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1he number oí Connecticut iníants who died between
2001 and 2013 where unsaíe sleep conditions were present was almost three
times the number oí iníants who died írom child abuse.

Lach year iníants die unnecessarily in Connecticut. 1his Public lealth Alert
outlines the tragedy oí iníant íatalities associated with unsaíe sleep conditions
and makes recommendations íor pre·ention.


Iníant latality Risk lactors

Sleeping in adult beds with adults and other children
Sleeping in beds with comíorters, blankets and du·ets
Sleeping on couches or chairs when caregi·ers sleep holding them
Sleeping in cribs with stuííed animals, blankets, toys and other items
O·erdressing,o·erheating baby
Propping bottles

Research also coníirms additional risk íactors associated with sudden
iníant death.
Mental health challenges, including depression
Substance use, including alcohol or drugs
Smoking
Obesity
Parental isolation



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1hat is an ´unsafe sleep related¨ infant fatality?
Unsaíe sleep related causes oí iníant death are linked to how or where a baby sleeps. Deaths
may be due to blockages oí the nose,mouth, entrapment,chest compression ,when an iníant
gets trapped between two objects, such as a mattress and wall, and cannot breathe or
o·erlying,, or suííocation írom a low oxygen,high carbon dioxide en·ironment ,under a
blanket,.

"CK C:>;7 LC ?7:97>8 ?7 (C77;D>?DE> L?; :BCA E789:; 8<;;=?7M DC7L?>?C78N
Iníants in Connecticut are more likely to die írom unsaíe sleeping conditions than írom
child abuse, car accidents, choking, drowning, íalls, or any other source oí accidental injury.

GHIJ '7:97> &9>9<?>O PO >Q; -EAP;B8
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or ´undetermined.¨
I
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:9D>CB8 988CD?9>;L K?>Q >Q;?B 8<;;= ;7T?BC7A;7>U


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\hen iníants die unexpectedly, this is called Sudden Unexpected Iníant Death ,SUID,.` SUID includes all
unexpected deaths: Deaths without a clear cause, such as SIDS, and deaths írom a known cause, such as
suííocation or other sleep-related causes. Sleep-related deaths are not SIDS. SIDS is term íor the sudden
death oí an iníant under 1 year oí age that cannot be explained, e·en aíter a complete death scene in·estigation,
autopsy, and re·iew oí the iníant's health history.

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GHII 97L GHIG '7:97> &9>9<?>O PO >Q; -EAP;B8
In 2011 and 2012 there were 43 iníants who died where the causes oí death were SUID, SIDS,
or undetermined.`
2

1here were 24 iníant cases in 2011 and 19 iníant cases in 2012.
30 were boys and 13 were girls.
%: >Q;8; [J E7;@=;D>;LF E7;@=<9?7;L ?7:97> L;9>Q8, JI ?7:97>8 Q9L B?8S :9D>CB8
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\C8> DCAAC7 E789:; 8<;;= ;7T?BC7A;7>8 ?7 (! :9>9<?>O D98;8
Co-sleeping in an adult bed with parents or siblings
Car seat
In a crib with blanket, pillows, or placed on their stomachs
Put to sleep with a bottle in an adult bed

'7:97> &9>9<?>?;8 ?7 (C77;D>?DE> CT;B !?A;
1he Oííice oí the Child Ad·ocate also conducted an e·aluation 211 iníant íatalities between
2002 and 2010 that were classiíied as due to SIDS, SUID, Undetermined or Accidental
Asphyxia.

11¯ iníant deaths were classiíied as SIDS, a íinding that may not accurately account
íor unsaíe sleep conditions present at the time oí death.

¯¯ iníant deaths were classiíied as undetermined,` a íinding oíten associated with
unsaíe sleep` conditions.

1¯ iníant deaths were classiíied as due to asphyxia.`
3


\e cannot say deíiniti·ely how many oí the 211 iníants outlined abo·e died írom unsaíe sleep
conditions, but an OCA re·iew oí at least 140 oí these deaths had íindings associated with
unsaíe sleep en·ironments including iníants sleeping in bed with adults, in bed with other
children, and in bed with adult pillows, toys, comíorters, stuííed animals and other items.

