doi:10.1111/j.1440-1754.2011.02228.

ORIGINAL ARTICLE

Autopsy ndings of co-sleeping-associated sudden unexpected

deaths in infancy: Relationship between pathological features and
asphyxial mode of death
jpc_2228

335..341

Martin A Weber, R Anthony Risdon, Michael T Ashworth, Marian Malone and Neil J Sebire
Department of Paediatric Histopathology, Great Ormond Street Hospital for Children and UCL Institute of Child Health, London, United Kingdom

Aim: Co-sleeping is associated with increased risk of sudden unexpected death in infancy (SUDI)/sudden infant death syndrome (SIDS). The aim
of this study is to examine autopsy ndings from a single UK specialist centre to determine the relationship between co-sleeping and cause of
death.
Methods: Retrospective analysis of >1500 paediatric autopsies carried out by paediatric pathologists over a 10-year period. SUDI was dened
as sudden unexpected death of an infant aged 7365 days; deaths were categorised into explained SUDI (cause of death was determined) and
unexplained SUDI (equivalent to SIDS).
Results: There were 546 SUDI; sleeping arrangements were specically recorded in 314; of these, 174 (55%) were co-sleeping-associated
deaths. Almost two thirds (59%) of unexplained SUDI were co-sleeping compared to 44% explained SUDI (95% condence interval (CI) 1.027.2%,
P = 0.03); however, this difference remained statistically signicant only for the rst 5 months of life (95% CI 3.533.2%, P = 0.01). In unexplained
SUDI aged < 6 months, there were no signicant differences between co-sleeping and non-co-sleeping deaths with respect to ante-mortem
symptoms, intrathoracic petechiae, macroscopic lung appearances, pulmonary haemosiderin-laden macrophages, and isolation of specic
bacterial pathogens; however, fresh intra-alveolar haemorrhage was reported more commonly in co-sleeping (54%) than in those that were not
(38%; 95% CI 1.430.5%, P = 0.03).
Conclusions: Co-sleeping is associated with unexplained SUDI/SIDS in infants aged < 6 months, suggesting that co-sleeping is related to the
pathogenesis of death in younger infants. The nding that intra-alveolar haemorrhage is more common in co-sleeping suggests that a minority
of co-sleeping-associated deaths may be related to an asphyxial process.
Key words:

autopsy; co-sleeping; infancy; SIDS; sudden unexpected death; SUDI.

What is already known on this topic

What this study adds

1 Co-sleeping is associated with around 50% of SIDS deaths in the

UK.
2 Co-sleeping is a risk factor for unexplained SUDI/SIDS if parents
smoke, or use alcohol or drugs.
3 Co-sleeping on a sofa is particularly dangerous.

1 Co-sleeping is associated with unexplained SUDI/SIDS in infants

less than 6 months of age, suggesting that co-sleeping is related
to the pathogenesis of sudden death in younger infants.
2 Intra-alveolar haemorrhage is more commonly reported at
autopsy in co-sleeping-associated deaths in infants under the
age of 6 months than in infants that were not co-sleeping, suggesting that a proportion of these co-sleeping-associated
deaths may be related to asphyxia.
3 The high proportion of co-sleeping deaths on a sofa in the
present study highlights an ongoing need for further public
awareness campaigns.

Correspondence: Prof Neil J Sebire, Department of Paediatric Histopathology, Great Ormond Street Hospital for Children, Great Ormond Street,
London WC1N 3JH, UK. Fax: +44 20 7829 7875; email: SebirN@gosh.nhs.uk
Conict of Interest: None
Accepted for publication 29 April 2011.

Introduction
Sudden unexpected death in infancy (SUDI), defined as the
sudden and unexpected death of an infant aged less than 1 year,
comprises a heterogeneous group of infant deaths, including
those in which a review of the death scene and complete postmortem examination will disclose a cause of death (explained

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MA Weber et al.

