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Sleep Medicine Reviews 32 (2017) 4e27

Contents lists available at ScienceDirect

Sleep Medicine Reviews


journal homepage: www.elsevier.com/locate/smrv

CLINICAL REVIEW

Parent-child bed-sharing: The good, the bad, and the burden of


evidence
Viara R. Mileva-Seitz a, b, *, Marian J. Bakermans-Kranenburg a, Chiara Battaini c,
Maartje P.C.M. Luijk b, d, e
a
Center for Child and Family Studies, Leiden University, Leiden, The Netherlands
b
Department of Child & Adolescent Psychiatry / Psychology, Erasmus University Medical Center, Rotterdam, The Netherlands
c
Department of Child and Adolescent Neuropsychiatry, Niguarda Ca' Granda Hospital, Milan, Italy
d
The Generation R Study Group, Erasmus University Medical Center, Rotterdam, The Netherlands
e
School of Pedagogical and Educational Sciences, Erasmus University Rotterdam, Rotterdam, The Netherlands

a r t i c l e i n f o s u m m a r y

Article history: The practice of parent and child sharing a sleeping surface, or ‘bed-sharing’, is one of the most
Received 29 August 2015 controversial topics in parenting research. The lay literature has popularized and polarized this debate,
Received in revised form offering on one hand claims of dangers, and on the other, of benefits e both physical and psychological e
3 March 2016
associated with bed-sharing. To address the scientific evidence behind such claims, we systematically
Accepted 7 March 2016
Available online 15 March 2016
reviewed 659 published papers (peer-reviewed, editorial pieces, and commentaries) on the topic of
parent-child bed-sharing. Our review offers a narrative walkthrough of the many subdomains of bed-
sharing research, including its many correlates (e.g., socioeconomic and cultural factors) and pur-
Keywords:
Parent-child
ported risks or outcomes (e.g., sudden infant death syndrome, sleep problems). We found general design
Bed-sharing limitations and a lack of convincing evidence in the literature, which preclude making strong general-
Co-sleeping izations. A heat-map based on 98 eligible studies aids the reader to visualize world-wide prevalence in
Systematic review bed-sharing and highlights the need for further research in societies where bed-sharing is the norm. We
Prevalence urge for multiple subfields e anthropology, psychology/psychiatry, and pediatrics e to come together
with the aim of understanding infant sleep and how nightly proximity to the parents influences chil-
dren's social, emotional, and physical development.
© 2016 Elsevier Ltd. All rights reserved.

Child sleep practices around the world today, this practice persists and traditional wis-
dom condones and encourages it; a Korean proverb goes, “A baby
To bed-share or not to bed-share? This seemingly innocuous must not sleep in an empty room alone, and an adult must keep
question has been labeled the ‘single most controversial topic watch next to it” [2]. In Tokyo, putting babies alone in a nursery is
related to pediatric sleep’ [1]. Bed-sharing (the practice of parent considered ‘cold and cruel’ [3]. Over the last two centuries, per-
and child sharing a sleeping surface) and co-sleeping (shared sleep manent dwellings and cribs became available in industrialized
that includes room-sharing, bed-sharing, and everything in be- nations, and bed-sharing ceased to be necessary for infant survival.
tween) are hotly debated. The literature is often polarized, filled Shifting cultural values put increasing emphasis on individualism,
with interesting questions, creative designs, and ultimately, insuf- romantic love, and the sanctity of marriage; bottle feeding and
ficient evidence. formula became viable feeding alternatives [4]. Bed-sharing began
Historically, humans have followed the mammalian pattern: to be regarded as psychologically harmful [4]. From the 20th cen-
mothers sleep in direct proximity to their young. In many cultures tury until now, putting infants to sleep on a separate surface has
been the norm throughout North America, Europe, and Western-
ized Asian nations. From the early 1990s, there has been a growing
literature on sudden infant death syndrome (SIDS) risk when bed-
* Corresponding author. Faculty of Social and Behavioural Sciences, Institute of
sharing. Campaigns and interventions have been implemented in
Education and Child Studies, PO Box 9555, 2300 RB Leiden, The Netherlands.
Tel.: þ31 071 527 3973; fax: þ31 071 527 3815.
much of the West in response.
E-mail address: viara.mileva@gmail.com (V.R. Mileva-Seitz).

http://dx.doi.org/10.1016/j.smrv.2016.03.003
1087-0792/© 2016 Elsevier Ltd. All rights reserved.
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 5

shar*”, “co-sle*”, “room-shar*”, “sleep location”, “unsafe sleep


Abbrevations practices” (for a full list, please see Appendix 1). We selected all the
scientific papers published from 1973 until the 1st of January 2016.
AAP American Academy of Pediatrics We included quantitative studies written in English, with a
ASD autism spectrum disorder complete abstract, reported statistics, and participants <18 y and
EW epochal awakenings their parents. Commentaries, debates, and letters to the editor/
GERD gastro-esophageal reflux disease author were included to capture the complexities of the debate.
HIV human immunodeficiency virus Reviews, meta-analyses, and all other research synthesis articles
REM rapid eye movement were also included. We excluded abstracts published in conference
SES socioeconomic status proceedings or symposia, to prevent overlap with published pa-
SIDS sudden infant death syndrome pers. We also excluded articles focused on bed-sharing involving
TA transient arousals humans and animals (e.g., bed-sharing with pets), between adults
WEIRD Western, educated, industrialized, rich, and (e.g., bed-sharing with a spouse), and articles where the co-
democratic (nations) sleeping/bed-sharing/room-sharing practice was not clearly indi-
WPPSIeR Wechsler preschool and primary scale of cated. Peer-reviewed manuscripts presenting research based on
intelligenceerevised tabulations of advice or themes in parenting and self-help books
were included.
The search yielded 3092 papers of which 1816 were excluded on
first pass because they did not address bed-sharing, 595 were
Controversy surrounding bed-sharing is not new. Mothers have subsequently excluded after careful reading of the text due to the
been historically blamed for the death of the infant if it occurred in exclusion criteria above, 22 could not be found in full text. The final
the shared bed [5]. The dangers of bed-sharing are referenced in the number was therefore 659. For a decision tree of the inclusion
Bible (I Kings iii, 19), as well as in the teachings of the Greek process, see Fig. 1.
physician and medical writer Soranus of Ephesos (ca 100AD), who We chose not to employ meta-analytic approaches to this re-
says, ‘the newborn should not sleep with the wetnurse, especially in view. The most important reason for this decision was that the
the beginning, lest unawares she roll over and cause it to be bruised or current empirical evidence within each of the specific reviewed
suffocated.’ [6]. subdomains (e.g., breastfeeding, maternal mood, SIDS) is prohibi-
The past decades have presented conflicting medical recom- tive of conducting an informative meta-analysis. For example, pa-
mendations to parents, and the debate over bed-sharing has any- pers reporting on the depressive symptoms of bed-sharing versus
thing but quieted. Hundreds of publications in some way address non-bed-sharing mothers do not provide sufficient information
bed-sharing. Some offer a broad moral or cultural perspective [7]. about the timing of the two variables to discern if depression pre-
A strongly phrased commentary piece in Pediatrics [8] argues Dr. cedes or follows (or emerges in tandem with) bed-sharing. The SIDS
Freud and Dr. Spock have encouraged a ‘cult of independence’: the literature suffers from its own methodological flaws, which will be
belief that the most important developmental goal for children is to reviewed. A narrative review seems to be adequate and timely also
become independent at a very early age (p 271) (also see [9]). for other reasons: 1) multiple topics are covered in the review,
Here we offer a narrative to guide the reader through the sub- some of which have been recently meta-analyzed (e.g., SIDS; [11]);
literatures on co-sleeping, including research on sleep problems, 2) a quantitative synthesis of previously published work cannot
autonomy, maternal mental health, and breastfeeding, as well as capture fully our intent to indicate the lasting limitations in the
the predominant theme of research on SIDS risk. We illustrate the existing literature and; 3) the conceptual and methodological ap-
complexities of research in this field, and identify current gaps in proaches to the research on bed-sharing have changed over time
knowledge. The ‘burden’ is on the multiple sub-disciplines to pro- and show considerable heterogeneity and differences in quality.
vide conclusive evidence in the risks versus benefits debate, evi- Thus, the primary focus of the current review is on thematic
dence which can be informative to parents and practitioners alike. overview and does not aim to combine contradictory findings
through quantitative integration.
Aims and method of the study
Prevalence of bed-sharing around the world
Following the taxonomy proposed by Cooper [10], this review is
designed to exhaustively outline the research findings and associ- To present the prevalence of bed-sharing practices around the
ated debate on the topic of bed-sharing. Our goals are twofold: 1) to globe, all studies were scrutinized for reported frequencies of bed-
integrate the past literature, and 2) to identify central issues in the sharing. We used the following decision rules: we included only
literature. The thorough and systematic review enabled us to create studies reporting prevalence rates for population-based (rather
a world-wide ‘heat map’ (chloropleth) of bed-sharing prevalence. than clinical or high-risk) samples. For population-wide interven-
The review is organized thematically, grouping studies relating to tion studies, we considered the post-intervention sample preva-
the same idea and aiming for a neutral stance, first presenting ar- lence rate, which was thought to provide the most recent stable
guments and evidence by the original authors and then reviewing estimate. If the intervention was applied to a small sample selected
this evidence critically. Our overall aim is to provide suggestions for from a wider population-based sample, we used the pre-
progressing the field, including the adoption of a new subfield of intervention prevalence statistic. Excluded were studies older
inquiry, which we term psychoanthropediatrics. than 20 y (published since 1995 or where samples were recruited
after 1995), studies with samples smaller than 40, and studies that
Article selection did not report on bed-sharing at or before 12 mo of infant age.
Finally, when studies report bed-sharing prevalence at multiple
We conducted the search between November 2012 and January ages of the infant, we used the test statistic that reflects highest
2016. We used the following databases: PubMed, PsycInfo, ERIC, prevalence in the first 12 mo of age.
Google Scholar, and EMBASE; and an extensive set of keywords to In multi-ethnic random population-based samples, we included
capture as exhaustively as possible the literature in this field: “bed- the prevalence statistic as reported. When one ethnic or
6 V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27

studies reported prevalence of bed-sharing for the same country,


these rates were averaged for that country. The rates were orga-
Initial search
nized into a world map, leading to a ‘chloropleth’ or ‘heat-map’ of
bed-sharing around the world, see Fig. 2. This chloropleth was
k = 3092
created using the online software GunnMap 2 (website: http://lert.
co.nz/map/).

