the risk of SIDS and other sleep-related infant deaths. For babies born between a gestation of 24 to 27 weeks, the risk is more than three times that for a term baby. Safe sleep provides a compensatory element. As with all babies, the AAP recommends room sharing rather than bed sharing with a sleeping parent. Keeping the baby close-by the adult bed in a Consumer Product Safety Commission approved crib, bassinet, portable crib or play yard is their recommendation. Parents can touch, hear and smell their baby because they are proximate to the adult bed, although not in it. Parents can bring the baby into bed to feed, nurture, cherish; but when mama is ready to sleep, the AAP recommends that the parent return the infant to the proximate crib. Side note: breast feeding is associated with a lower risk! By the way, the baby should be placed to sleep on the back, the crib should be bare (a bare crib really is a beautiful crib, even though we are programmed to imagine it to be lovelier if filled with all sorts of risk elevating materials such as bumpers, blankets, stuffed animals and pillows. No baby ever asked for a decorative pillow!) There should be no exposure to smoke.

I apologize if this comes off as a leading question, I'll do best to layout my question concern.

  • New dad here, I hear a whirlwind of BS from the mom groups my wife attends and wow there is a lot of misinformation out there. The biggest concern here I'm hoping you can elaborate on is the actual rate of occurrence of SIDS vs suffocating from parent negligence. A lot of people seem to assume that general suffocation is classified as SIDS when in fact it was just their child sleeping with a blanket and suffocating or some improper assembly or use of objects in the crib.

I guess I'm looking for a professional take on what is legitimately SIDS and what causes it. I refuse to read any mom blogs on the topic so I'm currently using my mother in laws decade old nursing text book for infant care.

Edit: spelling


A good and complex question. I'll attempt a short answer. There is no biomarker for suffocation. The diagnosis is determined via the conditions and circumstances of the sleep environment as it relates to the position, etc. of the infant. Perhaps the infant was belly and face down on a soft pillow with a large sibling sleeping on top of his head. While SIDS and suffocation share risk factors, they operate differently in each. With respect to suffocation, the infant is in a situation from which he/she cannot escape and which has blocked his/her airway. Anyone in that condition would succumb. With respect to SIDS, a baby may be resting with his face against a pillow but in a manner which would allow him/her freedom of movement. We are all programed to arouse to a drop in oxygen and to engage in self protective behaviors including head movement. However, babies whose deaths have been classified as SIDS have been found in very specialized research autopsies to be more likely than babies who died for any other reason to have an abnormality in the arcuate nucleus, a part of the brain that is sensitive to dropping levels of oxygen. With such an abnormality, they may continue to rebreath oxygen poor air without arousing and self-protecting, and without undergoing any of the body's self-protecting physiological reactions. In short, they are not trapped and could move, but don't. We cannot identify this vulnerability in living babies, and are far removed from the development of treatment or prevention once diagnosis in living infants is possible. However, we do know how to create an environment that would be protective of these infants. And, most importantly, the safe sleep recommendations also creates an environment with a lower risk for suffocation, a circumstance that can befall anyone, and one that broadens the impact of thee recommendations. The guidelines work! As application increases, rates of SUID decline.

Hi! Awesome for you to do an AMA on the subject. I'm a relatively new father and my daughter is just shy of 9 months old. For the past 2 months my daughter has been unable to sleep on her back. She will do everything in her power to roll to her belly. If we flip her, even during what appears to be REM sleep, she will wake during or shortly after the roll. So my question is does this pose any risk to her health. I guess my biggest concern is her neck because her head is always tilted to one side at night.

Thanks in advance!


Congratulations on new parenthood! One of life's best journeys! The AAP states that for the first year of life, initiate sleep on the back. At some point, perhaps between 6 and 8 months, an infant will develop and master two important skills: turning from back to belly and from belly to back. At that point, the AAP guidelines indicate that you can allow the infant to remain in the alternative position they purposefully assume after being placed on their backs. Check out the guidelines links I posted at the start of this AMA. Of course, continue to keep their sleep space free of all soft and loose bedding such as pillows, bumpers, blankets and stuffed animals.

When I was doing my research for my firstborn (5 months old now) I found a lot of resources conflated SUID and SIDS. I think there is a significant difference if the cause is truly unknown or if the scenario points to suffocation. Do you find there to be any issues with consistency in reporting? Do you feel that the difference is important?

Other countries, such as Japan, seem far more likely to co-sleep. Have their SUID/SIDS rates been compared? Is there something to learn there?

Thank you.


SUID=sudden unexpected infant death and is comprised of three categories: SIDS; accidental suffocation and ill-defined and unknown causes. The CDC and researchers now address SUID rates in order to adjust for potential diagnosis drift across the three categories and to be sure that there has been a true decline. With respect to suffocation, the environmental condition would have to rise to the level of causality and go beyond conjecture. These deaths are now referred to in the American Academy of Pediatrics guidelines as SIDS and other sleep-related infant deaths, and the guidelines essentially pertain to all.

SIDS to me always seemed a very nonspecific way of describing children stopping breathing. Does this nonspecific language come from historically not being able to pin down what was going on or is it more because under this title it is somehow less upsetting to discuss? Would education efforts be better served by a different name?


By definition, a diagnosis of SIDS is made only when a complete evaluation, consisting of an autopsy, and may include metabolic and genetic studies, a review of the medical history and a thorough death-scene investigation have failed to identify a cause. Please see an earlier response. Nomenclature in any situation is important. SIDS is a term that is in the vernacular. It is understood as the leading cause of infant mortality from one month to one year of age. By including it among sleep-related infant deaths, appreciation of the term has likely improved.

At what age is it safe to start sharing a bed with your child?


The AAP safe sleep guidelines pertain to the first year of life. With respect to bed-sharing, the AAP notes that it is especially risky and to be avoided under several conditions such as sleeping with a term infant under 4 months of age, parental smoking, if the infant is preterm of of low birth weight, if the surface is overly small or soft, the presence of soft bedding such as pillows and blankets, the presence of multiple people, the adult's use of alcohol or other sedating drugs, the presence of a non-parent. The links to the guidelines and technical report, posted at the start of this conversation, will provide more detail.

Dr. Ostfeld, can you talk about exposure to tobacco smoke as a SIDS risk factor? Can you explain why you have selected a population of "bedsharers" to target and inform instead of the larger population of smokers? Do you believe that bedsharing poses a larger risk than exposing infants to firsthand, secondhand, and thirdhand smoke?


Smoke exposure is a MAJOR risk factor! It is a focus of our research and is part of the risk reduction guidance. My conversation this morning was about reducing the risk of SIDS and other sleep-related infant deaths. I was happy to respond to questions about any of the risks delineated in the AAP guidelines. Each is uniquely important. Maternal smoking during pregnancy and exposure of the infant to household smoke after birth each independently contribute. Because it is an addiction, it remains a challenging practice to change, but a decline would have incredible benefit, for the topic at hand as well as for so many other health issues. We all should be supportive of initiatives to address smoking.

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