Caring for twin infants: The authors are grateful for the collaboration of Tamba Twins and Multiple Births Association , both in raising the initial research question, and in the recruitment of participants.
Parents of twin infants who participated in this study deserve the highest praise for so generously giving of their limited spare time to complete sleep logs and answer interview questions. The study aimed to assess sleeping arrangements used by parents for twin infants and to determine what information might be useful for health professionals and parents regarding twin infant sleep.
A self-selected sample of 60 families recruited via Tamba Twins and Multiple Births Association , local health professionals and newspapers maintained sleep logs and participated in telephone interviews when their twin infants were one, three and five months of age. Sleep duration was the primary reason given by parents for sleeping twins either apart or together, but no significant differences were found for parental or infant sleep duration.
Department of Health advice to parents on reducing the risk of sudden infant death syndrome SIDS recommends sleeping infants in their parent s room for the first six months of life.
Co-bedding appears to facilitate compliance with this recommendation via the use of a single cot. The strong association between hospital and home sleeping arrangements suggests that co-bedding twins on the postnatal ward may encourage parents to do so at home. By discussing sleeping arrangements for twin babies with parents, both hospital and community midwives could help to educate parents about the most appropriate ways of co-bedding twin infants and avoidance of unsafe practices.
Twins, multiple births, co-bedding, sudden infant death syndrome, SIDS, infant sleep, sleep safety Introduction UK national guidelines on sleeping environments for newborn infants recommend they should sleep in a supine position with their feet to the foot of a crib located in their parent s room, in order to reduce the risk of sudden infant death syndrome SIDS Department of Health, For parents of twin or higher-order multiple infants, this advice can pose a dilemma if infants share a cot or crib.
The British charitable parent-support organisation Tamba Twins and Multiple Births Association notes that parents of many twins prefer to co-bed their infants yet are concerned about the safest way to do so Tamba, letter to Foundation for the Study of Infant Deaths, Researchers observed that cobedded pre-term twins moved close together, touched, held, hugged, rooted and sucked one another. They smiled at each other, were awake at the same time, and experienced a reduced need for ambient temperature support Nyqvist and Lutes, ; Lutes and Vandenberg, ; Bingham, Such co-regulatory effects of twin infants upon one another are predictable given the synchronous behaviour and physiological patterns identified between fetuses in twin gestations e.
Gallagher et al, Given that parents of twins report inadequate sleep as the primary difficulty faced in rearing twin infants Chang, ; Haigh and Wilkinson, ; Yokoyama, , it is unsurprising that parents may favour strategies that are perceived to promote simultaneous sleep patterns in their infants.
Co-bedding of twin infants is therefore a topic on which both hospital and community midwives must be conversant. Sleeping arrangements for twin infants are also a cause for concern as twin and higher-order multiple infants experience an increased risk of SIDS e. Rintahaka and Hirvonen, ; Mitchell et al, ; Sanghavi, ; Hoskins, ; Daltveit et al, Parents must balance SIDS-reduction advice with night-time coping strategies when caring for multiples.
With the UK twin birth rate climbing from 9. In order to assist them effectively, healthcare staff need to comprehend the challenges faced by parents of multiples Holditch-Davis, and consider how they will advise such parents.
No publications were found in the clinical or academic literature on parental strategies for sleeping twin infants, or on the relative merits of co-bedding or separate sleeping arrangements for healthy twin infants at home see also Lewallen, A limited number of opinion papers, position statements and clinical reviews were found e.
Bingham, ; Boyd, ; National Association of Neonatal Nurses, ; Hayward, ; Hudson-Barr, ; Lewallen, , together with self-help publications for parents of multiples that address sleeping arrangements e. Gromada, ; Multiple Birth Foundation, , but as these latter publications are unreferenced and largely based on anecdote and personal experience, they cannot be considered a suitable foundation for evidence-based practice.
