A pediatrician received an unexpected autopsy report in her electronic medical record inbox. It was for a 3 week old infant that she had taken care of in the newborn nursery several weeks before but who had been cared for by a different outpatient group practice since discharge. The history was that the infant was found in the parents’ bed, lying between the parents with soft bedding over the infant. The conclusion was that the infant died from accidental overlying and/or suffocation. The medical record also documented that the family had been provided with education regarding infant safe sleep practices during the newborn period.
During that morning’s clinic, two more families were found to be following unsafe sleep practices and were strongly counseled to institute them. One mother said that she had always slept with her infants despite having a crib in her room; she reluctantly said that she would try to follow the advice. The other family did not have a crib or similar furniture, and the pediatrician worked with the social worker to obtain a crib. The family was very grateful for the assistance.
Parent-infant bed sharing is common with 46% in a US population. The rates depend on the definition used, the time period being instituted and also the consistency of the practice. One study noted that “even for those who do not consistently bed-share, some co-sleeping is common, with 60% of mothers of infants under 12 months of age reporting sharing a bed at least once.” Globally different countries report rates from 6-100%.
Sudden infant death syndrome (SIDS) is defined as “[t]he sudden unexpected death of an apparently healthy infant aged <1 y, in which investigation, autopsy, medical history review, and appropriate laboratory testing fail to identify a specific cause, including cases that meet the definition of SIDS." Sudden Unexpected Infant Death (SUID) is the current preferred term but many groups and organizations continue to use SIDS. Accidental strangulation or suffocation in bed is defined as "An explained sudden and unexpected infant death in a sleep environment (bed, crib, couch, chair, etc) in which the infant's nose and mouth are obstructed or the neck or chest is compressed from soft or loose bedding, an overlay, or wedging causing asphyxia."
Infants that die while in bed may have many reasons for the death such as an underlying health condition, SIDS or suffocation/strangulation, etc. Death inquiries may use different terminology for their findings and those terms may change over time. Multiple factors may not be noted on a death certificate or medical record which are often used for research studies. There is also some data supporting that infants who die alone in bed may have different reasons than those that are co-sleeping.
For many years the global health community has worked to change policies, improve infant sleep furniture, and especially educate health providers and families about safe sleep practices.
The basic ABC’s of infant sleep are:
- A – Alone – Infants should also have their own sleep space with no other people.
- B – Back – Infants should always be placed on their backs to sleep.
- C – Crib – Infants should use a crib, bassinet or portable play yard with a firm mattress and a fitted sheet. The surface should be flat and non-inclined, and the mattress should fit the device without gaps between mattress and device.
Other recommendations include:
- Infants should avoid sleeping on a couch, armchair or any seating device like a swing. Infants should be in car seats while riding in a car but the car seat should not be used for sleep otherwise.
- All loose materials should be kept out of the sleep space including pillows, loose blankets, stuffed toys etc.
- Infants are usually warm enough in one more layer of clothing than what the caretaker is wearing. Therefore, infants can be dressed in layers to provide appropriate warmth. Wearable blankets (sometimes referred to as sleep sacs) are preferred to loose blankets. Weighted clothing or bedding is not recommended.
An infant can be swaddled (i.e. arms wrapped within the clothing) until the infant shows signs of attempting to roll over (usually around 3-4 months), then the infant should have their arms free to be able to reposition themself.
- Infants who can roll should still always be placed onto their backs to sleep. If they assume a different position, they can remain in the position they assume and do not have to be repositioned.
- The infant sleep space is recommended to be in the parents’ room.
- Maternal breastfeeding and avoiding smoking is also recommended.
Overall in the US about 3500 infants die a sleep-related death per year.
One study of US National Center for Health Statistics found from 2007-2016 that infants’ deaths from strangulation/suffocation increased for all groups studied. They also found consistent with previous literature that teenage/young/lower educational attainment by mothers, lower gestational age, lower birth weight and male infants had higher risk of accidental strangulation/suffocation. There were also strong geographical differences. These could be due to improved definitions (i.e. accidental suffocation vs SIDS), different ways of reporting (i.e. using emergency responders to provide information about home sleep environment) and also community services (i.e. providing cribs to families). The author’s own state has a reported rate of accidental strangulation/suffocation of 10.1 per 100,000 live births.
Overall unintentional suffocation in infants < 1 year old from 1999-2015 in another study increased from 12.4 to 28.3 per 100,000 people. It occurred in all subgroups including race, ethnicity and urbanization. The authors state reasons for the increase are probably multifactorial. Despite much public education, the use of unsafe sleeping products and practices continues. Also there has also been "improved differentiation between suffocation and sudden infant death syndrome in death certificate reporting." The authors go on to state, "[o]ur data indicate more than 1100 preventable infant deaths [due to unintentional suffocation] occurred in 2015 [in the US], a statistic that warrants attention and action.”
Questions for Further Discussion
1. How are safe sleep guidelines different for preterm infants?
2. What are the recommendations for emergency use of other types of sleep devices?
3. What are the recommendations for safe sleep environments in the hospital setting?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Sudden Infant Death Syndrome and Infant and Newborn Care.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Infant Mortality Due to Unintentional Suffocation Among Infants Younger Than 1 Year in the United States, 1999-2015 – Google Search. Accessed September 15, 2023. https://www.google.com/search?q=Infant+Mortality+Due+to+Unintentional+Suffocation+Among+Infants+Younger+Than+1+Year+in+the+United+States%2C+1999-2015&oq=Infant+Mortality+Due+to+Unintentional+Suffocation+Among+Infants+Younger+Than+1+Year+in+the+United+States%2C+1999-2015&aqs=chrome..69i57.307j0j7&sourceid=chrome&ie=UTF-8
Collins-Praino LE, Byard RW. Infants who die in shared sleeping situations differ from those who die while sleeping alone. Acta Paediatr Oslo Nor 1992. 2019;108(4):611-614. doi:10.1111/apa.14692
Drowos J, Fils A, Mejia de Grubb MC, et al. Accidental Infant Suffocation and Strangulation in Bed: Disparities and Opportunities. Matern Child Health J. 2019;23(12):1670-1678. doi:10.1007/s10995-019-02786-5
Moon RY, Carlin RF, Hand I, The Task Force On Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990
Safe Sleep. Accessed September 18, 2023. https://www.aap.org/en/patient-care/safe-sleep/
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa