Bed- and Sofa-Sharing Practices in a UK Biethnic Population
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ARTICLE
Bed- and Sofa-Sharing Practices in a UK Biethnic
Population
AUTHORS: Helen L. Ball, MA, PhD,a Eduardo Moya, LMS, WHAT’S KNOWN ON THIS SUBJECT: Parent-infant bed-sharing is
MRCPCH,b Lesley Fairley, MSc,c Janette Westman, RM, BSc, a common behavior of breastfeeding mothers and various ethnic
MCGI, IBCLC,d Sam Oddie, MBBS, MRCP (Paed), FRCPCH,e groups. Under certain circumstances, it is associated with an
and John Wright, MB, ChB, BSc, FFPHM, FRCPc increased risk of sudden infant death. Blanket prohibitions
aParent-Infant Sleep Laboratory & Medical Anthropology
against bed-sharing conflict with breastfeeding promotion and
Research Group, Durham University, Durham, United Kingdom; inhibit safe bed-sharing discussion.
and bBradford Teaching Hospitals NHS Foundation Trust,
cBradford Institute for Health Research, dMaternity Unit, and
eBradford Neonatology, Ward M1, Bradford Royal Infirmary, WHAT THIS STUDY ADDS: Bed-sharing and sofa-sharing were
Bradford, United Kingdom almost mutually exclusive. Pakistani families avoided sofa-sharing
KEY WORDS and hazardous bed-sharing, and have a very low rate of sudden
bed-sharing, sofa-sharing, SIDS, infant care, Bradford Infant Care infant death syndrome. White British families were more likely to
Study, breastfeeding, infant sleep, Born in Bradford (BiB) smoke, drink alcohol, and sofa-share with their infants.
ABBREVIATIONS
aOR—adjusted odds ratio
BiB—Born in Bradford
BradICS—Bradford Infant Care Study
CI—confidence interval
OR—odds ratio abstract
SIDS—sudden infant death syndrome
SUDI—sudden unexpected death in infancy
OBJECTIVE: To describe the prevalence and associations of bed- and
sofa-sharing in a biethnic UK birth cohort.
Dr Ball is corresponding author and guarantor. She was
involved in all aspects of study design and funding application, METHODS: We surveyed 3082 participants in the Born in Bradford birth co-
was a member of the Bradford Infant Care Study (BradICS) hort study by using a telephone interview when infants were aged 2 to 4
steering committee that oversaw project management and
analysis, and was principal author of the submitted manuscript. months. We asked families about sleep surface sharing behaviors, and other
Dr Moya conceived of the initial project, was involved in all sudden unexpected death in infancy (SUDI)-related behaviors.
aspects of study design and funding application, chaired the
BradICS steering committee that oversaw project management
RESULTS: There were 15.5% of families that had ever bed-shared, 7.2% of
and analysis, and contributed to and approved the submitted families regularly bed-shared, and 9.4% of families had ever sofa-shared
manuscript. Ms Fairley designed the analysis plan in with their infants; 1.4% reported both. Regular bed-sharers were more
collaboration with the BradICS steering committee, conducted
commonly Pakistani (adjusted odds ratio [aOR] = 3.02, 95% confidence
all statistical analyses, drafted the methods and analysis
sections of the manuscript, and approved the submitted interval [CI] 1.96–4.66), had further or higher educational qualifications
manuscript. Ms Westman served as BradICS project manager, (aOR = 1.62, 95% CI 1.03–2.57), or breastfed for at least 8 weeks (aOR =
was involved in all aspects of study design and implementation, 3.06, 95% CI 2.00–4.66). The association between breastfeeding and bed-
was a member of the BradICS steering committee, and
contributed to and approved the submitted manuscript. Dr sharing was greater among white British than Pakistani families. Sofa-
Oddie was involved in all aspects of study design and funding sharing occurred in association with smoking (aOR = 1.79, 95% CI 1.14–
application, was a member of the BradICS steering committee 2.80) and breastfeeding for more than 8 weeks (aOR = 1.76, 95% CI
that oversaw project management and analysis, and contributed
to and approved the submitted manuscript. Dr Wright provided
1.19–2.58), and was less likely in Pakistani families (aOR = 0.21, 95% CI
liaison with the larger Born in Bradford cohort study, was 0.14–0.31), or single-parent families (aOR = 0.50, 95% CI 0.29–0.87).
involved in all aspects of study design and funding application,
CONCLUSIONS: The data confirm that bed-sharing and sofa-sharing
was a member of the BradICS steering committee that oversaw
project management and analysis, and contributed to and are distinct practices, which should not be combined in studies
approved the submitted manuscript. of unexpected infant deaths as a single exposure. The determinants
www.pediatrics.org/cgi/doi/10.1542/peds.2011-1964 of sleep-surface sharing differ between the UK Pakistani and UK
doi:10.1542/peds.2011-1964 majority communities, and from those of US minority communities.