One primary research study Byers et al, ; Polizzi et al, and most professional discussion of twin infant sleeping arrangements concerns neonatal intensive care units and is US-focused e. The RCM has published both a guidance paper and a position statement on bed-sharing and co-sleeping, however this pertains to adult-infant sleep contact, not the co-bedding of twins. This study was therefore conducted to explore the sleeping arrangements employed by UK parents with twin infants, and to generate primary data regarding sleeping arrangements and compliance with SIDS-reduction guidelines among twin families that could be used by hospital and community midwives and health visitors when addressing sleep issues with the parents of newborn twins.
Methods Approval was received from local and multi-centre NHS research ethics committees prior to the start of the study. Recruitment An opportunistic sample of new twin parents was recruited from November to June via leaflets enclosed in packs to new Tamba members. Families who volunteered, and met the inclusion criteria pregnant with, or recently given birth to, healthy twin infants of normal gestation with parents willing to complete sleep logs and interviews provided written consent and were enrolled in the study.
Local health professionals and newspapers also aided recruitment by bringing the study to the attention of families with twin infants.
All participants were from the UK. As the Human Fertilisation and Embryology Act of prohibits the retention of information concerning the nature of individual conceptions, we did not retain any information volunteered by parents regarding the conception of their twins. Key points Parents of newborn twins may prioritise nighttime coping over optimum care strategies, and may benefit from support and advice regarding twin infant sleeping arrangements -How twin infants are slept in hospital predicts sleeping arrangements at home.
Data collection Data were collected prospectively with parents completing seven nightly sleep-logs for their infants in the first and third postnatal months. Parents were asked to choose any convenient week, and to ensure the nights were consecutive. Interviews followed up items entered in the sleep logs, and discussed night-time care practices more generally.
A thematic framework was applied to the qualitative content analyses of interview data, utilising listing and pilesorting to identify themes.
One-month sleep logs were completed by 56 families, four families joined the study after the first month, and 50 families completed the three-month sleep logs. A socio-demographic breakdown of participants and drop-outs is provided in Table 1. We found no association between zygosity or gender and sleeping arrangement.
Parental interviews identified space constraints as the reason — when SS infants outgrew their Moses baskets, two cots could not normally be accommodated in the parental bedroom and thus both babies were moved elsewhere. Parents were more likely to sleep their infants together from birth, and then separate them as they grew, than to start them apart and move them together. No single explanation for separate sleep arrangements outweighed all others.
One family who slept their twins together noted they did so against the advice of midwifery staff, while four other families slept their twins together because they had been advised to do so. Some parents who co-bedded their twins expressed concerns about babies squashing or overheating one another, and devised barriers in the cot to attempt to prevent this.
Four families used pillows or rolled up blankets to separate their twins within the same cot, while five more swaddled or tucked blankets around their infants to try and restrict their movements. Parental experiences of midwifery advice differed. Three families reported specific advice from midwives to sleep their babies together, while one family were told their twins were not allowed to sleep together in the hospital. The head-to-head configuration had two variants; while infants who slept side-by-side did so in at least four different ways see Figure 1.
SS infants were separated by from 5cm adjacent cots to four metres separate rooms.
In all four cases, nonsupine infants slept apart. These outliers were covered with ten layers vest, sleep-suit, one sheet doubled over, two blankets folded to form six layers and eight layers vest, stretch-suit, four layers of sheets and two layers of blankets respectively. In the third month, CB twins slept under an average of 4. The difference at three months was not significant with or without the presence of any outliers.
Numbers using transitional objects were too small for statistical testing. There is a trend towards breastfed infants being slept together in the first month, and formulafed infants being slept apart in the third month, but no statistical association was found between feeding method and sleeping arrangement at either time point.
Using sleep log data, the authors explored whether sleep arrangement was related to synchrony of night-time feeds. By the third month, half of all CB and SS infants were fed at different times. In the first month, there was no difference in the average amount of night-time sleep obtained by infants sleeping together and apart — 7: No significant differences were found in the amount of sleep obtained by parents of twins who slept together and apart.
The slight reduction observed overall for the amount of sleep obtained by mothers of CB twins in the first month see Table 3 is entirely attributable to the greater proportion of breastfed infants in the co-bedded group. Discussion The three most important outcomes of this study for midwives and health visitors involve the implementation of SIDS-risk reduction guidelines, the association between hospital and home practices in twin sleeping arrangements, and suggestions for parents on ways to cope with the nighttime care of twins.
