Mothers Falling Asleep During Infant Feeding

Abstract

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DOI: 10.1542/6362115030112

Video Abstract

BACKGROUND AND OBJECTIVES

Falling asleep while feeding (FAF) infants is common. Our primary objectives were to examine (1) maternally reported prevalence of FAF and if planned; (2) association between FAF and sociodemographic factors, feeding method, and sleep location; and (3) if receipt of education about safe sleep and bedsharing risks was associated with FAF.

METHODS

In the Social Media and Risk-reduction Training study, US mothers of newborns were randomized to educational messaging promoting infant safe sleep or breastfeeding. We analyzed data from 1259 mothers who responded to the postpartum survey (mean infant age, 11.2 weeks). We used generalized estimating equation logistic regression models to examine the extent that sociodemographic characteristics, feeding type, usual nighttime feeding location, and intervention group were associated with FAF.

RESULTS

A total of 28.2% of mothers reported FAF usually or sometimes in the last 2 weeks, 83.4% of whom reported that FAF was unplanned. There were no differences in the odds of FAF by sociodemographic factors. Compared with mothers whose nighttime feeding location was their bed, mothers who reported feeding in a chair were less likely to FAF (33.6% versus 16.8%; adjusted odds ratio, 0.41; 95% confidence interval, 0.31–0.56). FAF was reported less frequently by mothers who received safe sleep interventions (15.6%), compared with mothers who received breastfeeding interventions (33.0%; adjusted odds ratio, 0.40; 95% confidence interval, 0.25–0.65).

CONCLUSIONS

FAF is reported commonly among US mothers and is predominantly unplanned. Mothers who received safe sleep messaging were less likely to report FAF. New parents need guidance on planning for optimal safety during infant feeding.

What’s Known on This Subject:

Infants require frequent nighttime feedings, and new mothers are at risk for falling asleep while feeding their infants. Sharing a sleep surface, especially a sofa or chair, is a known risk factor for sleep-related sudden unexpected infant death.

What This Study Adds:

We present prevalence of reported falling asleep while feeding young infants from a national intervention trial, factors associated with falling asleep while feeding, whether falling asleep was planned, and reasons for choice of nighttime infant feeding location.

Infants require frequent nighttime feedings, and parents are at risk for falling asleep while feeding (FAF) their infants.¹ This is particularly true for breastfeeding parents; oxytocin, released during feedings, can naturally lead to falling asleep.² Sharing a sleep surface, including a bed, couch, sofa, or chair, is a known risk factor for sleep-related sudden unexpected infant death (SUID), with the greatest risk occurring on a couch or sofa.^3,4 The American Academy of Pediatrics (AAP) advises against sleeping with an infant on the same surface (hereafter called bedsharing).⁵ Because the odds of SUID when sleeping with an infant are lower on an adult bed than on a sofa, couch, or chair, the AAP prefers an adult bed for feeding if a parent is at risk for FAF.⁵ However, it has been conjectured that parents may choose to feed their infants in a location other than their bed with the intent of staying awake during the feeding,¹ but should they fall asleep it will be in a riskier location for the infant. Little is known about the prevalence and location of FAF, whether it is planned, and if FAF is associated with sociodemographic factors, feeding type, feeding location, or education about safe sleep and risks related to bedsharing. Further, little is known about the reasons for choice of feeding location.

In the Social Media and Risk-reduction Training (SMART) study, mothers of newborns were randomized to receive educational messaging promoting either infant safe sleep (SS) or breastfeeding (BF) and then queried about feeding and sleeping practices. We previously reported the results of the SMART study interventions.⁶ Given the importance of this question with regard to counseling parents about both feeding and safe sleep, the availability of these data from SMART and gaps in the literature about FAF, the objectives of this analysis were to examine (1) maternally reported prevalence of FAF and if planned; (2) the association between FAF and sociodemographic factors, feeding method, and sleep location; and (3) if receipt of education about safe sleep and bedsharing risks from the SMART intervention was associated with FAF.

