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1he number o Connecticut inants who died between
2001 and 2013 where unsae sleep conditions were present was almost three
times the number o inants who died rom child abuse.

Lach year inants die unnecessarily in Connecticut. 1his Public lealth Alert
outlines the tragedy o inant atalities associated with unsae sleep conditions
and makes recommendations or preention.


Inant latality Risk lactors

Sleeping in adult beds with adults and other children
Sleeping in beds with comorters, blankets and duets
Sleeping on couches or chairs when caregiers sleep holding them
Sleeping in cribs with stued animals, blankets, toys and other items
Oerdressing,oerheating baby
Propping bottles

Research also conirms additional risk actors associated with sudden
inant 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?
Unsae sleep related causes o inant death are linked to how or where a baby sleeps. Deaths
may be due to blockages o the nose,mouth, entrapment,chest compression ,when an inant
gets trapped between two objects, such as a mattress and wall, and cannot breathe or
oerlying,, or suocation rom a low oxygen,high carbon dioxide enironment ,under a
blanket,.

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

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or undetermined.
I
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\hen inants die unexpectedly, this is called Sudden Unexpected Inant Death ,SUID,.` SUID includes all
unexpected deaths: Deaths without a clear cause, such as SIDS, and deaths rom a known cause, such as
suocation or other sleep-related causes. Sleep-related deaths are not SIDS. SIDS is term or the sudden
death o an inant under 1 year o age that cannot be explained, een ater a complete death scene inestigation,
autopsy, and reiew o the inant's health history.

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P;LU !Q; ?7:97> K98 9<8C 8K9LL<;L ?7 9 Q;9TO B;D;?T?7M P<97S;>U .=C7 9K9S;7?7M >Q;
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In 2011 and 2012 there were 43 inants who died where the causes o death were SUID, SIDS,
or undetermined.`
2

1here were 24 inant cases in 2011 and 19 inant 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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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 Oice o the Child Adocate also conducted an ealuation 211 inant atalities between
2002 and 2010 that were classiied as due to SIDS, SUID, Undetermined or Accidental
Asphyxia.

11 inant deaths were classiied as SIDS, a inding that may not accurately account
or unsae sleep conditions present at the time o death.

inant deaths were classiied as undetermined,` a inding oten associated with
unsae sleep` conditions.

1 inant deaths were classiied as due to asphyxia.`
3


\e cannot say deinitiely how many o the 211 inants outlined aboe died rom unsae sleep
conditions, but an OCA reiew o at least 140 o these deaths had indings associated with
unsae sleep enironments including inants sleeping in bed with adults, in bed with other
children, and in bed with adult pillows, toys, comorters, stued animals and other items.

Are unsafe sleep fatalities trending up or down in C1 over the years?
1his is as diicult question to answer.
Oerall the percentage o inant deaths classiied as SIDS has shown a downward trend, but
this has not translated into an oerall decline in inant deaths. low we categorize indings
regarding inant death has changed oer time, and ewer inants are now determined to hae
died rom SIDS. More inants are now categorized as haing died rom SUID--Sudden

2
See Note 3 inra.
3
Oer the last ten years, states are decreasing SIDS indings and increasing undetermined` and asphyxia`
indings as atality reiews and scene` inestigations become more thorough.
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Unexplained Inant Death-- an umbrella term coering multiple inant death causes, including
SIDS and suocation.

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4;T;B9< +LL?>?C79< 0;98C783
1. Inconsistent oicial use o SIDS` to explain inant atality. SIDS should only be an oicial
cause o death` when medical examination and scene inestigation reeal no other
potential causes or risk actors, such as abuse, unsae sleep conditions or underlying medical
issues. loweer, een today, SIDS may still be gien as the cause o death` een where
there has been limited or no scene inestigation, and limited police inestigation.
2. Inconsistent inestigations related to the scene o unexpected and unexplained inant
atalities result in lack o inormation that would be essential to understanding cause o
death. Not eery case is handled in the same way. Inants may be moed, scenes disrupted,
certain inormation not obtained, e.g., toxicology screens o parent.
3. Lack o uniorm training and protocols regarding examination and inestigation o
unexpected, unexplained child atalities. Len dierent medical examiners approach
cause o death` inestigations dierently.

DCI'S (B?>?D9< 0C<; ?7 '7:97> *;9>Q 2B;T;7>?C7
Based on our reiew o 2013 data, many amilies who suered a sudden inant death in
Connecticut had been inoled with the Department o Children and lamilies. 1here is
urther research to show that amilies under Child Protectie Serices` Superision are 3 times
more likely to hae a Sudden Inant Death than those that are not.
4
1his is likely due to related
risk actors or sudden inant death such as mental health challenges and substance abuse.

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





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1. +77E9< (Q?<L &9>9<?>O 0;=CB> 97L ";9B?7MU Support eorts by the Oice o the Child
Adocate and the Child latality Reiew Panel to report annually to the Connecticut General

4
Putnam-lornstein L. Schneiderman JU. Clees MA. Magruder J. Krous ll. A Prospectie Study o Sudden
Inant Death ater Reported Maltreatment. ]ovrvat of Peaiatric.. 11;1):112, 2011 ]av.
5
Connecticut Department o Children and lamilies, Standards and Practice or Sae Sleep Lnironments:
Assessing the Saety o an Inant`s Sleep Lnironment,` Practice Guide to be used in conjunction with DCl
Policy 34-12-8 ,2014,.
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Assembly the number o sleep-related deaths o inants. Legislation may consider the alue o
an annual hearing regarding atalities, causes, trends, and preention strategies.
2. 4E==CB> 2;L?9>B?D (CE78;<?7M 0;M9BL?7M 49:; 4<;;=U Lnsure reimbursement or primary
care proiders or the time spent counseling amilies regarding a sae sleep enironment or
inants. Analogous reorms were implemented in other states such as \ashington or oral
primary care.
i

3. '7DB;98; 4DB;;7?7M :CB \9>;B79< *;=B;88?C7U Gien the link in the national data between
mental health challenges and unsae sleep` atalities, it is critical that Medicaid and
commercial carriers support screening or maternal depression and increased access to in-
home supports or high need mothers. Although Connecticut has not done consistent, in-
depth inestigations into the parental proiles o parents who suer an inant loss as described
in this paper, our recent data does conirm a number o the inants who died had parents with
documented histories o substance abuse and inolement with the Department o 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 eidence-based serice or increasing caregier capacity and improing child
well-being. lome isiting programs proide essential support and education to new parents.
lome Visitation Serices, including dyadic and clinical home-based serices, should be
brought to scale as critical parts o our health care or maternal,child wellbeing. All pediatric
primary care proiders should hae direct connection to and collaboratie relationship with
home isitation programs or amilies.
5. Mandate safe sleep guidanD; PO Q;9<>Q D9B; =BCT?L;B8U Deise legislation, similar to
New \ork and Maryland eorts regarding Shaken Baby Syndrome that mandates anticipatory
guidance or proision o a sae inant sleep enironment is deliered by health care proiders
to caregiers 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 irst responders should respond to
child deaths as they would to any crime scene. Many departments ollow the Centers or
Disease Control Protocol or Sudden Unexplained Inant Death Inestigations ,SUIDI,.
Lorts should be made to ensure that protocols are ollowed and police departments and irst
responders hae adequate resources to implement SUIDI training. \ashington State created
guidelines or irst responders that can sere as a model or 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 inestigators conduct thorough scene
inestigations and collaborate with police in reenactments which hae led to greater
understanding o the causes o Sudden Unexplained Inant Deaths. Medical examiners should
adopt standard protocols or SUID inestigations and adopt standard language to identiy
causes o inant death. Lxaminers within the Connecticut oice still aryingly classiy
inant deaths as SIDS, SUID or Unexplained without clear distinction between terms. 1his
makes tracking inant death causation and creating public health responses much more
diicult.
8. +LLB;88 49<; C: .789:; '7:97> 6;LL?7M 97L 2C8?>?C7;B8U Regulate the sale and
adertising o bedding or inant cribs or cradles, and inant co-sleepers so that any deices
that are marketed meet Consumer Protection Saety Commission guidelines or saety.
iii

Maryland, or example, banned baby bumpers and positioners, deices that may be promoted
as preenting SIDS.

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1. ^E9<?>O #7M9M;A;7> 97L +88;88A;7>U Case planning must include skilled engagement and
inormation sharing regarding sae sleep practices, inant needs, resources or caregier
support and risk actors or inant death.
2. %E>B;9DQ 97L #LED9>?C7U Organization o outreach programs and dries, and utilization o
educational materials like brochures, lealets and DVDs. 1his should include tailoring o sae
sleep messages to speciic communities and using trusted igures in the community to adocate
these practices. Materials are aailable already rom: 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 Inant
and Child Death ,SICD, Resource Center, which proides outreach and education on the
subject o sae sleep practices and is aailable to proide ree on-site training to local districts
and other child welare 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 proiders,
day care centers, oster homes.
5. +LLB;88 P9BB?;B8 >C 89:; 8<;;=U Lxplore with parents any barriers or challenges to ensuring
a sae sleep enironment they may be experiencing and assist in identiying and accessing
needed resources. Document all actiities.

