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Safe Infant Sleeping

What is the Ideal Sleeping Environment?

INtroduCtIoNAlthough many organizations, including the American Acad-emy of Pediatrics (AAP, 2005), Health Canada (2008) and the Canadian Paediatric Society (CPS, 2004), have issued state-ments saying that the safest sleeping environment for an infant during the first year of life is a crib, bedsharing appears to be a common and increasing practice within North American soci-ety and across cultures (Ateah & Hamelin, 2008; Lahr, Rosen-berg, & Lapidus, 2005; Nelson, Taylor, & International Child Care Practices Study Group, 2001). Bedsharing is defined as a sleeping arrangement in which an infant shares the same sleep-ing surface with another person, usually a parent (CPS). The prevalence of this controversial practice is becoming evident through the examination of infant deaths caused by sudden in-fant death syndrome (SIDS) (Blair et al., 2009).

The relationship between bedsharing and SIDS is a com-plex, debated issue in the literature today. SIDS, defined as “the sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death

scene and review of the clinical history” (AAP, 2005, p. 1245), is the leading cause of postneonatal death in Canada (Health Canada, 2004). Lack of adherence to this definition has meant that some bedsharing deaths caused by suffocation or asphyxia are labeled as SIDS (Blanchard & Vermilya, 2007). Although SIDS rates decreased from the 1990s to the early 2000s, the in-cidence of SIDS has leveled off over the past couple of years (National Institute of Child Health and Human Development [NICHD], 2006). Several risk factors, such as maternal smok-ing during pregnancy (Carpenter et al., 2004; Mitchell, 2006; Ruys, de Jong, Brand, Engelberts, & Semmekrot, 2007; Ven-nemann et al., 2005), prone sleep position (AAP; CPS, 2004), breastfeeding less than 2 weeks, and low birth weight (Venne-mann et al.), have been identified and linked to an increased risk for SIDS. It is possible that while we are educating families about these specific risks, we have failed to address other safety issues, such as bedsharing.

Nurses are in a position of influencing the sleep behavior of parents and infants, but mixed messages from the literature

• Bedsharing poses many risks to infant health and safety.

• Despite the risks, some parents choose to bed-share for a variety of reasons.

• Nurses can help new parents find ways to be close to their sleeping infants without incurring the risks of bedsharing.

Bottom Line

122 © 2010, AWHONN http://nwh.awhonn.org

Lindsey Hoogsteen, RN, is a master of nursing student at the University of Manitoba in Winnipeg, Canada, and is supported by a graduate scholar-ship from the Foundation for Registered Nurses of Manitoba, Inc. The au-thor and planners of this activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this learn-ing activity. Address correspondence to: umhoogsl@cc.umanitoba.ca.

DOI: 10.1111/j.1751-486X.2010.01525.x

objectivesUpon completion of this activity, the learner will be able to:

1. Define and understand common terms describing infant sleeping arrangements.

2. Describe the most recent guidance from U.S. and Canadian health care organizations regarding safe infant sleeping environments.

3. List and describe the potential risks and benefits of bedsharing.

4. List ways nurses can help counsel new parents about safe infant sleeping.

Continuing Nursing Education (CNE) Credit

A total of 2 contact hours may be earned as CNE credit for reading “Safe Infant Sleeping: What is the Ideal Sleeping Environment?” and for completing an online post-test and participant feedback form.

To take the test and complete the participant feedback form, please visit http://JournalsCNE.awhonn.org. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees.

AWHONN is accredited as a provider of continu-ing nursing education by the American Credential-ing Center’s Commission on Accreditation.

Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity.

AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama #ABN0058.

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can be confusing to nurses working within a hospital or com-munity setting. Despite the guidance from the AAP and CPS, it is a fact that some mothers engage in bedsharing. As nurses, we must take an individualized approach toward patient educa-tion, while still promoting evidence-based recommendations.

BaCkgrouNd oN INfaNt SlEEpINg rECommENdatIoNSIn a response to epidemiologic data from Europe and Australia, in 1992 the AAP recommended that all infants be placed in a nonprone position (i.e., side or supine) to sleep in order to reduce the risk of SIDS (AAP, 2005). At this time, 13 percent of families in the United States reported putting their baby to sleep in a supine position (NICHD, 2006). In 1994, the “Back to Sleep” public awareness campaign was initiated in the United States; Canada launched its own “Back to Sleep” campaign in 1999, after there were 154 SIDS deaths in Canada in 1998 (Sta-tistics Canada, 2004).

