"Same Room, Safe Place".

There are many different professional stances on safe sleep and then there is the reality of caring for a newborn. There is a debate among professionals regarding safe sleep recommendations. The continum of recommendations vary from the American Academy of Pediatrics (AAP) Safe Sleep Guidelines to the bed-sharing recommendations from the Mother-Baby Behavioral Sleep Laboratory. The lack of consistent and uniform safe sleep recommendations from health professionals has been confusing for families but has more recently raised a real professional ethical dilemma. Despite years of focused safe sleep community education and interventions, sleep-related infant deaths are on the rise in many communities. This commentary calls for a united safe sleep message from all health professionals to improve health for mothers and infants most at-risk, "Same Room, Safe Place."

As a public health professional and maternal/infant health educator and researcher, I have watched the safe sleep debate from the sidelines over the years. There are many different professional stances on safe sleep and then there is the reality of caring for a newborn. Throughout my career, I have observed the use of most safe sleep recommendations from the American Academy of Pediatrics (AAP) Recommendations for Safe Infant Sleeping[1] to the co-sleeping recommendations from the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame.[2] The AAP policy statement and technical report includes the following recommendations: always place infant on back, always use a firm surface (no car seats or other sitting devices), infant should sleep in the same room but not in the same bed, no soft items or blankets in crib, no wedges or sleep positioners, no smoking during pregnancy or after birth, breastfeeding is recommended, encourage use of a pacifier during sleep, do not cover infant’s head, avoid use of home monitors/devices marketed to reduce the risk of sudden infant death syndrome, infants should receive all vaccinations, and supervised tummy time while infant is awake is recommended.[1] Researchers from the Mother-Baby Behavioral Sleep Laboratory also agree a smoke-free pregnancy and healthy gestation is key to a safe sleep environment. Breastfeeding, is listed as a second factor with strong influence related to infant safe sleep. Additional guidelines include the following: placing infants on their backs to sleep, on firm surfaces, on clean surfaces, in the absence of secondhand smoke, under light blanketing, and with their heads uncovered.[2,3] The main difference between the 2 sets of recommendations is the location of the infant. The Mother-Baby Behavioral Sleep Laboratory includes “safe co-sleeping guidelines” based on many years of research. The co-sleeping (defined as an infant in close proximity/sensory range to mother) guidelines include bed-sharing practices (infant and mother on same sleep surface) such as: no stuffed animals or pillows near infant, firm mattress with no gaps around bed or bed frame, no beanbag mattresses, no waterbeds, no couches/sofas, infant should only sleep with a person taking responsibility for the infant in bed (no other children), long hair should be tied up, the use of medications that affect arousal/awareness are not recommended, and obese adults are discouraged from bed sharing.[2,3] The AAP does not include bed sharing as part of their safe sleep recommendations.[1]

The lack of consistent and uniform safe sleep recommendations has been confusing but has more recently raised a real professional ethical dilemma. Recent research reports under half of available safe sleep information on the web follow AAP recommendations[4] and the voices of allied health professionals citing research on the improved health and breastfeeding outcomes of mother-infant dyads that co-sleep are becoming more frequent.[5,6] However, despite years of focused safe sleep community education and interventions, sleep-related infant deaths are on the rise in many communities.[7] The number of infant sleep-related deaths have doubled in 2016 in Wichita, Kansas and this is true in many other communities across the United States.[8] At a moment of community crisis when the need for urgent, swift, consistent, and trustworthy information is needed the most, where should mothers, families, and infant care givers turn? As health care and public health professionals, we have the responsibility to be the answer during these times.

In fact, many health professionals have taken oaths to uphold this responsibility. The Hippocratic oath includes, “I will endeavor to work in accord with my colleagues in a spirit of progressive cooperation and never by word or by act cast imputations upon them or their rightful practices.”[9] There are numerous other oaths for those practicing in the allied health professions, and despite not having one unified oath, the oaths are similar and include the duty to support preventive health care and protect the health of the public. For example, the University of Georgia College of Public Health’s oath includes,

As a public health professional, I hold sacred my duty to protect and promote the health of the public. I believe that working for the public’s health is more than a job, it is a calling to public service. Success in this calling requires integrity, clarity of purpose and, above all, the trust of the public. Whenever threats to trust in my profession arise, I will counter them with bold actions and clear statements of my professional ethical responsibilities.[10]

It is time to reflect on our own professional oaths and codes of ethics to which we are all bound.

Just as medical and public health recommendations have been created for years, let us combine research and evidence from multiple disciplines and come up with a safe sleep message on which all health professions can agree: “Same Room, Safe Place.” Debating the semantics of the behavior is a distraction because it does not matter to sleep-deprived parents and caregivers; is it co-sleeping or is it room sharing? These semantical debates are only slowing our progress.[11] Same Room, Safe Place supports safe sleep surfaces in close proximity, is backed by scientific evidence,[12] and has been shown to support successful breastfeeding mothers.[13] The use of “safe place” instead of “alone or separate” is an important message to reach high-risk populations. Research has indicated safe sleep messaging needs to include language of close proximity between the mother and infant to meet the social values expressed in high-risk environments (such as small living arrangements with multiple children or where environmental dangers are present). The use of terms such as “alone” or “separate” may be immediately dismissed because of the lack of congruence with social values.[14] The message “Same Room, Safe Place” should be accompanied with education regarding consequences associated with caregiver use of alcohol, tobacco, or other drugs (ATOD) and the risks associated with other soft surfaces such as recliners and sofas, consitent with previous safe sleep recommendations.[15]

The evidence behind “safe place” in the message is for the safety of all infants. It is a complicated task to explain how bed sharing/co-bedding could be the best sleep position for the mother and infant dyad if the mother/parent follow numerous and very specific steps (eg, no ATOD, short sheet the bed, no gaps around mattress, etc).[16] The safe place could be a co-sleeper attached to the adult bed,[5] a bassinet, or a baby box (based on the Finnish tradition from the 1930s). There are numerous options at various price points to support large community-wide educational programs and access to resources. This safe sleep message uses previous research findings reported by high-risk mothers and aligns with mothers’ strong desire to protect their infant.[14]

“Same Room, Safe Place” emphasizes the benefits of close proximity, helps support breast-feeding, and is safest for all infants. Let us move forward as health professionals collectively and rally behind one consistent safe sleep message to prevent future infant deaths. This tactic can help reduce the health disparities that have burdened communities for years, 17 by giving those most in-need the same message across the community and across medical and allied health professionals. This unity can then spread throughout our communities and through social media. Let us change population behavior across our communities through our own professional behavior change, by creating a more unified and mother-centered message.