Are ´unsafe sleep¨ fatalities trending up or down in C1 over the years?
1his is as diííicult question to answer.
O·erall the percentage oí iníant deaths classiíied as SIDS has shown a downward trend, but
this has not translated into an o·erall decline in iníant deaths. low we categorize íindings
regarding iníant death has changed o·er time, and íewer iníants are now determined to ha·e
died írom SIDS. More iníants are now categorized as ha·ing died írom SUID--Sudden

2
See Note 3 iníra.
3
O·er the last ten years, states are decreasing SIDS íindings and increasing undetermined` and asphyxia`
íindings as íatality re·iews and scene` in·estigations become more thorough.
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Unexplained Iníant Death-- an umbrella term co·ering multiple iníant death causes, including
SIDS and suííocation.

'> ?8 *?::?DE<> >C +<K9O8 97L (C7D<E8?T;<O *;>;BA?7; (9E8; C: '7:97> *;9>Q :CB
4;T;B9< +LL?>?C79< 0;98C783
1. Inconsistent oííicial use oí SIDS` to explain iníant íatality. SIDS should only be an oííicial
cause oí death` when medical examination and scene in·estigation re·eal no other
potential causes or risk íactors, such as abuse, unsaíe sleep conditions or underlying medical
issues. lowe·er, e·en today, SIDS may still be gi·en as the cause oí death` e·en where
there has been limited or no scene in·estigation, and limited police in·estigation.
2. Inconsistent in·estigations related to the scene oí unexpected and unexplained iníant
íatalities result in lack oí iníormation that would be essential to understanding cause oí
death. Not e·ery case is handled in the same way. Iníants may be mo·ed, scenes disrupted,
certain iníormation not obtained, e.g., toxicology screens oí parent.
3. Lack oí uniíorm training and protocols regarding examination and in·estigation oí
unexpected, unexplained child íatalities. L·en diííerent medical examiners approach
cause oí death` in·estigations diííerently.

DCI'S (B?>?D9< 0C<; ?7 '7:97> *;9>Q 2B;T;7>?C7
Based on our re·iew oí 2013 data, many íamilies who suííered a sudden iníant death in
Connecticut had been in·ol·ed with the Department oí Children and lamilies. 1here is
íurther research to show that íamilies under Child Protecti·e Ser·ices` Super·ision are 3 times
more likely to ha·e a Sudden Iníant Death than those that are not.
4
1his is likely due to related
risk íactors íor sudden iníant death such as mental health challenges and substance abuse.

'A=CB>97> GHI[ 2C<?DO *;T;<C=A;7> :BCA *(&
Connecticut Department oí Children and lamilies recently issued a new agency policy
emphasizing the role that case workers will play in educating íamilies about saíe sleep,` and
ensuring such expectations are part oí íamilies` case plans. 1his is a critical de·elopment gi·en
that DCl interíaces with thousands oí parents oí young children each year. Gi·en the
importance oí this new policy in reducing child deaths, DCl should incorporate this policy
into training and rigorously eníorce compliance through spot checks oí the records oí all
children under 1 year oí age.
5





0#(%\\#-*+!'%-4 &%0 )+1\+]#04
1. +77E9< (Q?<L &9>9<?>O 0;=CB> 97L ";9B?7MU Support eííorts by the Oííice oí the Child
Ad·ocate and the Child latality Re·iew Panel to report annually to the Connecticut General

4
Putnam-lornstein L. Schneiderman JU. Cle·es MA. Magruder J. Krous ll. A Prospecti·e Study oí Sudden
Iníant Death aíter Reported Maltreatment. ]ovrvat of Peaiatric.. 1ó1;1):112·º, 2011 ]av.
5
Connecticut Department oí Children and lamilies, Standards and Practice íor Saíe Sleep Ln·ironments:
Assessing the Saíety oí an Iníant`s Sleep Ln·ironment,` Practice Guide to be used in conjunction with DCl
Policy 34-12-8 ,2014,.
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Assembly the number oí sleep-related deaths oí iníants. Legislation may consider the ·alue oí
an annual hearing regarding íatalities, causes, trends, and pre·ention strategies.
2. 4E==CB> 2;L?9>B?D (CE78;<?7M 0;M9BL?7M 49:; 4<;;=U Lnsure reimbursement íor primary
care pro·iders íor the time spent counseling íamilies regarding a saíe sleep en·ironment íor
iníants. Analogous reíorms were implemented in other states such as \ashington íor oral
primary care.
i

