PROVIDENCE -- A 911 dispatcher receives an early morning call from a frantic mother who discovered her 4-month-old daughter face down in the crib in her bedroom. She was twisted in a soft blanket and was pale and unresponsive. The dispatcher instructs her to feel for a pulse and when not present, guides her through initiating CPR.

EMS arrives to find a cold infant without a heart rate or pulse. The EMTs initiate resuscitation and transport the infant to the emergency department where the medical team is unable to revive her, despite continued resuscitative efforts.

The mother provides a history that her daughter was last seen well at the 2 a.m. feed, 5 hours before she was discovered unresponsive. She had had nasal congestion over the past few days from a mild respiratory illness. While she typically slept on her back, during this illness she seemed most comfortable sleeping on her side propped up by a blanket rolled behind her back.

Unfortunately, this story is not unique. According to the Centers for Disease Control and Prevention [CDC], there are approximately 3,500 sleep-related deaths among infants each year in the United States. In fact, the U.S. has one of the highest infant mortality rates in the developed world.

In response to this, the American Academy of Pediatrics [AAP] launched the “Back To Sleep” campaign in 1994. This resulted in a significant decline in sleep-related infant deaths.

However, in recent years, this progress has plateaued. In order to continue making gains, we must ask why infants are still dying in unsafe sleep environments. For a variety of reasons, many families find it difficult to follow the AAP’s guidelines.

Common challenges include parental exhaustion and stress, financial limitations, and/or space constraints. Convenience, concern about the infant’s comfort, and cultural traditions can also play important roles.
Furthermore, given how rare sleep-related deaths are, many parents think that their infant is immune – they may deviate from the AAP recommendations because they underestimate the risks.

Steps for prevention
The reality is, approximately 12 infants die each year in Rhode Island from sleep-related causes. It can happen to any child at any time. However, there are certain steps parents and caregivers can take to create safe sleep environments for their infants. They include:

• Always place the baby on their back to sleep, both at night and during all naps. If the baby is comfortable rolling both ways [back to tummy and tummy to back], then you do not have to return the baby to their back if they roll onto their stomach.

• Place the baby to sleep on a firm, flat surface [ex. on a mattress in a safety-approved crib that is covered by a fitted sheet]. A firm surface is defined as a hard surface that does not indent when the baby is lying on it.

• Room share. Keep the baby’s sleep area in the same room the parent/caregiver sleeps in. Do this for the first six months or, ideally, for the first year.

• Swaddling is fine. However, make sure that the baby is always placed on their back and that the swaddle is not too tight to make breathing or moving their hips difficult. When your baby looks like they are trying to roll over, you should stop swaddling.

• Try giving a pacifier at nap time and bedtime. Make sure the pacifier is not attached to anything, like a string. If breastfeeding, it is recommended that the pacifier is not introduced until breastfeeding has been well-established [about 3-4 weeks].

What not to do
Here are some suggestions about what to avoid:

• Do not use pillows, blankets, loose bedding, toys, soft objects, or bumper pads anywhere in the baby’s sleep area.

• Do not let the baby get too hot while sleeping. Infant sleep clothing, such as a wearable blanket, can be used to keep the baby warm. Do not dress the infant in greater than one layer more than an adult would wear to be comfortable in that environment.

• For families that choose to co-sleep, there are certain high-risk situations that make it unsafe. Co-sleeping is most dangerous when 1.) The baby is less than four months, 2.) The baby was born prematurely or born with a low birth weight, 3.) The sleep surface is soft, 4.) There is loose bedding, like pillows or blankets in the bed, 5.) The parent/caregiver smokes, 6.) The parent/caregiver has been drinking alcohol, or 7.) The parent/caregiver has taken certain medications or drugs that could make it harder for them to wake up. If a parent/caregiver falls asleep with the infant in their bed, it is recommended that the baby is returned to their own crib/bassinet immediately.

Questions for health care providers
If you are a health care provider, you must ask yourself, “Why are infants still dying in unsafe sleep environments?”

You must acknowledge the social, economic, psychological, and cultural barriers that influence parents’ decisions. You must discuss these with your patients and, if necessary, connect them to the appropriate resources.

If you are a parent or caregiver who finds it challenging to follow these guidelines, please speak to a pediatric health care provider. You can also request a free, confidential home visit to get additional assistance. [Visit the following website: https://health.ri.gov/family visiting.]

We also encourage parents/caregivers to share this information and discuss it with family and friends. Raising a child is hard, especially for those without financial and/or social support. Help is available. You are not alone.

Martha Ormanoski, is an MD, ScM candidate at the Alpert Medical School of Brown University. Dr. Susan J Duffy, MD, MPH, is Vice Chair, Academic Affairs Department of Emergency Medicine and Professor of Emergency Medicine and Pediatrics at the Alpert Medical School of Brown University.

For more information, please visit:
• https://health.ri.gov/for/newparents/about/safesleep/
• https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
• https://www.cdc.gov/vitalsigns/safesleep/index.html
• https://safetosleep.nichd.nih.gov