by Bethany Mohr, M.D, University of Michigan, Child Protection Team

A couple in their thirties just moved into a new house with their 6 week-old daughter. The couple was waiting for the movers to deliver their belongings the next morning; including the baby’s crib. The baby’s father went out and bought an inflatable air bed. The couple filled the air bed using the included air pump until the bed was firm. The baby was laid down on the mattress on her back covered with a thin blanket. Mom went to check on the baby after doing some cleaning and found the baby enveloped in the deflated bed. EMS was called but was unable to resuscitate the baby.

In July of this year, over a 2-day period, 5 Michigan infants from Wayne County died while sleeping unsafely. These tragic deaths could have been prevented with safe sleeping practices; however, safe sleeping practices are often undermined by family traditions and poverty. Also, these deaths could have been potentially and mistakenly classified as SIDS.The infant mortality rate in Michigan has continued to fall along with the incidence of Sudden Infant Death Syndrome. However, SIDS is still responsible for more infant deaths in the United States than any other cause of death during infancy beyond the neonatal period. In order to classify a baby’s death as SIDS, the following criteria must be met:

• 1. Sudden death of an infant under 1 year of age
• 2. Death remains unexplained after a thorough case investigation, performance of a complete autopsy, examination of the death scene, and review of the clinical history.

In spite of these criteria, infant deaths may be misclassified as SIDS depending on how “thorough” the case investigation is and how closely the death scene is examined. Case investigations and death scene examinations may lead to a different determination of cause of death depending on who conducts these investigations and the standards utilized. All people potentially involved in such investigations should be knowledgeable about child death/injury interview and documentation guidelines (http://www.epicmedics.org/deathcardgood.doc ) and the use of a SUID Investigation Doll. Deaths mistakenly attributed to SIDS may lead to further infant deaths. For example, if no cause of death is identified, families may not receive the education and resources necessary to prevent further deaths due to unsafe sleeping practices or conditions. 
In order to clearly assess and document the number of infant deaths due to preventable causes, these deaths must be recorded into separate categories. For instance, in the State of Michigan, the total number of infant deaths is broken down by cause. However, no categories exist to clearly represent the number of infant deaths due to unsafe sleeping practices. Much debate exists regarding how to categorize these deaths when investigation reveals the presence of risk factors such as unsafe sleep position, location, bedding, or bed sharing; is the death due to SIDS, accidental suffocation, or should the manner and cause be classified as undetermined? In some cases, these deaths may be homicides when alcohol, drugs, or gross negligence is involved. Deaths due to neglect may also be classified as “natural” and caused by SIDS but, in actuality, are the result of neglect or intentional suffocation. In any case, deaths associated with unsafe sleeping practices cannot be simply considered and coded as “accidents.”
With regard to the term “SIDS”-SIDS is not truly a cause of death but the end result of a process which was not elucidated. The term “Sudden Unexpected Infant Death” has been proposed but is still wrought with the same drawbacks as the term “SIDS” if used alone. A lack of experience or time leading to an incomplete investigation may often lead to a diagnosis of SIDS.
The ultimate goal is prevention of these deaths. As a pediatrician who has worked in a busy university pediatric practice and newborn nurseries, I am constantly educating families about safe sleep. I am aware of many parents’ reluctance to not bed share with their babies. Although the recommendation is often to avoid bed sharing after consuming alcohol or prescription drugs which may decrease arousal or when extremely fatigued, selectively applying a public health warning is problematic (as previously stated by the Michigan FIMR Network). Bed sharing is an extremely controversial topic, especially with breastfeeding mothers and their babies. Strong cases have been made that bed sharing facilitates breastfeeding and enhances the maternal-infant bond. In spite of this, due to the potential tragic consequences of this sleeping arrangement, room sharing (infant sleeping in the parents’ room) is the best alternative. However, if a baby is brought into the parents’ bed for a feeding, the baby needs to be returned to their own sleeping environment to avoid the risks associated with bed sharing.
Parents must also be aware of potential risks even if a baby is in his/her own sleeping environment. A safe sleeping environment is deserved by every baby and education regarding an infant’s sleep environment must be offered to every parent, irrespective of their perceived level of experience in child-rearing and/or socioeconomic status. Babies are unsafe sleeping on soft surfaces such as some waterbeds, air mattresses, pillows, and comforters. All loose bedding is a risk as well as bumper pads, thick blankets, toys, and stuffed animals. If the environment is cold, babies should be dressed in a sleep sack, footed sleeper, or thin layers of clothing; babies should not be covered with heavy or multiple blankets. 
Safe sleeping conditions and practices must be maintained by secondary caregivers as well. Day care centers, in-home child care, relatives, and friends must all be familiar with safe sleep practices for infants and need to provide an appropriate sleep environment.
In addition, physicians and other medical providers need to “practice what we preach” and set examples for our patients and families. Day after day, bassinettes in hospital nurseries are cluttered with stuff animals and toys and the babies are tightly swaddled in, many times, more than one blanket. If we are teaching caregivers that an empty crib with a firm mattress covered with a tight fitting sheet and a thin blanket loosely laid over a baby is optimal, why are we reinforcing the opposite?
This month’s newsletter is dedicated to Safe Sleep Practices for Infants and the need for continued education, better investigations, and consistent and objective classifications of infant deaths by medical examiners in order to prevent these tragic and senseless deaths. The other articles in this issue provide further insight into this topic from the perspective of those dedicated to the safety of all infants.