3. '7DB;98; 4DB;;7?7M :CB \9>;B79< *;=B;88?C7U Gi·en the link in the national data between
mental health challenges and unsaíe sleep` íatalities, it is critical that Medicaid and
commercial carriers support screening íor maternal depression and increased access to in-
home supports íor high need mothers. Although Connecticut has not done consistent, in-
depth in·estigations into the parental proíiles oí parents who suííer an iníant loss as described
in this paper, our recent data does coníirm a number oí the iníants who died had parents with
documented histories oí substance abuse and in·ol·ement with the Department oí Children
and lamilies.
4. (C77;D> "CA; ,?8?>9>?C7 97L (<?7?D9< "CA;ZP98;L 4;BT?D;8 >C 2;L?9>B?D8U lome
·isitation is an e·idence-based ser·ice íor increasing caregi·er capacity and impro·ing child
well-being. lome ·isiting programs pro·ide essential support and education to new parents.
lome Visitation Ser·ices, including dyadic and clinical home-based ser·ices, should be
brought to scale as critical parts oí our health care íor maternal,child wellbeing. All pediatric
primary care pro·iders should ha·e direct connection to and collaborati·e relationship with
home ·isitation programs íor íamilies.
5. Mandate ´safe sleep¨ guidanD; PO Q;9<>Q D9B; =BCT?L;B8U De·ise legislation, similar to
New \ork and Maryland eííorts regarding Shaken Baby Syndrome that mandates anticipatory
guidance íor pro·ision oí a saíe iníant sleep en·ironment is deli·ered by health care pro·iders
to caregi·ers at newborn hospital discharge.
ii

6. #78EB; .7?:CBA )9K #7:CBD;A;7> 97L &?B8> 0;8=C7L;B 2BC>CDC<8 :CB 4ELL;7
.7;@=<9?7;L '7:97> *;9>Q '7T;8>?M9>?C78U Police and íirst responders should respond to
child deaths as they would to any crime scene. Many departments íollow the Centers íor
Disease Control Protocol íor Sudden Unexplained Iníant Death In·estigations ,SUIDI,.
Lííorts should be made to ensure that protocols are íollowed and police departments and íirst
responders ha·e adequate resources to implement SUIDI training. \ashington State created
guidelines íor íirst responders that can ser·e as a model íor Connecticut.
¯. #78EB; .7?:CBA 2BC>CDC<8 :CB >Q; %::?D; C: >Q; \;L?D9< #@9A?7;B 0;M9BL?7M 4ELL;7
.7;@=<9?7;L '7:97> *;9>Q '7T;8>?M9>?C78U Some in·estigators conduct thorough scene
in·estigations and collaborate with police in reenactments which ha·e led to greater
understanding oí the causes oí Sudden Unexplained Iníant Deaths. Medical examiners should
adopt standard protocols íor SUID in·estigations and adopt standard language to identiíy
causes oí iníant death. Lxaminers within the Connecticut oííice still ·aryingly classiíy
iníant deaths as SIDS, SUID or Unexplained without clear distinction between terms. 1his
makes tracking iníant death causation and creating public health responses much more
diííicult.
8. +LLB;88 49<; C: .789:; '7:97> 6;LL?7M 97L 2C8?>?C7;B8U Regulate the sale and
ad·ertising oí bedding íor iníant cribs or cradles, and iníant co-sleepers so that any de·ices
that are marketed meet Consumer Protection Saíety Commission guidelines íor saíety.
iii

Maryland, íor example, banned baby bumpers and positioners, de·ices that may be promoted
as pre·enting SIDS.

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'

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1. ^E9<?>O #7M9M;A;7> 97L +88;88A;7>U Case planning must include skilled engagement and
iníormation sharing regarding saíe sleep practices, iníant needs, resources íor caregi·er
support and risk íactors íor iníant death.
2. %E>B;9DQ 97L #LED9>?C7U Organization oí outreach programs and dri·es, and utilization oí
educational materials like brochures, leaílets and DVDs. 1his should include tailoring oí saíe
sleep messages to speciíic communities and using trusted íigures in the community to ad·ocate
these practices. Materials are a·ailable already írom: KKKUD>UMCT_L=Q_89:;>C8<;;= 97L
Q>>=3__KKKU7?DQLU7?QUMCT_4'*4 97L IZRHHZ`H` (0'6 XGV[GYU
3. (C<<9PCB9>?C7 K?>Q 6;8> 2B9D>?D; (;7>;B8U Collaborations may be done with Sudden Iníant
and Child Death ,SICD, Resource Center, which pro·ides outreach and education on the
subject oí saíe sleep practices and is a·ailable to pro·ide íree on-site training to local districts
and other child welíare agencies.
4. %7MC?7M AC7?>CB?7M 97L ;7M9M;A;7> B;M9BL?7M 89:; 8<;;=U Monitoring sleep conditions
in home as well as institutional settings, such as hospital inpatient units, childcare pro·iders,
day care centers, íoster homes.
5. +LLB;88 P9BB?;B8 >C 89:; 8<;;=U Lxplore with parents any barriers or challenges to ensuring
a saíe sleep en·ironment they may be experiencing and assist in identiíying and accessing
needed resources. Document all acti·ities.

0#(%\\#-*+!'%-4 &%0 %6Z5/-4F 2#*'+!0'('+-4 +-*
"%42'!+)4
1. #7M9M;A;7>F 988;88A;7>F 97L ;LED9>?C7U 1here should be a discussion on saíe sleep
practices, particularly with parents oí iníants who íall in high risk categories: low birth weight,
premature iníants, those írom socioeconomically disad·antaged backgrounds, or with parents
who smoke, drink or are substance abusers. Screening íor possible risk íactors and exploration
oí actual parenting practices are necessary components oí pre·ention.
2. +LLB;88 DC7D;B78_A?8=;BD;=>?C78U Practitioners should aim to not only iníorm caregi·ers
about sleep saíe practice guidelines, but also address any concerns about iníant sleep that they
may ha·e. Commonly held misconceptions include the stomach` or side` sleep position
being more comíortable íor the iníant and reducing chances oí regurgitation and choking.
3. +LLB;88 E789:; P;LL?7M 97L =C8?>?C7;B8 L?B;D><OU Use oí baby blankets, quilts or bedding
sets ad·ertised as `iníant íriendly, saíe`, baby positioners and bumpers and de·ices marketed
to reduce SIDS should be strongly discouraged.
4. \CL;<?7M 6;8> 2B9D>?D;8U Parents are more likely to íollow care practices when they see
nursery staíí consistently model this beha·ior in the hospital. Saíe sleep practices can be
modeled during postpartum care in hospitals as well as out-oí-hospital birth settings, such as
birthing centers.
5. (C<<9PCB9>?C7 K?>Q 6;8> 2B9D>?D; (;7>;B8U 1he use oí saíe sleep resources like Continuing
Lducation Program on Sudden Iníant Death Syndrome ,SIDS, Risk Reduction by NIClD
should be used to pro·ide iníormation and tools needed to communicate and model SIDS
risk reduction messages eííecti·ely and quickly.
6. ,9<E; C: +7>?D?=9>CBO 5E?L97D;U lospitals should consider practice policies that encourage
the deli·ery oí anticipatory guidance íor pro·iding a saíe iníant sleep en·ironment to caregi·ers
"#$%&
(

oí iníants whene·er they are encountered within the hospital ,e.g. well iníant ·isits, sick ·isits,
Lmergency Department ·isits, subspecialty care ·isits,.
¯. #7DCEB9M; 6B;98>:;;L?7M3 Breastíeeding, especially during the íirst 6 months, has been shown
to reduce the incidence oí Sudden Iníant Death by as much as halí, as long as saíe sleep practices
are íollowed aíter. Paciíier use is also encouraged and may ha·e a protecti·e eííect aíter the iníant
has been weaned oíí breastíeeding.