In 2000, the AAP revisited its policy statement on SIDS and sleeping arrangements and, on the basis of new evidence, stated that infants have the lowest risk of SIDS when they are placed on their back to sleep. However, if the side position was to be used, the AAP advised that caregivers should bring the dependent arm forward to reduce the likelihood of infants roll-ing on their stomachs (AAP, 2000). By 2003, the SIDS rate in the United States had declined 50 percent from when the “Back to Sleep” campaign began (NICHD, 2006), and in Canada the number of deaths from SIDS dropped from 327 in 1992 to 62 in 2003 (Statistics Canada, 2004).

In 2004, the CPS issued a position statement on safe sleep-ing environments for infants and children. This policy explored the issues of bedsharing and cosleeping and provided recom-mendations for a safe sleeping environment. In 2005, the AAP once again addressed its position statement on SIDS and made further adjustments. This time the AAP no longer recognized the side sleeping position as an acceptable alternative to supine. Additionally, it advised all caregivers to avoid soft bedding and it reviewed the hazards of adult/infant sleeping arrangements. In 2008, Health Canada issued a safe sleeping statement that stated that the safest place for infants to sleep is alone in a crib and that they should never be placed to sleep on unsuitable surfaces, such as a standard bed, water bed, air mattress, sofa, futon or armchair (Health Canada, 2008).

While the “Back to Sleep” campaign proved to be very ef-fective in lowering the occurrence of SIDS, the strong state-ments made against bedsharing, like the one by Health Canada (2008), caused some debate. Organizations such as the UNICEF U.K. Baby Friendly Initiative felt that this one-sided approach to bedsharing was not appropriate and made it very difficult to maintain its position that providing a safe sleeping environ-ment is possible while bedsharing (United Nations Children’s Fund [UNICEF], 2004).

prEvalENCE of BEdSharINgHistorically, breastfeeding mothers have slept with their infants in the same bed, because this close physical contact allows a mother to provide the infant with warmth, nutrition and pro-tection (Thoman, 2006). When formula feeding became more popular in Western societies, so did crib sleeping in a separate bedroom (Morgan, Groer, & Smith, 2006; Thoman). In the past it has been difficult to determine the exact rate of bedsharing due to different but similar terms used within the research. The terms bedsharing, cobedding, rooming-in and cosleeping have all been used interchangeably, each with their different mean-ing. For example, the CPS defines cosleeping as “a sleeping ar-rangement in which an infant is within arm’s reach of his or her mother, but not on the same sleeping surface” (CPS, 2004, p. 659), whereas the Royal College of Midwives defines it as when mother and baby share a bed and one or both of them are asleep (RCM, 2007). Although terms may sound similar, the distinction could mean the difference between life and death for the infant. It is imperative that health care professionals use the same terms with universal definitions in order to avoid con-fusion and mixed messages.

The prevalence of bedsharing is now on the rise in indus-trialized countries (Hauck, Signore, Fein, & Raju, 2008). In the United States bedsharing rates have doubled from 1993 to 2000 from 5.5 percent to 12.8 percent (Willinger, Ko, Hoffman, Kes-sler, & Corwin, 2003). In a recent Canadian study done by At-eah and Hamelin (2008), the authors found that 72 percent of the 293 mothers studied reported bedsharing with their baby on a regular or occasional basis. Although most of the partici-pants agreed that bedsharing carried risks, the majority still practiced this sleeping arrangement. In 2004, Blair and Ball looked into the prevalence and characteristics of bedsharing in England and found that almost half of all infants bedshared at some point with their parents. In the United States, Fu, Col-son, Corwin, and Moon (2008) found that although approxi-mately half of the mothers room-shared without bedsharing,

32 percent still bedshared with their infant despite knowing the increased risk in SIDS. Schluter, Paterson, and Percival (2007) studied the Pacific people of New Zealand and found that 50

Several risk factors, such as maternal smoking during pregnancy, prone sleep

position, breastfeeding less than 2 weeks, and low birth weight have been identified and linked to an increased risk for SIDS

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percent of infants usually bedshared with an adult. Bedsharing is a reality and is occurring worldwide, with the majority of the studies reporting one-third to half of mothers engaging in this practice. Significantly, these studies found that a several moth-ers continue to bedshare even when they are informed of the significant risks that may occur.