Accepted for publication Nov 11, 2011 Caution is needed in generalizing SUDI/SIDS risk factors across pop-
ulations with differing risk factor profiles, and care should be taken in
(Continued on last page) adopting SUDI/SIDS reduction guidelines from other contexts. Pediatrics
2012;129:e673–e681
PEDIATRICS Volume 129, Number 3, March 2012 e673
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015In many countries, parent-infant bed- suggestion from previous studies that bed-share, and ever sofa-share. All
sharing (sleeping together on the same parent-infant sleep-sharing may be mothers were asked “Does your baby
surface) is common among breast- practiced in different ways according to sleep in your bed when you are asleep?”
feeding mother-infant dyads,1–6 and a ethnic and sociodemographic charac- If the mother responded “Rarely (once
long-standing cultural practice for 1 or teristics, it is imperative to have data on or twice),” “Occasionally (less than once
more minority groups.7–12 Studies have the actual sleep-sharing practices within a week),” “Regularly (twice or more per
demonstrated an increased risk of any given community for whom guid- week),” or “Every night,” then they were
sudden infant death syndrome (SIDS) ance to parents is issued. The aim of this classified as ever bed-share. Regular
associated with bed-sharing for infants article is therefore to describe parent- bed-share was defined as responding
of parents who smoke,13,14 no risk as- infant sleep-sharing (bed-sharing and “Regularly” or “Every night” to this ques-
sociated with bed-sharing with mother sofa-sharing) in a multiethnic urban tion. Mothers were asked, “Has the
6 father, irrespective of maternal population in the United Kingdom, to mother ever fallen asleep with the
smoking status,11 whereas the European determine similarities and differences baby on a sofa or armchair?” Women
Concerted Action on SIDS investigation from bed-sharing practices in the United were defined to ever sofa-share if they
found a significantly increased risk of States and elsewhere, and to discuss responded “Once,” “Occasionally,” or
SIDS among the infants aged ,9 weeks implications for the formulation of infant “Regularly.” Mothers were excluded
of nonsmoking mothers who bed- “safe-sleep” recommendations. from analysis if the response to either
shared.15 In the Netherlands, the risk was of these questions was missing (n = 7).
increased only for infants ,2 months of METHODS Potential Risk Factors
age.16 Gessner et al17 estimate the max-
The Born in Bradford (BiB) and Bradford Several covariables, available from the
imum potential risk for bed-sharing
Infant Care Study (BradICS) have been baseline questionnaire, the hospital
infants of nonsmoking mothers to be
described elsewhere in detail.27,28 Briefly, birth record, or the BradICS telephone
,1/10 000. Research has recently begun
the BiB birth cohort study included 14 survey, were included as potential risk
to document more closely the particular
000 pregnant women who gave birth in factors in our analysis. The variables
parental behaviors and shared sleep
Bradford between May 2007 and May included were those previously shown
surfaces that present risks to infants.18
2011. Women were recruited at 26 to 28 to be associated with bed- or sofa-
Although the evidence linking parent- weeks’ gestation and completed a base- sharing and SUDI/SIDS risk in other
infant bed-sharing with increased risk line questionnaire. The BradICS study populations. Ethnicity was self-defined
of SIDS or accidental infant death is reports on 3082 women who gave birth by the mother when completing the
inconsistent and contested,19,20 inter- at the Bradford Royal Infirmary between baseline questionnaire. Other variables
national guidelines have been domi- June 2008 and September 2009. A total from the baseline questionnaire in-
nated by recommendations to avoid of 4131 mothers were contacted by cluded language in which the ques-
bed-sharing. These guidelines have telephone when their infants were 2 to 4 tionnaire was completed, marital and
been heavily influenced by authorities months of age and 3082 completed a cohabitation status, mother’s highest
in the United States (eg, Consumer telephone interview on infant care education qualification, Index of Multi-
Product Safety Commission,21 American practices; 84% of women completing the ple Deprivation based on postcode of
Academy of Pediatrics22), who have ad- telephone survey had complete baseline residence at registration to the study
vised against parents sleeping with their survey data (80% of the BiB sample (an area-based measure of average
infants. This advice has been adopted in completed the baseline survey). Analysis deprivation where areas are assigned
countries with different ethnic composi- in this article is restricted to white scores based on measures in 7 domains;
tions, cultural practices, and SIDS pro- British and Pakistani women who com- participant postcodes are mapped di-
files than the United States,23–25 even pleted the BradICS telephone survey, the rectly to Index of Multiple Deprivation
though other researchers have cau- BiB baseline questionnaire, and had scores for the area). Variables from
tioned against imposing particular cul- a singleton birth at the Bradford Royal the birth record included maternal age
tural values on diverse ethnic groups.3,26 Infirmary (n = 2180). The characteristics at delivery, parity, infant’s birth weight,
Given the lack of agreement regarding of the sample can be found in Table 1. and gestational age. Potential risk fac-
which practices are associated with tors reported as part of the BradICS
increased sudden unexpected death Outcome Measures study were the following: mother cur-
in infancy (SUDI)/SIDS risk when par- Three self-reported outcome meas- rently smokes, father currently smokes,
ents and infants sleep together, and the ures were used: ever bed-share, regular mother drinks alcohol in the evenings,
e674 BALL et al
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015ARTICLE
TABLE 1 Characteristics of Study Population were eligible for entry to or removal
Variable Category n % from the model.