Methods

Study Design

SMART study methods have been published previously.⁶ Briefly, SMART was a parallel-design cluster-randomized trial to test the efficacy of an in-hospital quality improvement (QI) program and mobile health (mHealth) messaging after the infant’s birth in improving SS practices. We enrolled a diverse sample of 1600 English-speaking mothers of healthy term newborns at 16 US birth hospitals from March 2015 to May 2016. Other caregivers were not surveyed in this study, and although we recognize that not all birthing or lactating parents identify as female or as mothers, we will use the terms “mother” and “breastfeeding” throughout the manuscript to be consistent with survey language. Mothers were randomized by hospital into 1 of 4 combinations of SS and attention-matched control BF interventions: (1) BF QI and BF mHealth (BF-BF); (2) SS QI and BF mHealth (SS-BF); (3) BF QI and SS mHealth (BF-SS); or 4) SS QI and SS mHealth (SS-SS). In-hospital QI programs promoted parental education and support of SS or BF. In the mHealth intervention, mothers received frequent, short (≤2 minutes) videos focused on SS or BF, delivered by text message or e-mail for 60 days after birth. All intervention materials were developed by study investigators using qualitative and quantitative data regarding facilitators and barriers to adherence^7–10 and prior successful interventions,^11–17 and reviewed by experts in safe sleep, breastfeeding, health education, social marketing, and by parents of infants. SS messages included advice to practice back sleeping, use a firm mattress, and avoid soft bedding, smoking, and bedsharing, with explanations as to why these practices were recommended. SS messages also included advice to place the infant’s crib or bassinet in the parent’s room, ideally next to the parental bed, to facilitate frequent feeding and comforting. BF messages promoted exclusive breastfeeding and addressed common barriers. All participants received messaging that parents who were at risk for FAF should feed on an adult bed with a firm, flat mattress and no soft bedding and then return the infant to their own sleep space after the feeding or as soon as the parent awakened after the feeding if they had fallen asleep. Mothers completed a survey online (79%) or by phone (21%) about infant care practices when the infant reached 60 days of age. Institutional review board approval was obtained from all participating institutions.

Definition of Variables

For this analysis, the main outcome was maternal report of FAF. Because sharing a sleep surface often occurs when breastfeeding¹⁸ and this can occur not just in beds but on surfaces such as sofas and armchairs that are known to vastly increase the risk of sudden unexpected infant death,^4,19–22 the question of FAF is clinically important. We asked whether mothers had fallen asleep while feeding (usually, sometimes or never) in the past 2 weeks, and, if usually or sometimes was selected, whether this was planned (yes/no). FAF was defined as “usually or sometimes” versus “never.” We assessed feeding type by asking: “Over the last 2 weeks, what has your baby been drinking?” “Only breast milk” was defined as those who reported “only breastmilk” and “breast milk and formula” was defined as those who reported “mostly breastmilk,” “equally breastmilk and formula,” or “mostly formula.” Formula feeding was defined as “only formula.” We assessed usual nighttime feeding location by asking: “Over the last 2 weeks, where have the nighttime feedings usually occurred? (my bed, a chair, a sofa, or other-specify).” We also asked: “Which of the following reasons influenced your choice about where to feed your baby at nighttime?” with choices related to safety, comfort, and convenience. Maternal race, ethnicity, education, marital status, age, parity, infant sex, and household income were obtained by self-report.

Statistical Analysis

The SMART study was powered to detect an intervention effect of a 10 percentage point increase in the prevalence of 4 infant safe sleep behaviors (sleep position, location, soft bedding use, and pacifier use), assuming a baseline prevalence of 50%–60% for these behaviors.⁶ The current analyses were done post hoc (ie, they were not planned as part of the primary analysis and therefore we did not conduct power calculations for these).

We first determined prevalence of FAF and, among those who reported FAF, the rate at which this behavior was planned. We examined sociodemographic factors (infant age at survey and sex, and maternal self-report of race and ethnicity, parity, age, education, marital status, and household income), feeding type and location, and intervention group stratified among mothers who did and did not report FAF. Using generalized estimating equation logistic regression models with birth hospital as the clustering variable, we calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the aforementioned sociodemographic covariates, which were chosen a priori, based on the literature and prior analyses from this study.⁶ We had no a priori reason to believe that FAF would differ by race or ethnicity and, in fact, we found only minor differences in results for analyses adjusting and not adjusting for these variables. Thus, there was no justification for including race and ethnicity as potential confounders and they were not included in our final models. We added feeding type, feeding location, and intervention group to the model to calculate the independent associations of these variables with FAF. Additionally, to better understand the extent to which feeding type may impact the association between the study intervention and FAF, we examined relationships stratified by feeding type. We also examined maternal reported reasons for choice of nighttime feeding location and assessed associations between these reasons and feeding location, comparing chair versus bed and sofa versus bed, using generalized estimating equation logistic regression models and adjusting for the same aforementioned covariates. All analyses were conducted using SAS 9.4 software.²³

