Skip to content
Link copied to clipboard

Reducing risks is key to saving infant lives

Parental education could prevent many sleep-related deaths

MILWAUKEE - Ten hours and 59 minutes into the new year, the Milwaukee Fire Department dispatched an engine to an apartment on the city's west side: A mother woke moments before beside her unresponsive infant son.

Twelve minutes later, the dispatcher called the Milwaukee County Medical Examiner's Office.

The boy was dead.

Malachi was born less than two months earlier, Nov. 11, 2010, his mother's 14th birthday. The mother told a medical investigator she spent New Year's Eve at church and in the morning found Malachi facedown beside her in a twin-size bed.

He was, she said, already cold to the touch.

Malachi was one of 35 sleep-related deaths in Milwaukee in the 30-month period that ended June 30.

Others include 2-month-old Gregory, who died while sleeping in a car seat as his 15-year-old mother slept on a bunk bed nearby. And Angelina, also 2 months, who died facedown in a bassinet, a set of safe-sleep guidelines printed on the sheet. And David, 12 days old, who suffocated in a filthy home beside his mentally ill mother who had fallen asleep while breast-feeding him on a makeshift bed of couch cushions.

In Milwaukee, which has one of the nation's highest infant mortality rates, premature birth is the leading killer of babies before their first birthday. But most of those deaths happen in the first month of life.

Over the next 11 months, sleep-related deaths - sudden infant death syndrome, suffocation while sleeping with an adult, asphyxiation from being wedged in the cushions of a couch - take the lead.

As the city works toward its newly set goal of driving the infant mortality rate to historic lows by 2017, a reduction of sleep-related deaths is both the most promising opportunity and most vexing challenge.

Eliminate the deaths entirely, and - if other factors stay the same - the goal is met.

The causes of prematurity are many and complex: poverty, access to health care, stress, poor health practices. But the risk factors tied to sleep-related deaths are known and in most cases easy to abate.

A safe sleep environment can be summed up as simply as ABC: Infants are safest when placed to sleep Alone, on their Backs, in a Crib free of blankets, pillows or other soft objects.

"Safe sleep is the low-hanging fruit on the prevention tree," said Jason A. Jarzembowski, director of perinatal pathology at Children's Hospital of Wisconsin.

Despite the City of Milwaukee's ongoing and aggressive safe-sleep campaign _ one that has included startling ads, educational services and even free cribs _ babies continue to die.

In the months that followed Malachi's death, six more Milwaukee infants died this year after sleeping with an adult or another child: Harmony, Brielle, Davion, Reneja, Demirrion and Ashley.

Two others died in what experts consider unsafe sleep conditions: Illie was found facedown on a pillow in his crib; Jordan had been placed to sleep on a leather couch.

"It should be easy," Jarzembowski said.

"But it's not been easy."

The Journal Sentinel examined the medical examiner's reports for all 35 sleep-related deaths in Milwaukee in the 2 {-year period ending June 30 and compared each case against newly published safe-sleep recommendations by the American Academy of Pediatrics.

Some of the 18 recommendations are beyond a parent's control, such as urging media and manufacturers to model safe-sleep practices in messages and advertising. Others are risks that are rarely, if ever, noted in medical examiner's reports, such as whether an at-home cardio-respiratory monitor was being used, something the academy discourages.

The review focused on eight modifiable risks _ that is, ones parents can do something about: sleep position; sleep surface; bed-sharing; soft objects and loose bedding; irregular prenatal care; exposure to smoke; caregiver alcohol or drug use; lack of breastfeeding.

The vast majority of infants died while exposed to multiple risks. No deaths occurred without the presence of at least one risk factor, and only one death occurred with just a single risk. At least four risk factors _ and as many as seven _ were present in three-quarters of the 35 deaths.

In 70 percent of all cases, clusters of risk were associated with an unsafe sleep environment, such as bed-sharing or use of an unsafe sleep surface.

In 60 percent of the unsafe environment cases, investigators noted the presence of unused cribs in the house.