Heat map

Bed-sharing assessed Perhaps not surprisingly, there is great diversity in the fre-
quency of bed-sharing around the world. Western nations exhibit
k = 1276 generally lower reported rates of bed-sharing than developing
nations. African and Asian countries have higher reported bed-
sharing prevalence than Europe and North and South America,
but for many countries prevalence rates are not known. Notable are
cases of wide variability in prevalence within a single nation (e.g.,
Canada, in which population-based prevalence ranges from 72% in
Study characteristics
Manitoba [12] to 12% in a cross-Canadian sample using online
- English
questionnaires [13]). This could reflect both methodological issues
- Complete abstract
e for instance, divergent methods used in collecting data, different
- Original research, meta-analyses,
questionnaires and ages of infants e and true intra-population
reviews differences in bed-sharing prevalence. Regional prevalence esti-
- Quantitative studies mates can be imprecise when multiple ethnicities and cultural
- Reports statistics groups live in the same region, when prevalence rates shift over
- Participants < 18 years geographic location within a region/country, and when practices
- Bed-sharing with humans have changed over time, as for example after the introduction of
campaigns and educational interventions aimed at modulating
k = 681 rates of bed-sharing [14].

Why parents bed-share: predictors and descriptors

Full text, included in review Reactive versus intentional bed-sharing

k = 659, among which A cross-cultural study indicated that bed-sharing rates (higher
for predominantly Asian countries than predominantly Caucasian
k = 98 on prevalence : countries) are stable during preschool years, suggesting little
- population-based samples change over this period once bed-sharing becomes established
- separate samples [15]. However, parents bed-share for many reasons. Aside from
- bed- versus room-sharing tradition, reasons to bed-share include breastfeeding facilitation,
infant irritability or illness, parental ideology, parental own sleep
k = 100 on SIDS experiences, convenience, anxiety, child safety, parent and child
emotional needs, better infant sleep, unavailability of other beds,
enjoyment, physical proximity to the infant, and better caregiving
Fig. 1. Decision tree for inclusion of papers in the review. [16e23], as well as, potentially, socioeconomic factors [24]. Inter-
estingly, bed-sharing was sometimes used as a strategy to coun-
teract the risk of prone sleeping, e.g., in an African American sample
socioeconomic group was overrepresented, we included this of US mothers [25]. Thus on one hand, bed-sharing can occur pro-
prevalence in Table 1 (all shortlisted studies to include in the heat actively, as a matter of routine and intention, whether due to cul-
map), but did not subsequently include it in the heat map and tural beliefs and practices or parenting preference [26]. Parents can
Table 2 (final country-specific averaged prevalence based on be aware of potential risks and bed-share intentionally for its
Table 1, excluding prevalence obtained from samples that are not benefits [27], or they can assert that bed-sharing has no risks
population-based [i.e., oversampled]). [19,28].
Articles that did not distinguish between room-sharing and On the other hand, bed-sharing can be reactive, influenced by
bed-sharing were excluded. When there was no information about factors, including the children, that directly or indirectly lead to the
the frequency of bed-sharing the prevalence statistic was based on initiation of bed-sharing [29]. In Western societies, bed-sharing
‘any’ amount of bed-sharing. When information on the frequency frequently emerges in response to problematic circumstances
and duration of bed-sharing was provided, we used bed-sharing [30]. Even when parents do not express intention to bed-share,
longer than two hours in duration per night, and excluded occa- many e indeed, sometimes a majority of parents in a given popu-
sional bed-sharers from the prevalence estimations in an attempt lation e end up bed-sharing at least occasionally [31e34]. Unlike
to capture routine bed-sharing prevalence. Studies were checked to intentional bed-sharers, reactive bed-sharers more often expressed
ensure they did not report on the same sample. A single study with concern about their practice [35]. The distinction between reactive
prevalence data in multiple countries was used to obtain separate and intentional bed-sharing is crucial for the interpretation of the
prevalence statistics for the countries that were included. This se- evidence and recommendations. Unfortunately, this distinction is
lection procedure left 98 studies for inclusion. When multiple mostly absent in the literature to date.
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 7

Table 1 Table 1 (continued )


Individual reports of prevalence of bed-sharing around the world (multiple entries
per country). Country Sample size (N) Prevalence (%) Reference

Country Sample size (N) Prevalence (%) Reference Russia 204 14.2 [248]
Russia 163 25.0 [122]
Argentina 81 15 [522] Saudi Arabia 289 75.0 [552]
Australia 200 2.5 [320] Scotland 220 25 [522]
Australia 44 27.0 [523] Scotland 202 14.3 [553]
Australia 738 3.0 [524] Singapore 1001 35.9 [13]
Australia 1073 8.6 [13] South Korea 1036 61.4 [13]
Australia 225 30 [522] Sri Lanka 60 82.0 [554]
Austria 199 25 [522] Sweden 241 65 [522]
Austria 200 35 [522] Sweden 5600 19.9 [555,556]
Brazil 44 100.0* [525] Taiwan 896 60.2 [13]
Brazil 3907 45.8 [135] Thailand 3692 60.6 [557]
Brazil 4231 48.3 [67] Thailand 988 77.2 [13]
Brazil 233 31.2 [526] Turkey 87 2.2 [522]
Brazil 3906 46.4 [216] Turkey 150 16.0 [391]
Cameroon 78 100.0 [527] Ukraine 489 9 [522]
Canada 70 80.0* [528]* UK 97 73.0* [63]
Canada 293 72.0 [12] UK 800 12.1 [13]
Canada 230 23 [522] UK 2560 7.1 [558]
Canada 501 12.4 [13] UK 3082 7.2 [83]
Central African Republic NA 100.0 [529] UK 40 42.5 [31]
Chile 226 64 [522] UK 253 47 [81]
China 1129 57.8 [117] UK 261 50 [62]
China 7505 67.6 [13] UK 7447 15.1 [64]
China 524 60 [107] UK 203 28 [57]
China 82 73 [530] US 10,355 22 [61]
China (excl. Hong Kong) 556 69.3 [522] US 100 41.0* [559]
Denmark 360 39 [522] US 185 10.2 [560]
England 253 47.4 [16] US 944 11.7 [561]
France 144 38.9 [405] US 309 36.9 [562]
Germany 998 8.9 [531] US 1867 35.2 [563]
Germany 121 23 [522] US 41 24.4 [60]
Hong Kong 99 32.0 [532] US 4505 5.0 [13]
Hong Kong 314 30.3 [522] US 2791 45.9* [91]
Hong Kong 1049 27.6 [13] US 5273 8.5 [564]
India 3982 70.7 [13] US 218 61.0* [317]
Indonesia 967 72.6 [13] US 126 48.0* [565]
Ireland 197 23.0 [533] US 101 88.0* [566]
Ireland 11,067 11.2 [73] US 394 48.0* [82]
Ireland 322 21 [522] US 8453 19.4 [567]
Israel 608 6.0 [534] US 708 32.5 [568]
Italy 704 18.3 [535] US 194 37.1* [569]
Italy 200 24 [522] US 944 21.9* [95]
Italy 2889 2.3 [536] US 2405 11.0 [570]
Japan 253 38.0 [105] US 259 30.4 [571]
Japan 872 69.7 [13] US 55 27.3* [572]
Japan 287 37 [522] US 77 51.0 [171]
Japan 52 40.4 [162] US 1778 14.4 [573]
Japan 1307 51.7 [537] US 359 16.6 [129]
Kenya ~100þ 100.0 [538] US 66 55.4* [574]*
Malaysia 682 73.5 [539] US 193 36.8 [200]
Malaysia 263 65.4 [540] US 18,945 13.5 [575]
Malaysia 997 44.0 [13] US 6595 69 [576]
Mongolia 80 100 [541] US 148 36 [577]
Mozambique 1994 100 [542] US 2486 59 [93]
Netherlands 1628 6.4 [359] Vietnam 1000 83.2 [13]
Netherlands 4782 20.9 [124] Wales 148 13.5 [578]
Netherlands 193 10.0 [202]
Netherlands 163 5.0 [203] NOTE: * indicates prevalence rates reported in studies using samples that were not
Netherlands 146 5.0 [543] population-based; rather these studies selected specific subgroups including ethnic
New Zealand 918 18.2 [544] or socioeconomic minorities; these studies were excluded from the final averaging
New Zealand 1376 54.9* [545]* of prevalence rates due to this oversampling (and because it was unclear to what
New Zealand 200 16.0 [17] extent the oversampling would affect the overall representativeness of the preva-
New Zealand 299 65.0* [495]* lence rates reported therein).
New Zealand 1081 5.8 [13]
New Zealand 209 13 [546] Parenting and children's books in the West and elsewhere give a
New Zealand 249 19 [522]
Nigeria 382 66.9 [547]
mixed message about desirable sleep practices and often lack an
Norway 9682 47.0 [548] underlying evidence-base [36e39]. They are typically dominated
Norway 55,831 28 [108] by a medical perspective which opposes bed-sharing and supports
NZ þ Australia 2154 7.2 [549] sleep training [40]. Rarely, when bed-sharing is encouraged, it is in
Pacific Islands 1376 50.0 [550]
lactation consultant programs that encourage breastfeeding [41],
Philippines 1034 65.1 [13]
Russia 192 15.1 [260] for adopted children after institutionalization [42], or as part of
Russia 120 26.0 [551] non-mainstream Western parenting philosophies (e.g., Attachment
Parenting e note that this does not directly relate to ‘attachment
8 V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27

Table 2
Country-based averages of prevalence rates of bed-sharing around the world.

