Warnings About Infant Bedding Risk Are Often Unheeded

Laura Putre

December 01, 2014

Many infants remain at risk for sudden infant death syndrome and unintentional sleep-related suffocation because of improper bedding, despite years of recommendations to the contrary, according to a new study of infant sleeping practices.

The use of soft objects and loose bedding (blankets, quilts, pillows, and similar materials deemed dangerous to infant sleep) decreased between 1993 and 2010 but remains a significant problem, researchers found.

Carrie K. Shapiro-Mendoza, PhD, MPH, from the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia and colleagues found that from 2008 to 2010, 54.7% of infants were still being put to sleep with dangerous bedding. This was down from 85.9% in 1993 to 1995, they report in an article published online December 1 in Pediatrics.

Despite the overall decrease, the decline in the use of hazardous bedding has slowed over time, and "[b]edding use for infant sleep remains common despite recommendations against this practice," the authors write.

Regardless of socioeconomic background, at least half of mothers put infants to sleep with hazardous bedding, the authors found.

Dr Shapiro-Mendoza and colleagues analyzed 1993 to 2010 data from the National Infant Sleep Position study. This annual telephone survey asked nighttime caregivers about infant sleeping practices such as sleep position and use of bedding, as well as sociodemographic questions to determine race, ethnicity, age, and educational background.

Rates of sudden infant death syndrome, the leading cause of infant death, have decreased slowly in the United States, going from 66.3 per 100,000 live births in 2000 to 52.7 per 100,000 in 2010. However, infant deaths related to unintentional sleep-related suffocation have more than doubled during that period, going from 7.0 live births per 100,000 to 15.9 per 100,000.

In an accompanying editorial, Rachel Y. Moon, MD, from the Goldberg Center for Community Pediatric Health, Children’s National Medical Center, Washington, DC, and the Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, and Fern R. Hauck, MD, from the Department of Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, called the slowing rate of decline in the use of hazardous bedding "disturbing."

They note that according to the report, 50% of US parents and two thirds of black and Latino parents "continue to use thick blankets, cushions, pillows, and other potentially hazardous soft bedding, either under or covering the infant."

Noting that there was no decline in the use of bedding under the infant since the survey began in 1993, the editorialists hypothesize (with the help of information gathered in the study and in focus groups) that parents persist in using soft bedding because they think the baby will be warmer/more comfortable. In addition, parents may also misinterpret the recommendation to place the baby to sleep on a "firm surface" as a taut surface and think that if they just pull the bedding tightly, they are following the recommendation. Caregivers may also mistakenly think that the recommendations apply only to bedding placed over the baby, not under, and use pillows and comforters on the sides of beds and couches to prevent the baby from rolling off.

"Recent trends in potentially hazardous bedding use tell us that current efforts to launch the new Safe to Sleep Campaign are coming at an opportune time," they write. "This new campaign broadens the message emphasizing the need to place infants on the back ("Back to Sleep") to one that emphasizes the importance of looking at the entire sleep environment, which includes potentially hazardous bedding use."

Clinicians can better inform parents about proper bedding use by addressing their concerns about the baby's warmth and comfort, the editorial states, suggesting alternatives like sleeper clothing instead of blankets. They can also clarify the meaning of the word "firm" and "emphasize that thick blankets and cushions should not be placed anywhere in the infant's sleep environment, "neither over nor under the infant."

During the years of the survey, the use of hazardous bedding was highest for infants of teenage mothers (83.5%) and lowest for infants born at term (55.6%). Education also played a role: The prevalence of hazardous bedding was 81.9% in infants born to mothers with less than a high school education and decreasing with increasing education level of the mother to a low of 57.7% in mothers with a college degree. Black and Latino mothers also had higher rates of hazardous bedding (75.3% and 76.1%, respectively) than white mothers (63.5%).

In 1996, the AAP made its first recommendations about avoiding soft bedding. In 1996, the Consumer Product Safety Commission, the National Institute of Child Health and Human Development, and the AAP Task Force issued a safety alert recommending that infants "be placed to sleep on their backs on a firm, tight fitting mattress in a crib that meets current safety standards and that pillows, quilts, comforters, sheepskins and other pillow-like soft products be removed from the crib."

The AAP issued an even more strongly worded statement against infant bedding in 2000.

After 2000 through 2010, the emphasis lessened, which "may explain differences in the rate of decline during the 2 periods," said the researchers.

Media images may reinforce misconceptions, the researchers write. A 2009 study in Pediatrics showed that more than two thirds of images in popular magazines showed infants sleeping with potentially hazardous bedding such as blankets and pillows.

The study was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health. The authors and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online December 1, 2014.


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