Ethnic group White British 885 44.4 We hypothesized that there would be
Pakistani 1115 55.7
ethnic differences in the association
Mother’s age, y ,20 109 5.5
20–24 527 26.4 between breastfeeding and cosleeping
25–29 685 34.3 based on previous reports that bed-
30–34 427 21.4 sharing is a general cultural practice
35+ 252 12.6
Language baseline completed English 1614 80.7 among South Asians,29 but is principally
Non- English 386 19.3 associated with breastfeeding among
Marital and cohabitation status Married and living with partner 1387 69.4 white British mothers.1 We tested this
Not married and living with partner 350 17.5
Not living with partner 263 13.1
hypothesis by assessing the interaction
Mother’s educational qualifications None 291 14.5 of ethnicity and breastfeeding dura-
Secondary school 642 32.1 tion in the final models for each of the
Further and higher 804 40.2
outcomes.
Other 230 11.5
Don’t know 33 1.75
Index of Multiple Deprivation quintile 1 (least deprived) 38 1.9 RESULTS
2 80 4.0
3 242 12.1 In this UK biethnic sample, with a mean
4 370 18.5 infant age of 16.2 weeks (SD 2.88 weeks),
5 (most deprived) 1270 63.5
Mother currently smokes No 1795 89.8 15.5% of mothers ever bed-shared, 7.2%
Yes 205 10.2 of mothers regularly bed-shared, and
Father currently smokes No 1616 80.8 9.4% of mothers ever sofa-shared with
Yes 384 19.2
Mother drinks alcohol in evenings Never and rarely 1847 92.4
their infants (Table 2). Only a very small
Some evenings and more often 153 7.6 proportion of mothers both bed-shared
Father drinks alcohol in evenings Never and rarely 1777 88.9 and sofa-shared (1.4%).
Some evenings and more often 223 11.1
Birth wt, g Mean (SD) 3.24 (0.55) The prevalence of bed-sharing (ever and
Gestational age, completed wk Mean (SD) 39.2 (1.7) regular) was greater for the Pakistani
Parity 0 775 38.8 than the white British mothers, and the
1 592 29.6
2 338 16.9 prevalence of sofa-sharing was lower
3+ 295 14.7 (Fig 1). Logistic regression analyses in-
Breastfeeding, wk Never & ,1 872 43.6 dicate that those mothers who bed-
1,8 442 22.1
$8 686 34.3
shared with their infants were different
Infant sleeps in own room No 1767 88.4 from those who sofa-shared.
Yes 233 11.6
Infant age at completion of survey, wk Mean (SD) 16.2 (2.88)
Ever Bed-Share
Univariable analyses (Table 3) demon-
father drinks alcohol in the evenings, Statistical Analysis strated that mothers who ever bed-shared
breastfeeding duration, infant sleeps were more likely to (1) be Pakistani
Univariable logistic regression was used
in own room, and infant’s age at com- (odds ratio [OR] = 1.92, 95% confidence
to investigate the association between
pletion of questionnaire. If data were interval [CI] 1.48–2.48), (2) have fur-
each of the potential risk factors and the
missing on any of the potential risk ther or higher educational qualifica-
3 outcomes (ever bed-share, regular
factors, they were excluded from tions (OR = 1.62, 95%CI 1.21–2.18), (3)
bed-share, and ever sofa-share).
be primiparous (OR = 1.40, 95% CI 1.03–
analysis (n = 173); this resulted in 2000 Multivariable models were constructed 1.90) or grand-multiparous (OR = 1.60,
mothers being included in the analysis: using a backward stepwise procedure.
