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Caring for twin infants: sleeping arrangements and their implications

9 January, 2009

Caring for twin infants: sleeping arrangements and their implications

The study 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.

EBM: July 2006

Helen L Ball PhD, MSc, BSc.
Senior lecturer and director, Parent-Infant Sleep Lab, Medical Anthropology Research Group, Department of Anthropology, University of Durham, 43 Old Elvet, Durham DH1 3HN England. Email: h.l.ball@dur.ac.uk

This study was funded by project grant 237 from the Foundation for the Study of Infant Deaths. 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.


Aim. 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.
Method. 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.
Results. The authors found significant associations between home sleeping arrangements and sleeping arrangements on the postnatal ward (chi-square=9.5, df=1, p=0.002), infant age (chi-square=5.45, df=1, p=0.0195), and sleep furniture used in the home (chi-square=36.13, df=1, p<0.0001). At one month of age, 60% of twins were co-bedded, 92% of which shared a cot while 86% of twins sleeping apart were in separate Moses baskets. Co-bedded twins were initially positioned sideby- side (68%), however eight co-bedding configurations were documented over the first three months. 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. Co-bedded twins were less likely to be moved from their parents’ room than those who slept apart (9% versus 33%), however a few parents of co-bedded twins introduced unnecessary hazards into their twins’ sleeping environments with the inappropriate use of bedding and make-shift barriers between the babies.
Conclusions. 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.

Key words: Twins, multiple births, co-bedding, sudden infant death syndrome, SIDS, infant sleep, sleep safety


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, 2004). The ‘feet-to-foot’ advice, designed to minimise the risk of an infant slipping under the bedcovers and overheating or suffocating, is targeted at singleton infants sleeping alone. 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, 1999).

The co-bedding of twins is cited in the neonatal literature as an effective strategy for ‘supporting both pre-term and full-term twins during their transition to extra-uterine life’ (Nyqvist and Lutes, 1998). 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, 1998; Lutes and Vandenberg, 1996; Bingham, 1997). 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.g. Gallagher et al, 1992). Evidence of fetal synchrony provides support for anecdotal reportsfrom parents that twin infants settle more easily, and sleep more ‘soundly’ when placed in co-bedded rather than solitary sleeping arrangements (e.g. Tamba message-board, 2005). Given that parents of twins report inadequate sleep as the primary difficulty faced in rearing twin infants (Chang, 1990; Haigh and Wilkinson, 1989; Yokoyama, 2002), 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.g. Rintahaka and Hirvonen, 1986; Mitchell et al, 1987; Sanghavi, 1995; Hoskins, 1995; Daltveit et al, 1997). Parents must balance SIDS-reduction advice with night-time coping strategies when caring for multiples. With the UK twin birth rate climbing from 9.6/1000 in 1980 to 14.7/1000 in 2003 (Multiple Birth Foundation, 2005), midwives and other healthcare providers will increasingly encounter parents in need of advice regarding the care of multiples. In order to assist them effectively, healthcare staff need to comprehend the challenges faced by parents of multiples (Holditch-Davis, 1999) and consider how they will advise such parents.

The publication databases PubMed, Medline, CINAHL and Web of Science were searched systematically using combinations of the terms ‘twin/multiple’ ‘infant/neonate/newborn’ and ‘sleep/cot/crib/co-bedding’ in search phrases. 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, 2003). A limited number of opinion papers, position statements and clinical reviews were found (e.g. Bingham, 1997; Boyd, 2001; National Association of Neonatal Nurses, 2001; Hayward, 2003; Hudson-Barr, 2003; Lewallen, 2003), together with self-help publications for parents of multiples that address sleeping arrangements (e.g. Gromada, 1985; Multiple Birth Foundation, 2000), 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, 2003; Polizzi et al, 2003) and most professional discussion of twin infant sleeping arrangements concerns neonatal intensive care units and is US-focused (e.g. Della-Porta et al, 1998; Hudson-Barr, 2003; Lewallen, 2003), the exception being Boyd’s (2001) clinical review that confirms a lack of UK research. The RCM has published both a guidance paper (2004) and a position statement (2004) 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.


Approval was received from local and multi-centre NHS research ethics committees prior to the start of the study.


An opportunistic sample of new twin parents was recruited from November 2000 to June 2002 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 1990 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. Hospital midwives
therefore have an opportunity to inform parents
about twin infant sleeping arrangements
-Twin infants separated for sleep from birth were
more frequently removed from their parents’ room
before three months of age than co-bedded twins,
despite Department of Health advice to keep infants
in their parents’ room for six months
-Parents devised at least eight different configurations
for co-bedding twin infants
-A small proportion of parents employed hazardous
co-bedding practices – the use of barriers and covers,
and the positioning of co-bedded infants, are issues
that should be discussed by hospital and community
midwives with parents of twin infants.