SUDI), and deaths that will remain unexplained even after such
investigations.1 The latter cases may also be classified as sudden
infant death syndrome (SIDS) if the infant died during sleep.2
Many risk factors have been identified for unexplained SUDI/
SIDS, including prone sleeping,37 co-sleeping,814 and maternal
smoking,8,1517 as well as high ambient room temperatures,
excessive clothing and/or bedding, head covering, preterm birth
and/or intra-uterine growth restriction, multiple pregnancy,
high parity, young maternal age and low socio-economic
class.8,1822 Previous studies have also consistently shown that
use of pacifiers (soothers or dummies), room sharing without
co-sleeping, and breastfeeding significantly reduce the risk of
SIDS.21,23
Co-sleeping or bed sharing remains a controversial risk factor
for SIDS; it is normal practice in many cultures, and despite
recommendations to the contrary, it is still commonly practiced
in the UK.24,25 However, there is strong epidemiological evidence
that co-sleeping is associated with an increased risk of SIDS
when there is a history of maternal smoking or where parents
have consumed alcohol or taken drugs in the preceding 24 h.8,26
Although the actual number of co-sleeping-associated SIDS
deaths has decreased in the UK, the proportion of unexplained
SUDI/SIDS deaths associated with reported co-sleeping has
increased from around 12% in the 1980s to almost 50% in
1999200320 to 54% in 20032006.26 While there are many
epidemiological studies on co-sleeping, autopsy-based data
relating to such deaths remain limited. The aim of this study is
to determine the prevalence and significance of co-sleeping in
relation to cause of death in a large series of SUDI infants
referred for autopsy to a single specialist centre in the UK and
investigated to a common protocol.

Methods
This study is a retrospective review of 546 SUDI autopsies,
reviewed as part of a larger series of >1500 consecutive paediatric autopsies performed over a 10-year period, 1996 to 2005,
at a single specialist centre. SUDI was defined as the sudden and
unexpected death of an infant aged 7 to 365 days. Local
research ethics committee approval was obtained prior to the
start of this project.
All post-mortem examinations were performed by specialist
paediatric pathologists at a single centre. Clinical information
regarding the circumstances of death was provided by Her Majestys Coroner (HMC) or the investigating police. A local
autopsy protocol was followed that included the use of detailed
ancillary investigations, which was modified slightly during the
10-year period, and comprised a full macroscopic post-mortem
examination in addition to histological examination, postmortem radiology, bacteriological and virological investigations,
and metabolic studies, as well as other analyses, such as biochemical or toxicological investigations, in selected cases. The
autopsies were entered into a specially designed Microsoft
Access database; to ensure consistency for data analysis and
interpretation, all data entry and data extractions were carried
out by a single paediatric pathologist (MAW). Using strictly
defined criteria, the final cause of death was classified as either
explained SUDI or unexplained SUDI following review of the
post-mortem findings (which included the macroscopic and his336

tological findings, and the results of all ancillary investigations)

and of the clinical history available to the pathologist at the time
of the autopsy (including any given details of the death scene
investigation). For the purposes of this study, co-sleeping was
defined as the sharing of a sleeping surface between the infant
and at least one adult or child during the infants last sleep.
Statistical methods used included the comparison of proportion
test and the MannWhitney U-test.