Country Total sample size (N) Average prevalence (%) Reference

Argentina 81 15 [522]
Australia 2280 8.5 [13,320,522e524]
Austria 399 30 [522]
Brazil 12,277 46.6 [67,135,216,526]
Cameroon 78 100.0 [527]
Canada 1024 31.8 [12,13,522]
Central African Republic NA 100.0 [529]
Chile 226 64 [522]
China 8786 66.2 [13,107,117,522,530]
Denmark 360 39 [522]
England 253 29.4 [16]
France 144 38.9 [405]
Germany 1119 10.4 [522,531]
Hong Kong 1462 28.5 [13,522,532]
India 3982 70.7 [13]
Indonesia 967 72.6 [13]
Ireland 11,264 11.7 [73,522,533]
Israel 608 6.0 [534]
Italy 3593 6.4 [522,535,536]
Japan 2771 54.4 [13,105,162,522]
Kenya ~100þ 100.0 [538]
Malaysia 1942 57.3 [13,539,540]
Mongolia 80 100 [541]
Mozambique 1994 100 [542]
Netherlands 6912 16.5 [124,202,203,359,543]
New Zealand 2657 12.7 [13,17,544,546]
Nigeria 382 66.9 [547]
Norway 65,513 30.8 [108,548]
Pacific Islands 1376 50.0 [550]
Philippines 1034 65.1 [13]
Russia 679 19.1 [122,248,260,551]
Saudi Arabia 289 75.0 [552]
Scotland 422 19.9 [522,553]
Singapore 1001 35.9 [13]
South Korea 1036 61.4 [13]
Sri Lanka 60 82.0 [554]
Sweden 5821 21.6 [522,555,556]
Taiwan 896 60.2 [13]
Thailand 4680 64.1 [13,557]
Turkey 237 10.9 [391,522]
Ukraine 489 9 [522]
UK 14,646 13.2 [13,31,62,64,81,83,558]
US 65,885 23.0 [13,60,61,93,129,171,200,560e563,567,568,570,571,573,575e577]
Vietnam 1000 83.2 [13]
Wales 148 13.5 [578]

NOTE: Averaged prevalence rates represent averages of all studies reporting prevalence rates for the same country (weighted based on the respective sample size (N) reported
by each study). Prevalence rates from studies using samples that are not population-based (i.e., oversampled for specific minority groups) are excluded from these averages.

theory’ in psychology e which promotes close contact, breast- child's sleep behaviors, potentially a ‘spill-over’ effect in which
feeding, and bed-sharing [43,44]). The actual relationship between problems with children's sleep behaviors carry over to other areas
bed-sharing and responsive night-time care e and its purported of family life [22,51]. Canadian parents who bed-shared in reaction
benefits e needs yet to be established. to infant nighttime problems reported lower marital satisfaction
Ramos et al. [45,46] are among the few authors who make the than parents who intentionally bed-shared [52], and Italian parents
distinction between intentional and reactive bed-sharing (also see of bed-sharers (reactive or intentional) reported more psychologi-
[47,48]), and they show that intentional bed-sharing parents are cal and couple distress [53]. Parental satisfaction was also higher in
more likely to bed-share all night, to endorse and be more satisfied non-bed-sharing (including room sharing here) Israeli parents [54].
with bed-sharing; in contrast, parents of reactive bed-sharers are On the other hand, an older study of US parents from Boston reports
more likely to have tried a ‘cry-it-out-method’ of sleep training and that parents who bed-shared as a response to night-visiting by
to report more night-time difficulties. These differences might be their children viewed this as the child's need for contact or security
explained by differing parental perceptions. American mothers who and perceived bed-sharing as a “nurturant aspect of family life”
viewed bed-sharing more favorably placed less emphasis on their [55]. Thus even if reactive, bed-sharing might be seen as desirable.
children learning to sleep through the night early and reported less Childrearing attitudes across ethnicities further influence how
struggle with their children sleeping through the night [49]. parents interpret children's behavior [56]. Also, a recent report
Reactive bed-sharing might have adverse or complicated effects argues that parental endorsement of attunement and structure,
on the family, particularly in societies where bed-sharing is not the two key parenting principles, also influences types of parenting
norm or is considered undesirable. Mothers' and fathers' practices; accordingly, bed-sharing was positively associated with
endorsement of bed-sharing was highly correlated within families attunement (reliance on infant cues and physical contact) [57]. This
in an American sample [50]. Furthermore, marital difficulties can be concept is similar to Roncolato et al.'s [26,48] notion that parents
associated with differences in parental perceptions of problems in fall into two types: regulators (mother-led caregiving) or
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 9

Fig. 2. Chloropleth of bed-sharing prevalence rates across the world. For additional information, see Tables 1 and 2 Gray shading indicates countries for which there are no data on
bed-sharing prevalence.

facilitators (infant-led caregiving). Without longitudinal and the bed-sharing group [81]. A single identified publication reports a
experimental designs, it is impossible to untangle the cause-effect lack of association between breastfeeding and bed-sharing (in a
relationships in these complex family dynamics. A long-standing low income, inner city US sample) [82]. The association between
challenge is the need for information about whether bed-sharing breastfeeding and bed-sharing can differ between ethnicities: in a
happens intentionally or reactively (e.g., [50]), and on the respec- large multi-ethnic British study, the relationship between breast-
tive correlates of these two types of bed-sharing. Furthermore, the feeding and bed-sharing was stronger for British white parents
distinction between the two might shift over time, such that some than for Pakistani parents [83].
parents who began bed-sharing reactively might eventually come In one of the few randomized trials of infant sleep location,
to value and enjoy the practice, and therefore become ‘intentional’ infants in the maternal bed or in a side-car (attached to the
bed-sharers. Though it is not always a clear-cut distinction, it is maternal bed) were breastfed more frequently than infants in
important to ask parents about the nature of their practices and stand-alone cots on a hospital ward in the UK [84], seeming to
what caused them, if anything, to choose one practice over another. corroborate the idea that close-proximity sleeping promotes
breastfeeding. Furthermore, in a laboratory observation with
manipulated infant sleep location, breastfeeding episodes were
Breastfeeding significantly longer and more frequent on the bed-sharing nights
than on the solitary sleeping nights [80]. In naturalistic laboratory
One of the most common reasons given for bed-sharing is the observations, bed-sharing infants woke up and fed more often [85],
facilitation of breastfeeding. There is a well-established link between and routinely bed-sharing infants had more feeds and shorter
breastfeeding and bed-sharing [58], but current evidence is mostly between-feed intervals per night than routinely solitary sleeping
correlational (reviewed in [5,59]). A positive association has been infants [86].
found in small and large samples from the US (n ¼ 41e10,355) [60,61], Suggested improvements to these studies include the inclusion
Great Britain (n ¼ 75e7500) [16,62e66], Sweden (n ¼ 1028e5605), of the daytime between-feed intervals and the complementary use
Brazil (n ¼ 2866) [67], Barbados (n ¼ 226) [68], New Zealand of polysomnography, actigraphy, and sleep diaries [87]. Further-
(n ¼ 1529) [69], the Netherlands (n ¼ 96) [70], Canada (n ¼ 293) [12], more, replication with larger samples is necessary, though often
Malaysia (n ¼ 682) [71], Australia (n ¼ 4507) [72], Ireland (n ¼ 11,134) cost-prohibitive.
[73], and in a worldwide sample of over 17 countries published by the Further research is indisputably required before we can
International child care practices study (ICCPS) [74]. One study of conclusively determine the direction of causality between bed-
African American mothers reports that the association only exists in sharing and breastfeeding. Current evidence supports a bi-
lower socioeconomic status (SES) groups [75]. directional model where bed-sharing is both a consequence of
Breastfeeding and bed-sharing appear to be mutually reinforc- breastfeeding e mothers who breastfeed might more often opt to
ing. Breastfeeding facilitation was one of the significant predictors bed-share to make feeding at night easier e and a facilitator for
of bed-sharing initiation in Italy and the US [76e78]; whereas continued breastfeeding (for debate on this topic, see [88]).
breastfeeding termination was reported to be the only significant
predictor of bed-sharing duration [63]. Infants routinely bed-
sharing since birth breastfeed three times longer than routinely Mood/depression
solitary sleeping infants [79,80]. Bed-sharing at three months was
protective against weaning up to age 12 mo in a large sample of There are reports of a positive association between bed-sharing
Brazilian mothers [67]. One British study provided evidence that and depressive symptoms: bed-sharing mothers had more despair
over the first three months of life, bed-sharing promotes breast- and anxiety in a sample from Barbados [68], and greater depressive
feeding, with declines in breastfeeding over time being smaller in symptoms in Australia [89], Ireland [73], and in the US [50,90]. The
10 V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27

