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	new baby sleep

Rooming-in at the Hospital: Assessing the Practical Considerations
By Martin Ward-Platt and Helen L. Ball
Issue 114 September/October 2002

Many mothers share a bed with their babies in the early months of the infant's life, particularly for breastfeeding. Although this practice is controversial among health professionals, it has been found to be beneficial in several ways: It reduces sleep disruption caused by frequent nighttime breastfeeds, promotes breastfeeding by encouraging frequent suckling, facilitates continued breastfeeding, soothes fractious infants, and promotes sleep for mother and baby.1,2,3,4,5

Many hospitals are now making a commitment to "baby-friendly" practices that encourage the early establishment and continued promotion of breastfeeding. Some are also developing policies on "bedding-in"-mother-infant bedsharing on the postnatal ward.6 In addition, baby-friendly guidelines require hospitals to allow mothers uninterrupted skin-to-skin contact for at least half an hour following delivery, to encourage breastfeeding within the first hour, and to advise mothers to keep their babies close to them at all times.7 The obvious extension to this practice is to help mothers maintain skin contact with their infants by bedsharing on the postnatal ward.

By allowing mothers to comfort, feed, and care for their babies in bed, bedding-in may assist the establishment of breastfeeding while helping mothers get more rest.8,9 In one British hospital, introduction of a bedding-in policy resulted in a halving of the rate of supplementation with artificial formula.10 Hospital bedding-in policies can provide a framework of guidelines through which some mothers can be allowed, even encouraged, to keep their babies in bed with them, both day and night, while on the ward.

There is currently no published research on the effects of bedsharing on mothers and infants in the immediate postnatal period, either in the hospital or the home environment. There are a number of well-known contraindications (smoking, alcohol consumption, use of drugs that affect sleep) and safety issues (careful use of duvets and pillows, avoidance of soft sleeping surfaces and sofa-sharing) relevant to bedsharing at home. But there are other factors that come into play on the hospital ward, from simple aspects of the physical environment (e.g., height and width of the hospital bed) to the complexities of how analgesics used during delivery affect both mother and infant, including whether or not such drugs are safe in a cosleeping context.

The first potential harm is accidental falls from the bed. Because of the height and narrowness of most hospital beds and the hardness of hospital floors, the consequences of a newborn falling from an adult bed can be serious. Bed width and height also require assessment, as babies may be more precariously positioned in high, narrow beds than in lower, wider ones. Most hospital bedding-in policies prescribe the use of some form of crib side when an adult bed is used with an infant. Traditional railing-type crib sides are inappropriate, because a baby can fall, or become trapped, between the bars. Solid, padded crib sides, which overcome these problems, are available. Crib sides designed for use by solitary-sleeping toddlers may present a safety hazard to neonates because of the possibility of entrapment between the crib side and the bed mattress.

Relatively new on the market are three-sided infant bassinets, based on the design of a standard hospital bassinet, that can be attached to the mother's bed and locked in place. These allow easy access to the infant for breastfeeding and caregiving, but provide a separate surface on which the infant can sleep. Comparative observations of the movements and interactions of mothers and newborns sleeping together in different types of hospital beds (e.g., wide delivery beds versus standard ward beds) would enable a scientific assessment of the benefits of wider and lower beds for bedsharing.

A second issue is that the ability of a newly delivered mother to respond to her baby is likely to be a critical determinant of the safety of bedsharing. The effects of opiate analgesics on infant behavior in the first few postnatal hours are well known. Infants exposed to pethidine show delayed and reduced sucking behavior and are drowsy and unresponsive in comparison with nonexposed infants.11,12,13 Unfavorable effects on the physiology and behavior of the newborn infant last up to three days after birth.14 There is evidence from older infants that bedsharing is unsafe when parents have used drugs or alcohol, but little is known about the effects that opiates in labor may have on a mother's handling of her baby, or how long these would last.