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69DS !C 4<;;= 2C8?>?C7
Studies ha·e consistently demonstrated that the practice oí placing iníants on their back to sleep
is linked with signiíicantly decreased rates oí iníant deaths, as opposed to those placed to sleep
on their stomachs or sides.
1he iníant should be placed on his,her back during e·ery nap time, in e·ery setting- at home, in
childcare, or during tra·elling.
Placing iníants who usually sleep on their backs to sleep on the stomach is a high risk íactor íor
sudden iníant death.
Iníants who are able to roll themsel·es on their stomach, usually aíter 5 months oí age, need not
be repositioned during sleep.

49:; 4<;;= #7T?BC7A;7>
1he saíest place íor an iníant to sleep is a hard suríace such as a crib or bassinet that complies
with the Consumer Product Saíety Commission recommendations. Places like couches, soías, car
seats and adult beds are unsaíe sleep en·ironments íor iníants, and may increase chances oí
suííocation and entrapment.
1he sleeping suríace should be co·ered with only a íirm mattress and íitted sheets. Other
extraneous items like soít bedding, pillows, blankets or comíorters increase the risk oí
strangulation, suííocation and o·erheating and should not be placed in the crib. Iníant positioners
and bumpers are also sleep hazards and should also not be used.
1he iníant should ideally be put to sleep in íitted sleepwear at a comíortable temperature.

0CCAZ8Q9B?7M PE> 7C> P;LZ 8Q9B?7M
Room- sharing, or placing an iníant`s cradle or bassinet in the same room as the care gi·er has
shown to be linked with lower rates oí Sudden Iníant Death, especially during the íirst 6 months
oí the iníant`s liíe.
Sharing a sleeping suríace has, on the other hand, been consistently demonstrated to increase the
risk oí suííocation and entrapment. 1he risk signiíicantly increases when the caregi·er has
consumed alcohol, is sedated, or excessi·ely tired.

6B;98>:;;L?7M
Breastíeed your baby íor as long as possible, preíerably íor the íirst year oí liíe. Aíter
breastíeeding your baby, =E> OCEB P9PO LCK7 C7 Q?8_Q;B P9DS ?7 9 DB?P CB P988?7;> K?>Q 9
:?>>;L 8Q;;>F K?>QCE> >CO8F P<97S;>8 CB =?<<CK8. Keep the baby`s crib or bassinet right next to
your bed, so you can see and hear your baby and be able to respond to his,her needs.


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)

4ACS?7M 97L .89M; C: +<DCQC<F *BEM8 CB !CP9DDC 2BCLED>8
Maternal smoking and exposure to tobacco smoke is a ·ery important risk íactor that has been
shown to play a role in almost a third oí sudden iníant deaths, with risk increasing exponentially
with increasing le·els and írequency oí exposure.

0;A;AP;B >C >9<S >C C>Q;B D9B;M?T;B8 9PCE> 89:; 8<;;= =B?CB?>?;8aa
Communicate with anyone who will be taking care oí the child: babysitters, grandparents, siblings,
child care pro·iders, boyíriends, and other caregi·ers.




´v¡¡ort ¡roriaea b, Yate |virer.it, Ma.ter. iv Pvbtic íeattb ´tvaevt, .v/eeta ´bvta.


i
http:,,www.inno·ations.ahrq.go·,content.aspx·id~3¯93
ii
http:,,www.ncsl.org,research,human-ser·ices,shaken-baby-syndrome-pre·ention-legislation.aspx., see also
https:,,www.medstarhealth.org,Pages,Ser·ices,Pediatrics,MedStar-lranklin,Pediatric-Community-Ser·ices-and-L·ents-at-MedStar-lranklin-
Square.aspx4Sleep ,outlining lranklin Square lospital in Baltimore Maryland`s aííida·it program íor both saíe sleep and Shaken Baby Syndrome,.
iii
http:,,www.cpsc.go·,en,Newsroom,News-Releases,2014,New-Iníant-Bedside-Sleeper-Standard-Appro·ed,