Co-sleeping in the newborn: scientific evidence, safety, and clinical recommendations

The practice of co-sleeping, defined as the sharing of the infant’s sleep environment with parents, represents a topic of significant clinical, epidemiological, and sociocultural relevance within modern perinatal pediatrics. Although it is sometimes adopted by families to facilitate night-time breastfeeding, enhance infant comfort, and strengthen the parent–infant bond, international scientific evidence and recommendations from major pediatric societies require a rigorous and contextualized interpretation.

A clear conceptual and operational distinction exists between room sharing and bed sharing, with different implications for sleep safety and postnatal outcomes.
In medical terminology and reference guidelines, co-sleeping includes two distinct configurations:

• Room sharing: the infant sleeps in the same room as the parents but on a separate, dedicated sleep surface (e.g., crib or bassinet) placed near the parental bed. This arrangement allows close supervision and a prompt response to infant cues without sharing the same sleep surface.
• Bed sharing: the infant sleeps on the same physical surface as an adult or other children. This practice carries specific risks and is not recommended as routine care by major pediatric guidelines.

The American Academy of Pediatrics (AAP), in one of its most recent policy statements, specifies that no form of bed sharing has been proven to be “safe” and does not recommend bed sharing as a standard practice, instead favoring room sharing for at least the first 6 months of life, a period of heightened neuromaturational vulnerability.

The primary concerns regarding bed sharing arise from its association with Sudden Infant Death Syndrome (SIDS) and sleep-related infant deaths, which have been extensively investigated through cohort and case–control epidemiological studies. These studies indicate that the risk of fatal events is significantly higher when infants sleep on the same surface as adults, particularly during the first 3–4 months of life, when physiological vulnerability is greatest.

International and National Guidelines

American Academy of Pediatrics (AAP)

The AAP’s clinical recommendations are among the most widely cited and implemented worldwide for preventing sleep-related infant deaths. Grade A recommendations include:

• Supine sleeping position (“back to sleep”) for all sleep periods.
• Use of a firm or semi-firm mattress on a separate sleep surface, free of soft objects or inclined sleepers.
• Room sharing with a separate sleep surface for at least the first 6 months and ideally up to one year.
• Avoidance of tobacco smoke, nicotine exposure, alcohol, marijuana, and opioids in the infant’s sleep environment.
• Discouragement of routine use of home cardiorespiratory monitors as a preventive strategy.

The AAP emphasizes that although bed sharing may occur occasionally during breastfeeding or comforting, the infant should be returned to a safe sleep surface as soon as the caregiver is ready to sleep.

WHO/UNICEF and Other Organizations

Public health organizations such as the World Health Organization (WHO) and initiatives like the UNICEF Baby Friendly Initiative combine an emphasis on sleep safety (supine position, firm surfaces, object-free environment) with recognition of the importance of physical contact and responsive breastfeeding during early life.

Italian Guidelines (SIP, SIN, SIPPS)

In Italy, guidelines from the Italian Society of Pediatrics (SIP), the Italian Society of Neonatology (SIN), and the Italian Society of Preventive and Social Pediatrics (SIPPS) align with international recommendations, emphasizing room sharing with a separate sleep surface and discouraging bed sharing.

Co-sleeping: Clinical Evaluation of Relational Benefits

The desire to practice co-sleeping is often motivated by psychophysiological considerations, such as optimizing on-demand breastfeeding, regulating neuroendocrine stress, and strengthening mother–infant bonding. Proximity promotes synchronization of behavioral and physiological signals (e.g., sleep–wake rhythms), may modulate cortisol activity, and supports oxytocin release, a neuropeptide associated with attachment.

However, clinical evidence does not support the notion that bed sharing is necessary to achieve these benefits. Alternative approaches, such as side-car or bedside cribs, allow physical closeness, facilitate night-time breastfeeding, and ensure continuous supervision without exposing the infant to the documented risks of bed sharing.

Overall, the integration of available evidence suggests that room sharing with a separate sleep surface represents the safest approach during the first months of life, significantly reducing the risk of SIDS and other sleep-related deaths while preserving closeness and nurturing care.
Conversely, bed sharing on shared surfaces is not recommended as a routine practice, as it is associated with increased risks that cannot be fully mitigated. The use of dedicated, safety-compliant sleep surfaces, combined with caregiver education and personalized pediatric counseling, represents the optimal strategy to balance infant safety and relational well-being in early life.