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 sae sleep
practices, particularly with parents o inants who all in high risk categories: low birth weight,
premature inants, those rom socioeconomically disadantaged backgrounds, or with parents
who smoke, drink or are substance abusers. Screening or possible risk actors and exploration
o actual parenting practices are necessary components o preention.
2. +LLB;88 DC7D;B78_A?8=;BD;=>?C78U Practitioners should aim to not only inorm caregiers
about sleep sae practice guidelines, but also address any concerns about inant sleep that they
may hae. Commonly held misconceptions include the stomach` or side` sleep position
being more comortable or the inant and reducing chances o regurgitation and choking.
3. +LLB;88 E789:; P;LL?7M 97L =C8?>?C7;B8 L?B;D><OU Use o baby blankets, quilts or bedding
sets adertised as `inant riendly, sae`, baby positioners and bumpers and deices marketed
to reduce SIDS should be strongly discouraged.
4. \CL;<?7M 6;8> 2B9D>?D;8U Parents are more likely to ollow care practices when they see
nursery sta consistently model this behaior in the hospital. Sae sleep practices can be
modeled during postpartum care in hospitals as well as out-o-hospital birth settings, such as
birthing centers.
5. (C<<9PCB9>?C7 K?>Q 6;8> 2B9D>?D; (;7>;B8U 1he use o sae sleep resources like Continuing
Lducation Program on Sudden Inant Death Syndrome ,SIDS, Risk Reduction by NIClD
should be used to proide inormation and tools needed to communicate and model SIDS
risk reduction messages eectiely and quickly.
6. ,9<E; C: +7>?D?=9>CBO 5E?L97D;U lospitals should consider practice policies that encourage
the deliery o anticipatory guidance or proiding a sae inant sleep enironment to caregiers
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o inants wheneer they are encountered within the hospital ,e.g. well inant isits, sick isits,
Lmergency Department isits, subspecialty care isits,.
. #7DCEB9M; 6B;98>:;;L?7M3 Breasteeding, especially during the irst 6 months, has been shown
to reduce the incidence o Sudden Inant Death by as much as hal, as long as sae sleep practices
are ollowed ater. Paciier use is also encouraged and may hae a protectie eect ater the inant
has been weaned o breasteeding.

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69DS !C 4<;;= 2C8?>?C7
Studies hae consistently demonstrated that the practice o placing inants on their back to sleep
is linked with signiicantly decreased rates o inant deaths, as opposed to those placed to sleep
on their stomachs or sides.
1he inant should be placed on his,her back during eery nap time, in eery setting- at home, in
childcare, or during traelling.
Placing inants who usually sleep on their backs to sleep on the stomach is a high risk actor or
sudden inant death.
Inants who are able to roll themseles on their stomach, usually ater 5 months o age, need not
be repositioned during sleep.

49:; 4<;;= #7T?BC7A;7>
1he saest place or an inant to sleep is a hard surace such as a crib or bassinet that complies
with the Consumer Product Saety Commission recommendations. Places like couches, soas, car
seats and adult beds are unsae sleep enironments or inants, and may increase chances o
suocation and entrapment.
1he sleeping surace should be coered with only a irm mattress and itted sheets. Other
extraneous items like sot bedding, pillows, blankets or comorters increase the risk o
strangulation, suocation and oerheating and should not be placed in the crib. Inant positioners
and bumpers are also sleep hazards and should also not be used.
1he inant should ideally be put to sleep in itted sleepwear at a comortable temperature.

0CCAZ8Q9B?7M PE> 7C> P;LZ 8Q9B?7M
Room- sharing, or placing an inant`s cradle or bassinet in the same room as the care gier has
shown to be linked with lower rates o Sudden Inant Death, especially during the irst 6 months
o the inant`s lie.
Sharing a sleeping surace has, on the other hand, been consistently demonstrated to increase the
risk o suocation and entrapment. 1he risk signiicantly increases when the caregier has
consumed alcohol, is sedated, or excessiely tired.

6B;98>:;;L?7M
Breasteed your baby or as long as possible, preerably or the irst year o lie. Ater
breasteeding 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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Maternal smoking and exposure to tobacco smoke is a ery important risk actor that has been
shown to play a role in almost a third o sudden inant deaths, with risk increasing exponentially
with increasing leels and requency o 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 o the child: babysitters, grandparents, siblings,
child care proiders, boyriends, and other caregiers.




vort roriaea b, Yate |virer.it, Ma.ter. iv Pvbtic eattb tvaevt, .v/eeta bvta.


i
http:,,www.innoations.ahrq.go,content.aspxid~393
ii
http:,,www.ncsl.org,research,human-serices,shaken-baby-syndrome-preention-legislation.aspx., see also
https:,,www.medstarhealth.org,Pages,Serices,Pediatrics,MedStar-lranklin,Pediatric-Community-Serices-and-Lents-at-MedStar-lranklin-
Square.aspx4Sleep ,outlining lranklin Square lospital in Baltimore Maryland`s aidait program or both sae sleep and Shaken Baby Syndrome,.
iii
http:,,www.cpsc.go,en,Newsroom,News-Releases,2014,New-Inant-Bedside-Sleeper-Standard-Approed,