• Article
  • July 30, 2018

Unsafe Infant Sleep Practices and SIDS Deaths Still Happen in the U.S.

Thousands of babies still die each year in the U.S. from Sudden Infant Death Syndrome. A safe sleep environment, inside and outside the hospital, can prevent these deaths.

By Megan McDonnell Busenbark

Spring 2018 cover

On the night of July 2, 2017, Jordan put her 7-month-old son, Sloan, in his crib with a blanket his great-great grandmother had made and another blanket he'd had since birth. Overnight, Sloan pulled one of the blankets through his crib rails and got stuck in it. The next morning, his mother found him dead in his crib.

Three-week-old Charlie was struggling to sleep one night. Since his mother was breastfeeding, his father offered to hold him so his wife could get some rest. The new father settled into the couch to watch television and fell asleep with Charlie on his chest. When he woke up, Charlie was dead.

Last year, Crystal, a mother in Bronx, N.Y., awoke to find her 3-month-old unconscious in her apartment. Her infant was the third baby in the New York City area to die that week from suffocation while sleeping in bed with a family member.

These are all real-life examples of babies from across the country who died as a result of unsafe sleep environments.

According to the U.S. Centers for Disease Control and Prevention (CDC), unsafe sleep practices contribute to about 3,500 sleep-related deaths of U.S. babies every year. And the U.S. has one of the highest infant mortality rates in the developed world.

Though these are sobering statistics, hospitals across the country are chipping away at these numbers through programs, policies and education for staff members and families. "This is a winnable battle because this is a problem we have solutions for," says Mary Aitken, M.D., M.P.H., pediatrician and director of the Injury Prevention Center at Arkansas Children's Hospital in Little Rock.

The evolution of an age-old problem

For decades, babies have died in their sleep—deaths that have long been attributed to Sudden Infant Death Syndrome (SIDS). SIDS is defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation, including a complete autopsy, examination of the death scene and review of the clinical history.

Helping hospitals serve as a safe sleep model

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Sleep-related infant deaths declined in the 1990s on the heels of the national "Back to Sleep" campaign launched by the American Academy of Pediatrics (AAP) and multiple partners. But the decline has slowed since, and new data show many parents still engage in unsafe behaviors associated with sleep-related infant deaths.

"Parents put their babies down in cribs with stuffed animals, and the animal falls on the baby's face and suffocates them," says Jamie Macklin, M.D., FAAP, FHM, internal medicine/pediatric hospitalist at Nationwide Children's Hospital in Columbus, Ohio. Or they co-slept or co-bedded with the baby, and the baby suffocated, was asphyxiated or fell out of the bed and got trapped between the dresser and the wall. "We've been realizing it's not unexplained SIDS," Macklin says. "It's suffocation and asphyxia—entrapment and strangulation—and all the other things we're seeing. And these are more prevalent now than the other SIDS deaths."

Why the unsafe behavior?

Parents face a myriad of challenges when caring for a newborn—timeless reasons, like the exhausted mothers heading back to work after having the baby and trying to breastfeed throughout the night while also getting sleep herself. In fact, breastfeeding has often been a driving force behind co-sleeping because mothers want to be readily available to breastfeed whenever their babies are hungry.

But they can do that while still creating a safe sleep environment for the baby just an arm's length away, according to Sessions Cole, M.D., neonatologist and chief medical officer at St. Louis Children's Hospital. "There are a variety of options where the baby is in his or her own safe sleep environment immediately adjacent to or attached to the mom's bed," Cole says.

Another common challenge, other than simply not knowing the current safe sleep recommendations, often comes from previous generations—parents and grandparents who put their children to sleep on their stomachs decades before studies indicated and experts realized the consequence.

Aitken says respectful communication with families is key when educating parents and their parents. She recommends presenting the changes in safe sleep recommendations as a progressive, positive move to promote the desired mindset shift. "Just like we didn't have vaccines for some diseases when grandma was born, now we're immunizing babies and protecting them in that way," says Aitken. "People didn't have car seats years ago either. So there have been a lot of changes."

getting started

Children's hospitals as the role model

Knowing families tend to model behavior once they go home, every hospital has the opportunity help families create safe sleep environments for their babies by modeling safe sleep behaviors in the hospital setting. "Families follow the nursing and physician staff recommendations, so if you're not practicing safe sleep while they are in the hospital, families will assume that's okay when they go home," says Merielle Bird, MBA, M.S.N., FNP-BC, a nurse practitioner who specializes in sleep disorders at St. Louis Children's Hospital.

Still, recent research shows only 25 percent of hospitalized infants are found in appropriate safe sleep environments. And internal audits at Nationwide Children's Hospital and St. Louis Children's Hospital revealed it was time for a change.

Nationwide Children's Hospital conducted baseline audits in 2012 and found the organization was only 2 percent compliant with current safe sleep recommendations. "That caused us to change," Macklin says.

St. Louis Children's Hospital observed 119 babies in spring 2017. Of those 119 babies, 7 percent were in a safe sleep environment. The majority of the other babies had loose blankets in the crib. "If the baby is only wearing a gown or a T-shirt, then the family or staff member might perceive they are cold," says Bird.

But practicing safe sleep behaviors comes with its fair share of challenges. Bird says a lack of materials often leads to unsafe sleeping environments at her institution. So she is working on creating a coverall—a one-piece pajama. Babies would wear it 24/7, potentially under a HALO SleepSack wearable blanket to eliminate the need for loose blankets.

