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“Soft” Does Not Equal “Safe,” at Least for Sleeping Babies :

April 27, 2021

One of the worst possible nightmare scenarios for any parent – or any pediatrician, for that matter – is when a perfectly healthy baby dies suddenly and unexpectedly.

One of the worst possible nightmare scenarios for any parent – or any pediatrician, for that matter – is when a perfectly healthy baby dies suddenly and unexpectedly. Most parents know that babies should sleep “back to sleep,” or according to the “ABCs of Safe Sleep” (alone, (on their) back, (in the) crib), but we know that knowledge often doesn’t equate with actual practice.

With improved and more consistent death scene investigation protocols and reporting, researchers continue to learn more about what happens when these babies die. This week in Pediatrics, we are early releasing an important article from investigators at the Centers for Disease Control and Prevention (CDC), the Michigan Public Health Initiative, and the University of Virginia that provides additional insights into these deaths (10.1542/peds.2020-035873). Dr. Sharyn Parks and colleagues analyzed data from the CDC Sudden Unexpected Infant Death (SUID) Case Registry, which is a population-based surveillance system built upon Child Death Review programs in 18 U.S. states and jurisdictions.

Between 2011 and 2017, details about 4,929 SUID cases were entered into the Registry, comprising 30% of all US SUID cases. The investigators defined  a sleep environment as being consistent with AAP safe sleep guidelines – meaning that the infant was found on the back on a firm sleep surface that was free of soft objects, bedding, bumper pads, or objects that could increase the risk of accidental suffocation.

While there is a lot of great information in this study, there are 2 take-aways that I want to emphasize in this blog.

First, nearly three-quarters of these sudden and unexpected deaths occurred in a sleep environment that was defined as unsafe, meaning that it was not consistent with the AAP guidelines.

Second, of the cases that were either explained by or possibly caused by accidental suffocation, 75% resulted from airway obstruction from soft bedding. 

Dr. Sunah Hwang from the University of Colorado, in her accompanying commentary, notes that, in Parks’ study, “in short, 1,145 infants may have survived their first year of life had soft bedding not been used during their sleep.” (10.1542/peds.2020-042135)

This is an important wake-up call to anyone who cares for babies.

Most pediatric health providers ask and counsel about sleep position – and we should definitely continue to do that. However, fewer routinely ask about the actual sleep environment. It’s important to ask and to counsel about this. Qualitative studies show that parents use soft bedding because they are concerned about the baby’s comfort (e.g., if I like to sleep with a pillow and a blanket, then my baby will want to sleep with a pillow and blanket as well) and – ironically – safety. For example, parents often will put pillows around a baby if the baby is on an adult bed to keep them from falling off the bed or use bumper pads to protect the baby from hurting her head if they bump against the side of the crib.

Parents often equate “softness” with “safety” – after all, playgrounds now have soft surfaces to cushion childrens’ falls, and parents often pad table corners to minimize injury. However, for sleeping infants, softness definitely does not make the environment safer. Thus we need to counsel parents and reassure them that the baby can truly sleep comfortably without bedding.

I’ve discussed my two important take-aways from this paper, but there is much, much more. I encourage you to read the entire paper and the commentary to get additional take-away messages that will change your practice when you counsel parents of infants. 

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