Why Babies Still Die in Their Sleep: Unsafe Infant Sleep
Let’s do an experiment: while sitting up in a chair, take in as deep of a breath as you can and let it out.
Now, tuck your chin into your chest and try to take another deep breath. It should feel restrictive and uncomfortable, like you can’t take in a full breath.
That positioning shows how babies breathe when sleeping in restrictive positions - their heads can fall forward, putting pressure on their necks and obstructing their straw sized airways. If left in that position, the baby can suffocate on their own body weight.
Most of us know the fundamentals of safe sleep – babies on their back in a crib with a firm mattress and no toys, blankets, pillows, or other items. Families have been hearing about the ABCs of safe sleep since the 1990s. The Back to Sleep campaign, now called the Safe to Sleep campaign, began in 1994 under a partnership between the American Academy of Pediatrics and the U.S. National Institute of Child Health and Human Development.
Despite robust public messaging on safe sleep for over 30 years, we have continued to see deaths linked to unsafe sleep. Even knowing the importance of safe sleep, sometimes the realities of parenting a new baby or a lack of adequate resources causes parents to overlook the very real danger unsafe sleep practices pose.
“It’s not that they are not aware of the ABCs. Somewhere there’s a disconnection,” said Felicia Clark, D-ABMDI, a former Child Death Investigator with Cook County’s Medical Examiner’s Office in Illinois. “The risk perception is really low. People just aren’t aware of how often it’s occurring.”
The reality is that in Cook County, the second largest county in the country by population, 208 sleep-related infant deaths occurred between 2019 and 2023. Almost all of those deaths, 99%, occurred in unsafe sleeping environments. Babies in Cook County almost never die in a crib/bassinet on their back without other items in the crib.
Data for Cook County has been compiled since 2022 by Community Partnership Approaches for Safe Sleep, or CPASS, the prevention team at the Cook County Sudden Unexpected Infant Death Case Registry. The group is housed at Rush University Medical Center and includes Felicia Clark as their coordinator, Gina Lowell, MD, MPH, FAAP as a principal investigator, and Kyran Quinlan, MD, MPH, FAAP as a public health advisor.
Each year in the United States, 3,500 infants die suddenly and unexpectedly before they reach their first birthday, with a majority taking place in the child’s sleeping environment. That’s 10 babies a day. That number has not dropped in over 25 years, marking unsafe sleep practices as a leading cause of death for children aged one month to a year.
“The Back to Sleep campaign, which is the ABCs of sleep, has not eliminated everything. It has dramatically decreased things,” said Elizabeth Murray, DO, FAAP, a pediatric emergency medicine physician for nearly 20 years. “Now things have plateaued.”
There are ways to decrease your baby's chances of Sudden Unexpected Infant Death – also known as SUID – including placing your baby for every sleep on the back, in a flat, firm sleep surface with nothing else on the surface but the baby. Human milk, pacifier use, and avoidance of tobacco smoke exposure also lower the risk. Unsafe sleep practices that can dramatically increase the baby's risk of SUID include non-crib sleeping and sharing a sleep surface with another person. Many sleep accidents happen when tired parents fall asleep while feeding their baby. According to data from the CDC and Rush University Medical Center, two thirds of SUID victims died while sharing a sleep surface with an adult.
The situation often plays out as follows: an infant wakes up in the night, either hungry or seeking affection. A parent leaves their bed to comfort the child, rocking them back and forth in their arms. No matter how hard they try, nothing is helping, the baby stays fussy and doesn’t fall back to sleep. In desperation, the parent brings the baby into bed with them, hoping to relax or feed while also providing their child some comfort.
As happens far too often, the parent falls asleep. You know the feeling, when your body forces sleep upon you no matter how much you try to fight it. In your unconscious, likely sleep deprived state, your body reacts without you even needing to think about it. Your brain tells your body to roll over, it obliges. Or, the baby and parent fall asleep feeding and the baby slips into the crook of their parents' arms and is unable to breathe freely.
“Your decision making in those exhausted moments may not always be as clear and intentional as you wish them to be," said Dr. Lowell. “It’s very difficult to guarantee that there won’t be a moment in the night where you are completely unaware as to where you are, where the baby is, where things have shifted in the sleep environment.”
Extra items such as stuffed animals, blankets, or pillows also pose a suffocation risk to children with the same data showing 93% of unsafe sleep deaths had soft bedding items included in the sleep environment. While these items seem innocuous, they can quickly become deadly if they block the infant’s airway as babies simply aren’t strong enough to remove the blockage. They then suffocate, as 27% of those infant deaths tracked in Cook County did.
“If we can just use the word suffocation – embrace it, talk about it…it makes so much more sense for parents,” Dr. Lowell said. “Now suddenly the why of the ABCs is crystal clear. Of course, I don’t want a pillow or blanket in there because my baby’s nose and mouth are so little they could suffocate.”
Dr. Murray knows the realities of sudden unexpected infant death well owing to her 20 years of work in pediatric emergency medicine. She recalls one winter night when a father burst into the emergency department with his limp child in his arms, begging for help. The family lived nearby and when he woke up to find the child not breathing, he didn’t think twice before scooping the infant up and racing to the hospital. He didn’t even have time to put on shoes, something Dr. Murray hadn’t noticed until she had to tell the father that his child couldn’t be revived.
Dr. Quinlan, who also serves as Professor of Pediatrics at Rush University Medical Center in Chicago, said unmet needs due to broader social drivers, including poverty, are a significant factor that raises the risk of death due to unsafe sleep. He speaks of a family made up of a young single mother and her two children, aged 2 years and 4 months. The family suffered a house fire and had to temporarily stay at her mother’s home. However, this wasn’t a long-term solution for the family and they would in turn need to be moved to a shelter.
“Which tells you a lot. Her mom has a place but she’s waiting for a shuttle to go to a shelter. The support systems were not all there for this young mom with two kids,” explained Dr. Quinlan. “When you don’t have everything going for you, you’re young, you have two kids, fire. It’s like how many things can you take?”
While waiting for a shuttle to take her to a shelter, she fell asleep with the children on the couch. In their sleep, the two-year-old shifted on top of the baby, causing the death.
“It may be partly our role as pediatricians to help families gain a healthy fear of this threat,” Dr. Quinlan said. “What parents may not realize, and we could help them with, is that sleep related infant death is by far the leading cause of death after a baby comes home from the hospital after being born.”
He compared moving the baby from a safe crib or bassinet into an adult bed to co-sleep as dangerous as tending to a fussing child strapped in the backseat while driving your car down the highway.
“Take advantage of whatever you can to make things more safe. You are still a phenomenal parent if you are setting your phone to alert every 10 minutes while you’re feeding your baby,” Dr. Murray said. “You are not exhausted because you are a bad parent. You are exhausted because being a parent is exhausting.”
Pediatricians don’t want to scare parents, but they do want parents to understand the harsh reality of the danger posed to infants by unsafe sleep. They know parents want what is best for their children and that doesn’t always come easily. These stories represent real families, real infants, and real deaths. But we can prevent further deaths by telling these stories and continuing to teach parents and families about the ABCs of safe sleep with the intensity and level of importance it deserves.
Every parent wants to protect their child and keep them safe. But the odds of their child becoming a victim to SUID are far greater without safe sleep practices. Unless we change that.
The Sudden Unexpected Infant Death Prevention Program is funded by Cooperative Agreement Number UF745730 from the US Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) as part of an award totaling $500,000 annually with 0 percent financed with non-governmental sources. Its contents are solely the responsibility of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.
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