885 (44.3%) white British and 1115 All variables with a significance level of TABLE 2 Prevalence of Cosleeping Variables
(55.8%) Pakistani. We did not have ac- P , .05 were included in the multi- Outcome n %
cess to data regarding maternal pre- variable model and variables with a
Ever bed-share 310 15.5
natal smoking. In general, fewer than significance level of P . .1 were re- Regularly bed-share 143 7.2
4% of Pakistani women smoked before moved from the model. The final model Ever sofa-share 188 9.4
pregnancy. was chosen when no further variables Ever bed-share and ever sofa-share 27 1.4
PEDIATRICS Volume 129, Number 3, March 2012 e675
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015Adjusted ORs (Table 6) for variables
that remained significant in the multi-
variable analyses indicate that mothers
who ever sofa-shared with an infant
were more likely to be (1) smokers (OR
= 1.79, 95% CI 1.14–2.80) or (2) those
who breastfed for more than 1 week (OR
= 1.56, 95% CI 1.04–2.35) or 8 weeks (OR
= 1.76, 95% CI 1.19–2.58) and less likely
to be Pakistani (OR = 0.21, 95% CI 0.14–
0.31) or single mothers without a part-
ner (OR = 0.50, 95% CI 0.29–0.87).
FIGURE 1 Ethnicity, Breastfeeding, and
Prevalence of cosleeping practice by ethnic group.
Bed-Sharing
Women who never breastfed, or did so
95% CI 1.10–2.35), and (4) have a partner (OR = 0.39, 95% CI 0.21–0.71), for less than 1 week, had the lowest
breastfed for more than a week (OR = and (2) for the father to consume al- proportions of all forms of sleep-
1.48, 95% CI 1.03–2.13) or at least 8 cohol on a regular basis (OR = 0.45, sharing (Fig 2); however, in multivari-
weeks (OR = 3.51, 95% CI 2.63–4.69). 95% CI 0.22–0.94) (Table 3). able analysis, for ever bed-sharing,
These mothers were less likely to (1) be Adjusted odds ratios (Table 5) for var- only those who breastfed for 8 weeks
,20 years of age (OR = 0.50, 95% CI iables that remained significant in the or more had a significant increase (OR
0.25–0.98), (2) not be living with multivariable analyses indicate that = 3.17, 95% CI 2.34–4.30); those who
a partner (OR = 0.55, 95% CI 0.36–0.84), mothers who regularly bed-share were breastfed for fewer than 8 weeks were
or (3) have their infant sleep in a room more likely to (1) be Pakistani (OR = not significantly different from those
alone (OR = 0.59, 95% CI 0.38–0.92). 3.02, 95% CI 1.96–4.66), (2) have further who did not breastfeed. The same was
Adjusted odds ratios (Table 4) indicate or higher educational qualifications true for regular bed-sharing (breast-
that mothers who ever bed-shared (OR = 1.62, 95% CI 1.03–2.57), and (3) feeding for 8 or more weeks, OR = 3.06,
with their infants were more likely to have breastfed for at least 8 weeks (OR 95% CI 2.00–4.66). For sofa-sharing,
(1) be Pakistani (OR = 2.09, 95% CI 1.47– = 3.06, 95% CI 2.00–4.66). both breastfeeding groups ever
2.97), (2) be living with a partner (not shared a sofa more than those who did
married) (OR = 1.59, 95% CI 1.01–2.51), Sofa-Share not breastfeed (1,8 weeks, OR = 1.04,
(3) be first-time mothers (OR = 1.46, Mothers who sofa-shared with their 95% CI 1.04–2.35; 8 weeks or more, OR =
95% CI 1.06–2.02), and (4) have breast- infants had characteristics different 1.76, 95% CI 1.19–2.58) (Tables 4–6).