BENEfItS of BEdSharINgThe literature has identified multiple benefits to both mothers and infants with regard to bedsharing practices (see Box 1). The main benefit is the facilitation of breastfeeding. One of the first studies to look at breastfeeding and bedsharing was done by McKenna, Mosko, and Richard in 1997. They studied Latino mother-infant pairs and found that infants who bedshared rou-tinely breastfed longer during the night than infants who slept solitarily. The researchers hypothesized that bedsharing may reduce the risk of SIDS, as breastfeeding is thought to be pro-tective against SIDS.

Following this, Chen and Rogan (2004) specifically looked at breastfeeding and postnatal death and found that breastfeed-

ing infants had a decreased risk of postnatal death in the United Sates. This is supported by Ball’s (2003) study that investigat-ed night-time caregiving practices of 253 families during the first 4 months of an infant’s life. She concluded that there was a significant relationship between bedsharing and breastfeed-ing persistency, and supported the hypotheses that bedsharing promotes breastfeeding. Ball, Ward-Platt, Heslop, Leech, and Brown (2006) found that bedsharing promoted more frequent feedings compared with babies who slept on a separate sleep-ing surface in the same room as their mothers, while Blair and Ball (2004) concluded that mothers that bedshared were twice as likely to breastfeed at 3 to 4 months than mothers who slept apart from their infants. These results are significant, because breastfeeding is linked to better physical health, mental ability (Grossman, 2000), protection again infectious diseases and a protection from SIDS (Chen & Rogan).

In addition to increasing breastfeeding rates, bedsharing also promotes skin-to-skin contact, which has been known to contribute to the growth and development of infants, and in maintaining baby temperature and weight gain (Charpak et al., 2005). Ball (2002) also found that bedsharing has positive psy-chological effects on infants and she concluded that bedshar-

ing enabled mothers to settle and better care for their infant in times of an illness. As well, working mothers have found bedsharing to be a time to bond after being away from their infant all day (Ball, 2003; Donohue-Carey, 2002). Bedsharing has also been associated with a more restful maternal sleep that is adaptive to monitoring an infants’ status (Mosko, Richard, & McKenna, 1997) and increasing maternal vigilance (Richard, Mosko, McKenna, & Drummond, 1996). Additionally, Richard et al. looked at 12 Latino breastfeeding mother-infant pairs and found that none of the mothers who bedshared placed their infant in the prone position, which is in contrast to the four infants that were placed prone while solitary sleeping. There-fore, the authors concluded that bedsharing minimizes the use of the prone sleeping position, which is highly correlated with a decrease in SIDS (AAP, 2005, CPS, 2004).

Several other studies have also reported evidence to sup-port the practice of bedsharing. Okami, Weisner, and Olmstead (2002) completed an 18-year longitudinal study showing that bedsharing in infancy was not related to sleep problems, sexual pathology or any other problematic consequences by 18 years of age and they concluded that when engaged in responsible bedsharing, it is a very safe practice. Gessner, Ives, and Perham-Hester (2001) investigated prone sleeping, bedsharing and sleeping outside the crib to SIDS and in the absence of other risk factors (e.g., smoking, drinking) SIDS deaths associated with parental bedsharing were rare. This is echoed by Blair et al. (1999) and James, Klenka, and Manning (2003), who con-cluded that it is the smoking, alcohol consumption and other risk factors that place the infant at risk, not the actual act of sharing a bed with the baby.

rISkS of BEdSharINgIn addition to possible benefits, bedsharing also carries with it certain risks (see Box 1). Multiple studies have examined the association between bedsharing and SIDS, and have yielded mixed results. Vennemann et al. (2005) studied modifiable risk factors for SIDS in Germany and found that bedsharing with an adult was associated with a significantly increased risk of SIDS. Ruys et al. (2007) also found that even after adjusting for breastfeeding and smoking, bedsharing remained a significant risk factor for SIDS for infants under 4 months of age. Tap-pin, Ecob, and Brooke (2005) from Scotland and McGarvey, McDonnell, Hamilton, O’Regan, and Matthews (2006) from Ireland reported increased risks of SIDS for bedsharing infants younger than 11 and 10 weeks, respectively. Although Carpen-ter et al. (2004) did not find an association between SIDS and bedsharing, they did find that there were significant risks for SIDS when smoking or alcohol was combined with bedshar-ing. Although Mosko et al. (1997) reported that bedsharing led to a more restful maternal sleep, Kelmanson (2008) found that bedsharing infants had significantly higher problems with sleep duration and night awaking scores. This Russian study found

It is imperative that health care professionals use the same terms with universal definitions in order to avoid

confusion and mixed messages

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that it was more common for bedsharing infants to sleep too little, wake more often and need more help to fall back asleep after waking.