Researchers cannot, with certainty, weigh the risk of any particular factor. Nor is it well understood how the factors relate to each other.

That is because the rate at which the risks are being taken in the general population is unknown. We don't know how many children sleep in adult beds or how many babies do not breast-feed or how many babies who are not breast-fed are put to sleep in adult beds.

What is known is what risk factors are present when a baby dies.

"The presence of a risk factor does not always mean it caused death," said Rachel Y. Moon, a pediatrician at the Children's National Medical Center in Washington, D.C., and the lead author of the pediatric academy's updated safe-sleep recommendations.

Some children, Moon said, are especially susceptible to sudden infant death. Some are especially resilient.

"Then you have the 90 percent in between," she said.

The numbers from the medical examiner's reports provide a look at the nature of the problem. The words _ even in their precise, detached manner _ paint a picture of the agony of families that have lost a child.

The death of 2-month-old Jaylen.

On Oct. 28, 2009, the boy's parents went to work, leaving him home with his siblings, ages 2 and 3, and his 22-year-old uncle.

The uncle told investigators he had fed Jaylen formula around 1 p.m. Once Jaylen fell asleep, the uncle placed him alone on his parents' bed.

The uncle said he made sandwiches for the other kids, then checked on Jaylen. The baby was unresponsive. Frantic, the uncle called 911 and then called Jaylen's mother. The mother told investigators the uncle was hysterical when he called.

"I killed Jaylen," he told a rescue worker. "I killed Jaylen."

While the boy's parents were at the hospital, the uncle took a .40-caliber handgun from the father's safe, walked to a nearby bus shelter and shot himself in the head.

The most common cause of sleep-related death, here and nationwide, is SIDS.

In Milwaukee, during the 30-month period examined by the Journal Sentinel, nearly three times as many babies died of SIDS as of the next leading cause.

SIDS is defined by the Centers for Disease Control and Prevention as "the sudden death of an infant less than one year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history."

"It is a diagnosis of exclusion," said Milwaukee County Medical Examiner Brian Peterson.

Parents around the country whose children have died of SIDS say not knowing how or why their baby died deepens their suffering and stigmatizes them in the eyes of people who assume that, without a medical explanation, the parents must somehow be responsible.

"No matter what they think, we're still parents of a dead child," said Steven Stuart, whose 2-month-old son, Colin, died March 2.

"It hurts just as bad. We just don't have an answer to: 'Why?'"

Stuart, who lives with his wife, Ellen, and their 4-year-old daughter in Greenbelt, Md., is a frequent contributor to the blog "Grieving Dads Project," and the author of his own blog, "Colin's Corner."

Colin, born three weeks early, was a small baby - 4 pounds, 13 ounces. He was so skinny and wrinkly that a friend called him Benjamin Button, the fictional character who was born old and became younger with age.

The nickname "Button" stuck.

Stuart had just finished feeding his son a bottle of breast milk. Colin was lying face up on Stuart's chest. Stuart was watching television. Colin stopped breathing.

Stuart jumped to his feet. He and his wife called 911, tried to revive their son and waited for the rescue workers to come.

Ellen Stuart went with Colin to the hospital while Steven Stuart stayed home, talking to the police. He was still talking to them, holding his daughter, when his wife called to say Colin was dead.

It was four months before a medical examiner could make official an initial diagnosis of SIDS.

The diagnosis did nothing to ease Stuart's guilt and pain.

"As a father, your job is to provide and protect," he said. "You feel like you failed."

In Milwaukee, when a sleep-related risk, particularly co-sleeping, can't be either proved or ruled out as having contributed to an infant's death, the death is designated SIDS II.

Three-quarters of the 24 SIDS deaths reviewed by the Journal Sentinel were labeled that way.

When a death is proven to have been caused by an unsafe sleep factor, the specific cause of that death is stated. These deaths account for one in five of all sleep-related deaths. They are usually caused by some form of asphyxia, which includes varieties of suffocation, choking and breathing toxic gases.