Results

The survey was completed by 1263 participants; we excluded 4 mothers who did not answer the question on the usual location of nighttime feedings, resulting in an analytical sample of 1259. Table 1 provides the characteristics of the 1259 mothers and infants, both overall and stratified by FAF in the past 2 weeks. The mean infant age at survey completion was 11.2 weeks (standard deviation, 4.4 weeks), and 72.7% completed the survey between 8 and 12 weeks of infant age. Overall, 355 (28.2%) mothers reported FAF usually (n = 26) or sometimes (n = 329) during the prior 2 weeks. Because of the small number of responses in the “usually” category, we combined “usually” and “sometimes” FAF into 1 FAF category for subsequent analysis. Among these 355, 307 mothers responded to the question asking if FAF was planned; of these, 256 (83.4%) reported FAF was unplanned.

TABLE 1.

Sociodemographic and Behavioral Characteristics Among Mothers Who Fall Asleep While Feeding

Characteristic	Total N (%)	Fall Asleep Usually or Sometimes N (%)	Fall Asleep Never N (%)	Adjusted OR (95% CI) (Demographics Only)	Adjusted OR (95% CI)
Total	1259	355 (28.2)	904 (71.8)
Infant age (wk)
8–11	915 (72.7)	264 (28.9)	651 (71.1)	REF	REF
12–15	171 (13.6)	40 (23.4)	131 (76.6)	0.75 (0.51 − 1.09)	0.73 (0.48 − 1.13)
16–19	86 (6.8)	25 (29.1)	61 (70.9)	0.97 (0.62 − 1.52)	0.97 (0.57 − 1.67)
20+	87 (6.9)	26 (29.9)	61 (70.1)	1.02 (0.57 − 1.83)	1.27 (0.71 − 2.29)
Infant sex
Male	615 (48.8)	175 (28.5)	440 (71.5)	REF	REF
Female	644 (51.2)	180 (28.0)	464 (72.0)	0.97 (0.82 − 1.16)	0.92 (0.74 − 1.13)
Live births
1	525 (41.7)	140 (26.7)	385 (73.3)	REF	REF
2	418 (33.2)	115 (27.5)	303 (72.5)	1.06 (0.79 − 1.41)	1.04 (0.73 − 1.48)
3+	316 (25.1)	100 (31.6)	216 (68.4)	1.27 (0.95 − 1.71)	1.22 (0.87 − 1.71)
Maternal age (y)
<20	85 (6.8)	21 (24.7)	64 (75.3)	1.12 (0.63 − 2.01)	1.14 (0.70 − 1.86)
20–29	642 (51.0)	176 (27.4)	466 (72.6)	1.01 (0.71 − 1.44)	0.96 (0.67 − 1.37)
30+	532 (42.3)	158 (29.7)	374 (70.3)	REF	REF
Race and ethnicity
Non-Hispanic White	414 (32.9)	108 (26.1)	306 (73.9)
Non-Hispanic Black	342 (27.2)	111 (32.5)	231 (67.5)
Hispanic	406 (32.2)	110 (27.1)	296 (72.9)
Other	97 (7.7)	26 (26.8)	71 (73.2)
Maternal education
Less than high school	88 (7.0)	21 (23.9)	67 (76.1)	0.73 (0.41 − 1.31)	0.92 (0.50 − 1.70)
High school or GED	311 (24.8)	83 (26.7)	228 (73.3)	0.88 (0.56 − 1.37)	1.01 (0.63 − 1.63)
Some college	435 (34.7)	127 (29.2)	308 (70.8)	0.99 (0.68 − 1.45)	1.15 (0.78 − 1.69)
College or more	420 (33.5)	123 (29.3)	297 (70.7)	REF	REF
Marital status
Never married	549 (44.1)	149 (27.1)	400 (72.9)	REF	REF
Married	639 (51.4)	184 (28.8)	455 (71.2)	1.04 (0.81 − 1.34)	0.85 (0.64 − 1.13)
Separated/divorced/widowed	56 (4.5)	21 (37.5)	35 (62.5)	1.56 (0.96 − 2.53)	1.72 (0.91 − 3.28)
Household income
Less than $20,000	180 (14.3)	53 (29.4)	127 (70.6)	0.88 (0.58 − 1.36)	1.00 (0.71 − 1.40)
$20,000 − 49,000	238 (18.9)	70 (29.4)	168 (70.6)	0.88 (0.61 − 1.28)	0.84 (0.61 − 1.14)
$50,000 or more	434 (34.5)	132 (30.4)	302 (69.6)	REF	REF
Unknown	407 (32.3)	100 (24.6)	307 (75.4)	0.72 (0.49 − 1.06)	0.74 (0.51 − 1.07)
Feeding type
Only breast milk	457 (36.5)	170 (37.2)	287 (62.8)		REF
Breast milk and formula	411 (32.8)	124 (30.2)	287 (69.8)		0.71 (0.56 − 0.90)
Only formula	385 (30.7)	60 (15.6)	325 (84.4)		0.31 (0.22 − 0.42)
Feeding location
My bed	748 (59.4)	251 (33.6)	497 (66.4)		REF
A chair	304 (24.1)	51 (16.8)	253 (83.2)		0.41 (0.31 − 0.56)
A sofa	180 (14.3)	45 (25.0)	135 (75.0)		0.73 (0.47 − 1.12)
Other	27 (2.1)	8 (29.6)	19 (70.4)		1.27 (0.44 − 3.68)
Intervention groupa
BF-BF	303 (24.1)	100 (33.0)	203 (67.0)		REF
SS-BF	301 (23.9)	107 (35.5)	194 (64.5)		1.15 (0.83 − 1.59)
BF-SS	335 (26.6)	98 (29.3)	237 (70.7)		0.77 (0.56 − 1.05)
SS-SS	320 (25.4)	50 (15.6)	270 (84.4)		0.40 (0.25 − 0.65)

