Bed Sharing in Toddlerhood: Choice Versus Necessity and Provider Guidelines

A sleeping toddler is not only a welcome sight for parents, but sleep promotes children’s physical growth, behavior, and emotional and cognitive development. ¹ During toddlerhood, children’s sleep/wake patterns evolve and consolidate rapidly into longer nighttime sleep duration and less daytime sleep, as circadian rhythms are developed. ² To assist their toddlers with these sleep transitions, many parents develop bedtime routines to help their toddlers prepare for sleep. In high-income countries, such as the United States, many children sleep in a crib and subsequently in a bed either alone or with a sibling. However, in some cases, toddlers sleep with their parent(s).

Bed Sharing

Bed sharing, sharing a bed or another sleeping surface, is a common practice in many countries, and is often perceived to improve sleep problems and promote family closeness. ³ For example, bed sharing is highly prevalent in Africa (100% in some countries), Mongolia (100%), Vietnam (83%), India (72%), and China (66.2%).^3,4 In the United States, although bed sharing is not the norm, it occurs in almost one quarter (23%) of families. ⁴

Bed Sharing Recommendations

The American Academy of Pediatrics (AAP) recommends against bed sharing during infancy, citing epidemiologic evidence that bed sharing increases the risk of sudden infant death syndrome (SIDS). ⁵ The AAP does not provide sleep environment recommendations for toddlers, ⁶ and although toddlers are not at risk of SIDS, bed sharing poses other risks including maternal mental health symptoms and detriments to maternal and child sleep. ⁷ A large Norwegian study (N = 55,831) indicated that bed sharing was an independent and graded predictor of both nighttime awakenings and short sleep duration in infants. ⁸

Bed sharing is associated with multiple negative outcomes including infant and child sleep problems, ⁴ parental distress, ⁵ increased night awakenings, ⁹ and reduced overnight sleep. ⁹ In contrast, children who sleep on their own, rather than sleeping with a parent, obtain more sleep, have fewer nighttime awakenings, have less difficulty at bedtime, fall asleep faster, and are perceived as having fewer sleep problems, ⁹ leading to the recommendation that independent sleep among toddlers promotes the development of self-soothing ability and minimizes sleep problems. ² Nevertheless, many parents of toddlers believe that bed sharing is the best sleeping arrangement for their family. ¹⁰

Why People Bed Share

There are many reasons why families choose to bed share. In addition to cultural norms emphasizing family closeness and the development of interdependence, ³ parents may bed share as a means of coping with toddler sleep problems, ¹¹ despite a lack of research supporting the effectiveness of bed sharing to resolve sleep problems. Common patterns are for parents to lie down with their child to initiate sleep or to bring their child into bed following an awakening (reactive bed sharing). ¹¹ Parents may also believe that bed sharing fulfills their child’s and their own emotional needs, resulting in better sleep for the entire family. ¹⁰ Additionally, parents may find it more convenient and safe to have the child in the same bed with them, where they can watch and protect the child (ie, from aggressive siblings, vermin, fires) during sleep. ¹⁰ Understanding the sociocultural reasons for bed sharing can help providers support families and help them develop alternative strategies.

For many families, bed sharing may be an economic necessity rather than a choice. In the United States, bed sharing is more common among low socioeconomic status (SES) families, often attributed to lack of available beds, rooms, heat, or cooling. ⁵ Parents with limited education are more likely to bed share with their toddler than better educated parents. ¹² Compounding the risks of bed sharing, children of low SES families are at increased risk for sleep deficiencies, such as insufficient sleep duration, irregular sleep times, and poor sleep quality. ¹³ Such deficiencies in toddlerhood could ultimately lead to chronic sleep deprivation and poor sleep and health outcomes across the lifespan. Poor sleep has been linked to chronic health outcomes such as obesity, type 2 diabetes, cardiovascular disease, and hypertension. ¹⁴ Ultimately, bed sharing may increase the risk for larger health disparities.