The third issue is the effect of bedding-in on the quality of maternal and infant sleep. Hospital research has shown that mothers who are separated from their infants at night do not sleep any better than mothers whose babies remain at their bedside, while babies separated from their mothers sleep considerably less than do those sleeping beside their mothers.15,16,17 This information drives the current practice of encouraging rooming-in, rather than removing infants to the nursery at night in order to give the mother a good night's sleep. We therefore need to confirm whether mothers and infants who sleep together during the immediate postnatal period achieve more or less sleep than those who share the same room but not the same bed.

The issue of maternal and infant sleep links with that of maternal and infant fatigue after labors of differing intensity and stressfulness. Research data on postpartum maternal fatigue in relation to length of labor is sparse, and information on the effects of a long and exhausting labor on the first postpartum maternal sleep is nonexistent.18 So there are no data upon which to make judgments as to the safety of mothers and babies bedsharing after exhausting deliveries.

Another issue is that of maternal satisfaction. A recent Norwegian study found that insufficient sleep and rest is a source of dissatisfaction for many women on postnatal wards.19 The development of maternal confidence in infant caregiving is also likely to be a strong determinant of mothers' satisfaction with their postnatal stay.

In terms of caregiving,would bedding-in on the first or second night after delivery have an impact on the establishment of breastfeeding? While this seems likely, there is only a little direct evidence to suggest that it is true.20 The effects of skin-to- skin contact and suckling within a short time of birth are well known, but research into the optimal method for reinforcement of these practices over the subsequent days has rarely included research on bedsharing.

There are clear benefits of prolonged skin-to-skin contact ("kangaroo care") between mother and infant in the immediate postnatal period. In many respects, mother-infant bedding-in is an extension of this prolonged contact for the duration of the hospital stay. Unfortunately, much of the research on this has been done on premature babies, and it is not clear how far this research can be extrapolated to term infants. Skin-to-skin contact has been shown to be analgesic for newborns and helps infants recover rapidly from birth-related fatigue.21,22 It encourages spontaneous breastfeeding, promotes continued breastfeeding, and helps to conserve energy, all of which increase the well-being of the newborn infant.23,24,25 In addition, preterm neonates seem to sleep longer, experience less agitation and less instability of heart rate and breathing, and have more stable oxygenation.26

Skin-to-skin contact was also associated with a significant increase in maternal oxytocin levels in two Swedish studies, suggesting that uterine contraction may be enhanced and milk ejection improved, to the benefit of both mother and infant.27,28 Furthermore, skin-to-skin contact is also associated with lower maternal anxiety and more efficient participation of mothers in caring for their newborn infants.29 All of this is encouraging, but there are no definitive answers to the questions arising among term babies in their first postnatal days. As we have shown, there is at present little solid evidence to resolve these debates.

Bedsharing has mostly been studied among breastfed infants of three or more months of age.30,31,32 In studies of parent-infant bedsharing in both the home and sleep lab environment, we have used infrared video to examine the bedsharing environment, sleep-related behavior, nighttime breastfeeding, and sleep patterns in mothers, fathers, and infants two to six months of age. These studies, by our group and others around the world, illustrate that bedsharing is associated with longer and more restful maternal and infant sleep and with successful breastfeeding.33,34,35 Babies who sleep with their mothers feed more frequently (thus stimulating milk supply) and for longer periods than babies who breastfeed without bedsharing.36

To extend these studies to the first nights after delivery, we have undertaken a pilot study of bedding-in on the postnatal wards of the Royal Victoria Infirmary, Newcastle upon Tyne. We used nighttime infrared video recording to examine mother and baby behavior on the first postnatal night. We observed that some mothers barely slept on the first postpartum night, while others, exhausted or under the influence of opiate analgesics, slept heavily. Many babies also appeared exhausted at this time. It may be that the second postpartum night is the most critical for the establishment of breastfeeding, so in the future we will need to observe both the first and second postpartum nights. Bedding-in is unlikely to be ideal for every mother and baby, but we hope to provide the information upon which informed choices and recommendations can be made.