Sleeping Arrangements in Families With Twins
Sleeping Arrangements in Families With Twins
This study describes home sleeping arrangements used by parents of twins and investigates whether room sharing (twins in the same room as parents) or cobedding (crib sharing between twins) influences parental nighttime sleep duration or sleep quality. A secondary analysis of data obtained from a longitudinal study of sleep in 104 families with twins was undertaken. More than 65% of twins were cobedded at 4 weeks; this decreased to approximately 42% by 13 weeks of age. Approximately 64% of families practiced room sharing at 4 weeks; this decreased to approximately 40% by 13 weeks of age. Mothers and fathers who both room shared and cobedded their twins at 9 weeks of age were most likely to experience restricted sleep duration when compared with other sleeping arrangements. Results suggest that parents of twins may not be following the most recent American Academy of Pediatrics recommendations regarding safe infant sleep for multiple-birth infants.
Little is known regarding home sleeping arrangements in families of twins. With a few notable exceptions, investigations of sleeping arrangements for twins have largely been restricted to the practice of cobedding of hospitalized multiples (ie, crib sharing between multiple-birth infants). Such studies have examined short-term outcomes related to safety and benefits of cobedded hospitalized twins compared with twins who are cared for in separate cribs. Reported benefits have not been well substantiated. Available evidence is generally limited by small sample sizes and lack of scientifically rigorous study designs, resulting in an inability to strongly endorse or reject the practice of cobedding for multiple-birth infants.
Despite a lack of compelling evidence for benefits, cobedding of multiple-birth infants has been touted as a developmentally supportive strategy and has been widely adopted in hospitals over the past two decades. This is important because care practices related to infant sleep and the sleep environment modeled in hospitals are often continued by parents in the home. In addition, lay publications targeted at postpartum mothers of twins promote cobedding as a natural extension of the previously shared intrauterine environment and claim that sleep duration is lengthened for cobedded twins, that waking and feeding periods become synchronized, that tight finances can be stretched by having twins share a crib for the first several months, and that all of this translates into easier care of the twins. Furthermore, families believe that their twins prefer to be cobedded and that it continues the bond that began between the twins in utero and view it as a strategy for parents themselves to obtain more sleep.
Perhaps, the most compelling reason that sleeping arrangements in families of twins should be of concern to nurses and other health care providers is the link between the sleep practices and sleep environment of infants and sudden infant death syndrome (SIDS). Sudden infant death syndrome remains the third leading cause of death in infancy and is the leading cause of death in infants beyond the neonatal period. A preliminary analysis of 2009 mortality data shows that SIDS accounted for 2168 deaths in the United States, for a rate of 52.5 per 100 000 live births. Evidence to date does not support multiple births as an independent risk factor for SIDS after controlling for low-birth-weight and preterm birth. However, because most twins are both low birth weight and born preterm, twin infants are at high risk for SIDS. In 2009, more than 56% of twins were low birth weight and more than 58% were born preterm.
In 1992, the American Academy of Pediatrics (AAP) issued its first recommendation aimed at reducing the risk of SIDS, advising that healthy term infants not be placed in the prone position for sleep. The "Back to Sleep" campaign began in 1994, resulting in more than a 40% reduction in infant deaths attributed to SIDS in less than 10 years. Three subsequent policy statements were issued by the AAP in 2000, in 2005, and, most recently, in late 2011. These statements expanded SIDS risk reduction strategies beyond use of the supine position to include changes in infant care, sleep practices, and the infant's environment. The major recommendations include exclusive use of the supine position for sleep; encouragement of room sharing with a parent; pacifier use at the initiation of bedtime; avoidance of exposure to tobacco prebirth and postbirth; use of a crib that conforms to current safety standards; avoidance of soft sleeping surfaces and loose bedding or objects in the infant's bed; avoidance of excessive layers of clothing or blankets that could result in infant overheating; avoidance of cosleeping (ie, having the infant sleep on the same surface with another person), particularly in cases where the infants is sharing a bed with adults other than the parent or with siblings/other children; and a suggestion to use an appropriately sized infant sleep sack that prevents the infant's face from being covered by blankets. The most recent AAP statement additionally placed emphasis on the protective role of human breast milk feedings and up-to-date AAP/Centers for Disease Control and Prevention immunizations. Of particular note, for the first time, the AAP report specifically addressed sleeping arrangements for twins and higher-order multiples. Acknowledging that many of the known risk factors for SIDS apply to multiple-birth infants, the AAP recommends that separate sleep areas be provided for multiple-birth infants and that cobedding should be avoided both in the hospital and at home.