fed for at least 8 weeks (OR = 3.17, 95% from those who ever or regularly bed- There is some evidence (Figs 3 and 4) of
CI 2.34–4.30). shared. Univariable analysis (Table 3) significant interaction between ethnicity
found sofa-sharing mothers (1) to be and breastfeeding for ever bed-share
Regular Bed-Share unmarried but cohabiting with a part- (Wald P value for interaction term =
Mothers who regularly bed-shared are ner (OR = 2.14, 95% CI 1.51–3.03), (2) to .0979) and regular bed-share (Wald
a subset of those who ever bed-shared. be smokers (OR = 2.21, 95% CI 1.48– P value for interaction term = .0629);
Univariable analyses reflect many of the 3.30), (3) to consume alcohol regularly among women who breastfed for 8 or
characteristics of the larger ever bed- (OR = 2.87, 95% CI 1.88–4.37), (4) to know more weeks, white British women were
share group in terms of ethnicity, ma- their infant’s father consumes alcohol more likely to ever and regularly bed-
ternal age, education, high parity, longer regularly (OR = 2.99, 95% CI 2.07–4.32), share than Pakistani women. This
breastfeeding duration, and infant sleep and (5) to have their infant sleep in his suggests that the association between
location (see Table 3). In addition, mothers or her own room (OR = 2.44, 95% CI bed-sharing and breastfeeding differs
who regularly bed-shared were more 1.68–3.55). Sofa sharers were signifi- between the white British and Pakistani
likely to be non-English speakers (OR = cantly less likely to be Pakistani (OR = groups; however, the study was not
2.19, 95% CI 1.52–3.17), and less likely 0.24, 95% CI 0.17–0.34) and non-English specifically powered to detect this in-
(1) to be unmarried but living with speakers (OR = 0.39, 95% CI 0.23–0.65). teraction.
e676 BALL et al
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015ARTICLE
TABLE 3 Results From Univariable Logistic Regression Analyses for All Outcomes
Variable Category Ever Bed Shares Regular Bed Share Ever Sofa Share
OR 95% CI OR 95% CI OR 95% CI
Ethnic group White British 1 — 1 — 1 —
Pakistani 1.92 (1.48–2.48) 3.52 (2.31–5.37) 0.24 (0.17–0.34)
Mother’s age, y ,20 0.50 (0.25–0.98) 0.10 (0.01–0.74) 1.03 (0.51–2.08)
20–24 0.74 (0.54–1.02) 0.69 (0.44–1.08) 0.82 (0.54–1.24)
25–29 1 — 1 — 1 —
30–34 0.91 (0.66–1.27) 0.69 (0.42–1.11) 1.24 (0.83–1.85)
35+ 1.15 (0.80–1.68) 1.43 (0.89–2.30) 1.49 (0.94–2.34)
Language baseline completed English 1 — 1 — 1 —
Non-English 1.30 (0.97–1.74) 2.19 (1.52–3.17) 0.39 (0.23–0.65)
Marital and cohabitation status Married and living with partner 1 — 1 — 1 —
Not married and living with partner 0.71 (0.51–1.00) 0.39 (0.21–0.71) 2.14 (1.51–3.03)
Not living with partner 0.55 (0.36–0.84) 0.66 (0.38–1.15) 1.05 (0.65–1.69)
Mother’s educational qualifications None 1.02 (0.67–1.55) 2.07 (1.20–3.59) 0.85 (0.51–1.40)
Secondary school 1 — 1 — 1 —
Further and higher 1.62 (1.21–2.18) 2.05 (1.31–3.20) 1.09 (0.77–1.55)
Other 1.26 (0.82–1.94) 1.37 (0.71–2.64) 1.10 (0.66–1.82)
Don’t know 1.89 (0.79–4.50) 2.11 (0.61–7.33) 0.99 (0.29–3.34)
Index of Multiple Deprivation quintile 1 (least deprived) 1 — 1 — 1 —
2 2.47 (0.67–9.20) 0.95 (0.08–10.80) 0.73 (0.22–2.41)
3 1.53 (0.44–5.29) 1.76 (0.22–14.05) 1.15 (0.42–3.15)
4 2.67 (0.80–8.95) 3.03 (0.40–22.91) 0.89 (0.33–2.40)
5 (most deprived) 2.13 (0.65–6.99) 3.20 (0.43–23.54) 0.53 (0.20–1.40)
Mother currently smokes No 1 — 1 — 1 —
Yes 0.70 (0.45–1.09) 0.50 (0.24–1.03) 2.21 (1.48–3.30)
Father currently smokes No 1 — 1 — 1 —
Yes 1.06 (0.78–1.44) 1.13 (0.74–1.71) 1.28 (0.89–1.83)