relationship between depression and bed-sharing might be problems in their children. Alternatively, parents who bed-share
dependent on ethnicity. Maternal depression was associated with might choose this practice in response to pre-existing sleep prob-
increased bed-sharing for black mothers, but not for white mothers lems, as in the case of reactive bed-sharing parents. Or, parents who
in the United States [91]. In a large multi-ethnic cohort from the bed-share might under-report or over-report the presence of sleep-
Netherlands, depression was positively associated with bed- problems, according to their attitudes about bed-sharing or their
sharing but only in Dutch mothers, and not in Turkish, Moroccan, sheer proximity to the child. Each assumption is supported by some
or Caribbean-descent mothers [92]. Different SES variables associ- evidence.
ated with bed-sharing across ethnicities were also found in a US Bed-sharing has been widely associated with infant and child
sample [93]. sleep problems [47] including frequent night-waking [102e104]
As with breastfeeding, the direction of influence is unclear. and/or time spent awake at night [60], nighttime crying [105], re-
Mothers who are more anxious or depressed might be more likely quests for comfort and getting out of bed at night [104], nightmares
to wake up a sleeping infant, and bring that infant to their own bed [106], and less nighttime sleep [107]. A large Norwegian study
for monitoring (e.g., [94]). Conversely, mothers who perceive bed- (N ¼ 55,831) indicated that bed-sharing was an independent and
sharing as problematic might suffer from greater anxiety because graded predictor of both night-time awakenings and sleep duration
of it [53]. Maternal negativity similarly might influence sleep ar- [108]. In preschool-aged children adopted from China (mostly
rangements: in a longitudinal study in low-income US families, girls), sleep problems were more often reported in children who
maternal negative regard (hostility or rejection of the child) pre- bed-shared or shared a bedroom with parents [109]. A similar
dicts bed-sharing [95], whereas in South Germany, maternal finding was reported for school-aged children [110] and adoles-
distress about crying in the first five months predicts bed-sharing cents in China [111]. Bed-sharing has also been associated with
at 56 mo [96]. In a Russian study, lower quality of infant care sleep-wake transition disorders and sleep-breathing disorders in
(less developmental stimulation and environmental organization) older children [112]. Bed-sharing American preschoolers were less
by mothers was associated with more bed-sharing [97]. likely to sleep in their bed all night, to fall asleep in their own bed,
The difficulty with interpreting findings on the relation between to fall asleep alone, to keep a regular bedtime, or to use a nightlight
mood and bed-sharing is that maternal mood as a function of infant [113]. In the UK, partial-solitary sleeping infants (bed-sharing less
sleep location has not been a topic of interest on its own right, and than two hours a night) were 1.8e1.9 times more likely to have
has most often been reported incidentally and typically only if slept regularly through the night at eight weeks of age than regu-
mood associates with bed-sharing. Thus both the breastfeeding and larly bed-sharing infants [114]. Solitary sleeping American pre-
mood literature emphasize the need to distinguish between reac- schoolers slept through the night earlier, weaned earlier, and fell
tive and proactive bed-sharing. asleep alone earlier than bed-sharing children [115]. In school-age
Italian children, bed-sharers had a significantly later bedtime,
Fathers shorter nighttime sleep duration, higher bedtime resistance, and
higher sleep anxiety [53]. Bed-sharing was associated with
Very little research has explored the triadic bed-sharing expe- increased night waking and bedtime resistance among lower SES
rience, or characteristics and behavior of fathers who bed-share. white children and higher SES black children in the US [56]. Thus
Ball et al. [98] showed that first-time fathers had anxieties about SES has complex and potentially ethnicity-specific associations
bed-sharing with their infants, and that after using strategies to with bed-sharing and related behaviors, and these ought to be
overcome these initial anxieties they took pleasure in the pro- further explored.
longed intimate contact with their infants. However, reactive Interestingly, children in special schools had more sleep prob-
parenting strategies (e.g., reactive co-sleeping, or sharing a room lems, including greater rates of sleeping in the parents' bed; and
with an infant at a later stage than early infancy) were associated parents of these children were postulated to be more indulgent or
with fathers' declined satisfaction with the sleep arrangements anxious, thus ‘inadvertently encouraging sleep problems’ [116].
(compared with early bed-sharers or early co-sleepers) [22]. However, children with special needs and developmental disabil-
Physiologically, bed-sharing in fathers in the Philippines was ities might experience communication and self-soothing diffi-
associated with significantly lower evening testosterone and a culties. A developmental perspective would be interesting as a
greater diurnal decrease in testosterone from waking to evening follow-up in these samples.
[99]. One study revealed that bed-sharing fathers rarely have There is mixed or inconclusive evidence on the association be-
contact with the infant during the night [100]. More research is tween sleep-problems and bed-sharing as well. In Chinese infants
needed on the role of partners in bed-sharing, and their role in (1e23 mo), bed-sharing was not associated with sleep problems
triadic bed-sharing. [117], whereas in preschoolers (3e4 y) from the same sample it was
[118]. Chinese bed-sharing school-age children had more anxiety
‘Consequences’ and ‘Risks’ of bed-sharing and daytime sleepiness, but were not different from solitary
sleeping children on parasomnias (sleep disorders such as sleep-
In the following paragraphs, we discuss associations between walking, sleep terrors, and sleep paralysis) [119]. Similarly, in a
bed-sharing and multiple dimensions of child development. For the large Canadian sample, bed-sharing children had greater odds to
same reasons bed-sharing prevalence is difficult to establish e e.g., belong to a persistently short-duration sleeping trajectory across
rates vary across cultures and socioeconomic clusters e it is also early school years [120]. In a Russian study, low birth weight infants
challenging to establish the relation between bed-sharing and did not routinely bed-share more than controls, but did need more
many of the purportedly related risks or benefits. parental assistance at bedtime, and were brought into the parental
bed more often after awaking at night [121], in another Russian
Sleep problems sample, the practice of swaddling, often used to reduce sleep
problems, was not associated with bed-sharing [122].
Despite the directional nature of the questions asked, the liter- The nature of bed-sharing might impact the findings. There was
ature on sleep problems and sleep practices (reviewed by [101]) has a lower risk of sleep-onset and night-awakening difficulties for
not resolved the underlying direction of associations. It is most Canadian children who bed-shared at sleep onset compared with
frequently assumed that parents who bed-share create sleep children who bed-shared after night-awakenings [123]. The
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 11