Bedsharing can pose significant hazards to the infant, in-cluding death due to overlying by a parent, another adult or sibling. In one study, 13 percent of mothers that bedshared re-ported an experience of rolling onto or partway on their infant (Ateah & Hamelin, 2008) and another study noted that babies who bedshared were at an increased risk of adverse affect com-pared with those who coslept (Ball et al., 2006). In addition, the design of an adult bed creates significant risk to an infant (Grossman, 2004). Asphyxia due to an infant becoming en-trapped between the mattress and another object (e.g., wall, footboard, headboard, another piece of furniture) is just one of the risks. Pillows and comforters are also known to cause as-phyxia due to airway obstruction (Nakamura, Wind, & Danello, 1999). Willinger et al. (2003) found that infants who bedshared were three times more likely than those who did not to sleep under two bed covers; soft bedding and high thermal environ-ments can cause an increased risk for SIDS (AAP, 2005).

Bedsharing does pose significant risks to infants. The ar-gument against this is that it is not the actual bedsharing that causes the risks but the factors that surround the practice (e.g., bedding, paternal smoking, nonbreastfeeding and other mater-nal characteristics). Unfortunately, for younger infants, the cor-relation between SIDS and bedsharing is clear and most would agree that it is not acceptable.

rECommENdatIoNSA review of the literature regarding the benefits and risks of bedsharing has resulted in mixed opinions, but a majority of professional organizations express concern for this sleeping practice. The CPS continues to maintain its recommendations for a safe sleeping environment that it issued in its 2004 state-ment, which it reaffirmed in 2009. It concludes that although no sleeping environment is completely risk free, it is recommended that “for the first year of life, the safest place for babies to sleep

is in their own crib, and in the parent’s room for the first six months” (CPS, 2004, p. 662). Although the CPS acknowledges that some parents will choose to bedshare, it does not provide health care professionals with any specific instructions regard-ing safe bedsharing strategies. Although it does not endorse bedsharing, the CPS promotes cosleeping, defined as “a sleep-ing arrangement in which an infant is within arm’s reach of his or her mother, but not on the same sleeping surface” (CPS, p. 659), as a safe alternative to bedsharing. Cosleeping has been known to be a protective factor against SIDS and still have the benefits of having the mother in close contact with the infant (AAP, 2005; Blair et al., 1999; CPS; Grossman, 2004).

The AAP has taken a similar position to the CPS; it recom-mends a “separate but proximate sleeping environment” (AAP, 2005, p. 1252) and recommends that infants do not bedshare with an adult or with other children during sleep. In 2008, Health Canada released a consumer information statement that states that the safest place for an infant to sleep is alone in a crib (Health Canada, 2008). Both the Departments of Health in Scotland and the United Kingdom advise that the safest place for a baby to sleep in a cot or crib in the caregivers’ room for the first 6 months of life (Tappin et al., 2005).

UNICEF U.K. Baby Friendly Initiative (2008), the RCM (2007) and the Academy of Breastfeeding Medicine (ABM) (2008) all acknowledge the benefits of bedsharing and provide guidance but express caution regarding this practice. These or-ganizations believe that bedsharing has been seen as a nega-tive practice and discouraged by many public health authorities based on incorrect data and insufficient evidence (ABM). These organizations advocate bedsharing for the benefit of breastfeed-ing, but have specific guidelines for caregivers to follow (ABM; RCM; UNICEF U.K. Baby Friendly Initiative). Safe bedsharing guidelines include recommendations such as sleeping on a firm flat mattress where the infant is unable to fall out of bed or get wedged between the mattress and wall, maintaining a room temperature of 16 to 18°C, not allowing the infant to overheat due to overdressing or blankets covering the baby’s head, and

BOx 1 BENEfItS aNd rISkS of BEdSharINg

BENEfITS

Promotes breastfeeding (more frequent feeds; longer duration of breastfeeding)

Increases bonding time

Promotes skin-to-skin contact

Increases maternal vigilance

Positive psychological changes in infants

RISkS

Increases risk for SIDS (especially younger infants)

Risk of death due to overlaying

Unsafe design of adult beds for infants

Interrupted infant sleeping patterns

Increases risk of asphyxia due to entrapment or airway obstruction

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the removal of all loose bedding and extra pillows. Additional-ly, the guidelines recognize that parent who smoke or are under the influence of alcohol or drugs should never bedshare with their baby. As well, bedsharing should not occur with parents that have any illness or condition that affects their awareness of their baby, those who are unusually tired and would fail to

respond to their baby and those who have chosen to bottle-feed their baby (ABM; Blanchard & Vermilya, 2007; UNICEF U.K. Baby Friendly Initiative).

