Cook Children’s Medical Center has seen 30 infant deaths linked to unsafe sleep situations since January 2022, more than the number of fatal gunshot wounds and drownings combined.

That’s why safety advocates at Cook Children’s are sharing the risks that pillows, loose garments, blankets and other objects can pose in an infant’s sleeping environment.

The majority of unsafe sleep deaths in 2022 and so far in 2023 involved co-sleeping with at least one parent or caregiver, who awoke to find the child unresponsive. Trauma records at Cook Children’s list a variety of other circumstances too, including babies placed on a pillow with a propped bottle, in the crib with a blanket or pillow, in a recliner or on the couch next to a sleeping adult, or wearing a loose T-shirt that covered their face. By the time these infants arrived at the medical center, they were in cardiac arrest or respiratory failure.

Sharon Evans, trauma injury prevention coordinator, said the number of unsafe sleep deaths in the past 15 months is at the highest peak since she started in her role at Cook Children’s in 2008. Demographic data shows the group with the highest unsafe sleep deaths were Black boys from 2 months to 6 months old.

Infant deaths linked to unsafe sleep from 2022-2023

Candle Johnson, APRN, CPNP-PC at Cook Children’s Renaissance Neighborhood Clinic in south Fort Worth often talks about Safe Sleep with her patient families. As a Black nurse and Certified Pediatric Nurse Practitioner, it’s important to her that all patient families, including Black families, receive education and know that she is passionate about keeping their baby safe.

“Unless it hits home, it doesn’t really resonate. We want them to understand this is a very preventable situation,” Johnson said. “Let’s be proactive today, so we don’t have to be reactive tomorrow. If a fatality happens, then how do we go forward when we could have prevented it from the beginning?”

Sometimes patient families share with Johnson that co-sleeping is a generational habit and give her pushback. While those conversations can be tough, Johnson knows it’s important to break through those misconceptions. She shares why it’s important that the baby sleeps separately on a flat surface, like a crib or bassinet.

“It seems to be so much easier to co-sleep when breastfeeding,” Johnson said. “I do advise against that because even though it may be easier, it’s not safe. No one can control their body function once they’re sleeping. When you’re in a deep sleep and your infant is next to you, you’re not able to say ‘I won’t roll over on them.’”

An infant can get wedged between the headboard and mattress, suffocate under blankets, or come under the adult’s body if they’re sleeping together, Johnson said.

She discussed barriers that could increase the risk of an infant being fatally injured from unsafe sleep situations. Those challenges might include a lack of education about safe sleep, distrust of medical advice, young maternal age, and inability to afford a separate crib or bassinet, Johnson said. In a crowded one-bedroom residence, she said, everyone in the household might sleep in one bed due to space constraints.

Data from Cook Children’s on unsafe sleep deaths in 2022-2023 show that the infants were in sleeping positions or circumstances that contributed to their deaths, not to be misidentified as SUID, sudden unexpected infant death. SUID describes the sudden and unexpected death of a baby in which the cause was not obvious; SUID cases are not all preventable. 

According to the U.S. Centers for Disease Control and Prevention (CDC), about 3,500 sleep-related infant deaths occur each year in the United States.

When it comes to sleep risks, the message is just as critical as the safety rules for other potential hazards such as swimming pools and riding in a vehicle. Parents know to buckle their children into lifejackets and car seats. Safe sleep also involves precautions:

• Always place your baby on their back to sleep. Side and stomach sleeping are not safe for infants who can't roll over.
• Use a firm, flat mattress or sleeping surface with tightly-fitted sheets. The surface shouldn’t be sloped.
• Share a room but not a bed with your baby. Babies should sleep in their own cribs or bassinet.
• Clear your baby’s sleep area of blankets, pillows, bumper pads and soft toys.
• Sleep sacks are recommended instead of swaddling, especially after your baby is able to roll over. 

Parents want to do their best, but they’re often exhausted by midnight feedings and other aspects of caring for an infant, Evans pointed out. They might decide impulsively to lie down beside their sleeping baby in an adult bed for just a few minutes, leading to a tragic outcome.

“Nobody intentionally does it,” she said. “I don’t think any of the parents who are co-sleeping feel like there’s any danger.”

Evans encourages parents and caregivers to consistently follow the evidence-based guidelines for safe sleep. Even if the baby’s fussy. Even if co-sleeping makes it easier to breastfeed. Even if you grew up co-sleeping as the family norm, put the baby in a crib or bassinet every night and for every nap.

Daniel Guzman, M.D. treats patients in the Cook Children’s Emergency Department (ED). It’s particularly heartbreaking to see infants needing emergency care for injuries that happened while they slept, he said. “You always hear ‘I never thought it was going to happen to me.’ The amount of pain that you see these families go through is just horrific. It hurts me every single time.”  

Dr. Guzman, who is a father of three, empathizes with moms and dads who are worn out by the demands of parenting an infant. He starts conversations whenever he hears parents in the ED report they sleep in the same bed as their baby. “I’m quick to say, ‘Let’s talk about this. What can we do to make you guys safer?’”

