Fern R. Hauck, MD, MSSpencer P. Bass, MD Twenty-First Century Professor of Family MedicineProfessor of Public Health SciencesDirector, International Family Medicine ClinicUniversity of Virginia Department of Family Medicine

To Reduce Crib Deaths, Get Rid of Blankets, Pillows, Bumpers and Soft Objects

MedicalResearch.com Interview with:

Fern R. Hauck, MD, MSSpencer P. Bass, MD Twenty-First Century Professor of Family MedicineProfessor of Public Health SciencesDirector, International Family Medicine ClinicUniversity of Virginia Department of Family Medicine

Dr. Hauck

Fern R. Hauck, MD, MS
Spencer P. Bass, MD Twenty-First Century Professor of Family Medicine
Professor of Public Health Sciences
Director, International Family Medicine Clinic
University of Virginia Department of Family Medicine

MedicalResearch.com: What is the background for this study?

Response: Unintentional suffocation is the leading cause of injury deaths among infants under one year of age in the US. 82% of these deaths are attributed to accidental suffocation and strangulation in bed. The Sudden Unexpected Infant Death Case Registry was established by the Centers for Disease Control and Prevention (CDC) in 2009 to collect data on sudden unexpected infant deaths (SUID) to better understand trends and characteristics associated with these deaths. Data from 10 states, which account for about one-third of all US SUID cases, are captured in the Registry.

The CDC developed the Case Registry classification system in 2014 to differentiate SUID cases into several groups; explained suffocations with unsafe sleep factors is one of those categories, and the subject of this study. We analyzed infant deaths (children under one year of age) that occurred from 2011-2014 among states participating in the registry at the time of the study (Arizona, Colorado, Georgia, Louisiana, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, and Wisconsin). Among the 1812 cases in the Registry from 2011-2014, 250 (14%) were classified as suffocation. The remaining cases were classified as unexplained SUID.

MedicalResearch.com: What are the main findings? 

Response: The median age of death was 3 months old and most deaths (84%) occurred in the infant’s home. The racial-ethnic breakdown of infants is: non-Hispanic white (40%), non-Hispanic African American (34%, Hispanic 16% and other, missing or unknown (9%).

The three main mechanisms of suffocation were soft bedding (69%), overlay (19%) and wedging (12%). Soft bedding deaths most often occurred in an adult bed (49%), and crib or bassinet (27%). Most (92%) were found in a non-supine position, and almost half (48%) were sharing a sleep surface with another person, most commonly one or both parents (66%). The objects obstructing the infants’ airways were blankets (34%), adult mattresses (23%), and pillows (22%). Infants 4 months and younger were more likely to have been obstructed by a pillow or couch/recliner cushion, while older infants were more likely to have been obstructed by blankets.

Overlay deaths occurred in 51 (19%) of the infants who died from suffocation, and almost ¾ of these (71%) occurred in an adult bed. Half were found nonsupine. Half (47%) of the infants were overlaid by their mothers, and ¼ (25%) by father or sibling (22%). Among the 40 overlay deaths in which an adult overlaid the infant, 23% of the adults were reported to have been impaired by alcohol or drugs around the time they went to sleep with the infant. 10 deaths occurred after an adult fell asleep while feeding the infant, 7 of these had been while breastfeeding.

33 suffocation deaths were attributed to wedging; Almost half (45%) of these infants were sharing a sleep surface at the time of death and ¾ (73%) occurred in an adult bed. The most frequent objects between which the infant was wedged were a mattress and wall (48%).

The age at death differed by cause of death: overlay deaths occurrred in the younger infants (median 2 months), soft bedding in older infants (median 3 months) and wedging in the oldest (median 6 months). Younger infants are less likely to get themselves into a wedged position because they are less mobile and cannot roll over on their own. At the younger ages, infants are more likely to be overlaid as they are smaller, and unable to move away. Likewise, younger infants who were sleeping on or near a pillow may have lacked the mobility and neck strength to lift their head off the pillow to prevent airway obstruction. Older infants who are more mobile may have gotten tangled in blankets but were not yet coordinated enough to free themselves.

MedicalResearch.com: What should readers take away from your report? 

Response: The main take away is that these deaths were all preventable. The most common characteristics of all three forms of suffocation were nonsupine sleep position and sleeping in an adult bed. The American Academy of Pediatrics has well publicized guidelines for reducing the risk of SUID and these include placing baby to sleep alone on a firm mattress in a safety approved crib or bassinet The guidelines recommend against blankets, pillows, bumpers or other soft objects in the crib/portable crib or bassinet. Placing the crib or bassinet in the parents’ room is recommended for at least the first 6 months of life and bedsharing (sharing a a sleep surface) is not recommended, especially with parent(s) who smokes or if there is any impairment of alertness of the parent including drug or alcohol use.

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: I would recommend that similar analyses been done with the SUID Case Registry as new cases are added and classified to determine trends over time, with the main purpose of eliminating these deaths through education of families and health professionals. Since there are a large number of families who are not following safe sleep advice, we also need to continue to explore reasons for this nonadherence, and develop ways to better communicate with these families about safe sleep. Several studies are currently underway to do this, and I would encourage funding agencies to continue to support such research. 

I have no disclosures.


“Sleep-Related Infant Suffocation Deaths Attributable to Soft Bedding, Overlay, and Wedging,” (Erck Lambert, AB, et al. Pediatrics.April 22, 2019, https://doi.org/10.1542/peds.2018-3408).

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Last Updated on April 25, 2019 by Marie Benz MD FAAD