Results
During the 10-year study period (1996 to 2005 inclusive), a
total of 1516 paediatric post-mortem examinations were performed in the centre; of these, 965 were infants under the age
of 1 year, of which 546 met the criteria for SUDI (sudden
unexpected death of an infant aged 7 to 365 days). In 202
(37%) infants, an identifiable cause of death was diagnosed
following a detailed post-mortem examination (explained
SUDI); the other 344 (63%) deaths remained unexplained
despite extensive post-mortem investigations (unexplained
SUDI).1 In 36 of the 546 SUDI, there was no information
provided by HMC or the police about whether the infant had
died during sleep. Of the remaining 510 SUDI, 361 (71%)
were reported as having died during sleep, but in 47 of these,
no specific information was provided regarding their precise
sleeping arrangements during the last sleep. Of the remaining
314 infants, 174 (55%) were co-sleeping-associated deaths,
while 140 (45%) were not.
There were significantly more deaths associated with sleep in
the unexplained SUDI group (279 of 329 unexplained SUDI in
whom the sleep status was recorded, 85%) compared to the
explained SUDI group (82 of 181 infants in whom the sleep
status was recorded, 45%; difference 39.5%, 95% confidence
interval (CI) 31.1% to 47.5%, P < 0.0001; Fig. 1). In the unexplained SUDI group, in more than half of all sleep-associated
deaths, the infant had been co-sleeping, usually with one or
both parents (144 of 246, 59%), compared to only 44% in
explained SUDI (30 of 68, 44%; difference 14.4%, 95% CI 1.0%
to 27.2%, P = 0.03; Fig. 2).
Co-sleeping-associated deaths occurred at a significantly
younger age in both explained and unexplained SUDI, likely
reflecting that this sleeping practice is more common in
younger infants (Fig. 3). However, co-sleeping-associated
deaths were significantly more common in unexplained SUDI
than explained SUDI in the first 5 months of life (132 of 201
(66%) unexplained SUDI vs. 24 of 51 (47%) explained SUDI;
difference 18.6%, 95% CI 3.5% to 33.2%, P = 0.01), but not
in older infants aged 612 months (12 of 45 (27%) unexplained SUDI vs. 6 of 17 (35%) explained SUDI; difference
8.6%, 95% CI -15.1% to 35.3%, P = 0.38; Fig. 4), suggesting
that co-sleeping may play a role in the pathogenesis of unexplained SUDI in a proportion of deaths in the younger age
group. Overall, 32 of all 174 (18%) co-sleeping associated
deaths were reported to have co-slept on a sofa, 26 of which
were in the unexplained SUDI group (26 of 144, 18%); 10 of
the 26 (38%) were reported to show intra-alveolar haemorrhage at post-mortem.
Limiting further analysis to unexplained SUDI infants aged <
6 months (n = 201), there were no significant differences

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MA Weber et al.

Co-sleeping in SUDI

90%
P < 0.0001
80%

Death during sleep

Not associated with sleep

70%
60%
50%
Fig. 1 Deaths associated with sleep. There
were signicantly more deaths associated with
sleep in the unexplained SUDI group (279 of 329
infants in whom the sleep status was recorded)
compared to the explained SUDI group (82 of
181); in contrast to the former, the explained
SUDI group showed no signicant difference
in prevalence between sleep- and non-sleepassociated deaths (difference 9.4%, 95% CI
-19.5% to 0.9%, P = 0.08).

40%
30%
20%
10%
0%
Unexplained SUDI

70%

Explained SUDI

P = 0.03

Co-sleeping
Not co-sleeping

60%
50%
40%
30%
Fig. 2 Co-sleeping in unexplained and
explained SUDI. There were signicantly more
co-sleeping-associated deaths in the unexplained SUDI group (144 of 246 infants that died
during sleep and in whom specic information
was provided regarding their precise sleeping
arrangements during their last sleep) compared
to the explained SUDI group (30 of 68).

20%
10%
0%
Unexplained SUDI

between co-sleeping-associated deaths and non-co-sleeping

deaths with respect to ante-mortem symptoms (as reported by
parents), intrathoracic petechiae and macroscopic appearances
of the lungs (as described by the pathologist at the time of the
post-mortem examination), or pulmonary haemosiderin-laden
macrophages and isolation of specific bacterial pathogens
(Table 1). However, intra-alveolar haemorrhage was reported
more commonly in unexplained SUDI that were co-sleeping
(54%) than in unexplained SUDI that were not (38%; difference 16.5%, 95% CI 1.4% to 30.5%, P = 0.03).