Mother drinks alcohol in evenings Never and rarely 1 — 1 — 1 —
Some evenings and more often 0.86 (0.53–1.38) 0.70 (0.34–1.46) 2.87 (1.88–4.37)
Father drinks alcohol in evenings Never and rarely 1 — 1 — 1 —
Some evenings and more often 0.80 (0.53–1.20) 0.45 (0.22–0.94) 2.99 (2.07–4.32)
Birth weight Per kg increase 0.98 (0.78–1.22) 0.96 (0.70–1.31) 1.11 (0.84–1.47)
Gestational age Per wk increase 0.97 (0.91–1.04) 0.94 (0.86–1.03) 0.97 (0.89–1.06)
Parity 0 1.40 (1.03–1.90) 1.25 (0.81–1.95) 0.91 (0.64–1.30)
1 1 — 1 — 1 —
2 1.27 (0.87–1.87) 1.37 (0.81–2.32) 0.58 (0.35–0.97)
3+ 1.60 (1.10–2.35) 1.72 (1.02–2.90) 0.85 (0.53–1.36)
Breastfeeding, wk Never & ,1 1 — 1 — 1 —
1,8 1.48 (1.03–2.13) 1.27 (0.72–2.22) 1.33 (0.90–1.97)
$8 3.51 (2.63–4.69) 3.79 (2.51–5.73) 1.34 (0.95–1.90)
Infant sleeps in own room No 1 — 1 — 1 —
Yes 0.59 (0.38–0.92) 0.49 (0.25–0.98) 2.44 (1.68–3.55)
Infant age at completion of survey Per 1-wk increase 0.99 (0.95–1.03) 1.00 (0.99–1.01) 0.93 (0.88–0.98)
DISCUSSION
characteristic was that both groups sleeping with their infants in more
Bed-Sharing Versus Sofa-Sharing included mothers who were more likely hazardous situations.18
Mothers who bed-shared and sofa- to have breastfed their infant: bed- In the United Kingdom, researchers
shared with their infants comprised sharers for at least 8 weeks and sofa- confirmed that bed-sharing in combi-
2 groups with little overlap: very few sharers for at least a week. That smokers nation with smoking was associated
mothers reported ever doing both. may sofa-share is not surprising, given with an increased risk of SIDS (OR =
Multivariable logistic regression reveals that they are specifically advised not 12.35, 95% CI 7.41–20.59) but found no
that mothers who ever bed-shared were to bed-share. That a group of breast- increase in risk for infants of parents
more likely to be Pakistani and first-time feeding mothers slept with their infants who did not smoke (OR = 1.08, 95% CI
mothers. In contrast, mothers who ever on sofas is consistent with the sugges- 0.45–2.58).18 In 2006, the same team
sofa-shared were more likely to be tion that some breastfeeding mothers reported that over a 20-year period in
white British, smokers, and living with are doing so in an attempt to avoid bed- the United Kingdom, the proportion of
a partner (not married). The only shared sharing and inadvertently ending up children who died of SIDS while sleeping
PEDIATRICS Volume 129, Number 3, March 2012 e677
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015TABLE 4 Results From Multivariable Logistic Regression Analyses for Ever Bed Sharing SIDS infants who died while sleep-
Variable Category Adjusted sharing on a sofa.18 The results of the
OR 95% CI current study support the conclusion
Ethnic group White British 1 —
that bed-sharing and sofa-sharing are
Pakistani 2.09 (1.47–2.97) practiced by different families under
Marital and cohabitation status Married and living with partner 1 — different circumstances. This hetero-
Not married and living with partner 1.59 (1.01–2.51)
geneity would imply that bed- and sofa-
Not living with partner 1.07 (0.67–1.71)
Mother’s educational None 0.86 (0.55–1.33) sharing should not be combined in
qualifications Secondary school 1 — studies on infant sleep safety and SIDS,
Further and higher 1.34 (0.98–1.83) and casts doubt on the validity of pre-
Other 1.41 (0.91–2.21)
Don’t know 1.86 (0.75–4.58) vious studies where bed- and sofa-
Parity 0 1.46 (1.06–2.02) sharing have been combined.