distinction has parallels to reactive versus intentional bed-sharing: Thompson, and Dawson [146] argue that night-time waking and
when parents bed-share with children from the beginning of the lack of consolidated sleep in infancy are culturally constructed as
night, this suggests they are intentionally doing so; whereas when ‘sleep problems’, and necessitate subsequent behavioral training
bed-sharing occurs in response to, or following a night-awakening and treatment programs which have led to the “quest for solo
event, this is a more reactive approach. In a large, multi-ethnic sleep” and a strong emphasis on early acquisition of independent
cohort from the Netherlands, bed-sharing at 24 mo (but not at skills by children and ‘self-soothing’ [147,148]. In this cultural
two mo) was associated with significantly greater odds of sleep framework, bed-sharing is thought to interfere with self-
problems at 24 mo, but this effect disappeared when controlling for regulation; to prevent or delay night-time sleep consolidation; or
child sleep problems at 18 mo [124]. This might indicate that sleep to give rise to parent-child interaction patterns which encourage
problems are related to the emergence of bed-sharing after the problematic sleep-related behavior in children. For instance, bed-
infancy period and supports a reactive bed-sharing strategy. Early sharing is said to “block the development of appropriate stimulus
infancy bed-sharing and nighttime awakening in Swedish children control and prevent the development of appropriate sleep” [149],
did not predict childhood bed-sharing and sleep problems [125]. In or seen as the primary grounds for the development of disorders
a very large international online survey (n ¼ 29,287 parents), sol- with sleep initiation or sleep maintenance [150]. It is suggested that
itary sleeping children obtained more sleep, woke less at night, had in some cultures bed-sharing might be easier because of better
less difficulties at bedtime, fell asleep faster, and were perceived as regulated infant temperament (e.g., the Japanese), rather than the
having fewer sleep problems than bed-sharing children; these other way around. France and Blampied call bed-sharing a ‘coercive
differences were mainly observed in the predominantly Caucasian behavior trap’, where parents bed-share in order to reduce the
countries, and not in the predominantly Asian countries; it seemed aversive events of infant distress [151]; this trap, however, is seen to
it was not bed-sharing that predicted these differences, but apply to parents who view bed-sharing and child sleepetime ac-
parental presence at bedtime, which was much higher in the pre- tivities as problematic [147], which might be framed by cultural
dominantly Asian countries [126,127]. Once more, the compara- context [152e157].
bility of reports by bed-sharing and solitary sleeping parents is Cultural factors might thus create a bias in bed-sharing research.
challenging to establish. Bed-sharing parents might better tabulate The majority of research in the present review comes from Western
sleep awakenings, simply due to their night-time proximity to their nations where bed-sharing is not the norm. In fact, such Western,
children [128], leading to higher frequencies; or, they may dismiss educated, Industrialized, rich, and democratic (WEIRD) societies
night-time awakening events as ‘normal’, leading to under- are “among the least representative populations one could find for
reporting. generalizing about humans” [158]. In the many cultures where bed-
Finally, multiple studies report no association between bed- sharing is the norm, this practice is far less likely to be given a focus
sharing and sleep problems in healthy [125,129e132] and clinical in the first place. In a commentary, Katherine Dettwyler argues that
samples [133,134], many of which are from non-Western nations for people in ‘bed-sharing’ cultures, “it isn't a matter of being
with higher rates of bed-sharing. In a large study from Brazil bed- accepted or encouraged, [bed-sharing] is simply what they do”; and
sharing was not an independent determinant of nighttime that describing other cultural staples with similar words (e.g., “Rice
waking [135]. Kawasaki et al. [136] argue that the relative absence eating is overtly accepted, if not encouraged, in Asian countries”)
of sleep problems in Japanese infants may be due to both these would make equally little sense [159]. Underrepresented are
infants' predisposition to easier habituation to night-time negative studies of children who are among the minority if solitary-sleeping.
stimuli and also to a nighttime environment that promotes A single study of sleep problems in India indicated that lack of bed-
extensive close physical contact between parents and infants, as co- sharing was associated with increased sleep problems [160].
rooming and bed-sharing are the norm in Japan. A study that Cultural factors not only create biases in sample representation,
compared Japanese and US children aged 6e48 mo indicated that but also in the methodologies used to assess sleep practices. For
more US children had bedtime struggles, and bed-sharing in the US instance, a novel infant sleep questionnaire asks parents to report
sample was related to more bedtime struggles, nighttime awak- on the frequency of bringing baby into bed and how long this
enings, and overall stressful sleep problems; in the Japanese sample ‘problem’ has persisted [161]; it does not provide parents who
bed-sharing was associated only with night awakening [137,138]. In intentionally bed-share an option to report this. Furthermore, reli-
another Japanese sample, it was bedtime rather than bed-sharing ability of the children's sleep habits questionnaire was lower in a
that predicted sleep disturbances [131]. In Singapore, where bed- Chinese sample [128], and the higher rate of bed-sharing in China is
sharing with parents, siblings, relatives, and maids is normal, sol- one of the explanations suggested for this lower reliability. Such
itary sleepers had significantly more nightmares and more sleep- questionnaires would be difficult to implement in non-Western
disruptions [139]. Less frequent bad dreams in bed-sharers was settings. Finally, cultural factors influence how parents report on
also observed in a Canadian sample [140]. The heterogeneity of sleep practices. This is important, as most of the statistics obtained
findings indicates that dependent on the nature of bed-sharing, in these studies rely exclusively on parent-reports of children's
pre-existing problems, type of assessment, SES, and cultural prac- sleep problems and practices.
tices, the association between bed-sharing and sleep problems can
differ. Furthermore, the bi-directional nature of parental and child Parental perceptions
behaviors surrounding sleep should be taken into account [141] in Culture and immediate context influence parental perceptions of
future studies to disentangle the equivocal bed-sharing-sleep infants' sleep. For instance, American mothers who reactively bed-
problems association. Very few studies have explored the associa- shared (in this case, after one year of age, but not in infancy) re-
tion between bed-sharing and parental sleep quality, but those that ported significantly more sleep awakenings and found these awak-
did indicate a negative association (e.g., [142,143]). enings more problematic than mothers who bed-shared from early
infancy, or those who did not bed-share [115]. In another American
Sleep problems as a cultural construct study, both reactive and intentional bed-sharers had higher re-
The previous paragraph highlights one of the difficulties with ported sleep problems (resisting bedtime and night-time awak-
bed-sharing studies: Sleep problems can be a cultural construct ening) than solitary sleepers but when the scores were weighted for
[144,145] and bed-sharing is said to be one of the parental practices parental perceptions of problematic behavior, reported sleep prob-
most influenced by cultural practice and beliefs [2]. Blunden, lems for the intentional bed-sharers decreased [46]; furthermore,
12 V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27

reactive bed-sharers were the most likely to be dissatisfied with the saturation in bed-sharing infants [182]. Although rates of bed-
sleep arrangements. Increased vigilance or awareness of night-time sharing between preterm and term infants did not differ in US in-
problems in bed-sharing parents might also play a role, as for fants [188], another report indicated that bed-sharing preterm in-
example in explaining the rate of nightmares and other sleep fants had temperature acrophases (peaks) that occur more typically
problems in bed-sharing Saudi school-aged children [106]. Indeed, in daytime hours, suggesting beginning entrainment to a daye-
the accuracy of sleep diary records can be affected by the distance night pattern [189]. Other differences include a higher heart rate
between mothers and infants at night [162]. and lower heart rate variability in bed-sharers [190]. Furthermore,
infant nicotine levels are higher in infants of smokers, and bed-
Bed-sharing in response to pre-existing sleep- and other problems sharing is a contributing factor [191].
Bed-sharing can emerge as a sleep inducing parenting technique Laboratory studies reveal sleep architecture differences be-
[163,164], or as a reaction to infants' nighttime awakenings [165]. tween bed-sharers and solitary sleepers, but these studies use very
Accordingly, sleep problems up to three years prior were predictive small sample sizes and the results are not always consistent. Total
of bed-sharing at 56 mo [166]. Parents can bring children into their sleep duration and sleep-wake rhythms do not differ between
bed in response to night-time difficulties throughout infancy and groups [180,192], although bed-sharing infants wake more often
later childhood, including nightmares, illness, or fear [167]. [85], have reduced stage 3e4 sleep, and greater overlap with
Accordingly, problematic bedtime behavior or disruptive behavior maternal arousals [9,193]. Japanese bed-sharing (and co-rooming)
during the night was a significant predictor of bed-sharing initiation infants had significantly more active sleep than solitary sleepers
in Italy [76]. Similarly, a greater proportion of enuretic four-year olds [130]. In solitary sleepers, there was a paucity of epochal awaken-
had a habit of sleeping in the parents' bed after urinating in the ings (EW) and transient arousals (TA) in stage 3e4 sleep, compared
diaper compared with non-enuretic children [168], and an associ- with stage 1e2 or REM sleep, which supports the premise that
ation between enuresis and bed-sharing was also reported in a infant arousability is diminished in stage 3e4. In bed-sharing
Chinese sample of schoolchildren [169]. In autistic children, bringing dyads, EWs and TAs were more frequent [194]. In fact, bed-
the child into the parents' bed was one of the most frequently tried sharing is suggested to promote infant arousability, which the au-
parental solutions to promote sleep in their children [170]. thors argue might protect against SIDS [195]. Conversely, when not
Bed-sharing is also associated with mothers' perceptions of in- sleeping with their parents, routinely bed-sharing infants had more
fant separation distress, dysregulation, negative mood, and man- quiet sleep and longer bouts of quiet sleep at five weeks; and
agement difficulty, which suggests that bed-sharing is initiated in showed less active sleep, fewer arousals in active sleep, and less
response to problematic child behavior, rather than the cause of it wakefulness at six months [196]. The authors argue bed-sharing is
[60]. Significant predictors of bed-sharing include past history of stressful and that the ‘extreme’ sleep patterns of bed-sharers e
sleep problems, bedtime resistance, sleep anxiety, and night both during bed-sharing and during solitary sleep e predispose
awakenings and nighttime fears [53]. Not many quantitative these infants to SIDS. Unfortunately, no study has examined the
studies have examined this relation. Sleep and fatigue in the first development of these patterns of sleep behavior from birth.
month postpartum in a sample of 72 families from San Francisco Furthermore, physiological evidence is not strong that bed-sharing
were not related to bed-sharing [171], but more sleep was obtained in fact represents an ‘extreme’ sleep environment.
by a sample of mothers who breastfed and bed-shared, compared Interestingly, there is evidence to suggest mother-infant sleep
with bottle-feeding mothers [172]. In sum, culture and context rhythms could be linked [197] via physiological synchrony [198]. In
influence what parents say, do, and think about their children's a laboratory study comparing solitary sleeping and bed-sharing in
sleep and their own strategies to deal with their children's sleep. A the same dyads, bed-sharing reduced the amount of maternal stage
fruitful discussion about the consequences of bed-sharing should 3e4 sleep (quiet sleep), increased the amount of stage 1e2 sleep,
begin by considering these factors. but did not alter REM sleep and total sleep duration [199]. Similar
findings were reported in the same sample for child sleep: reduc-
Physiological correlates of the bed-sharing child tion of stage 3e4 sleep and increase in stage 1e2 sleep on the bed-
sharing night compared to the solitary sleeping night [195]. Un-
A series of small studies have examined physiological and physical fortunately these studies employed rather small samples, and no
characteristics of bed-sharing infants in the lab or at home (see replication studies have followed. A single recent study in a
[173e176]). Compared with solitary sleepers, bed-sharing infants community-based sample of American mothers reported steeper
more often sleep on their side [85,177] and do so facing the mother diurnal cortisol curves in mothers in the non-bed-sharing group
[100,178,179] and in close proximity to her [180]. However, there is compared with the bed-sharing group [200].
inconsistent evidence for whether bed-sharing infants are exposed to Population-based epidemiological studies of physiological var-
more or less expired air, and whether this is a protective or potentially iables and bed-sharing reveal inconsistent and inconclusive find-
dangerous aspect of bed-sharing [100,178,179,181]. In laboratory ings. One study reports that compared with solitary sleepers, bed-
studies, head covering occurred far more frequently for bed-sharing sharing children have greater physiological reactivity (cortisol in-
infants [177], but the majority of head covering events (80%) and crease) in response to inoculation at six and twelve months [201].
head uncovering events (68%) were facilitated by the mother [100]. This may indicate either an adaptive or maladaptive response in the
Thus mothers both caused airway covering and facilitated uncovering face of lacking literature to support either claim. Other studies
[182]. Bed-sharing parents also looked at or touched their infants found that a history of bed-sharing predicted lower cortisol reac-
more often than parents of cot-sleeping infants [177]. tivity to stress [202]; more specifically, solitary sleepers had higher
Physiologically, bed-sharing infants have been reported to have cortisol in response to a bathing session at five weeks of age, but no
higher baseline body temperatures [183,184], a greater increase in differences were found in response to a vaccination at two months
temperature after sleep onset [85], higher axillary temperatures [203]. Neonatal weight loss in the first week postpartum was not
during non-rapid-eye-movement-sleep (REM) [185], and generally associated with bed-sharing status in rural Central Africa [204].
warmer thermal conditions (including more bedding [186] and Taken as a whole, these few studies on the physiological correlates
face-covering events) than solitary sleepers [85]. In contrast, Ball of bed-sharing in both epidemiological and laboratory designs
[187] found no differences in temperature between bed-sharing highlight the multiple gaps in our understanding of healthy
and solitary sleeping infants, and no evidence of lowered oxygen ‘optimal’ infant sleep and sleep architecture. It seems rather logical
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 13