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. Sleep logs, which were issued and returned by mail, provided a structured form on which parents recorded their infants’ sleep parameters, their own care-giving activities, and information on environmental factors and unusual events. Semistructured telephone interviews were conducted with mothers at the end of their infants’ first, third and fifth months of life, following receipt and review of sleep logs from parents, and lasted approximately 45 minutes. Interviews followed up items entered in the sleep logs, and discussed night-time care practices more generally.

Data analysis

Sleep log and interview data were coded, categorised andanalysed in a database, and 10% of the data were doubleentered for reliability (kappa=0.92). Statistical analyses of quantitative data were performed using Microsoft Excel and
SPSS. A thematic framework was applied to the qualitative content analyses of interview data, utilising listing and pilesorting to identify themes.

Table 1. Socio-demographic breakdown of families who completed participation in the study and those who dropped out


A total of 110 families volunteered for this study, 85% (93) of which met the inclusion criteria. Of those enrolled, 65% (60/93) provided sufficient information to be included in the data analysis. 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. Paternal age and household income differed significantly between completers and drop-outs, and more drop-outs identified themselves as ‘single’ parents.

Sleep arrangements: age, zygosity and gender

In the first month, more twin infants slept together than apart (34 versus 22/56). By three months, the ratio was reversed (20 versus 30/50); the relationship between sleeping arrangement and age was statistically significant (chisquare= 5.45, df=1, p=0.0195). Although a third (10/29) of initially co-bedded (CB) twins were sleeping separately (SS) by three months of age, 19/29 (66%) were still co-bedding, and three pairs continued to co-bed beyond five months of age. We found no association between zygosity or gender and sleeping arrangement.

Sleep location: room and furniture

Full data for both one and three months were available for 44 infants. Most slept in their parents’ room – 77% (34/44) during the first month and 68% (30/44) in the third month. Of these, 65% (22/34) and 47% (14/30) were co-bedded in the first and third months, while 50% (5/10) and 29% (4/14) of babies in separate rooms were co-bedded in first and third months. We found no statistical association between co-bedding and sharing the parental room at either one or three months, however the majority (9/14) of twins who were not in their parents’ room at three months had been slept apart at one month. 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. A strong association was found between sleep furniture and sleeping arrangements in the first month (chi-square=36.13, df=1, p<0.0001) – 92% of infants in cots were slept together, while 86% of infants in Moses baskets were slept apart. 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. A third of CB twins in the first month were separated by the third month (10/31, 32%, third month data missing for five pairs), and only one pair who had slept apart in the first month was co-bedding by the third (1/19, 5%, third month data missing for one pair).

Parents’ reasons for sleeping twins apart in the first month were varied, with the notion that infants would disturb one another if they slept together being the primary explanation (23%). Other reasons included parents’ preference, infants’ perceived preference, concern regarding suffocation, overheating or SIDS if co-bedded, emulation of hospital practice, and infants’ size or ill-health. No single explanation for separate sleep arrangements outweighed all others. Of the 34 families who co-bedded their twins in the first month, ‘babies’ preference’ (53%) and a parental desire to synchronise infant-feeding and waking times (14%) were the most common explanations. 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. Parents who separated previously CB twins believed they were beginning to disturb one another’s sleep (4/10) or were becoming too big for the same cot (4/10).

Hospital experience

Following delivery, 33 (55%) twin pairs were CB in hospital and 24 (40%) were slept separately (data missing for three families). Of those subsequently CB at home, 76% (25/33) had been CB on the postnatal ward, and of those sleeping apart at home, 63% (15/24) were also SS on the postnatal ward. The association between the sleeping location at home and hospital was significant for both the first (chisquare= 9.5, df=1, p=0.002) and third months (chisquare= 4.5, df=1, p=0.03). 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.

Co-bedding configurations

When co-bedded on the postnatal ward, 91% of twins were positioned side-by-side in a bassinette. One pair were placed top-to-tail (side-by-side with one head at each end), and a further two pairs slept together in the mother’s bed. At home in the first month, CB infants also predominantly (23/34 pairs: 68%) slept side-by-side (6/34 head-to-head; 4/34 feet-to-feet; 1/34 top-to-tail), but by the third month exhibited greater positional variability – side-by-side (7/19: 37%), head-to-head (6/19: 32%), and feet-to-feet (6/19: 32%) in equal proportions. Parents’ diagrams of their infant’s co-bedded configurations reveal a wide range of variation. 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).

In the first month, over a third of CB twins were in physical contact all night (36%, 13/36). Other infants’ proximity ranged between 5cm and 60cm for those sharing a cot or Moses basket, and from 30cm to 180cm for those using separate sleep furniture. The proportion of CB infants sleeping in close proximity in the third month was similar to that in the first (42%, 8/19) with other CB infants no more than 30cm apart. SS infants were separated by from 5cm (adjacent cots) to four metres (separate rooms).

Figure 1. Specific co-bedding configurations as depicted by parental illusions

Sleep position, swaddling and bedding

In the first month, almost all infants (86%, 48/56) slept supine, regardless of sleeping arrangements. The 14% (8/56) of infants positioned laterally were equally divided between CB (4) and SS (4). In the third month, supine sleep again predominated (92%, 47/51) with one family each sleeping their twins lateral and lateral/prone, and two families (4%) sleeping one or both infants prone. In all four cases, nonsupine infants slept apart.

