Unsafe Bedding Widely Used, Increasing Risk of Sudden Infant Death

Health Letter, February 2015

By Michael Carome, M.D.

baby on bed
Image: SvetlanaFedoseyeva/Shutterstock.com

For parents, the death of a child is a devastating tragedy. It can be particularly shocking when a healthy infant dies while sleeping in what is presumed to be the safe environment of a crib.

A recent federal study published in the journal Pediatrics revealed that parents in the U.S. commonly put their infants to bed with soft bedding, even though doing so is a known risk factor for sudden infant death syndrome (SIDS) and unintentional sleep-related suffocation. This disturbing finding signals the need for more aggressive and more effective education to teach parents how to keep their infants safe while sleeping.

SIDS: Who’s at risk?

SIDS is the leading cause of death for infants age one month and older.[1] In 2010, more than 2,000 infants in the U.S. died from SIDS, which translates into 53 deaths out of every 100,000 live births.[2],[3]

The American Academy of Pediatrics (AAP) defines SIDS as the “sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.”[4] Consistent with this definition, the exact cause of the syndrome is unknown, but it is likely due to a variety of factors.

SIDS rarely occurs during the first month of life and peaks in incidence from two to four months of age.[5] Major risk factors for SIDS include sleeping in the prone position (sleeping on the stomach), sleeping on soft surfaces, maternal smoking during pregnancy, overheating, late or no prenatal care, young age of the mother, prematurity or low birth weight, and male sex.[6] African-Americans and Native Americans are at greater risk of SIDS than whites and Hispanics.[7]

A series of studies from the U.S., Europe, New Zealand and Australia published over the past two decades have consistently found that soft bedding placed under and around a sleeping infant increases the risk of SIDS threefold to sevenfold.[8] Examples of soft bedding dangerous for infants include pillows, thick blankets, quilts, comforters, sheepskins and porous mattresses.[9]

Concerns also have been raised about soft or loose bedding contributing to unintentional sleep-related suffocation of infants. The incidence of such deaths increased twofold in the U.S. from 2000 to 2010, reaching 16 deaths per 100,000 births.[10]

In 1992, in an effort to prevent SIDS, the AAP formally recommended that healthy infants be placed for sleep on their backs or sides, rather than in the prone position.[11] The AAP updated its recommendation in 1996 and indicated that placing infants wholly on their back confers the lowest risk and is the preferred sleep position, although placement on the side also significantly lowers the risk.[12] The AAP also recommended in 1996, and again in 2000 with greater detail, that soft surfaces and objects, such as pillows or quilts, be absent from an infant’s sleeping environment.[13]

The Pediatrics study [14]

The new study in Pediatrics, published online on Dec. 1, 2014, assessed for the first time how often parents and other caregivers adhere to the AAP’s recommendation regarding avoidance of soft bedding for sleeping infants. The news overall was not good.

The National Institutes of Health (NIH) funded the study, which was conducted by researchers from the Centers for Disease Control and Prevention (CDC), Yale School of Medicine, Boston University and NIH. The researchers analyzed data from the National Infant Sleep Position (NISP) study regarding infant bedding use from 1993 to 2010.

Data for the NISP study were gathered through an annual national telephone survey of a random sample of more than 1,000 nighttime caregivers of infants who were less than 8 months old. Eighty percent of those surveyed were mothers of the infants. The interviewers asked questions about infant sleeping practices, including sleeping position, location for sleep (for example, crib or adult bed) and use of soft or loose bedding under or covering the infant. Demographic information about the infants and caregivers also was collected. A total of approximately 19,000 infant caregivers completed the survey from 1993 to 2010.

The researchers found that over the course of the study, the reported use of dangerous soft bedding for sleeping infants decreased significantly but remained unacceptably high at the end of the study period: The average rate of use was 86 percent for 1993 to 1995 and 55 percent for 2008 to 2010.

Notably, most of the decline in use of soft bedding occurred from 1993 to 2000, with little change since then. Also, the observed declines were limited to the use of soft bedding to cover infants, with no significant decline in the use of soft bedding placed underneath infants. From 2008 to 2010, half of the caregivers of white babies reported use of soft infant bedding, whereas about two-thirds of caregivers of Hispanic and black babies reported such use.

