Every year in the U.S., around 3,500 infants die from sudden unexpected infant death (SUID) which is a sleep-related death. SUID is the leading cause of death for babies up to one year of age in the country.
SUIDs include sudden and unexpected deaths where a cause can be identified (including accidental suffocation or strangulation in bed) and sudden infant death syndrome (SIDS) where a cause of death cannot be determined.
While sleep-related infant deaths rates declined in the 1990s from “Back to Sleep” campaigns, they have remained stagnant since 2000. This has prompted urgent wake-up calls by pediatric doctors and updated recommendations for safe sleep from the American Academy of Pediatrics. In comparison, childhood deaths from car crashes have reduced dramatically over the decades.
Pam Hoogerwerf directs the injury prevention program at UI Stead Family Children’s Hospital, a Cribs for Kids Gold Certified hospital and one of nearly 50 Injury-Free Coalition for Kids sites in the U.S.
“We do outreach around our community and state educating families about the importance of safe sleep,” she said. “Place your baby on their back for all sleep times. Use a firm sleep surface in a safety-approved crib. Keep soft bedding such as blankets, pillows, bumper pads, and soft toys out of the sleep area. Have your baby share your room, not your bed.”
SIDS is a diagnosis of exclusion, when the cause of death remains unknown after careful scene investigation, medical tests, and an autopsy. Most SIDS deaths (90%) occur between birth and six months of age, a critical developmental period for babies.
Because the underlying cause of SIDS is unknown, it is not entirely preventable. However, there are known practices that put babies at risk of SIDS such as babies sleeping on their side or stomach, being around cigarette smoke, and overheating while sleeping (e.g., when the room is too warm, or when babies have too many clothes on).
In other cases of sudden unexpected infant death (SUID), determining a cause of death is possible with careful scene investigation, medical tests, and autopsy. These causes include accidental strangulation, asphyxia, neglect, abuse, infection, and metabolic disease.
Accidental suffocation and strangulation of an infant in bed is caused, for example, by bedding and blankets with the sleeping child or instances of wedging or entrapment that can occur when a child sleeps on certain surfaces or with other people. These are known causes of SUID and are preventable.
University of Iowa Safe Sleep Study
A University of Iowa study surveyed over 800 pregnant women at 28 weeks of pregnancy and asked about their knowledge, attitudes and planned infant sleep practices (e.g., location for sleep, sleep space, and sleep position). The women were given safe sleep information and surveyed again during their postnatal doctor visits after they had their babies about their knowledge, attitudes and actual infant sleep practices.
The study was led by Dr. Charles Jennissen, a pediatric emergency medicine physician in the University of Iowa Department of Emergency Medicine and the Stead Family Department of Pediatrics. In Iowa, there are around 40 sleep-related infant deaths a year (2014 Iowa Child Death Review Team report).
“The number of infants less than one year of age who die of SUID in the United States is equal to the number of all children and teens less than 20 years of age who die of motor vehicle crashes,” said Jennissen. “It is important that we work together to inform families how they can decrease their risk of losing an infant and put significant resources into studying the causes of these infant deaths.”
The UI study found an association of lower incomes and planned unsafe infant sleep practices such as putting babies to sleep on their stomachs or sides. More women making less than $10,000 a year agreed that sleeping on the stomach was safe or were unsure (23%) or sleeping on the side was safe or were unsure (45%) than those of higher incomes of $>75,000 a year (6% stomach, 14% side).
Around 12% of all pregnant women said they planned to or were not sure if they would use a crib bumper and 14% said they planned to have their babies sleep with a blanket or were not sure. However, higher proportions of younger women and those with lower incomes planned to do these unsafe infant sleep practices or were not sure what they were going to do regarding these practices (<$10,000 income: 45% crib bumper and 53 % blanket; 18-24 years of age: 39% crib bumper and 27% blanket).
Feeding breast milk to infants reduces their risk for SIDS. The study found that pregnant women who were younger (18-24 years), making less than $50,000 and/or on Medicare/Medicaid insurance were more likely to disagree or were not sure that feeding a baby breast milk reduces the risk of SIDS.
Sleeping in the same room with your baby (but in separate sleep spaces) is a safe infant sleep practice. Most pregnant women in the study (88%) reported that they planned to sleep in the same room with their babies. However, of those who planned to have their babies sleep in the same room, 16% were putting their babies to sleep in a different room. Those with higher incomes (greater than $75,000 a year) had an even greater percentage (21%) following this unsafe sleep practice.
Of the 92% who planned to put their babies to sleep on their backs, 10% were not doing so after they had their babies.
After the pregnant women were given safe sleep information and had their babies, more of them reported doing safe infant sleep practices like giving their babies a pacifier and having their babies sleep alone and without crib bumpers and blankets. However, less women reported breastfeeding their babies (75% compared to 86% who planned to breastfeed before their babies were born).
The ABCs of safe sleep are A (Alone in crib), B (Back to sleep) and C (Crib empty of all objects). Practicing safe sleep can be hard (e.g., babies crying in their cribs/bassinets or challenges with breastfeeding) and struggles for parents/ obstacles to overcome are not uncommon. However, following the ABCs of safe sleep may save your infant’s life.
To lower the risk of SIDS and other sleep-related deaths (from UI Stead Family Children’s Hospital):
- Always lay your baby on their back for sleep, at naps and at night.
- Baby should sleep in a safety-approved crib, bassinet, or pack-n-play covered with a fitted sheet.
- Do not place any soft objects, including pillows, blankets or bumper pads, in baby’s sleep area.
- Dress your baby in a sleeper or sleep sack for comfort and warmth during sleep.
- Weighted blankets, sleepers or swaddles should never be placed on or near sleeping infants.
- Infants should never be placed for sleep on a couch, sofa, armchair or similar cushioned surfaces.
- Keep baby’s crib in your bedroom, close to your bed ideally for the first 6 months after birth.
- Don’t smoke cigarettes or marijuana during pregnancy or after birth. Don’t allow anyone else to smoke around your baby.
- Feed your baby breast milk for at least the first 2 months and longer if you so desire.
- Give your baby a pacifier for naps and at bedtime.
- Do not let your baby get too hot during sleep.
- Your baby should receive routine vaccinations and regular health checkups.
- Tummy time is important, but only when baby is awake and you are watching closely.
Hoogerwerf said parents should avoid using commercial devices or unsafe products with their babies like in-bed co-sleepers, weighted swaddles, wedges, and positioners. In addition, babies shouldn’t sleep in a car seat outside of a moving car.
“Sleeping in an inclined seat, like a car seat or swing, can cause a baby’s head to fall forward and obstruct their airway,” she said.
The Safety Store at the UI Stead Family Children’s Hospital sells infant safe sleep products such as sleep sacks and portable play yards (pack-n-plays). Hoogerwerf said the hospital’s injury prevention program is constantly doing training for staff to keep them updated on the most current safe sleep guidelines.
“We model safe sleep in all inpatient units where babies one year and under are receiving care. We provide pack-n-plays to families of our newborns that do not have a safe sleep environment at their home,” she said.
Published October 9, 2023
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