A greater proportion of CB than SS twins were swaddled for sleep (24% versus 9%), but as most infants were not swaddled in either first or third months, the authors found no statistical association between swaddling and sleeping arrangement. The average number of layers of clothing and bedding used in the first month for CB and SS twins was not significantly different (mean = 4.5 versus 5.1) – however, the mean for CB twins was reduced to 4.1 and the difference became significant (t-test, p=0.002) when two extremely over-wrapped outliers were removed from the data-set.

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 4.1 layers (range 2 to 7) compared with 4.3 layers for SS twins (range 1 to 10). The difference at three months was not significant with or without the presence of any outliers.

Table 2. Feeding method and sleeping arrangements

Sleep aids and dummies

Most infants in this sample did not use dummies (86%), and so no significant relationship was found for sleeping arrangement and dummy use, although a greater proportion of SS than CB twins used dummies in the first month (23% versus 9%). Only three pairs of infants used any form of sleep aids/transitional objects in the first month (3/56, 5%), while six did so in the third month (5/6 being SS pairs). Numbers using transitional objects were too small for statistical testing.

Feeding and sleep duration

Data for both ‘usual’ feeding method (determined at interview) and feeding data from sleep logs are shown by sleeping arrangement in Table 2. 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. A greater proportion of CB (and breastfed) twins were fed simultaneously at night during the first month than SS infants (44% versus 32%), while parents of the latter pursued three different strategies (feeding simultaneously, consecutively, and a combination of methods) in roughly equal proportions. 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 – 7:59 hrs (together) versus 8:11 hrs (apart). However, by the third month parents reported that SS infants obtained significantly more night-time sleep (mean=10:18 hours) than CB infants (mean=9:17 hours; ttest, p=0.008) (see discussion). 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.


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.

Implementation of SIDS risk reduction guidelines

Infant sleep location

National SIDS-reduction guidelines (Department of Health, 2004) stress the importance of keeping infants in their parents’ room for night-time sleep for the first six months of life. CB twins were less likely to be moved from their parents’ room than infants who were slept apart. Infantswere rarely relocated from separate Moses baskets into the same cot – once parents had established separate sleeping arrangements for their twins, they seldom switched. Although infants who shared a single cot tended to remain in their parents’ room, lack of space for two full-size cots caused parents to move SS twins from the parental bedroom. An important message that both hospital and community midwives could therefore convey to the parents of twin infants is that co-bedding facilitates keeping twin infants in the parents’ room at night, thereby complying with SIDS-risk reduction guidance.

Make-shift barriers

Attempts to separate CB infants via make-shift barriers are a cause for concern. Safety guidelines are clear in advising parents to keep cots free of suffocation hazards such as pillows and soft toys (Henderson-Smart et al, 1998), but four families intentionally introduced pillows or rolled-up blankets/towels into their infants’ sleep environment in an effort to keep them apart. 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. Where parents placed infants side-by-side or head-to-head in the same cot, they could implement ‘feet-to-foot’ guidance. However, if parents positioned infants side-byside widthways or diagonally in the cot, it was impossible to secure bed-covers around babies’ lower bodies and parents simply draped loose sheets or blankets over each infant. 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, 2004).

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 (2005). 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.g. Svensson et al, 2005; DiGirolamo et al, 2001), 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. Some parents used co-bedding to synchronise their infants’ sleep-wake patterns and feeding bouts, and possibly obtain longer stretches of sleep themselves. Sleep log data revealed equal sleep duration for infants positioned ‘together’ and ‘apart’ in the first month, and longer sleep duration for separately sleeping infants in the third month. 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, 2003).

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. It is disappointing to note that only 20% of twin infants in this sample were exclusively breastfed in the first month, dropping to 8% (four pairs) in the third month. 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. Those who failed to return sleep diaries, ceased participating because they were ‘too busy’, or who failed to maintain contact may have found the transition to twin parenthood too overwhelming to be able to document it. 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. The prioritisation of strategies to cope with caring for two infants simultaneously may cause parents of twins to pursue care practices that are less than optimum for their infants’ health (moving young infants from parents’ room, early introduction of artificial formula, hazardous use of pillows, barriers and bedding in cots). 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.

Table 3. Parental sleep per night and sleeping/feeding practises (hours:mins)


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. Infants who slept apart were often moved from their parents’ room much earlier than at the six months recommended for reducing the risk of SIDS. Midwives may wish to consider encouraging the co-bedding of twins in order to facilitate keeping them in the parental bedroom by the use of a single cot, and co-bedding on the postnatal ward may encourage co-bedding at home.

A small proportion of CB infants faced hazards due to parental introduction of barriers, folded blankets and loose covers to the cot, and twins were CB in a variety of configurations. Parents of twins may benefit from specific information from both hospital and community midwives about avoidance of unsafe practices, and the most appropriate ways of co-bedding twin infants.


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