Sudden infant death syndrome risk reduction recommendations that encourage room sharing with a parent and discourage a shared sleep surface with another child may present particular challenges in the case of twins. Two studies conducted in the United Kingdom and one study from New Zealand documented that between 45% and 77% of twins shared a room with the parents in the first 4 to 6 weeks at home; this decreased to 34% to 68% who room shared at 3 to 4 months of age. This compares to a study of US mothers where 85% of singleton infants slept in the same room as their mother during the first 3 months. Mothers of twins in the United Kingdom cited space constraints as the reason that twins no longer room shared with the parents: parental bedrooms did not accommodate the space required by two infant cribs once the babies outgrew their bassinets.
Ball's study of 60 British families reported that 61% cobedded their twins at 1 month with 40% cobedding at 3 months. The mailed survey of 109 mothers of twins in New Zealand documented that 54% of twins shared a crib at 6 weeks of age; this decreased to 31% by 4 months and 10% at 8 months. In the UK study, 65% of twins who room shared with the parents also cobedded at 1 month; this decreased to 47% who cobedded in the parent's room at 3 months. In the New Zealand study, 28% of twins were cobedding and room sharing in their parent's room at 6 weeks of age. Both studies noted a tendency for cobedded twins to be more likely to room share with the parents, but over time, increased infant size prompted a transition from cobedding to separate cribs and household space limitations prompted a discontinuation of room sharing with the parent.
The number of twins born in the United States annually has risen dramatically since 1980. In 2009, the twin birth rate was 33.2 per 1000 live births, the highest ever recorded, yet no published studies of sleeping arrangements in US families with twins were located. This study reports the results of a secondary analysis of sleeping arrangements in US families of twins recruited from a medium-sized Midwestern metropolitan area. Because room sharing of parents and twins and cobedding of twins was felt to influence parental sleep, these data were collected as part of a larger study of sleep patterns in parents of twins. The influence of sleeping arrangements on sleep duration and sleep quality of mothers and fathers is also reported here. Findings of this study are applicable to recent recommendations from the AAP for safe sleep of twins and higher-order multiples.
Abstract and Introduction
Abstract
This study describes home sleeping arrangements used by parents of twins and investigates whether room sharing (twins in the same room as parents) or cobedding (crib sharing between twins) influences parental nighttime sleep duration or sleep quality. A secondary analysis of data obtained from a longitudinal study of sleep in 104 families with twins was undertaken. More than 65% of twins were cobedded at 4 weeks; this decreased to approximately 42% by 13 weeks of age. Approximately 64% of families practiced room sharing at 4 weeks; this decreased to approximately 40% by 13 weeks of age. Mothers and fathers who both room shared and cobedded their twins at 9 weeks of age were most likely to experience restricted sleep duration when compared with other sleeping arrangements. Results suggest that parents of twins may not be following the most recent American Academy of Pediatrics recommendations regarding safe infant sleep for multiple-birth infants.
Introduction
Little is known regarding home sleeping arrangements in families of twins. With a few notable exceptions, investigations of sleeping arrangements for twins have largely been restricted to the practice of cobedding of hospitalized multiples (ie, crib sharing between multiple-birth infants). Such studies have examined short-term outcomes related to safety and benefits of cobedded hospitalized twins compared with twins who are cared for in separate cribs. Reported benefits have not been well substantiated. Available evidence is generally limited by small sample sizes and lack of scientifically rigorous study designs, resulting in an inability to strongly endorse or reject the practice of cobedding for multiple-birth infants.
Despite a lack of compelling evidence for benefits, cobedding of multiple-birth infants has been touted as a developmentally supportive strategy and has been widely adopted in hospitals over the past two decades. This is important because care practices related to infant sleep and the sleep environment modeled in hospitals are often continued by parents in the home. In addition, lay publications targeted at postpartum mothers of twins promote cobedding as a natural extension of the previously shared intrauterine environment and claim that sleep duration is lengthened for cobedded twins, that waking and feeding periods become synchronized, that tight finances can be stretched by having twins share a crib for the first several months, and that all of this translates into easier care of the twins. Furthermore, families believe that their twins prefer to be cobedded and that it continues the bond that began between the twins in utero and view it as a strategy for parents themselves to obtain more sleep.