Adjusted models include infant age at survey and sex, maternal parity, age, education, marital status, and household income, feeding type and location, and intervention group. Messaging during the newborn hospital stay is noted first, followed by the messaging received during the 60 d following discharge home.

BF, receipt of breastfeeding messaging; CI, confidence interval; OR, odds ratio; SS, receipt of safe sleep messaging.

Table 1 shows our predictors of interest stratified by FAF and adjusted odds of FAF. Feeding type, feeding location, and study intervention group were associated with reported FAF. Compared with mothers whose feeding type was breast milk only, the odds of reported FAF were lower among those whose feeding type was breast milk and formula (37.2% versus 30.2%; aOR, 0.71; 95% CI, 0.56–0.90) or formula only (37.2% versus 15.6%; aOR, 0.31; 95% CI, 0.22–0.42). Compared with mothers whose nighttime feeding location was the mother’s bed, those reporting feeding location in a chair were less likely to FAF (33.6% versus 16.8%; aOR, 0.41; 95% CI, 0.31–0.56). There were no differences in nighttime feeding location between mothers feeding breast milk only, breast milk and formula, or formula only. Compared with mothers who received only breastfeeding interventions (BF-BF), those who received only safe sleep interventions (SS-SS) were less likely to report FAF (33.0% versus 15.6%; aOR, 0.40; 95% CI, 0.25–0.65).

To better understand the extent to which the type of feeding impacts the association between the study intervention and odds of FAF, we performed analyses stratified by feeding type (Fig 1). Despite differences in overall rates of reported FAF by feeding type, within each feeding type, the impact of the intervention on FAF was similar. Across the 3 feeding types, compared with the BF-BF group, those in the SS-SS group had lower odds (0.38–0.42) of FAF. One other comparison showing a significant difference compared with the BF-BF group was for the BF-SS group in the breast milk and formula group (37.3% versus 27.3%; aOR, 0.57; 95% CI, 0.39–0.82). The proportions of mothers feeding only breast milk in the BF-BF and SS-SS groups were similar and thus not likely to affect the reported outcomes. To ensure that the survey responses at older infant ages did not unduly impact the preceding results, a sensitivity analysis was conducted among the 967 mothers who completed the survey between 60 and 90 days of infant age, with similar results.