In relation to bedsharing, there is a general consensus in the literature and from all organizations that bedsharing should not occur with parental smoking, alcohol consumption, illicit or mind-altering drug use, bedsharing on a couch or sofa, with siblings, with soft bedding and surfaces (i.e., waterbeds) or when the adult is extremely fatigued (ABM, 2008; Blanchard & Vermilya, 2007; Carpenter et al., 2004; James et al., 2003; Mor-gan et al., 2006; Ruys et al., 2007).

ImplICatIoNS for NurSESNurses and other health care professionals must be prepared to offer evidence-based advice and education appropriate to individual situations. The literature is clear in showing a link between bedsharing and SIDS among younger infants. Despite these risks, some mothers are still choosing to bedshare. One cannot ignore the benefits of breastfeeding and bedsharing and, in a time when there is strong advocacy for breastfeeding, it is difficult to disregard this positive correlation. But where does this leave nurses who are faced with families choosing to bedshare?

To achieve the benefits of bedsharing without the risk, cos-leeping—defined as having the baby within arm’s reach of his or her mother but not on the same sleeping surface—is the recom-mended choice. In a Western society in which beds are com-monly filled with duvets, comforters and pillows and in which some mothers are engaging in smoking and alcohol use, we need to understand that bedsharing can potentially pose mul-tiple risks to the infant. Being in close proximity to the infant, as in cosleeping, has benefits such as increased breastfeeding frequency (Ball et al., 2006) and decreased risk of SIDS (AAP, 2005; CPS, 2004). Actively promoting cosleeping as a safer al-ternative to bedsharing is one strategy that nurses can use to help ensure infant safety.

Another strategy is to address the reasons why parents are choosing to bedshare. Ball (2002) and Hauck et al. (2008) found that besides breastfeeding, mothers were motivated to bedshare due to infant irritability and illness and to help the mother and infant sleep better. Other authors have found that mothers choose to bedshare for enjoyment, to promote bonding and to increase time spent with the baby (Ball, 2003; Buswell & Spatz, 2007). It can be beneficial for nurses to provide parents with information on how to soothe and comfort their child using other techniques instead of taking them to bed. Although it is uncommon, some families indicated that they chose to bed-share due to not having another place for the baby to sleep. Car-lins and Collins (2007) addressed this issue through the Cribs for Kids campaign, an innovative program aimed at decreasing infant mortality resulting from SIDS and accidental suffocation by providing families in need with cribs.

A third strategy is to strongly advocate parents against couch sharing and other risk factors for SIDS, such as prone sleeping, sleeping on soft surfaces, maternal smoking and ma-ternal impairment due to alcohol or prescription or illegal drug use. Sleeping on a couch is not bedsharing and it is not a safe practice, but according to a study done in the United Kingdom, is causing an increase in the number of infant deaths (Blair, Sidebotham, Berry, Evans, & Flemming, 2006). All literature advocates against couch sharing due to the high correlation between couch sharing and SIDS and the substantial risk for asphyxia or suffocation (AAP, 2005; CPS, 2004; Tappin et al., 2005). Furthermore, nurses should continue to promote the “back to sleep” message. According to the National Infant Sleep Position study, the number of mothers placing their baby in the prone position is on the rise (NISP, 2008). Even if bedsharing, infants must be placed in a supine position while sleeping and, as nurses, we need to continue to strongly advocate for this rec-ommendation to ensure safe infant sleeping habits.

A fourth strategy for nurses is to advocate for hospitals and communities to adopt a protocol for parent education about safe infant sleeping techniques. It is the responsibility of the nurse to provide the family with current information about safe sleeping environments. As nurses, we can take a harm-reduc-

To achieve the benefits of bedsharing without the risk, cosleeping—

defined as having the baby within arm’s reach of his or her mother but not on the same sleeping surface—

is the recommended choice

Recommendations for safe infant sleeping practices are an

important part of the patient education of new parents

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tion approach rather than ignoring something that is occurring and could potentially promote breastfeeding. Nurses ought to “weigh the relative risks and benefits and provide evidence-based information to fit the individual needs and complex so-cial, economic, and cultural context of the family” (Morgan et al., 2006, p. 686). Safe bedsharing techniques include sleeping on a firm, flat mattress with the infant unable to fall or get stuck or wedged between the mattress and another object; having a blanket that does not cover the baby’s head and does not over-heat the baby; having no pillows or loose bedding; having the room temperature at 16 to 18°C; never leaving the baby alone; and ensuring that bottle-fed babies are not bedsharing (ABM, 2008; Blanchard & Vermilya, 2007; UNICEF U.K. Baby Friend-ly Initiative, 2008). Along with this, safe sleeping guidelines and pamphlets on the risk factors for SIDS should be developed to be given out to new mothers.