For example, a 3-month-old boy, Kymarius, died April 5, 2009, after spending the night sleeping with his grandmother on a couch. The grandmother told a medical examiner she thought she might have rolled onto the baby. The medical examiner ruled his death was caused by "asphyxia due to overlying."

Two weeks later, a 1-month-old boy, Tyler, died after sharing a bed with his mother and older sister. The investigator noted there was an unused bassinet, empty and in working order, in the room where Tyler died.

After a complete investigation, the medical examiner could not prove that something happened while co-sleeping that caused Tyler's death, and his death was labeled SIDS II.

"We cannot say the mere act of sharing a sleep surface causes death," Peterson said.

The American Academy of Pediatrics recommends that parents and caretakers share a room with their babies but not a bed.

"There is evidence that this arrangement decreases the risk of SIDS by as much as 50 percent," the new recommendations from the group say. "In addition, this arrangement is most likely to prevent suffocation, strangulation and entrapment that might occur when the infant is sleeping in an adult bed."

The National SUID/SIDS Resource Center's warning is more blunt:

"The only safe place for babies to sleep is in their own cribs."

That is the Milwaukee Health Department's position, which the agency underscored last month with a new safe-sleep ad that sparked national debate - in newspapers, on TV and in blogs - over its shocking tone.

The ad is a photograph of a baby sleeping in an adult bed, surrounded by puffy pillows and blankets, with a large knife tucked in the covers nearby.

"Your baby sleeping with you can be just as dangerous," the text reads.

The ad also gives a phone number for the Health Department's "Cribs for Kids" program, which provides needy Milwaukee families with free cribs and instruction on how to create a safe sleep environment.

Almost immediately, a Facebook page went up: "Campaign Against Milwaukee's Co-Sleeping Campaign."

In Arizona, a 26-year-old mother of two, Corey Planer, started a petition against the ad, which had attracted 1,400 signatures by early December.

"When I see the ad, I see a woman's body compared to a butcher's knife," Planer said.

Anthropologist James J. McKenna, author of "Sleeping with Your Baby: A Parent's Guide to Cosleeping," called the ad "repugnant."

McKenna estimates 50 percent to 84 percent of new parents in the United States - especially those who are breastfeeding - bring their children into their beds for part or all of the night. It is not, he says, merely a cultural preference. It is a biological impulse.

"It's like trying to nullify hiccuping or sneezing," said McKenna, director of the University of Notre Dame's Mother-Baby Behavioral Sleep Laboratory. "It's a reflexive behavior to reach out to our babies and bring them close."

When done safely - when risks such as smoking, alcohol and drug use and unsafe surfaces are eliminated - bed sharing promotes breastfeeding, deepens bonding, helps stabilize breathing and temperature and encourages babies to sleep on their backs, he said.

Milwaukee Health Commissioner Bevan Baker said he welcomes the debate. People need to be talking about safe sleep.

"The ad may be controversial," he said. "But there is no controversy when it comes to saving the life of a baby. There is no debate that there is danger associated with the adult bed."

In Milwaukee County, every co-sleeping death is referred to the district attorney's office.

But, both locally and nationally, criminal prosecutions of co-sleeping deaths are few and far between, said Deputy District Attorney Patrick Kenney, who oversees the Family and Sensitive Crimes Division.

Unsafe sleep, he said, is a public health issue.

"It is rarely a criminal justice issue," he said.

An exception is when an extremely intoxicated adult sleeps with an infant. Even this exception is difficult to prosecute. Unlike driving, the law sets no blood-alcohol standard for safe co-sleeping. And even when an adult admits to drinking, the death typically is not discovered until hours after the person stopped drinking, making blood-alcohol tests less reliable.

Evidence of alcohol or drug use - empty beer cans near the bed, incriminating admissions by co-sleeping adults - were found in 12 of the 35 deaths reviewed by the Journal Sentinel. Only one resulted in criminal charges.

