Infant safe sleep advice in N.S., N.B. parenting books not explicit on bed-sharing risks

Safe Sleep is an investigative series examining what risk factors were present in more than 1,300 incidents of infant death over an 11-year span in Canada.

Before her son Liam was born, Leah Holt did a lot of reading on infant sleep methods and ultimately decided her newborn would sleep in a bassinet next to her bed.

That choice was in line with infant safe sleep best practices as outlined by Health Canada.

But when Liam was about four and a half months old, he wasn't doing much sleeping at all — and neither, of course, was she.

Holt, who lives in Cole Harbour, N.S., had seen other mothers posting in online social groups about their experiences with bed-sharing, so she decided to give it a try.

"I kind of had in the back of my head, like, oh, this is not recommended by the official documents and things like that, but I know people do it all the time and it seems to be fine."

• Unsafe sleep practices present in hundreds of infant deaths in Canada, CBC investigation finds
• Some provinces, territories not tracking race of infants who die in their sleep
• Waking up: How some parents and grandparents are learning about safe sleep for their infant

One night, after she had placed her blanket only over her lower legs, Holt awoke to find the corner of the blanket covering Liam's face. When she pulled it away, he gasped for air before eventually falling asleep again.

"It was terrifying.… I thought, OK, this is proof to me that I shouldn't be doing this."

After Holt's alarming incident with the blanket, she stopped bed-sharing at night and revisited the official guidelines on safe sleep, including Loving Care, a booklet created in Nova Scotia and distributed by Public Health to parents there and in New Brunswick.

The book advises that the safest place for babies under six months to sleep is in a crib near the caregiver's bed. But it goes on to explain how to "make bed-sharing as safe as possible," by ensuring the mattress is firm and that babies can't get trapped under sheets, blankets or pillows, among other precautions.

That advice is echoed in Breastfeeding Basics, a 2015 book published by Nova Scotia's Health Department that is also handed out to new parents.

"I think that's where I got confused, because I was hearing ... 'If you do [bed-share], this is how you can do it safely,'" Holt said. "And I thought, OK, well, if there's a safe way to do it, then why wouldn't I do it?"

But some experts say the safe sleep guidelines in Loving Care are incomplete and lack an emphasis on accidental yet preventable deaths.

'I think it legitimizes bed-sharing'

Data collected under access to information, as part of a CBC News investigation, shows that between 2009 and 2019, at least 1,338 infants in Canada under the age of one died during sleep in what Health Canada deems an unsafe sleep situation, such as being placed on a soft sleeping surface, on their tummy or with another person present in bed.

Of the 476 deaths from eight provinces and territories that the CBC had enough information to analyze, at least 61 per cent involved bed-sharing, and 77 per cent involved sleeping on a surface not designed for infants, such as an adult bed or a couch.

In a separate analysis by Statistics Canada of infant deaths in sleep between 2015 and 2020, 53 per cent of the babies were found to have been sharing a bed at the time. Of those deaths that took place while bed-sharing, 32 per cent involved a sleeping environment that included pillows, blankets or other objects. In 79 per cent of bed-sharing deaths, the baby was sleeping on an adult bed, and in 16 per cent, it was on a couch or armchair. 

In twenty-three per cent of bed-sharing infant deaths, toxicology reports showed a parent and/or baby had drugs or alcohol in their system.

Safe sleep guidelines provided by Health Canada recommend against using pillows, blankets or other objects in the sleeping environment, and that a baby be placed to sleep only in a crib, cradle or bassinet.

Amy Smeltzer of Halifax bed-shared with each of her three children when they were babies, as she didn't have risk factors that could make it more dangerous, such as smoking or taking drugs or some medications.

But not everyone in her circle was on board. Smeltzer said she experienced disapproval from extended family for her decision to bed-share.

So when she saw the guidelines in Loving Care, she felt vindicated.

"I remember calling my husband over when I read the section on safe places to sleep, because I was so thrilled with their approach to it," Smeltzer said. "I think it legitimizes bed-sharing. It's not just saying that bed-sharing is OK, it's also acknowledging that there are solid reasons that a mom might prefer bed-sharing over co-sleeping or putting their child in a crib, and it really normalizes that."