CoNCluSIoNRecommendations for safe infant sleeping practices are an im-portant part of the patient education of new parents, and this is not the type of information for which “one size fits all.” By assessing families’ socioeconomic status, maternal characteris-tics, cultural beliefs and prior practices, nurses will be able to fully educate parents about recommendations with regard to safe infant sleeping environments. NWH

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Royal College of Midwives. (2007). Position statement: Bed sharing and co-sleeping. Retrieved from http://www.rcm.org.uk/college/campaigns-and-policy/position-statements/?locale=en

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post-test QuestionsInstructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submit-ted to AWHONN will not be accepted.

1. Which of the following is the most accurate description of “bedsharing”?

a. a sleeping arrangement in which an infant shares a bed with another infant

b. a sleeping arrangement in which an infant shares the same sleeping surface with another person, usually a parent

c. a sleeping arrangement in which an infant sleeps in a bed, rather than a crib, with or without other people

2. How does the Canadian Paediatric Society defi ne “cosleeping”?

a. a sleeping arrangement in which an infant is within arm’s reach of his or her parent, but not on the same sleeping surface

b. a sleeping arrangement in which mother and baby share a bed and one or both or them are asleep

c. a sleeping arrangement in which an infant shares a crib with another infant

3. How does the Royal College of Midwives defi ne “cosleeping”?a. a sleeping arrangement in which an infant is within

arm’s reach of his or her parent, but not on the same sleeping surface

b. a sleeping arrangement in which mother and baby share a bed and one or both or them are asleep

c. a sleeping arrangement in which an infant shares a crib with another infant

4. In 1992, when the AAP recommended non-prone sleep-ing positions for infants, what percentage of U.S. families reported putting their babies to sleep in a supine position?

a. 7 percentb. 13 percentc. 21 percent

5. In 2003, by how much had SIDS rates declined in the United States since the inception of the “Back to Sleep” public awareness campaign?

a. 25 percentb. 50 percentc. 75 percent

6. Which of the following is Not one of the updates the American Academy of Pediatrics made to its position on infant sleeping in 2005?

a. It advised all caregivers to avoid soft bedding.b. It no longer recognized the side sleeping position as

an acceptable alternative to supine. c. It recommended bedsharing as a way to promote

breastfeeding.

7. In what year did Health Canada issue a statement saying that the safest place for an infant to sleep is alone in a crib?

a. 1992b. 2003c. 2008

8. Historically why have breastfeeding mothers slept with their infants in the same bed?

a. doctors recommended itb. to help their infants maintain a supine sleeping positionc. to provide provide warmth, nutrition and protection

9. from 1993 to 2000, bedsharing rates in the U.S. increased from ___ to ___ ?

a. 3.5 percent to 7.8 percentb. 5.5 percent to 12.8 percentc. 7.5 percent to 15 percent

10. In a Canadian study published in 2008, what percentage of the 293 mothers studied reported bedsharing with their baby on a regular or occasional basis?

a. 27 percentb. 59 percentc. 72 percent

11. Which of the following is a potential benefi t of bedsharing? a. increased maternal stressb. increased maternal wakefulnessc. increased maternal vigilance

12. Which of the following is Not a potential risk of bedsharing?a. increased risk of asphyxiation b. increased risk of irregular infant feeding patternc. increased risk of SIDS

13. Which of the following can increase the risks associated with bedsharing?

a. bright lightsb. fi rm beddingc. parental fatigue

14. When counseling mothers who choose to bedshare with their infants, what can nurses discuss as a safer alternative?

a. sleeping in the same room with the infant but on a different sleeping surface

b. sleeping with the infant but only on a large (queen- or king-size) bed

c. sleeping with the infant on a hard sofa instead of a soft bed

15. What is a strategy nurses can use when educating parents who bedshare about infant sleeping arrangements?

a. discuss the reasons why the parents are choosing bedsharing

b. state the current AAP recommendations but do not discuss the issue further

c. refer parents with questions about bedsharing to the pediatrician