The Safe Baby Sleep Council, led by Cook Children’s helps provide sleep sacks and pack-and-plays to families. Reducing the number of unsafe sleep deaths will require greater public awareness plus resources, Dr. Guzman said.

“Cook Children’s is here to make that difference and provide not only the education and the information, but the tools that make us safer,” he said. “If we get one person to hear the message and have a shift in their mindset, we’ve already done our job. But we want to do more and we’re going to continue to do more.” 

Anu Partap, M.D., M.P.H., Physician Director of Health Equity at Cook Children's, said many dynamics factor into sleep-associated infant deaths, including financial hardship and housing arrangements. Input from community leaders is key, Dr. Partap said.

“We need to engage the communities who are losing their babies at higher rates and work with them to figure out what we can do to stop loss of life. Communities who are affected are our partners in protecting their children,” she said. “Learn from them and share with them what we know. We have to work together to solve this and we can.”

The last few weeks have been hard, to say the least. Although the new year brought hope that we would begin to look to a “return to normal” after one year of the COVID-19 pandemic, things haven’t felt so positive. It is only natural to yearn for what once was - allowing my kids to participate in group sports without the worries. To do in-person learning without the fear that we will receive an email indicating our child was exposed to the virus, and to go on a dinner date with my husband (to make up for the canceled date from last year as the lockdown and worries began).

In the last few weeks, losing my own grandmother to COVID-19 reminded me of all the families that have experienced a loss of a loved one in the last year. Although this happens routinely as part of the cycle of human life, I am reminded that there has been “extra” loss of life, and likely many more families impacted by loss than would have occurred otherwise.

The loss of a loved one is experienced at different stages for most. A difficult part of this process sometimes goes unnoticed but is worth highlighting. Being a parent and responsible with the difficult task of explaining death to a child in a way that is developmentally appropriate is not easy.

The best way to approach this situation is to be aware of how children understand death and this will help you pick the right thing to say. It’s important to remember that even young children who don't understand death will react to grieving parents. Older children will themselves grieve. Parents should support their children through this process in order to resume their lives without significant distress or interruption.

Children have a different understanding of the finality of death. Your approach to discussing death will depend on your child's level of understanding of four main concepts of death:

• Irreversibility (i.e., death is permanent)
• Finality (i.e., all functioning stops with death)
• Inevitability (i.e., death is universal for all living things)
• Causality (i.e., causes of death)

Babies and Toddlers

Infants and toddlers do not understand death but do sense what a caregiver may be experiencing. It is important to take care of yourself and progress through your own grief while maintaining routines that will help foster healthy progress through the life event.

Preschoolers

Preschoolers see death as temporary. They are concrete thinkers and usually see things for what they appear and hearing things literally. It is important to avoid euphemisms like, "She has gone to sleep," or "…traveled to the great beyond." Children at this age cannot understand these phrases and can sometimes even generate fears about traveling or sleeping. Be prepared for this age child to ask again and again where the deceased is and or when they will come back. Always answer with a clear message, which of course can be softened with the mention that the memories will remain. At this stage, children typically have a hard time talking about what they feel and their fears may come out at unexpected times such as during play.

School Age

School-age children begin to understand death as a final event but can have difficulties understanding it is universal. Make sure to offer clear, simple, and honest explanations about what happened and allow them to ask questions. Help them when they have difficulties finding the right words to explain their feelings. At this age, they may not understand the causality of death and they may personify death. Sometimes at this age, they may worry they will be left alone and begin to think about the death of a significant caretaker. Things that are important to do at this point include:

• Remind your child that not everyone who gets sick will die.
• Reassure them of your health.
• Let them know how many people in their life care for them.
• Support children to do things to reduce their anxiety and be sensitive that they may not want to talk or think about the deceased because it is too painful.
• Take care of yourself and make sure you have support.

Adolescents

Adolescents understand death the way adults do but can have difficulties or be resistant to expressing their feelings. They begin to think abstractly and this can cause some difficulties which can lead to risky behavior or even guilt about being alive. Supporting teenagers in finding healthy ways to express their feelings is very important.

Being aware of normal responses to death, as well as signs that they may need professional help, is an important part of supporting the grieving child. Younger children can revert to immature behaviors or angry outbursts. These typically are a result of unexpressed emotions such as frustrations or confusion. In school-age children, difficulties concentrating, sleeping, or physical complaints including stomachaches and headaches can occur. Teens often experience a wide range of emotions including sadness, anger, guilt, and helplessness. Teens may either withdraw or do the opposite, and engage in risky behavior.

This time is difficult for the entire family and it is important to take the time for yourself to deal with the grief. Kids of any age can sense the emotions of a caretaker and respond accordingly. If you ever have a concern that the child is experiencing extreme symptoms and/or the symptoms of grief are not resolving, ask your child’s pediatrician for help.