FIGURE 1.

Percent of participants reporting falling asleep while feeding (FAF) by feeding type and intervention group.

Hospital intervention is noted first, followed by intervention after discharge. The number above each column represents the denominator used to calculate the percentage reporting FAF. The adjusted odds ratio (aOR) and 95% confidence interval (CI) shown in the figure above the columns for each feeding type compares the only safe sleep interventions (SS-SS) group with the only breastfeeding (BF-BF) group.

To better understand our observation that feeding location was associated with the odds of FAF, we assessed the associations between usual feeding location and the reported reasons that impacted the choice of feeding location (Fig 2). The most common reasons for choice of nighttime feeding location were, “it was more comfortable for me” (58.9%) and “to better comfort my baby” (47.7%), with both reported with similar frequency across sleep locations (bed, chair, sofa) (Table 2). The next most common reasons in descending order were: “this is where I was sleeping,” “it was easier to stay awake,” “trying not to disturb someone,” “to avoid a location that was unsafe,” and “I needed more light.” Each of these reasons differed by feeding location (Table 2).

FIGURE 2.

Percent of participants reporting each reason for selecting their usual nighttime feeding location by feeding location.

Reasons reported by mothers for their choice of usual nighttime feeding location are presented for each feeding location (my bed, a chair, a sofa). Multiple responses were permitted.

TABLE 2.

Reasons for Choice of Nighttime Feeding Location by Feeding Location

					Chair Versus Bed	Sofa Versus Bed
Reason for Choice of Nighttime Feeding Location	Total N (%)	My bed N (%)	A chair N (%)	A sofa N (%)	Adjusted OR (95% CI)	Adjusted OR (95% CI)
Total	1259	748 (59.4)	304 (24.1)	180 (14.3)
It was more comfortable for me
Yes	742 (58.9)	453 (60.6)	174 (57.2)	105 (58.3)	0.99 (0.77 − 1.27)	1.07 (0.84 − 1.35)
No	517 (41.1)	295 (39.4)	130 (42.8)	75 (41.7)	REF	REF
To better comfort my baby
Yes	600 (47.7)	356 (47.6)	147 (48.4)	83 (46.1)	1.12 (0.87 − 1.44)	0.94 (0.65 − 1.36)
No	659 (52.3)	392 (52.4)	157 (51.6)	97 (53.9)	REF	REF
This is where I was sleeping
Yes	402 (31.9)	338 (45.2)	22 (7.2)	35 (19.4)	0.09 (0.05 − 0.15)	0.30 (0.22 − 0.40)
No	857 (68.1)	410 (54.8)	282 (92.8)	145 (80.6)	REF	REF
It was easier to stay awake
Yes	359 (28.5)	149 (19.9)	137 (45.1)	69 (38.3)	3.45 (2.71 − 4.41)	2.72 (1.88 − 3.94)
No	900 (71.5)	599 (80.1)	167 (54.9)	111 (61.7)	REF	REF
I was trying not to disturb someone
Yes	271 (21.5)	112 (15.0)	86 (28.3)	70 (38.9)	2.20 (1.60 − 3.00)	3.87 (2.55 − 5.87)
No	988 (78.5)	636 (85.0)	218 (71.7)	110 (61.1)	REF	REF
No particular reason
Yes	177 (14.1)	113 (15.1)	32 (10.5)	27 (15.0)	0.69 (0.46 − 1.05)	1.10 (0.77 − 1.57)
No	1082 (85.9)	635 (84.9)	272 (89.5)	153 (85.0)	REF	REF
To avoid a location I was told is unsafe
Yes	167 (13.3)	57 (7.6)	86 (28.3)	23 (12.8)	4.73 (3.17 − 7.04)	1.67 (1.02 − 2.73)
No	1092 (86.7)	691 (92.4)	218 (71.7)	157 (87.2)	REF	REF
I needed more light
Yes	112 (8.9)	41 (5.5)	41 (13.5)	28 (15.6)	2.84 (2.09 − 3.86)	3.67 (2.04 − 6.60)
No	1147 (91.1)	707 (94.5)	263 (86.5)	152 (84.4)	REF	REF

Adjusted models include infant age at survey and sex, maternal parity, age, education, marital status, and household income, feeding type and location, and intervention group.