that the long course of evolutionary history might have led to the Cognition
evolution of adaptive mechanisms for physiological regulation
during parent-infant bed-sharing, and the research has pointed in A Chinese cohort study shows a negative correlation between
this direction. To further test these assumptions, cross-cultural bed-sharing and cognitive ability, as assessed using the Chinese
studies of substantial sample size should include the collection of version and norms of the Wechsler preschool and primary scale of
physiological and polysomnographic data from infants (and their intelligenceerevised (WPPSIeR) [243]. In a study of low-income
parents) during sleep in multiple settings (e.g., bed-sharing, room- families in the US, bed-sharing was not related to cognitive out-
sharing, solitary sleep). comes (letter-word identification, applied problems) after con-
trolling for maternal and child characteristics [95]. A longitudinal
sample of American families (including some ‘counterculture’
families who chose intentional bed-sharing from infancy) sug-
Somatic disorders
gested a positive effect of early bed-sharing on cognitive compe-
tence at six years of age [244]. The handful of studies and their
A number of disorders are associated with increased rates of
mixed findings perhaps indicate that not every outcome is readily
bed-sharing, including somatic and genetic disorders like migraine
hypothesized as associated with bed-sharing, since explanations
and tension-type headaches in children and adolescents
for an association (or the lack thereof) are not self-evident.
[205e207], gastro-esophageal reflux disease (GERD) [208],
dermatitis [209], epilepsy [210,211], febrile seizure [212], Down
Behavior problems
syndrome [213], and intellectual disability [214].
Colic in infancy was not associated with bed-sharing at four
The evidence of an association between bed-sharing and child
years of age in a Swedish study [215]. Bed-sharers had greater odds
behavioral problems is not clear. In Finland and the US, bed-sharers
of being obese in a large sample of Chinese preschoolers [118]. In
did not differ from solitary sleeping children on internalizing or
Brazil, children bed-sharing at the age of three months had higher
externalizing problems or overall behavioral problems [47,245]. Bed-
odds for hospital admission due to pneumonia, but only if they
sharing was not associated with three-year olds' symptoms of anxiety
were not breastfed; no increased odds were found for admission
or depression in a large multiethnic cohort in the Netherlands [124],
due to diarrhea [216]. No difference was found between cases of
nor with anxiety in a sample of Turkish children [246]. In a Chinese
children with respiratory illness and controls in whether the chil-
sample [247], bed-sharing was not associated with child behavior
dren shared their beds with others (though it was not specified
regulation. However, it was associated with more empathy and con-
with whom, and as it pertained to children's bedrooms, it was likely
science, but only in children of mothers with positive attitudes to-
they shared with siblings) [217]. In a large multi-ethnic cohort, bed-
wards co-sleeping. On the other hand, 14.2% of bed-sharing healthy
sharing at 24 months (but not at two months) was associated with
infants from St. Petersburg had significantly less mother-reported
wheezing and asthma at ages three, four and six years [218]. In a US
infant positive mood and appeared less persistent (i.e., were less
study, maternal respiratory symptoms were not associated with
able to maintain a specific activity for a longer period of time) [248]. In
bed-sharing [219]. The direction of these mixed findings was often
the US, bed-sharing infants were found to be more reactive, less
not clear, and although it seems tempting to infer causality from the
adaptable, and less rhythmic than solitary sleepers [113].
associations, in the case of somatic disorders, bed-sharing as a
In a clinical sample of children with behavior problems, asso-
parental monitoring tool of existing health conditions can be just as
ciations were reported between bed-sharing and tantrums, lack of
plausible [220,221]. This calls for cautious interpretation of such
self-confidence, and aggressive behaviors [249]. Bed-sharing was
findings, and careful design of future studies.
also more prevalent in children with mental and behavioral disor-
ders like autism spectrum disorder (ASD) and severe learning dif-
ficulties [250e255].
Infections, disease, and health In the one of the few longitudinal studies, bed-sharing was
assessed at ages five months, three, four and six years; no positive
Bed-sharing has been examined as a risk factor for the spread of or negative effects were found at age six on measures of behavioral
infectious diseases and parasites. It has been associated with and emotional maturity, including mood and affect, school
infection with Helicobacter pylori, a bacterium that colonizes the adjustment, interpersonal relationships, self-acceptance,
human stomach, and with gastric carcinoma and ulceration vandalism, crimes, and substance use [244]. This study did, how-
[222e225], although these findings are inconsistent [226e229]. ever, find a small positive association of bed-sharing with cognitive
Bed-sharing within the family has also been described as a risk competence in six-year-olds [244].
factor for transmission of pertussis [230], hepatitis B [231], scabies The mixed findings of such studies might be based on mothers'
[232], respiratory diphtheria [233], and head lice [234e236]; un- different motives for bed-sharing [5]. Finally, some have argued that
fortunately, most of these studies did not describe the nature of the in cultures with high rates of bed-sharing, there is an absence of the
bed-sharing (i.e., between siblings or between children and par- child problems that are found in North America to be associated with
ents) and often include older children. bed-sharing, particularly emotional and behavior problems [153].
In a review, Bloomfield et al. [237] indicate that although
crowding and bed-sharing are often used as proxy indicators of Attachment, dependence, transitional objects
microbial exposure, it is yet to be elucidated how accurate these
are. No association was found between bed-sharing and tinea Parental attitudes and societal wisdom in Western nations
capitis (ringworm on the scalp) [238], meningococcal disease [239], reflect the idea that placing children on a separate sleeping surface
or human immunodeficiency virus (HIV) infection in families of as early as birth encourages autonomy, self-soothing, self-reliance,
HIV-infected children [240]. A small study in Canada indicates that and later independence. Klackenberg [256] reported that bed-
fungal concentrations in mattress dust samples were not correlated sharing was ‘difficult to shake off’, with evidence of persisting
with number of individuals sharing a bed [241]. Finally, a survival bed-sharing tendencies for children who bed-shared at age four.
analysis of children bed-sharing at age eleven indicated that these American mothers and fathers of solitary sleeping children viewed
children did not die earlier than non-bed-sharers [242]. their arrangement as important for children's independence [22].
14 V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27