Infantswere rarely relocated from separate Moses baskets into the same cot — once parents had established separate sleeping arrangements for their twins, they seldom switched. Make-shift barriers Attempts to separate CB infants via make-shift barriers are a cause for concern. Hospital midwifery staff could warn parents against this before leaving the postnatal ward, and community midwives could reinforce this in the home.
In a related study where the authors observed the sleep behaviour of CB and SS twin babies Ball, in preparation , supine sleeping twins did not present a suffocation or overheating hazard to one another, and did not disturb each other even when sharing a Moses basket. The use of barriers for CB twins is therefore unnecessary and could result in harm. Use of covers The variety of co-bedding configurations employed by parents was unexpected, and revealed another potential problem. In this situation an infant can grasp and pull an unsecured cover over its head Ball, unpublished video data.
Midwives should therefore reinforce SIDS-risk reduction messages regarding unsecured covers with parents whose twin infantsshare a cot. The use of baby-sleeping bags that replace the use of covers might be particularly useful for CB twins who could then share a cot in any configuration. That two families dramatically over-wrapped their babies is alarming. The major culprit in both cases was the use of multiple-folded sheets and blankets.
Parents possibly failed to recognise that a twice-folded blanket constituted four layers of bedding. This issue is not exclusive to twin infants, but it serves as a reminder to midwives and health visitors that recommending the use of one or two blankets may be insufficiently specific, and the number of layers of coverings should be emphasised when advising parents Department of Health, The influence of hospital practices Postnatal ward practice was strongly associated with the sleeping arrangements adopted by parents at home.
Although few parents overtly acknowledged that hospital sleeping arrangements influenced their home sleeping arrangements, the association between the two was statistically robust, and is reinforced by the findings of Polizzi et al It is possible that parents failed to report that they requested certain postnatal infant care arrangements, but from reviewing our interviews the authors consider it more likely that they unconsciously followed the practice employed by staff; or found that their twins were accustomed to the arrangement employed in the hospital and perceived them to prefer it.
Whatever the explanation, postnatal ward practice is known to be influential on parental behaviour e. Svensson et al, ; DiGirolamo et al, , therefore hospital and community midwives should develop and reinforce consistent policies regarding sleeping arrangements for twin infants, and explain these to parents. Coping with the night-time care of twins This study provides some insights into how parents of twin infants cope with night-time parenting.
It should be remembered, however, that at three months a greater proportion of CB twins were located in the parental room than SS twins, many of whom were in a separate room.
Unless infants always cried loudly immediately upon waking, parents may have over-estimated the duration of sleep obtained by infants in a separate room, although this cannot be confirmed without observation.
Furthermore, SS twins at three months were predominantly formula-fed while a greater proportion of CB infants were breastfed, which has direct implications for infant sleep duration Ball, No significant differences were found for duration of parental sleep when infants slept together or apart.
The tendency towards co-bedding for breastfed infants suggests that with a larger sample a significant association may emerge. This is an area for breastfeeding promotion to address. Generalising these results It is important to note that the families who were willing and able to participate in this study were most likely to be coping with their twin babies.
It should also be noted that the parents who persisted with the study were more financially well-off and more likely to be married than those who dropped out, suggesting a possibly more stable and supportive environment. A further limitation of the sample in this study is that the families who participated had to have joined Tamba and responded to the call for volunteers. If we accept that this sample represented a group of fairly affluent, well educated, mature parents of twins see Table 1 with the motivation to seek support from a twins group and self-assurance to volunteer to participate in a research study, it is instructive to note failure in heeding various elements of SIDS-risk reduction advice.
This suggests that parents of twins may benefit from additional support from health professionals in considering and implementing night-time care practices — and that advice should be specifically designed for twin parents on issues such as safe and unsafe ways of co-bedding, and the pros and cons of separating twin babies into Moses baskets at birth.
You can never be too prepared for two. Jill Irving Child health nurse.
Conclusion This sample of 60 families employed various strategies for sleeping their twin infants. Neither co- nor separate bedding arrangements for twin infants afforded parents more sleep in the neonatal period.
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