1 1 —
2 1.22 (0.82–1.82) Bed-Sharing, Ethnicity, and
3+ 1.49 (0.99–2.25)
Sociodemographics
Breastfeeding, wk Never & ,1 1 —
1,8 1.40 (0.97–2.03) Parents who ever, or regularly, bed-
$8 3.17 (2.34–4.30)
shared in the current study were
different from those who are charac-
TABLE 5 Results From Multivariable Logistic Regression Analyses for Regular Bed Sharing terized as bed-sharers in US studies of
Variable Category Adjusted infant care. Our data show that infants
of teenage mothers, single mothers, and
OR 95% CI
fathers who consumed alcohol were the
Ethnic group White British 1 —
Pakistani 3.02 (1.96–4.66)
least likely to bed-share, whereas being
Mother’s educational None 1.66 (0.95–2.92) the infant of a highly educated mother,
qualifications Secondary school 1 — a first-time mother, being breastfed, or
Further and higher 1.62 (1.03–2.57)
being of Pakistani origin was associated
Other 1.66 (0.85–3.26)
Don’t know 1.89 (0.53–6.82) with being more likely to bed-share. In
Breastfeeding, wk Never & ,1 1 — the US Infant Feeding Practices Survey
1,8 1.15 (0.65–2.02) II, non-Hispanic black mothers were
$8 3.06 (2.00–4.66)
more likely to bed-share, as were lower-
income women, unmarried women, and
TABLE 6 Results From Multivariable Logistic Regression Analyses for Ever Sofa Sharing those who breastfed or smoked.31 Other
Variable Category Adjusted US studies report the prevalence of bed-
OR 95% CI sharing in the United States is higher
Ethnic group White British 1 —
among mothers who are younger, never
Pakistani 0.21 (0.14–0.31) married, have less than a high school
Marital and cohabitation status Married and living with partner 1 — education, lower household incomes,
Not married and living with partner 0.82 (0.54–1.23)
are of black or Asian ethnicity, or live in
Not living with partner 0.50 (0.29–0.87)
Mother currently smokes No 1 — southern states.2,12 McCoy et al2 repor-
Yes 1.79 (1.14–2.80) ted that breastfeeding was associated
Breastfeeding, wk Never & ,1 1 — with bed-sharing throughout the first 6
1,8 1.56 (1.04–2.35)
$8 1.76 (1.19–2.58) months of life; breastfeeding was sig-
Infant age at completion of survey Per 1-wk increase 0.95 (0.90–1.00) nificantly associated with bed-sharing
among white non-Hispanic and Asian
mothers, but not among black and His-
with their parents rose from 12% to of sleep-sharing occur on sofas. A sub- panic mothers. Young maternal age and
50%, whereas the absolute number sequent study on hazardous sleeping unmarried status were associated with
of SIDS deaths in the parental bed environments identified a significant bed-sharing among black non-Hispanic
halved,30 and deaths of infants sleeping interaction between sleep-sharing deaths mothers. In the United States, therefore,
with their parents on a sofa increased, and recent parental use of alcohol or bed-sharing is often characterized as
suggesting the most dangerous forms drugs, and an increased proportion of being practiced by young, unmarried,
e678 BALL et al
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015ARTICLE
Zealand Cot Death study revealed that
bed-sharing was a SIDS risk in Maori
families among whom maternal smok-
ing was common, but not for Pacific
Islanders who bed-share but do not
smoke.8,13,32 In contrast, although the
SIDS rate in the 1990s for US black
infants was twice that for white infants,
the Chicago Infant Mortality Study found
no interaction between bed-sharing and
maternal smoking either during preg-
nancy or postpartum; only bed-sharing
with individuals other than parents was
FIGURE 2 identified as a SIDS risk factor in mul-
Prevalence of cosleeping practice by breastfeeding duration. tivariate analysis.3 South Asian infants
in the United Kingdom generally,33 and
Bradford specifically, have a lower SIDS
Ever bed share
9
rate than white British infants (0.2/1000
8 vs 0.8/1000 per annum, 2003–2008,
7
6 Bradford and Airedale District, com-
5
piled by E.M., Bradford SUDI pediatri-
OR
4
3 cian, based on unpublished data from
2
1 births and deaths registry). Pakistani-
0 origin mothers in Bradford rarely
Never & < 1-8 weeks 8+ weeks Never & < 1-8 weeks 8+ weeks
1 week 1 week smoke and neither mothers nor fathers
White Pakistani consume alcohol.34 Pakistani infants
were much more likely to bed-share
FIGURE 3
Interaction between breastfeeding duration and ethnicity on association with ever bed-sharing. than sofa-share. Ethnic minority practi-
ces with regard to sleep-sharing in the
United Kingdom are therefore different
Regular bed share from those defined among minority
30 groups in New Zealand and the United
25 States. It should not be assumed that
20
families who bed-share have similar
OR
15
characteristics or outcomes across
10
different geographic locations and care
5
should be taken in generalizing the
0
Never & < 1-8 weeks 8+ weeks Never & < 1-8 weeks 8+ weeks findings across different minority eth-
1 week 1 week
nic groups
White Pakistani
Bed-Sharing and Breastfeeding
FIGURE 4
Interaction between breastfeeding duration and ethnicity on association with regular bed-sharing. Multiple studies have documented an
association between bed-sharing and
poorly educated mothers from minority between bed-sharing and SIDS are breastfeeding.1–6,30,34–36 The current study
ethnic groups living in circumstances of clearly demonstrated in particular cul- reinforces this association and suggests
socioeconomic deprivation, and by mo- tures and circumstances. For example, that the interaction between breastfeed-