How to Support Families Who Bed Share

Sleep deprivation underlies many health and behavior problems. An initial step in supporting families is to ask about sleep routines and habits, including bed sharing. The National Sleep Foundation recommends that toddlers get between 11 and 14 hours of sleep per day and that adults get between 7 and 9 hours per day. ¹⁵ Toddlers and parents who sleep less than the recommended number of hours are at risk for sleep deprivation and associated problems. Informing parents of the recommendations from the National Sleep Foundation or the AAP ensures that they are aware of the recommendations and is an important step in their decision to consider alternatives to bed sharing. However, information alone is not sufficient to produce behavior change, ¹⁰ particularly if environmental or economic barriers make it difficult to change.

It is beneficial for providers to assess the etiology of bed sharing to help families identify alternatives. Motivational interviewing techniques may help providers understand parents’ motivations for bed sharing. In cases where bed sharing is a result of the environmental context, it may be beneficial to identify practices that minimize the risks of bed sharing. For example, implementing a consistent bedtime routine has been associated with decreased sleep problems, fewer nighttime awakenings, and increased sleep duration. ¹⁶ Consistent bedtime routines often include activities such as teeth brushing, book reading, good night hug, and lights out. ¹⁷ These calming activities can help toddlers relax and fall asleep. Lights should be turned off within 30 minutes of completing a routine to aid in sleep-wake cycle regulation and promotion of melatonin release. ¹⁸ Along the same line, electronics should not be used within an hour of bedtime, not only because of the light they emit, but also because of their relation with adverse sleep outcomes, such as increased awakenings, later bedtimes, daytime sleepiness, and short nighttime sleep duration. ¹⁸ Finally, providing the toddler with a comfort item such as a stuffed animal or blanket may help provide a positive sleep environment. ¹⁸

Even in the presence of bed sharing, increasing the consistency of a nighttime routine (including the strategies listed above) might lessen the negative effects of bed sharing. ⁹ Additionally, promoting toddler independent sleep initiation by having the toddler fall asleep alone (ie, not being held or rocked to sleep) has been associated with longer sleep duration and fewer nighttime awakenings,^2,9 even in the context of eventual bed sharing later in the night. Although an ultimate goal may be to decrease bed sharing practices, intermediate strategies such as having the toddler transition to their own bed or to a sibling’s bed may help families minimize some of the difficulties associated with bed sharing.

Parent’s desire to bed share may also stem from a belief that bed sharing promotes family closeness or that bed sharing can satisfy their own need for closeness. Parents with mental health symptoms may bed share to seek their own comfort, potentially engendering their toddler’s sleep difficulties and bedtime struggles once parents choose to end the bed sharing practice. In contrast to expectations that bed sharing promotes closeness, bed sharing has been associated with poor parent sleep quality, short duration, and mental health symptoms, ⁷ and may interfere with toddlers’ need for autonomy marked by sleep initiation and self-soothing. Many parenting practices that do not involve sleep have been associated with parent-child closeness, including responsive parenting whereby parents listen to their child, and respond quickly and in an age-appropriate, although not necessarily conciliatory manner. ¹⁹ Engaging in “special times” for play or book reading are another alternatives to promote parent-child closeness.

Concerns about sleep and bed sharing have also given rise to public health and policy-level strategies. In Georgia, the state health department implemented a crib distribution program to help reduce less adaptive infant sleep practices including bed sharing. ²⁰ Crib distribution may be most effective when parents also receive guidance on implementing bedtime routines, particularly if they are transitioning their toddler from bed sharing to independent sleeping. Future research could examine the effectiveness of toddler bed distribution programs in low-income areas where bed sharing is an economic necessity. If such programs are found to be successful, this strategy could inform public policy on affordable housing.

Helping toddlers develop healthy sleep patterns, including the ability to fall asleep unassisted and to return to sleep after awakenings, is an important task of parenthood. Bed sharing may impede appropriate sleep pattern development in toddlerhood. Identifying families’ reasons for bed sharing enables providers to support families as they identify strategies that can promote healthy sleep patterns for their toddler. Addressing bed sharing in this critical developmental age can promote sleep health that extends throughout the lifespan.