Perhaps, the most compelling reason that sleeping arrangements in families of twins should be of concern to nurses and other health care providers is the link between the sleep practices and sleep environment of infants and sudden infant death syndrome (SIDS). Sudden infant death syndrome remains the third leading cause of death in infancy and is the leading cause of death in infants beyond the neonatal period. A preliminary analysis of 2009 mortality data shows that SIDS accounted for 2168 deaths in the United States, for a rate of 52.5 per 100 000 live births. Evidence to date does not support multiple births as an independent risk factor for SIDS after controlling for low-birth-weight and preterm birth. However, because most twins are both low birth weight and born preterm, twin infants are at high risk for SIDS. In 2009, more than 56% of twins were low birth weight and more than 58% were born preterm.
In 1992, the American Academy of Pediatrics (AAP) issued its first recommendation aimed at reducing the risk of SIDS, advising that healthy term infants not be placed in the prone position for sleep. The "Back to Sleep" campaign began in 1994, resulting in more than a 40% reduction in infant deaths attributed to SIDS in less than 10 years. Three subsequent policy statements were issued by the AAP in 2000, in 2005, and, most recently, in late 2011. These statements expanded SIDS risk reduction strategies beyond use of the supine position to include changes in infant care, sleep practices, and the infant's environment. The major recommendations include exclusive use of the supine position for sleep; encouragement of room sharing with a parent; pacifier use at the initiation of bedtime; avoidance of exposure to tobacco prebirth and postbirth; use of a crib that conforms to current safety standards; avoidance of soft sleeping surfaces and loose bedding or objects in the infant's bed; avoidance of excessive layers of clothing or blankets that could result in infant overheating; avoidance of cosleeping (ie, having the infant sleep on the same surface with another person), particularly in cases where the infants is sharing a bed with adults other than the parent or with siblings/other children; and a suggestion to use an appropriately sized infant sleep sack that prevents the infant's face from being covered by blankets. The most recent AAP statement additionally placed emphasis on the protective role of human breast milk feedings and up-to-date AAP/Centers for Disease Control and Prevention immunizations. Of particular note, for the first time, the AAP report specifically addressed sleeping arrangements for twins and higher-order multiples. Acknowledging that many of the known risk factors for SIDS apply to multiple-birth infants, the AAP recommends that separate sleep areas be provided for multiple-birth infants and that cobedding should be avoided both in the hospital and at home.
Sudden infant death syndrome risk reduction recommendations that encourage room sharing with a parent and discourage a shared sleep surface with another child may present particular challenges in the case of twins. Two studies conducted in the United Kingdom and one study from New Zealand documented that between 45% and 77% of twins shared a room with the parents in the first 4 to 6 weeks at home; this decreased to 34% to 68% who room shared at 3 to 4 months of age. This compares to a study of US mothers where 85% of singleton infants slept in the same room as their mother during the first 3 months. Mothers of twins in the United Kingdom cited space constraints as the reason that twins no longer room shared with the parents: parental bedrooms did not accommodate the space required by two infant cribs once the babies outgrew their bassinets.
Ball's study of 60 British families reported that 61% cobedded their twins at 1 month with 40% cobedding at 3 months. The mailed survey of 109 mothers of twins in New Zealand documented that 54% of twins shared a crib at 6 weeks of age; this decreased to 31% by 4 months and 10% at 8 months. In the UK study, 65% of twins who room shared with the parents also cobedded at 1 month; this decreased to 47% who cobedded in the parent's room at 3 months. In the New Zealand study, 28% of twins were cobedding and room sharing in their parent's room at 6 weeks of age. Both studies noted a tendency for cobedded twins to be more likely to room share with the parents, but over time, increased infant size prompted a transition from cobedding to separate cribs and household space limitations prompted a discontinuation of room sharing with the parent.
The number of twins born in the United States annually has risen dramatically since 1980. In 2009, the twin birth rate was 33.2 per 1000 live births, the highest ever recorded, yet no published studies of sleeping arrangements in US families with twins were located. This study reports the results of a secondary analysis of sleeping arrangements in US families of twins recruited from a medium-sized Midwestern metropolitan area. Because room sharing of parents and twins and cobedding of twins was felt to influence parental sleep, these data were collected as part of a larger study of sleep patterns in parents of twins. The influence of sleeping arrangements on sleep duration and sleep quality of mothers and fathers is also reported here. Findings of this study are applicable to recent recommendations from the AAP for safe sleep of twins and higher-order multiples.
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