Following the recent publication of a study in the Lancet (1) on Sudden Infant Death among bed-sharing babies and a subsequent meeting at the National Patient Safety Agency to consider guidance on bed-sharing, the UNICEF UK Baby Friendly Initiative has issued the following statement:

In recognition of the fact that mother-infant bed-sharing appears to be associated with longer and more successful breastfeeding, the UNICEF UK Baby Friendly Initiative has for some time been working to help health professionals enable breastfeeding mothers to share a bed with their baby whilst maintaining the safest possible environment. A sample bed-sharing policy has been developed for hospitals and a leaflet for parents produced with the Foundation for the Study of Infant Deaths (FSID). Both documents are designed to promote safety while protecting breastfeeding, by educating health professionals and parents on the benefits and contra-indications to bed sharing and the safety issues related to it. UNICEF has also been urging NHS trusts to acknowledge the need to provide training for health professionals on all aspects of bed-sharing, including effective communication to parents of key messages appropriate to their needs and circumstances.

The Lancet paper suggested a slight increase in the risk of sudden infant death among babies of non-smoking mothers who bed-shared all night in the first eight weeks of life. This was followed by a large amount of publicity and media coverage advising against bed sharing.

At present, the UNICEF UK Baby Friendly Initiative is unable to support blanket recommendations against bed sharing in the early weeks for the following reasons:

• There is some controversy as to whether the results of the Lancet study clearly and unambiguously indicate an increased risk of bed sharing with non-smoking parents in the absence of other known risk factors. There is serious disagreement among the study authors about the statistical methods employed, the significance of the findings and their implications for parents. Similar concerns have also been raised about a forthcoming Scottish study on the same subject. Until these issues are resolved, it remains inappropriate to give advice to parents based on the results of this study.
• There is concern that simply advising parents against bed sharing without giving practical information about how to cope with a very young baby at night may increase risk. Breastfed babies often feed frequently and for long periods in the first few weeks after delivery. Breastfeeding can also have a soporific effect on the mother (this is nature's way of allowing her to rest). If mothers feel that they must not bed share there is a least a theoretical risk that they will sit on a sofa or chair and fall asleep there, putting their babies in far more danger than if they had shared a bed. There is an additional concern that the sleep deprivation caused by sitting up for large parts of the night will drive mothers to eventually either ignore the recommendation and take their baby into bed when they are excessively tired (a known risk factor) or to give up breastfeeding.
• Bottle fed babies are significantly more likely to suffer infections and respiratory illness both of which put young babies at risk (2). There is evidence that bottle-fed babies are not as easily roused from sleep as those who are breastfed which again could put babies at risk (3). The health benefits of breastfeeding to mothers and babies are considered so great that targets for increasing breastfeeding have been set in the UK and health professionals all over the country are working hard to achieve them.

There is anecdotal evidence that health professionals may simply advise parents against bed sharing if they perceive it to be banned or discouraged at an institutional or national level. This means that parents are denied a full discussion about important topics such as the benefits, contraindications and safety issues. Parents may also be less likely to raise the subject for fear of disapproval. Nevertheless, recent research conducted in the UK (4) indicates that while all-night bed sharing is relatively unusual, it is very common for parents to take their baby into bed for shorter periods at night, particularly for breastfeeding, comforting and settling babies.

It is therefore essential that the benefits, risks and alternatives to bed sharing are carefully weighed and that parents be given full information appropriate to their needs in order to encourage safe practice and to protect breastfeeding. The UNICEF UK Baby Friendly Initiative recommends that:

• Health professionals should ensure that parents are given full information about this issue in the antenatal and early postnatal period. Community staff should reinforce the information once mothers and babies are at home. The UNICEF/FSID leaflet 'Sharing a bed with your baby' is designed to support this.
• All NHS Trusts should develop guidelines for staff in order to ensure safe and appropriate practice both in hospital and at home.
• Trusts should provide all relevant health care staff with adequate education to allow them to discuss this issue with all parents as appropriate to their needs.

UNICEF recommends that discussions with parents about bed sharing should address the following factors:

• the circumstances under which co-sleeping should be discouraged (parental smoking, alcohol or drug consumption, excessive tiredness, inappropriate sleep surfaces such as sofas, etc)
• the use of bed sharing as a care strategy for breastfeeding mothers and babies
• the additional risk of accidents if a baby sleeps in an adult bed, coupled with support to avoid or minimise these risks

UNICEF has suggested to the Royal College of Midwives and the Community Practitioners' and Health Visitors' Association that talks continue to ensure that adequate guidance on bed sharing be available to health professionals, including the issue of effective risk assessment for all mothers and babies.

All interested parties have agreed that the joint UNICEF/FSID leaflet 'Sharing a bed with your baby' provides clear, comprehensive and evidence-based information for parents and that it should continue to be used. UNICEF will continue to monitor research developments to ensure that the leaflet remains evidence-based.

UNICEF further recommends that all future research into infant death and sleeping environments should unambiguously record data on all important factors, which must include the baby's sleep surface, maternal and paternal smoking status, alcohol and drug consumption and infant feeding method. These factors should be recorded at the time of infant death (rather than relying on data for other periods such as feeding method at delivery or smoking status during pregnancy) and the results should be adjusted to control for them.