At the same time, advocates of bed-sharing cite the encour- gratification of sexual impulses” [266]. These theories were based
agement of autonomy as one of the positive reasons for bed-sharing on psychiatric populations and reflect outdated thinking about
[257]. Some pediatricians and psychiatrists argue that bed-sharing child development, but sometimes persist in the literature [267].
enhances maternal-child attachment at night, during a develop- Newer studies with both healthy and psychiatric populations fail to
mental period when the toddler is becoming more independent support the earlier notions of sexualized bed-sharing infants. A study
during the day [258]. It is somewhat surprising then, that after such assessing the effects of early bed-sharing on later sexual adjustment
ado about whether sleep location influences the development of (using retrospective questionnaires to assess bed-sharing) indicated
early childhood autonomy, nearly no empirical evidence exists to different results for males and females: males who had bed-shared
support either side's claims. The few identified studies that tackle with their parents between birth and five years of age had greater
this question show mixed evidence: early bed-sharers had a later self-esteem, less guilt and anxiety, greater frequency of sex, and
age of learning to sleep on their own, but the mothers of these greater tendency toward casual sexual relationships; for girls, bed-
children also placed less importance on their children's ability to sharing between birth and five years of age was related to less
fall asleep alone [49]. On the other hand, mothers of bed-sharing discomfort about physical contact/affection in adulthood [268]. Chil-
preschoolers in South Carolina were more supportive of chil- dren's receiving names from the parents for their genitals was also
dren's independence [115]. Once more, the cross-sectional and associated with bed-sharing, among other factors [269]. Findings from
correlational designs of these studies make it difficult to determine an eighteen-year longitudinal study suggest that early bed-sharing is
how parental intentions, attitudes, and beliefs, influence the extent not related to negative psychosexual outcomes [244].
to which children's behavior is seen as problematic.
The association between bed-sharing and secure attachment e
Sudden infant death syndrome (SIDS)
the measure of parent-child bonding that is a staple of develop-
mental psychology e has not been directly tested. One study
A substantial portion of the reviewed literature deals with
indicated that ambivalent attachment was related to sleep prob-
sudden infant death syndrome (SIDS) either directly or indirectly.
lems, which were in turn associated with active physical comfort-
Since bed-sharing was first identified as a potential risk factor for
ing strategies (including bed-sharing) [163]. According to the
SIDS, the association between the two has been addressed in
authors, the association between ambivalence and sleep problems
multiple countries, across multiple time-points, and with multiple
is related to inconsistent maternal availability, which acts as a
types of designs. The studies were initially retrospective non-
‘intermittent reinforcer of both infant distress during nighttime
controlled and small-sample assessments of location of infant
separations and interactive behaviors such as [bed-sharing]’ [259].
death. Over the years they have come to incorporate control groups
However, the questionnaire used to assess parental comforting
e recruited in various ways e and multiple covariates, including
strategies did not have good psychometric properties.
parental use of drugs, alcohol, smoking, type of sleeping surface,
A handful of studies have considered attachment objects or
breastfeeding, and others. The literature is summarized in
comforting behaviors in bed-sharers. For instance, nearly half of a
Supplementary Table 1 and has been reviewed extensively
sample of children with autism bed-shared with parents, and
[59,270e299]. The literature includes some position papers [300],
moved closer to their parents and physically reached out to parents
and reviews from an evolutionary framework [301e304]. For a
during the night, which the authors argue resembles the comfort
recent meta-analysis, see [11]. Here we review the potential risk
and proximity seeking behaviors described in attachment research
mechanisms for SIDS in bed-sharing infants, interventions and
[255]. Bed-sharing was not associated with pacifier use in healthy
recommendations to reduce infant bed-sharing, and issues that
Russian infants [260], but was associated with less sucking
complicate the debate on bed-sharing as a risk factor for SIDS.
behavior (pacifier or thumb) in a small observational study of
British infants [261]. A study from the US indicated that the pres-
ence of a parent at the onset of sleep rather than where the child Risks
slept for the night (alone, in parents' room or in parents' bed) was There are purported risks to bed-sharing infants of airway
the biggest predictor of using a transitional object or thumb- covering or obstruction [305,306], overlying [307,308], asphyxia
sucking [262]. One study examining the parenting practice [309], mechanical suffocation [310], strangulation [311], and nasal
Attachment Parenting (close contact, breastfeeding, bed-sharing) hemorrhage and oronasal bleeding [312e314]. Observation and
revealed a low rate of use of transitional objects [263]. In Cauca- laboratory studies show that some potentially unsafe practices
sian middle-class families from Maine, US, solitary sleepers had occur during bed-sharing. These include the use of sheepskin
more longstanding and stronger attachment to transitional objects bedding [315], soft bedding [316,317], bottle propping [316],
and sleep aids [77]. As with previous sections, the majority of these sleeping on the sofa [316], pillows [318], non-prone position [319]
studies are cross-sectional and correlational and do not take into (but see [317], and more thermal insulation [320]. In a small lab-
account parental intentions. oratory study, the majority of bed-sharing infants spent some part
of the night with their airway passages covered, compared with
Sexual adjustment two out of 20 cot-sleeping infants [182]. However, these covering
events did not correspond to significant differences in heart rate or
The early literature contains references to Freudian and other oxygen saturation, and mothers frequently uncovered their infants
theories of psychological harm befalling bed-sharing children. at night [182]. One recent study shows that the multivariate risk of
Childhood exposure to parental nudity, bed-sharing, and ‘primal bed-sharing after controlling for other hazardous circumstances is
scenes’ were suggested to be damaging to the development of a not significant [321] and another suggests the evidence for the risks
normal sexual identity, and has been even likened to child sexual of bed-sharing is ‘low quality’ [322].
abuse, yet there was no evidence of negative or harmful effects that There have also been suggested physiological benefits (e.g.,
actually stem from these practices [264,265]. Similarly, the authors breastfeeding, physiological regulation [257,323e326]) and safety
of an old, small study of a US psychiatric outpatient sample of bed- benefits (e.g., position infants flat on the mattress, below pillow
sharing children aged twelve years and under conclude that chil- level, mother and infant oriented toward each other) of bed-sharing
dren share the bed for three categories of motives: “reduction of [327]. Yet accidental asphyxia during breastfeeding is possible
phobic anxiety, reduction of separation anxiety, and the [328], and much debate surrounds the issue [329e333].
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 15

In the laboratory, bed-sharing was associated with more central with bed-sharing to allow parents peace of mind about safety while
apneas, fewer obstructive apneas, and more periodic breathing than sleeping within arms' reach of their infants [410].
in the solitary environment [334]. However, data from the New
Zealand cot death study show no association between apnea and Debate
infant care practices known to be associated with SIDS, such as prone The literature on SIDS is accompanied by a weighty controversy
sleep position, bed-sharing, lack of pacifier use and bottle feeding and debate (e.g., [258,411e425]). The themes of the debate are often
[335]. There might be a genetic predisposition for SIDS risk, known polarized, either opposing bed-sharing as inherently risky [426] or
as ‘long QT syndrome’, although the benefits of studying this syn- supporting bed-sharing as a ‘natural’ parental practice in which
drome are debated [336]. Several other theories have been put forth, context human-infant physiology has evolved [427], or having
including that bed-sharers and solitary sleepers might have differ- falsely-presented, biased, or overestimated risks (e.g., [428e433]).
ential mechanisms leading to SIDS. For instance, bed-sharing SIDS A hefty portion of the debate surrounds the limitations of SIDS
cases exhibit a smaller male to female ratio (2:1 for solitary sleeping research that implicates bed-sharing, such as the failure to account
and 0.8:1 for bed-sharing) [337], greater hypoxia exposure [338], for ‘routine’ bed-sharing. Detailed clinical histories do not exist in
and lower levels of beta-amyloid precursor protein (a biomarker of most SIDS studies, because “no one ever asks the parents” [434] and
traumatic axonal injury) [339] compared with solitary sleeping SIDS thus an infant dying of SIDS on the only night it bed-shared creates
cases. Furthermore, bed-sharing is associated with a greater risk of a coincidence which may lead to the potentially erroneous identi-
SIDS in the non face-down group of children, but not in the face- fication of bed-sharing as a risk factor [435]. Of two empirical
down group of children [340]. Yet another theory suggests infants studies ever taking into account routine vs. night-of-death-only
dying of SIDS have a dietary insufficiency in selenium and iodine, bed-sharing, neither showed a significant relation between
which can compromise nighttime thermoregulation and elevate routine bed-sharing and SIDS risk [14,436].
SIDS risks in bed-sharers [341]. The risk mechanisms associated with The field is also hampered by coroners and pathologists' use of
SIDS are complex and multiform, hampering clear explanations different terminology and varying criteria for SIDS diagnosis
about the mechanisms behind the association between bed-sharing [437e439]; and by a growing “reluctance to diagnose SIDS when
and SIDS. A coupling of epidemiological research and physiological the death occurs while sharing the parental bed” [440]. For further
observational studies must occur for these mechanisms to be un- empirical and debate articles on this topic, see [441e444] [empir-
covered. Prospective studies of SIDS are nearly impossible, but at the ical] and [445e449] [debate]. Other criticisms that have been
very least future studies ought to account for the parental intentions debated include inadequate design of studies purporting to show a
surrounding bed-sharing in SIDS cases: was the decision to bed- link between bed-sharing and SIDS [450e452], such as including
share made only on the night of SIDS death, and in response to only numerator data [453,454] and not including relative data
aberrant circumstances with the infant on that particular night? Or about deaths in cots [310,455e463].
was it a routine for that particular infant? There is significant debate about whether bed-sharing has been
unnecessarily singled out among other risk factors and applied to all
Recommendations and interventions groups regardless of existing other risk factors [446,464e473], or
Recommendations against bed-sharing in the context of SIDS whether a sweeping anti-bed-sharing message is best
reduction have been made multiple times since 1992 [342e362], but [290,324,330,354,432,450,474e479]. Ultimately, this boils down to
they are often unclear, inconsistent, or contradictory [363e366], and the argument that causality cannot be inferred from epidemiological
change over time [367,368]. For instance, guidelines for hospitalized or cross-sectional studies [480e482]. Some argue there is not enough
children urge against bed-sharing [369] whereas guidelines for evidence to either support or reject bed-sharing [449,453,476,483e4
midwifery practice [370,371] and nursing [59,372] often indicate 86], that the assertions of risks are unjustified [487] or should be
there is “no right answer” [373e375] and bed-sharing is a “complex qualified to high-risk groups only [488], and that after identifying
practice” [58]. Although not government policy, many professionals significant SIDS risk factors ‘the benefit of any further message on
rely on the recommendations of the American Academy of Pediatrics reducing the risk of SIDS is likely to be marginal at best’ [435].
(AAP), which recommends no bed-sharing situation as safe In the case of the New Zealand cot death association, the rec-
[376,377]. There are, however, disagreements within the AAP on ommendations target the highest risk groups who smoke [489],
recommendations and advice [378e381]. On the internet, only 20% including Maori mothers [490e496] who place a cultural emphasis
of all websites located by Google Search using 13 key phrases on bed-sharing [397] and express confusion that putting baby in a
including “infant sleep position” and “infant sleep surface” offered cot would give it cot-death [497]. Anti-bed-sharing messages to
information in accordance with AAP recommendations [382]. Maori parents might lead to distrust or disregard for safe sleeping
At least in the US there is a call for a strong and no-nonsense advice [472]. The Maori issue raises an important point in the
approach in recommending against bed-sharing [383e387], but at ongoing debate: culture can complicate discussions of bed-sharing
the same time pediatricians are advised to be nonjudgmental and to and sleep [438,498e503]. Some argue that there are actually lower
be aware of one's own cultural biases [388,389]. Yet clinicians' advice SIDS cases in countries in which bed-sharing is common (e.g.,
against bed-sharing does not always influence the decision to bed- Zimbabwe, Hong Kong) even in the presence of high risk-factors
share [18,390]. In Turkey and in the US, the majority of mothers [456,504e508] and that culture-specific language can pathologize
were aware of bed-sharing as a risk for SIDS [391,392]. Early cam- bed-sharing [159] or reveal inherent Western-culture biases
paigns aimed at reducing SIDS risks found increases in the number of against bed-sharing [426,479,509e511]. Practitioners in multi-
bed-sharing and room-sharing families following the campaign ethnic settings must often consider culture specific caregiving
[393,394]. Interventions and risk-reduction campaigns to reduce practices [512] and might encourage room-sharing with the infant
infant bed-sharing have had mixed success [156,295,395e406]. In- sleeping on a separate, but proximal, sleep surface [389]. Fleming,
terventions aimed at decreasing bed-sharing in older children e as Pease, and Blair recently concluded that the evidence of risks of
an attempt to curb sleeping problems e showed a mixed efficacy as bed-sharing for breastfeeding mothers who do not smoke, drink
well [144,407,408]. A recent review suggests using a socio-ecological alcohol, or use recreational drugs is “very limited” [513] Undoubt-
model to explore multiple levels of influences on bed-sharing, edly, most bed-sharing research, including research on SIDS, is
enabling the development of better interventions for target groups Western-centric and would greatly benefit from a more complete
[409]. Finally, portable sleeping spaces might be used in conjunction examination of worldwide practices, risks, and patterns.
16 V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27