The investigators also identified the most frequently used types of hazardous soft bedding. Over the course of the study, thick blankets and quilts or comforters were the most frequently reported types of hazardous soft bedding used to cover infants (38 and 20 percent, respectively). Thick blankets and cushions were the most frequently reported types of soft bedding placed under infants (29 and 4 percent, respectively).

A key question is why so many parents, despite warnings, continue to place their infants to sleep with soft bedding. According to the authors of a commentary accompanying the Pediatrics study, the “major reasons for using soft bedding are comfort/warmth and safety. Many parents worry that their infant will become cold or otherwise be uncomfortable if they do not use bedding. … They worry that the [sleeping] surface is too hard and thus uncomfortable, so will use cushions and blankets to soften the surface.”[15]

Speaking to The New York Times, Dr. Carrie Shapiro-Mendoza — the lead author of the Pediatrics study and a senior scientist in the CDC’s Division of Reproductive Health — said, “Parents get a lot of mixed messages. A relative will give them a quilt or fluffy blanket that they may feel obligated to use, or they look at magazines and see a baby sleeping with a pillow.”[16]

The takeaway message from these study results is clear: Health care providers and public health agencies need to redouble their efforts to educate parents and other caregivers not to use any soft bedding when putting infants to sleep.

Keeping your sleeping infant safe

When caring for your baby at sleep time, you should always adhere to the following guidelines to minimize the risks of SIDS and unintentional suffocation:[17]

  • The safest place for an infant to sleep is in a crib or bassinet. Any crib should conform to the safety standards of the Consumer Product Safety Commission.
  • The sleeping surface for the baby should be firm and covered with a tautly fitted sheet and no other bedding.
  • Never put an infant to sleep on an adult bed, water bed, soft mattress, sofa or other soft surface.
  • Place your infant wholly on his or her back.
  • Never put soft materials in an infant’s sleeping environment. These include pillows, quilts, comforters, sheepskins, thick blankets and stuffed toys.
  • Avoid bed sharing with adults and siblings.
  • Avoid overheating the infant by using light clothing and avoiding overbundling. The bedroom temperature should be comfortable for a lightly clothed adult.

References

[1] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

[2] Safe to Sleep. Fast facts about SIDS. http://www.nichd.nih.gov/sts/about/SIDS/Pages/fastfacts.aspx. Accessed December 12, 2014.

[3] Shapiro-Mendoza CK, Colson ER, Willinger M, et al. Trends in infant bedding use: National Infant Sleep Position Study, 1993-2010. Pediatrics. Published online December 1, 2014. DOI: 10.1542/peds.2014-1793.

[4] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

[5] Ibid.

[6] Ibid.

[7] Ibid.

[8] Moon RY, Hauck FR. Hazardous bedding in infants’ sleep environment is still common and a cause for concern. Pediatrics. Published online December 1, 2014. DOI: 10.1542/peds.2014-3218.

[9] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

[10] Shapiro-Mendoza CK, Colson ER, Willinger M, et al. Trends in infant bedding use: National Infant Sleep Position Study, 1993-2010. Pediatrics. Published online December 1, 2014. DOI: 10.1542/peds.2014-1793.

[11] American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89(6):1120-1126.

[12] American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): Update. Pediatrics. 1996;98(6):1216-1218.

[13] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

[14] Shapiro-Mendoza CK, Colson ER, Willinger M, et al. Trends in infant bedding use: National Infant Sleep Position Study, 1993-2010. Pediatrics. Published online December 1, 2014. DOI: 10.1542/peds.2014-1793.

[15] Moon RY, Hauck FR. Hazardous bedding in infants’ sleep environment is still common and a cause for concern. Pediatrics. Published online December 1, 2014. DOI: 10.1542/peds.2014-3218.

[16] Saint Louis C. Federal study finds 55 percent of infants sleep with soft bedding, raising risk of death. December 1, 2014. The New York Times. http://www.nyti.ms/1CwMiKC. Accessed December 13, 2014.

[17] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

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