That was the March 8, 2009, suffocation death of 6-day-old Ceianna Buchanan.

Ceianna's mother, Rose Prescott, told investigators she had been so drunk she did not remember putting Ceianna to sleep. The infant was found on her stomach, pressed into the back of a suede couch.

The medical examiner ruled Ceianna died of "asphyxia due to suffocation due to overlaying by an adult during co-sleeping on a couch."

While the death was ruled an accident, a criminal complaint charging Prescott with second-degree reckless homicide noted that another infant daughter had died while sleeping with Prescott less than a year before.

Prescott pleaded guilty to child neglect causing Ceianna's death. She was sentenced to two years in prison and 10 years of extended supervision.

Assistant District Attorney Matthew Torbenson, who prosecuted the Prescott case, said there are two potential homicide charges that might be issued when an infant dies while sleeping with an adult. One is child neglect resulting in death and the other is reckless homicide.

As a practical matter, both charges require the state to prove defendants appreciated the risk they were taking by sleeping with an infant.

"This is the great unknown," Torbenson said, "the risk level associated with co-sleeping and how each independent factor contributes to the level of risk."

This is the quandary. Not even doctors, researchers and health professionals know how to weigh that risk.

Shortly before Christmas 2003, Sarah and John Pouzar were watching television in the drafty bungalow they shared in West Allis, Wis., with two cats, a dog and their 3-month-old son, RJ.

The lights on the tree were on. RJ was tucked in his crib. The Pouzars, not wanting to wake RJ, had shut the door to his room.

The Pouzars' mixed Labrador - Jonah - would not settle down. He kept scratching at RJ's door, trotting to the couch where the Pouzars sat, then back to the door.

John finally got up to let Jonah into RJ's room so the dog could see the baby was fine.

He wasn't.

A quilt covered RJ's face. When John pulled it away, he saw RJ had partially swallowed a small blanket.

"He brought him out and he was pale, he was gray and limp and gasping," said Sarah, a pediatric nurse and patient care manager at Children's Hospital.

"He was literally suffocating," she said.

"I don't know what Jonah heard that night, but I would have woke up in the morning and my baby would have been gone."

What bothers Sarah is that she didn't know putting blankets and toys in her baby's crib was a risk. Not until after the incident did a pediatrician tell her soft objects in a crib are a risk for suffocation.

"Why didn't I know that?" she asked. "A pediatric nurse. Why didn't I know that was a risk?"

One of the Academy of Pediatrics' recommendations is to expand the national campaign to teach safe-sleep practices. Jarzembowski is head of the safe-sleep program at Children's, which began in April 2010.

He said the staff is expected to model safe sleep practices and to teach them to the families of patients.

He is also part of a pilot study to plumb the sleep practices of various Milwaukee communities. The study is designed to determine how exactly parents put their babies to sleep.

Jarzembowski hopes the study will help place sleep-related risks in context.

In the meantime, he said, people will have to make decisions based on what is known.

"I don't know how unsafe it is," he said. "But I know you are always safer not sleeping with your child."



In October, the American Academy of Pediatrics issued new recommendations for a safe sleeping environment for babies. The idea is to reduce risk factors tied to SIDS and other sleep-related deaths. A look at key provisions.

Sleep environment

Always place the baby on his or her back.

Use a firm sleep surface.

Room sharing without bed sharing is recommended.

Keep soft objects and loose bedding out of the crib.

Other ways to reduce risk

Pregnant women should receive regular prenatal care.

Avoid smoke exposure during pregnancy and after birth.

Avoid alcohol and illicit drug use during pregnancy and after birth.

Breastfeeding is recommended.

Consider offering a pacifier at nap time and bedtime.

Avoid overheating.

Do not use home cardio-respiratory monitors - or related marketed devices - as a strategy for reducing the risk of SIDS.

Infants should be immunized in accordance with recommendations of the American Academy of Pediatrics and the Centers for Disease Control and Prevention.

Supervised, awake tummy time is recommended to facilitate development.