Discussion retrospective. The anthropological research has often assumed the


inherent ‘naturalness’ of this practice, but most research has been
Following an exhaustive narrative review of 659 studies address- either done on very small samples or has not been replicated.
ing bed-sharing, we note a rather disproportionate emphasis in the Psychologists e particularly developmental psychologists and
literature on the pathological, abnormal, and worrisome dimensions attachment theorists who we believe are sorely needed e have
of bed-sharing. As a relatively new cultural phenomenon, the practice shied away from the conversation thus far, despite the widespread
of putting infants to sleep in a separate surface has come to dominate lay use of terms such as ‘attachment’ in relation to bed-sharing.
the literature as the normal and correct strategy for infant sleep. The Evidence that is to form the basis of world-wide recommendations
reviewed literature has many common themes that warn of dangers must be sound. McKenna, Ball, and Gettler have encouraged anthro-
for bed-sharing parents e from the most ominous SIDS, to sleep pologists to become more involved in pediatrics research and have
problems, maternal depression, suboptimal infant emotional devel- called for a more holistic, integrative approach to the study of bed-
opment, and many others. The discrete empirical evidence behind sharing [4]. To date, the literature and associated advice is predomi-
each of these purported risks is often lacking. A sheer volume of nantly informed by the pediatrics literature [519]. Thoman argues that
literature does not readily equate with quality designs, and many views on bed-sharing must continue to be informed by evidence from
covariates and confounders are different across studies, adding to the epidemiology, physiology, and anthropology e if issues are to be
heterogeneity of studies. This is most apparent in the SIDS literature, addressed by more than strongly held opinions [5], and a recent call
the topic which appears to be the most polarizing, but also exists in for cross-fertilization in this field has been made [377]. However,
other subdomains of bed-sharing literature. For SIDS and bed-sharing, developmental psychology has not been mentioned before and
the storm of controversy has brewed for over twenty years; and the therefore much work still needs to be done to foster an informed
target has continually shifted: from bed-sharing in smoking and discussion in this area [413]. Developmental psychology might be a
drinking mothers, to e recently e all bed-sharing [514]. The under- particularly helpful recruit in the pursuit of a more integrative disci-
lying message of the opponents of bed-sharing is that it is a dangerous pline. The study of bed-sharing from infancy through childhood re-
practice, associated with harms for both infant and parent mental and quires careful probing of different age-dependent covariates,
somatic health. predictors, and consequences. The socio-emotional and physical
In the midst of this is the ongoing voice of the ‘pro-bed-sharing’ needs of children, and the effects of parental practices across child-
community, supported by a handful of laboratory studies evidencing hood, must be examined through a developmental lens.
purported physiological and behavioral benefits of bed-sharing. This It is time for scientists to stray from the thick grooves made in the
side, too, is burdened by a lack of evidence. The underlying message field of bed-sharing. It is time for pediatrics/epidemiology, anthro-
of this side is that bed-sharing is a natural, evolutionarily meaningful pology/evolutionary psychology, and psychiatry/developmental
practice with many benefits for both parents and their children, but psychology, to join forces in a new subfield that we label
most of the associated studies are prohibitively small and lack psychoanthropediatrics. Psychologists and psychiatrists (‘psycho’)
replication efforts. The conversation does not seem to have changed can assess normative and clinical developmental issues; sociologists
in the last 25 y [506]. If bed-sharing is a natural, evolutionary and anthropologists (‘anthro’) can inform the field about evolu-
meaningful practice [515], then there must be supportive evidence tionary and cultural issues; and pediatricians can assess clinical
of underlying physiological, biological, or psychological correlates. risks, health costs and benefits, and burdens on families of particular
While McKenna and others have diligently pursued this line of work rearing practices. The field of psychoanthropediatrics can and
for decades, with clever designs and intriguing first findings point- should extend beyond sleep studies, to include other controversial
ing to a synchrony between caregivers and their infants, more evi- parenting practices and parent-child interactions that would benefit
dence has not followed. McKenna and Gettler recently argued that from this multidisciplinary approach. Helping future studies move
there is “no such thing as infant sleep, there is no such thing as forward could be achieved by the integration of expertise and,
breastfeeding, there is only breastsleeping” [516], a concept which potentially, by “adversarial collaboration” [377] between scholars on
has met some early opposition [517]. The differences in opinion opposite sides of the debate tasked with three common goals. First,
surrounding children's autonomy and sleep problems as a function improving study designs, starting from longitudinal and cohort
of bed-sharing have not been resolved. We do not know what designs, via observations of parenting practices to experimental
‘normal’ infant sleep architecture looks like. It is unclear whether studies. Second, implementing more cross-cultural studies with
this lack of continued research into normative physiological and attention for cultural biases and beliefs which ‘can be so powerful
psychological characteristics and potential benefits in bed-sharing that parents are known to act on them, setting aside what their
children stems from a cultural taboo on the practice, or whether senses might tell them about their own children’ [520]. Third, by
the SIDS research has stymied the exploration of bed-sharing in a working from a psychoanthropediatrics framework, encompassing
non-clinical context. Other factors that should be considered include knowledge from developmental, culture sensitive and clinical per-
the widely varying cultural and ethnic backgrounds of the studies spectives. These collaborative efforts will then allow scholars,
reporting on parenting practices and bed-sharing, even within the practitioners, and parents to make well-informed choices about
same nation; as well as the wide age-ranges across which studies on daily parenting practices [521], while keeping the healthy devel-
bed-sharing have been conducted. Esposito et al. [518] call for a opment of the child e and the child's family e at the forefront.
multilevel approach to the analysis of predictors of bed-sharing,
with the goal of constructing a physio-bioecological analysis of Conclusion
sleeping arrangements in early infancy.
If the reviewed literature is to be any indication, the debate
The need for psycho-anthro-pediatrics surrounding bed-sharing is not likely to disappear. An increasing
number of studies alleging SIDS risk in bed-sharing infants does not
We argue that conclusive evidence is lacking not because of equate to a simple majority-wins vote-count, particularly if publi-
negative findings, but rather because of a lack of focus on current cation bias and methodological flaws restrict the clarity of the ev-
gaps in knowledge. The pediatric research has assumed for better idence. Much of the world bed-shares and appears to do so without
or for worse that bed-sharing is likely a risk to be eradicated, but great risks. Similarly, stating the ‘naturalness’ of a practice does not
most such research is correlational and cross-sectional or alleviate the stress that many parents report when bed-sharing.
V.R. Mileva-Seitz et al. / Sleep Medicine Reviews 32 (2017) 4e27 17

Cultural and societal factors cannot simply be discarded in these Acknowledgments


discussions. Correlational and cross-sectional designs can only
carry us so far. Headway can be made when the major players face We gratefully acknowledge the contribution of Marit Spillenaar
the multi-faceted complexities of this parenting practice and Bilgen, Nora Abdulgani Naji, and Afza Iqbal to the data collection.
honestly appraise the methodology with which they aim to relieve We also would like to thank Marinus van IJzendoorn and Henning
the burden of evidence. Tiemeier for critical evaluation of the manuscript. The present
study was supported by grants from the Netherlands Organization
for Scientific Research (NWO): an NWO RUBICON prize no 446-11-
023 to VRM-S, and NWO VICI grant no. 453-09-003 to MJB-K. MJB-K
Practice points
was also supported by the Gravitation programme of the Dutch
Ministry of Education, Culture, and Science and the Netherlands
1. Parent and child bed-sharing is one of the most contro-
Organization for Scientific Research (NWO grant number
versial topics in parenting research, and parents and
024.001.003) and the European Research Council (AdG 669249).
practitioners often make decisions based on information
from the popularized and polarized debate.
2. Many studies that address bed-sharing focus either on Appendix A. Supplementary data
the problematic and dangerous effects, or on the positive
and natural side of the practice, but both sides struggle Supplementary data related to this article can be found at http://
without convincing empirical evidence. dx.doi.org/10.1016/j.smrv.2016.03.003.
3. The lack of sound study designs precludes making
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