Discussion
The results of this study show that co-sleeping is common, with
more than half of all SUDI infants referred to our centre for
autopsy having shared a sleeping surface with one or both parents
during their last sleep. For both unexplained SUDI and explained
SUDI deaths, co-sleeping was commoner in young infants; this
notwithstanding, co-sleeping was found to be significantly more
prevalent in unexplained SUDI compared to explained SUDI for

Explained SUDI

infants under 6 months of age. These findings suggest that

co-sleeping may be related to the pathogenesis of sudden unexpected death in around 20% of younger SUDI deaths. Significantly, of the unexplained SUDI deaths occurring during sleep
in infants aged < 6 months, intra-alveolar haemorrhage was
more prevalent in co-sleeping-associated deaths than in infants
that were not co-sleeping, suggesting that a small proportion of
co-sleeping-associated deaths may be related to asphyxia.
Co-sleeping remains a contentious risk factor for SIDS,24,27
despite epidemiological studies having shown an apparent association between co-sleeping and SIDS.814,26,28 The Confidential
Enquiry into Stillbirths and Deaths in Infancy (CESDI) SUDI
Studies demonstrated a significantly increased risk of SIDS for
co-sleeping infants if at least one parent smoked (OR 12.35,
95% CI 7.4120.59) or the mother had consumed more than
two units of alcohol in the previous 24 h (OR 14.37 95% CI
4.6644.29), but not for non-smoking parents (OR 1.08, 95% CI
0.452.58);8 these associations were recently confirmed in a
subsequent UK-based study, which showed that co-sleeping
significantly raised the risk of SIDS if parents had recently

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MA Weber et al.

P < 0.0001

P = 0.01
Co-sleeping
Not co-sleeping
Median

300

Interquartile range

Age in days

95th Centile
5th Centile

200

Fig. 3 Age of co-sleeping. In both groups,

co-sleeping was more frequent at a younger age
(unexplained SUDI: co-sleeping median age in
days (interquartile range) 52.5 (29.587) vs. not
co-sleeping 104 (57174), MannWhitney U-test
P < 0.0001; explained SUDI: co-sleeping 59 (35
109) vs. not co-sleeping 97.5 (79173), Mann
Whitney U-test P = 0.01).

100

Unexplained SUDI

Explained SUDI

70%
Unexplained SUDI

P = 0.01

Explained SUDI

60%
50%
40%
P = 0.38

30%
20%
10%
0%
1* 5

6 12
Age in months

consumed alcohol or drugs (odds ratio (OR) 14.34; 95% 3.78

78.76) but not if parents had neither used alcohol nor drugs (OR
2.27; 95% CI 0.935.57), suggesting that the increased risk of
SIDS is not conferred by bed sharing per se but that the risk is
modified by the circumstances in which co-sleeping occurs.26
The results of the current autopsy-based study are supported
by several published epidemiological reports. A recent systematic review of 40 studies reporting on the association between
SIDS and co-sleeping, including 30 case control studies and 10
prospective cohort studies conducted in 10 different countries,
found an association between bed sharing and SIDS for younger
infants, the strength of the association decreasing with increasing age.13 In a recent large multicentre case control German
study published subsequent to the systematic review,
338

Fig. 4 Co-sleeping-associated deaths in unexplained and explained SUDI in infants aged 1 to

5 months and 6 to 12 months. (* = rst month
includes infants aged 7 to 30 days). In the rst
5 months, 132 of 201 (66%) unexplained SUDI
that occurred during sleep were associated with
co-sleeping, compared to only 24 of 51 (47%)
explained SUDI.

co-sleeping during last sleep was associated with an increased

risk of SIDS (multivariate OR 2.73, 95% CI 1.345.55),
although the risk of SIDS remained significant only in younger
infants less than 13 weeks old (multivariate OR 19.86, 95% CI
2.33169.54).28 Similarly, in a study from Scotland, bed sharing
was associated with an increased risk of SIDS in infants less than
11 weeks old (OR 10.20, 95% CI 2.9934.80), and this association remained significant even when mothers did not smoke
(OR 8.01, 95% CI 1.2053.3).11 In a recent Dutch study of 138
SIDS deaths less than 6 months of age, bed sharing was found to
be a significant risk factor for infants less than 4 months of age
after adjusting for breastfeeding and parental smoking, but not
for older infants.14 The consistent finding of an association
between unexplained SUDI/SIDS and co-sleeping in younger

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MA Weber et al.