thers who breastfeed. in New Zealand bed-sharing is a common ing and bed-sharing (especially regular
In the United Kingdom, as in the United practice for both Maori and Pacific bed-sharing) is greater for white British
States and New Zealand, bed-sharing is Islanders; however, only among the than Pakistani mothers who breastfeed
a cultural practice among particular Maori population is bed-sharing linked for more than 8 weeks. It is beyond the
ethnic minority groups. Associations with an increased risk of SIDS.8 The New scope of this study to determine causality
PEDIATRICS Volume 129, Number 3, March 2012 e679
Downloaded from pediatrics.aappublications.org by guest on March 5, 2015or conclude that less bed-sharing would cross-sectional nature of our data28; behaviors such as smoking and alcohol
lead to less breastfeeding. however, this study also presents consumption.18
Although no case-control studies have a major strength as the largest study of Our data led us to challenge the notion
calculated odds ratios for SIDS risk Pakistani families in the United King- that assumptions and guidance about
among breastfeeders who bed-share, dom, who comprise the second largest infant care practices can or should be
breastfeeding has generally been found minority ethnic group in the United exported from one cultural setting
to reduce the risk of SIDS.25,37 Data Kingdom (after Indian families). Infants (such as the United States) to another
from the Alaska Pregnancy Risk As- belonging to the highest SIDS-risk cat- (such as the United Kingdom). Evidence
sessment Monitoring System survey egories are underrepresented in the
regarding the nature and extent of
suggest a maximum potential risk of sample,28 and we may therefore have
parent-infant sleep contact and related
bed-sharing–related SIDS among non- underestimated the extent of the re-
behaviors is crucial in ascertaining
smoking mothers is likely to be ,1 in lationship between some behaviors.
whether infants are at risk in shared-
10 000.38 Caution should therefore be Although we examined who was most
sleep scenarios, and in tailoring ad-
taken in making sweeping recommen- likely to bed-share, we did not ask op-
vice to parents.
dations regarding the avoidance of bed- erational questions about bed-sharing,
sharing, which does not appear to carry such as firmness of mattresses, and types
the same risk for all families, and may of bedding used. Although Pakistani fam- CONCLUSIONS
lead to unintended consequences, such ilies in the United Kingdom have an in-
as reduced breastfeeding, or adoption creased prevalence of bed-sharing and This study supports the view that bed-
of more risky strategies, such as sofa- a lower incidence of SIDS, it is beyond sharing and sofa-sharing are distinct
sharing. The American Academy of Pe- the scope of this study to determine if practices, which ought not to be com-
diatrics’ position on bed-sharing reflects there are specific differences in the bined in studies of unexpected infant
the characteristics of mothers who practices of bed-sharing that contribute deaths as a single exposure. Sleep-
sleep-share with infants in the United to this association. We also cannot ad- surface sharing practices in the UK
States and how they do so,22 yet not all dress reports that younger infants may Pakistani community differ from those
sleep-sharing is inherently risky, even be more vulnerable to bed-sharing–re- of the UK majority community, and from
within the United States. Data from lated SIDS than older infants, as we did those of minority communities in the
Alaska led researchers to conclude: not question families about the age of United States. Health policy makers
“Among parents who do not use tobacco, infants when sleep-sharing began.16 should exercise caution in generalizing
alcohol or other drugs, sleeping with The current study supports the con- SUDI/SIDS risk factors across pop-
their infant is a perfectly reasonable clusions of previous studies that in ulations with differing risk factor pro-
and potentially beneficial option”.38 the United Kingdom emphasis on un- files. Care should therefore be taken in
We are aware of the limitations of safe sleep-sharing should predomi- adopting SUDI/SIDS reduction guide-
telephone survey methods, and the nantly target sofa-sharing and parental lines from other contexts.
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(Continued from first page)
Address correspondence to Helen L. Ball, MA, PhD, Professor of Anthropology, Parent-Infant Sleep Laboratory and Medical Anthropology Research Group, Dawson
Building, South Rd, Durham University, Durham, UK DH1 3LE. E-mail: H.L.Ball@dur.ac.uk
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDED: Funded by the Foundation for the Study of Infant Deaths (FSID), United Kingdom.
PEDIATRICS Volume 129, Number 3, March 2012 e681
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DOI: 10.1542/peds.2011-1964
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Downloaded from pediatrics.aappublications.org by guest on March 5, 2015Bed- and Sofa-Sharing Practices in a UK Biethnic Population
Helen L. Ball, Eduardo Moya, Lesley Fairley, Janette Westman, Sam Oddie and John
Wright
Pediatrics 2012;129;e673; originally published online February 20, 2012;
DOI: 10.1542/peds.2011-1964
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
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published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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