National guidelines warn against bed-sharing

Unlike national and some international safe sleep guidelines, Loving Care does not explicitly state any connection between bed-sharing and the increased risk of sudden infant death syndrome (SIDS) or suffocation for the general population, simply explaining, "there has been a lot of research looking at whether bed-sharing is safe or whether it increases the risk of SIDS." It only specifies that bed-sharing increases the risk of SIDS if parents smoke or smoked during pregnancy.

But Canada's new guidelines for parents, which were released in October 2021, are more clear on the risks for the general population: "bed-sharing increases a baby's risk of SIDS and suffocation." 

The joint statement from the Public Health Agency of Canada, Health Canada, the Canadian Paediatric Society and Baby's Breath Canada — a foundation focusing on SIDS and sudden and unexpected infant deaths — goes into greater detail, saying bed-sharing is not advised and that "sharing a sleeping surface increases the risk of SIDS, suffocation from overlay or entrapment and overheating."

The American Academy of Pediatrics goes even further, explicitly stating that bed-sharing is not recommended for any babies and sharing a statistic that about 3,500 infants in the U.S. die each year while sleeping due to SIDS or accidental deaths from suffocation or strangulation.

Books under review

Flora Murphy, Nova Scotia Health's manager of Early Years Public Health, Science and Systems Performance, told the CBC in an email that Public Health regularly reviews the content of its publications, but that process has been "significantly affected" by its COVID-19 response.

Public Health was also in the process of reviewing the use of the books in 2019, and will resume those efforts when the pandemic response slows down.

"We acknowledge that as we are able to return to our pre-pandemic responsibilities and processes, there is work to ensure any updates in best practice are reflected in the support we provide Nova Scotians," Murphy wrote.

Bruce Macfarlane, a spokesperson from New Brunswick Health, said Public Health in that province will review new and emerging evidence with Nova Scotia Health before the Loving Care books are printed again later this year. 

Macfarlane said New Brunswick provides other information on safe sleep to parents, including during prenatal visits and at discharge from the hospital. The province also has a safe sleep website and has been using social marketing campaigns on safe sleep in recent months.

Of the 30 infant sleep deaths recorded in New Brunswick between 2009 and 2019, at least 20 cases involved sharing a sleep surface with another person. Of the remaining 10 instances, the CBC did not have enough information about seven to determine whether the infant was bed-sharing; the other three did not involve bed-sharing.

Nova Scotia did not provide enough information to the CBC to determine whether infant deaths involved sharing a sleep surface.

Bed-sharing relatively common

According to data collected in 2015 and 2016 by the Canadian Community Health Survey, about 33 per cent of Canadians who had given birth in the previous five years said they frequently shared a bed with their infant under 12 months, and 27 per cent said they bed-shared occasionally. 

Breastfeeding was the most common reason given for bed-sharing, followed by facilitating sleep.

Smeltzer said those factors contributed to her decision to bed-share.

"I found that I could sleep better if I could just nurse my child until he fell asleep, until I fell asleep … without the interruption of having to physically get up."

Jeanine Young, deputy head of the school of nursing, midwifery and paramedicine at the University of the Sunshine Coast in Australia, studies bed-sharing and infant mortality and helps develop evidence-based safe sleep advice for caregivers.

She said the Loving Care book should include stronger advice about preventing fatal sleeping accidents.

"Using only the term SIDS I don't think is helpful in being as effective as we possibly can be with our public health messaging because … there are interventions that we can put in place that we know will reduce the risk of sudden and unexpected death in infancy," said Young.

"I think that key messages about sleep environment could be more targeted and made more simple."

'A really difficult topic'

Jennifer Doering, an associate dean at the University of Wisconsin-Milwaukee's college of nursing, agrees. 

"Parents need information about how to prevent accidental suffocation and strangulation in bed, which is a really difficult topic to talk about. But it happens. And so I felt [the Loving Care] guidelines could have said more about a focus on preventing overlay of either a person or a limb, which does cause death in a sleep environment, especially in a bed-sharing environment."

Doering, who has researched bed-sharing and international safe sleep guidelines, added that she'd like to see the Loving Care books mention the danger posed by having a baby sleep on the same surface with siblings, as well as the danger posed by air mattresses.

Despite aspects that could be improved, both Young and Doering said the guidelines should be lauded for including advice on how to make bed-sharing safer, rather than simply telling parents not to do it.

"People are going to sleep with their baby," said Doering. "If guidelines don't address the reality that parents are going to sleep with their babies, whether they mean to or not, then those guidelines are accepting a certain level of death as acceptable."