Table 1

Co-sleeping in SUDI

Unexplained SUDI in the rst 6 months of life (n = 201): comparison of post-mortem ndings between co-sleeping and non-co-sleeping infants

Ante-mortem clinical symptoms

Intrathoracic petechiae
Congested and/or haemorrhagic lungs
Intra-alveolar haemorrhage
Alveolar haemosiderin-laden macrophages
Group 2 pathogens
Staphylococcus aureus

Co-sleeping
n = 132 (%)

Not co-sleeping
n = 69 (%)

Odds ratio (95% CI)

31 (23)
52 (39)
83 (63)
68 of 126 (54)
3 of 126 (2)
60 of 129 (47)
47 of 129 (36)

13 (19)
36 (52)
42 (61)
24 of 64 (38)
3 of 64 (5)
32 of 66 (48)
27 of 66 (41)

0.38
0.08
0.76
0.03
0.25
0.76
0.54

1.32 (0.61 to 2.98)

0.60 (0.32 to 1.12)
1.09 (0.57 to 2.06)
1.95 (1.01 to 3.80)
0.50 (0.06 to 3.83)
0.92 (0.49 to 1.75)
0.83 (0.43 to 1.60)

Note that the rst month includes infants aged 7 to 30 days; ante-mortem clinical symptoms = clinical symptoms reported by parents, such as fever,
respiratory symptoms, and diarrhoea and vomiting; group 2 pathogens are dened as pathogenic organisms, which when found in blood in life in the
investigation of a bacteraemic/septicaemic illness would be interpreted as signicant or possibly signicant and which are recognised to cause septicaemia
and/or death without there necessarily being an identiable focus of infection; these include group A beta-haemolytic streptococcus, group B betahaemolytic streptococcus, Escherichia coli, Haemophilus inuenzae type b, Listeria monocytogenes, Neisseria meningitidis, Staphylococcus aureus and
Streptococcus pneumoniae. Petechial haemorrhages of the thymus, heart and/or lungs as described by the pathologist in the post-mortem report. As
described by the pathologist in the post-mortem report on macroscopic examination of the lungs. As described by the pathologist on histological
examination of the lungs. Isolated on post-mortem culture from any site.

infants regardless of smoking status,11,13,14,28 as also demonstrated in the present study, suggests that young infants may be
intrinsically vulnerable to the risks of co-sleeping, even if the
mechanism(s) involved remain unclear.
It is recognised that in a small proportion of co-sleeping
infants, death may be caused by accidental asphyxia due to
overlaying, but for the majority, the mechanism of death is
poorly understood, with little direct evidence to support a
diagnosis of asphyxia.29 That said, the diagnosis of asphyxia is
notoriously difficult at post-mortem as there are no specific
pathological findings.30 It has previously been suggested that
moderate to severe degrees of pulmonary haemorrhage may be
a marker of asphyxia due to either accidental or inflicted suffocation,31 although its recognised that intra-alveolar haemorrhage
(IAH) per se is common in SIDS and reported in more than half of
cases.32 One such study found that significant IAH, which the
authors arbitrarily defined as >5% of the total lung surface area
assessed, was significantly more prevalent in SIDS infants that
were co-sleeping/potentially overlain than in SIDS infants that
were not.31 However, Berry33 observed that the majority of the
co-sleeping deaths in that study occurred in younger infants,
that younger age of death was associated with more extensive
IAH, and that further work was required to ascertain whether
young age or co-sleeping, or both, were independent variables
resulting in increased IAH. The present study has also shown
that IAH in infants < 6 months of age is more prevalent in
co-sleeping than in infants that were not co-sleeping; while not
specific, this further suggests that a proportion of otherwise
non-suspicious co-sleeping-associated deaths in younger infants
might be related to asphyxia, either as the cause of death, or
occurring in combination with other factors.
The main reasons given by parents for bed sharing include the
facilitation of breastfeeding, comforting an irritable infant
and/or helping the infant or mother get better sleep.25,27 Previous studies have shown an increased association between