CI, confidence interval; OR, odds ratio.

Discussion

Our study examined prevalence of maternal reports of FAF and factors that may contribute to FAF in the early postpartum period in a diverse sample of >1200 US mothers. We found that reported FAF in the past 2 weeks was common (28%), with nearly three quarters (70%) of these mothers reporting that their usual nighttime feedings occurred in their bed. Factors significantly associated with the odds of FAF include feeding type (lower for mothers who partially breastfed or formula-fed), feeding location (lower in a chair), and SMART intervention group (lowest for mothers who received both safe sleep interventions). Most mothers (83%) who reported FAF did not plan to fall asleep. Nearly one quarter (24.1%) and 14.3% of mothers who reported FAF identified that their usual nighttime feedings occurred on chairs and sofas, respectively. These findings highlight a great need to acknowledge the strong likelihood of FAF among new mothers and to counsel mothers in the risks of SUID when FAF may occur.

The relatively high percentage of self-reported FAF on chairs and sofas is concerning because these are extremely unsafe sleep locations, with a 49- to 67-fold times higher risk for SUID.⁴ A study by Kendall-Tackett et al of nearly 5000 US mothers of infants 0–12 months found that about half the mothers were feeding their infants at night and, of those, 44% did so in a bed, whereas 55% were on a chair, sofa, or recliner.¹ Almost three quarters of the mothers who fed in bed reported FAF, and 44% of those sleeping on a chair, sofa, or recliner reported FAF. However, because this was not a representative sample, the outcomes cannot be presumed to reflect the prevalence of these practices in the United States. In another study, 52% of the 201 mothers of infants ages birth to 6 months surveyed reported that on 1 typical night in the previous week they had experienced FAF.²⁴ This occurred more commonly among mothers of older infants, those who were lying down when feeding, and those who were breastfeeding, consistent with our findings of higher rates of FAF among exclusively breastfeeding mothers. Nighttime feeding frequency may be higher in mothers who exclusively breastfeed because breast milk is more easily digested than formula, and this along with release of oxytocin and its relaxation effects may contribute to the higher rates of FAF in this group.²

Few studies have examined mothers’ reasons for their usual nighttime feeding location. We found that, among mothers who usually fed their infant on a chair or sofa at night, common reasons were to avoid a location that they were told is unsafe, to not disturb someone, and because it was easier to stay awake. These findings are similar to those of Gaydos et al,²⁵ who conducted focus groups with 60 African American, low-income, first-time mothers. Some participants noted that when they bedshare, they do so on other surfaces (chairs, sofas) so that they will not become too comfortable and fall asleep while holding the baby. In its updated 2022 safe sleep recommendations, the AAP recognizes that parents may FAF.⁵ Because it is relatively less hazardous to fall asleep with the infant in the adult bed than on a chair or sofa,^3,19–21,26 the AAP advises that infants be brought into the adult bed for feedings if there is a chance that the parent may FAF and that infants be placed back in their own sleep space when the parent awakens.⁵ It is important for parents to plan ahead with regard to a nighttime feeding location. In our study, mothers who fed on a chair or sofa were more likely to say they were doing so to not disturb others or because it was easier to stay awake. Parents need help from clinicians in navigating these priorities in the safest way. Although no studies have asked about whether parents remove pillows, blankets, or other soft of loose objects before bringing their infant into the adult bed to feed, given the clear evidence of increased risk of sudden unexpected infant death in the presence of these objects, it would be prudent to advise parents to remove these objects when they are at risk for FAF in an adult bed.⁵ Indeed, some countries take this approach in their public health guidance regarding bedsharing.²⁷ Although feeding in the adult bed may promote breastfeeding and avoid the most hazardous locations should the parent FAF, clinicians should also inform parents that placing the infant after feeding in a bedside bassinet, crib, or portable play yard in close proximity is the safest option.

