During the past several years, more public attention has been given to the problem of sleeping accidents involving infants and small children. In 1994, the American Academy of Pediatrics, U.S. Department of Health and Human Services and U.S. Consumer Product Safety Commission (CPSC) joined forces for a “Back to Sleep” campaign. This campaign encouraged parents to place small children on their backs at bedtime as a way to reduce the risk of sudden infant death syndrome (SIDS). Since the initiation of “Back to Sleep”, the incidence of SIDS has decreased by 38 percent. However, there continues to be an unacceptable number of deaths on an annual basis in children who sleep in adult beds. To further define this problem, Nakamura and colleagues performed a retrospective review of fatalities in children in sleeping accidents occurring between 1990 and 1997.

The authors reviewed data collected by the CPSC on deaths that occurred in children younger than two years of age. These deaths were noted to be associated with adult beds, waterbeds and day beds. The information was collected from a variety of sources, including death certificates, medical examiner reports, media articles and referrals from other federal agencies. Cases were assigned to one of four major incident scenarios: (1) death by smothering related to the overlaying of an adult or another child on the victim; (2) positional asphyxia related to wedging between the mattress and the wall, the bed frame or an adjacent piece of furniture; (3) suffocation on a waterbed related to airway obstruction when the child was lying face down; or (4) strangulation related to neck compression between the side railings of a daybed, or the headboard or footboard of a regular bed.

In reviewing information from three CPSC databases, the authors found 515 reported deaths in children younger than two years of age during the seven-year period. There were 121 deaths related to overlaying of the child by a parent, sibling or other adult. Entrapment fatalities from several scenarios occurred in the remaining 394 children. This included 296 on regular adult beds, 79 on adult waterbeds, 10 on adult daybeds and nine on adult-sized beds fitted with bed rails. The majority of these deaths resulted from suffocation or strangulation caused by entrapment of the child's head in various structures of the bed.

Looking more specifically at the deaths related to overlaying, the ages of all 121 children ranged from one to 12 months, with 77 percent occurring in infants younger than three months of age. Only 13 of these cases occurred with waterbeds, and only two involved prior drug or alcohol consumption. The authors cite earlier data that associated breast-feeding and cosleeping in bed as a risk for overlaying deaths but did not specifically address that scenario in this study.

Of the entrapment deaths, 42 percent were caused by wedging of the infant between the mattress and an adjoining wall, 43 percent by wedging between the mattress and headboard or footboard, 8 percent by strangulation involving bed railings, and 7 percent by entrapment between the mattress and an adjacent piece of furniture. Almost 70 percent of these deaths occurred in children younger than six months of age, and 89 percent were in children younger than one year of age.

The authors note the data indicate the majority of sleep-related deaths occur in children younger than one year of age. During the time reviewed for this study, an average of 64 deaths per year occurred, with the majority being preventable. They encourage physicians to educate parents about the dangers of inappropriate sleeping arrangements for infants and small children. Three specific recommendations are noted: (1) children younger than two years of age should sleep in cribs that meet federal safety standards and industry voluntary standards; (2) children younger than two years of age and children with disabilities whose movements are restricted should not sleep in adult beds (including waterbeds) that present any risk of entrapment between the mattress and a wall, footboard, headboard, side railings or adjacent furniture; (3) children younger than two years of age and children whose movements are restricted should not sleep in adult beds with railings that present a risk of strangulation or head entrapment.

editor's note: This report contains some disturbing statistics, which the authors note represent only reported cases and thus are undoubtedly a significant underestimation of the scope of this problem. Their report calls on physicians to discuss the sleeping issue with parents at every well-child visit to help prevent unnecessary tragedies.—j.t.k.