co-sleeping and both the rate and the duration of breastfeeding,

although this does not necessarily imply a causal relationship.13
In a recent longitudinal, population-based study in the UK,
co-sleeping was associated with a significantly higher prevalence of breastfeeding in the first 15 months of life in the groups
that bed shared in infancy and that bed shared constantly
throughout the 4-year study period.25 It has been argued that
co-sleeping represents a biologically and culturally evolved
behaviour, as human infants, like other primate infants, require
close physical contact between themselves and their mothers to
regulate body temperature, breathing and other vital functions.34 However, the authors emphasise that this does not make
co-sleeping inherently safe, and that it is the context and
manner in which such practices are performed that make them
safe or unsafe. Most epidemiological studies lack the complexity
and/or statistical power to differentiate between these different
(i.e. safe vs. unsafe) sleep practices, but the observation that
there are many cultures where bed sharing is commonly practiced but which carry a low incidence of SIDS, such as Japan and
Hong Kong, supports the notion that other co-factors may be
important in mediating the risk of SIDS associated with
co-sleeping.24
The high proportion of co-sleeping deaths on a sofa (18%)
in the present study is especially worrisome, and highlights an
ongoing need for further public awareness campaigns.
Co-sleeping with an infant on a sofa has been shown to carry
an almost 23 times greater risk of SIDS than infants not
co-sleeping (OR 22.05, 95% CI 6.5274.56, compared with an
OR of 2.07, 95% CI 1.462.95, for infants found in the parental bed);8 similar data are reported in other studies.9,11,12,26 The
reason for this association remains unclear, although it is possible that co-sleeping on a sofa increases the risk of accidental
asphyxia.35
The main limitations in the present study relate to the absence
of reliable information about other associated risk factors for

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SIDS, such as parental smoking or alcohol use. This is an inherent issue with any retrospective autopsy-based study, since the
clinical details are dependent on the information supplied by
HMC and/or police at the time of the autopsy. The major
strengths of this study relate to its large sample size, this being
the largest single-centre pathology study to date in which all
SUDI autopsies were carried out by a small number of specialist
paediatric pathologists to a common autopsy protocol, and the
use of an appropriate post-mortem comparison group (the
explained SUDI group) to determine the significance of differences in the frequency of co-sleeping in relation to cause of
death. Moreover, this is the first time that specific autopsy
findings have been compared between co-sleeping and non-cosleeping unexplained SUDI/SIDS infants, demonstrating that
there are no specific pathological findings at post-mortem to
determine mode of death in this setting.
In conclusion, while co-sleeping is common, it is associated
with unexplained SUDI in infants aged < 6 months. While there
is evidence to suggest that other co-factors are required while
bed sharing to confer the increased risk of SIDS, our data
support previous findings that co-sleeping may be related to the
pathogenesis of sudden unexpected death in younger infants.
The finding that IAH is more commonly reported in co-sleepingassociated deaths than in age-matched infants that were not
co-sleeping suggests that a proportion of co-sleeping-associated
deaths may be related to asphyxia.

Acknowledgements
This study was supported by a grant from The Foundation for
the Study of Infant Deaths (FSID). The sponsor had no role in
the study design, in the collection, analysis and interpretation of
data, in the writing of the manuscript, or the decision to submit
the paper for publication.

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