We also found that mothers who received the SS-SS intervention were 60% less likely than those who received the BF-BF intervention to FAF, suggesting that educational messaging provided on SS including falling asleep, impacted mothers’ behaviors regarding FAF or their reporting of behaviors regarding FAF. This is not surprising, as we have previously shown that, although rates of exclusive breastfeeding at 2–5 months were similar in the 2 groups and rates of any breastfeeding at 2–5 months were similar in the 2 groups for mothers who intended to breastfeed for 6 months or longer, their reported bedsharing rates were significantly lower in the SS-SS group.²⁸ It is reassuring that our intervention decreased reported rates of bedsharing,²⁸ and as shown in the current analysis, appears to have decreased reported FAF while not negatively impacting rates and duration of breastfeeding. Although FAF was not our main outcome in SMART, the video messages included education about ways to safely feed infants at night and avoid FAF, especially in the most hazardous locations. We are aware of only 1 other study that assessed if receiving advice from multiple sources about safe sleep or breastfeeding was associated with adherence to sleep location and feeding recommendations.²⁹ This prevalence study, which informed the development of SMART and was conducted by the same research team, found that mothers who received advice had higher adherence to both sleep location and feeding recommendations, and receiving advice to room share without bedsharing was not associated with a decrease in breastfeeding.²⁹

Previous observational studies have reported a consistent and even dose-dependent relationship between bedsharing and breastfeeding duration.²⁸ It is unclear whether this is a causal relationship or a strong association.^30–34 Our data demonstrate that those who were breastfeeding reported falling asleep more frequently, making the environment in which they feed particularly important. Families need guidance to adhere to both breastfeeding and safe sleep recommendations, and this study contributes to the growing body of knowledge of nighttime feeding behaviors and practices. Based on current knowledge of the importance of breastfeeding and its protection against SUID,³⁵ it is important to ensure that any safe sleep messaging does not negatively impact breastfeeding rates, but rather ensures that if any FAF occurs, these episodes be under the safest possible circumstances. Clinician awareness that falling asleep is often unplanned paves the way for counseling aimed at helping families plan for safer nighttime feeding practices to avoid falling asleep in unsafe locations such as couch or sofa, whereas the approach to a family who plans FAF may be different.

This study has many strengths, including a large, diverse national sample, a randomized trial design, and minimization of recall bias by asking about behaviors over the past 2 weeks. However, there are several limitations. Because participation was limited to English-speaking mothers, results cannot be generalized to those who speak other languages. Because only mothers were surveyed, we do not have data about other caregivers feeding infants, who may also be at risk for FAF. Data about feeding and falling asleep practices were self-reported, and there may be a bias toward reporting the perceived socially desired practice (eg, breastfeeding, not falling asleep or planning to fall asleep, not feeding in an adult bed). If this were the case, then self-reported rates of both FAF and bedsharing would be even higher than we found. However, similar survey questions were used in previous published work by our group,^36–38 and reported rates of each practice were consistent with other studies.^37–40 Mothers also completed the survey between 2 and 6 months, and feeding and sleep practices often evolve during this interval; however, >90% responded between 8 and 15 weeks of infant age (mean, 11.2 weeks), and a sensitivity analysis of those completing the survey between 60 and 90 days of infant age showed similar results. The question asking if FAF was planned or unplanned has not been validated or recommended previously for clinical practice, nor to our knowledge has it been reported elsewhere. We did not ask about the time of day FAF occurred nor the duration of the sleep period in which FAF occurred. It is currently unknown whether the duration of the sleep period, such as a short doze versus a longer or deeper sleep, impacts the risk of SUID. It is possible that unexpected events such as suffocation may occur regardless of the sleep duration in which FAF occurs. Further investigation would be needed to determine if there are any differences between nighttime and daytime FAF and if there are differences in FAF by sleep duration and potential risk of SUID. Finally, we were unable to account for whether the mothers in either group received any messaging, contrary to those included in the interventions; however, we would expect that randomization would help account for any variability.

Conclusions

FAF is commonly reported among US mothers in the early postpartum period, with the majority of episodes being unplanned. Our results highlight the importance of pediatric clinicians discussing the high likelihood that FAF happens with new parents and how to plan to optimize safety. Further studies of innovative interventions are needed to assist parents in following both safe sleep and breastfeeding recommendations.

Glossary

AAP

American Academy of Pediatrics

aOR

adjusted odds ratio

BF

breastfeeding

CI

confidence interval

FAF

falling asleep while feeding

QI

quality improvement

SMART

Social Media and Risk-reduction Training

SS

safe sleep

SUID

sudden unexpected infant deaths