In addition to loose blankets, Macklin's audit at Nationwide Children's turned up stuffed animals, diapers and wipes in the crib because it was a convenient place to keep them. After doing a deep dive with the nursing staff, the team realized it needed to come up with new spaces to put these items. New shelving or containers helped change the environment and corrected the organization's sleep practices.

Today, the hospital's current safe sleep compliance rate is 81 percent. Macklin says it will be impossible to get to 100 percent since many older infants are able to roll onto their stomachs and sides. "I encourage hospitals to take a look and see what's going on around them," Macklin says. "At Nationwide, we didn't realize how we were doing until we looked. Sometimes, it's hard to know there is a problem until you really see what's happening on the front lines."

Serving as that role model for parents and families is critical, Macklin says, because families watch what frontline teams do. There's a need to model appropriately. That's a concept St. Louis Children's Hospital takes to heart, too. Each NICU baby is issued a HALO SleepSack swaddle to be used while the infant is in the hospital. This approach is designed to reinforce the nursing staff's knowledge of safe sleep practices while allowing parents and families to observe these practices in the hospital. Research has shown that the observations parents make in the NICU have a significant effect on how they care for their baby once they get home.

getting started

The education component

Aitken began her career just as the AAP's new safe sleep recommendations were coming out in the early 1990s. Today, she and her team at the Injury Prevention Center at Arkansas Children's Hospital are fighting hard against the high infant mortality rate in the state—about 8.2 deaths per 1,000 live births in 2016. That's substantially higher than the U.S. rate of 5.8 deaths per 1,000 live births in the same year.

The hospital is coming at safe sleep education from nearly every angle. Working in lockstep with the Arkansas Department of Health and other partners in the state, the groups have developed an aggressive plan to reduce those rates.

They identified 40 community hospitals that deliver babies across the state and educated providers on safe sleep environments, helping them develop policies and educational tools. As a result, 78 percent of these hospitals are now certified by the Cribs for Kids National Safe Sleep Hospital certification program (Arkansas Children's is also a Cribs for Kids certified hospital). The team at Arkansas Children's also educated day care centers in the state. "So many babies spend as much time at day care as they do with their parents," Aitken says. "It's critical these audiences are educated on safe sleep practices."

Partnerships within the community are also important. Arkansas Children's joined forces with community groups to provide Safety Baby Showers for expectant mothers and their family members. Mothers who attend the showers receive safe sleep education and safety products as shower gifts.

The team conducted 10 focus groups with 46 male caregivers of infants ages 2 months to 1 year to discuss infant sleep routines, parental roles, sources for safe sleep information and messaging suggestions for safe sleep promotion. Aitken and her team identified a need for messaging for male caregivers that includes information and statistics and a little less bias.

"So much of the education goes toward the women when the dads are taking responsibility too," Aitken says. "And the theme from these focus groups is these dads want to be part of the picture. They say, ‘We're not just showing up when the baby is ready to throw a ball. We're taking care of these babies, we need this information, and we need it to be directed at us recognizing the important role we have.'"

Educate early, educate often

Cole and the team at St. Louis Children's Hospital have built a robust educational platform as well. They are building a new video series to educate staff members and families. Educational cards will attach to each crib and bassinet in the hospital, showing visuals of babies in safe sleep environments with safe sleep tips for parents.

The team holds what it calls Safety Stop appointments for families in the hospital or in the community, where they receive education about safe sleep as well as car, helmet and home safety—and can access sleep products like bassinets and wearable blankets. Cole and the team recently started reaching out to obstetrical offices and clinics to get the education started very early on with expectant mothers and their families.

"Providing parents and grandparents with information in the third trimester helps them prepare the home environment, helps them understand what a safe sleep environment looks like and increases the effectiveness of postpartum education," he says. "There's a different atmosphere in the prenatal period when you can have a productive dialogue about safe sleep practices that will complement the education families receive once the baby comes."

Advances in safe sleep

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Use community resources

Rishelle Eithun, M.P.H., knows the power of a community coming together to champion a cause. In her role as safety and injury prevention coordinator at American Family Children's Hospital in Madison, Wisconsin, she and her team have worked with everyone from the public health department and the medical examiner's office to faith-based groups, community hospitals and law enforcement agencies on safe sleep training and education.

In one instance, Eithum and her team developed a consistent, county-wide safe sleep message that would resonate with families in to help decrease infant deaths. "We did focus groups with families to ask them how their perceptions and beliefs about infant sleep lead to their current safe sleep practices," she says. "They knew what the message was. They knew what the best practice was. They knew what they should be doing. But they weren't actually doing it."

Another key takeaway: families didn't connect with the current safe sleep educational literature and visuals out there. In one case of a picture showing a baby safely in a crib, some parents said it looked as though that baby was in a jail-like environment. So the team created new marketing billboards with pictures of local families to enhance engagement and to fuel ongoing conversations in the community about the billboards and safe sleep practices.

As part of the outreach program at American Family Children's Hospital, Eithun and her team provide education, Pack ‘n Plays and bassinets every year to families who need them to ensure a safe sleep environment in the home.

Doing it all for the babies…and their families

The reason Aitken has focused her work on injury prevention is because of the effect it has on families—especially when those families suffer that unimaginable, tragic loss.

"I remember working in the emergency room during one of the last months of my residency," Aitken recalls. "Three mornings in a row, we had a SIDS baby come in. These are the stories you take with you and think about and you never want to see happen again."

Megan McDonnell Busenbark is a writer and founder and principal of Encore Communications, LLC, in New Fairfield, Connecticut.

Send questions or comments to magazine@childrenshospitals.org.