Abstract
We conducted a retrospective review of incidents associated with co-sleepers. A total of 26 incidents (6 deaths and 20 injuries) were reported to the Consumer Product Safety Commission. Of these, 5 deaths were caused by asphyxia, and 1 was attributed to sudden infant death syndrome (SIDS). The mean age at death was 3.1 months. Two-thirds of deaths had known risk factors for SIDS. Of the 20 injuries, entrapment (60%) and suffocation (35%) hazards were most common. Almost half of the injuries occurred after the co-sleeper was improperly assembled. Infant deaths and injuries associated with co-sleepers are infrequent. Most deaths were associated with other SIDS risk factors. Many deaths and injuries were associated with improper use or assembly of the co-sleeper. It is important for pediatricians to advise parents not to use previously owned co-sleepers or to use co-sleepers in any way other than what is specifically stated in the product instructions to avoid infant injury or death.
Introduction
After the American Academy of Pediatrics (AAP) recommended in 1992 that all healthy infants be placed in a nonprone position for sleep, there was a drastic decline in the incidence of sudden infant death syndrome (SIDS). 1 More recently, the decline in incidence of SIDS, which is defined as a sudden death that remains unexplained after thorough investigation, 2 has plateaued, but the incidence of other sleep-related deaths caused by suffocation, asphyxia, and entrapment has increased. 1 This trend prompted the AAP’s revised and more inclusive guidelines for a safe infant sleeping environment in 2011. 1 These most recent AAP policy statement recommendations include supine position while sleeping, use of a firm sleep surface, room-sharing without bed-sharing, keeping soft or loose objects and bedding out of the sleeping area, avoiding smoke exposure, breastfeeding, avoiding overheating, and immunization of infants. 1 However, more than 4000 infants a year in the United States continue to die suddenly and unexpectedly. 3
Despite the evidence behind these recommendations, there are often cultural barriers or personal beliefs that keep parents from following these guidelines. For instance, despite evidence that bed sharing may increase the risk of SIDS and other sleep-related infant deaths, 4 many parents desire to bed-share in order to be close to their child, to promote bonding, and for ease of feeding. 5 Many also feel that it is safer to have the infant in bed with them than in a crib, so that they can be more attuned to how the infant is sleeping. 5 The decision on whether or not to bed-share is sometimes further complicated by some health professionals continuing to promote bed-sharing as a way to improve sleep patterns and facilitate breastfeeding. 6 Studies show that bed-sharing is common; 76% of American mothers, 7 72% of Canadian mothers, 8 and 65% of British mother 7 report bed-sharing.
Co-sleepers could be seen by parents as a safe way to bed-share with their infants. There are 2 basic models of co-sleepers, one that attaches to the side of the bed (bedside co-sleeper) and one that is meant to be placed in the bed (in-bed co-sleeper). There have been many studies investigating the safety of bed-sharing, but little research has been done on the safety of using co-sleepers as a potential compromise for parents wishing to have the infant close to them without exposing their infant to the risk of bed-sharing. Therefore, we reviewed data collected by the Consumer Product Safety Commission (CPSC) relating to infant deaths and injuries that were associated with co-sleepers to determine any safety risks created by these co-sleepers and possible strategies for minimizing these risks.
Methods
We conducted a retrospective review of all incidents, including death and injuries, involving co-sleepers reported to the CPSC. Reporting to the CPSC is voluntary and can be done by fire, police, and insurance investigators; coroners and medical examiners; health care personnel; and manufacturers, retailers, and consumers. Information is obtained from death certificates, medical examiner and coroner reports, police and fire department reports, and media accounts. Data were obtained through a Freedom of Information Act request. We requested all incidents with the following search terms: co-sleeper, close sleeper, bedside sleeper, and portable infant sleeper. We also requested information on reports associated with the trade names of commonly used co-sleepers. CPSC staff searched 3 CPSC databases: the In-Depth Investigation file (INDP), the Injury or Potential Injury Incident file (IPII), and the Death Certificate file (DTHS). Two of the databases (IPII and DTHS) contain information from death certificates and reports from medical examiners, coroners, emergency personnel, and media. 9 Additionally, the CPSC conducts in-depth investigations, including interviews with family members, witnesses, and other local officials on an as-needed basis about specific cases; the investigation reports are housed in the INDP database.
After receiving the cases, to identify hazard patterns, we reviewed the information on demographic characteristics, type and mechanism of injury, cause of death when applicable, associated environmental risk factors, and involvement of co-sleeper in the incident. This study received exemption from review by the institutional review board of Children’s National Medical Center.
Results
A total of 30 cases provided by the CPSC were reviewed. Four of these cases were reports that parents felt that their co-sleeper was unsafe but did not include any description of an injury, so these cases were excluded. Finally, 26 cases associated with co-sleepers, including 6 deaths and 20 injuries, were analyzed (Tables 1 and 2).
Infant Deaths Associated With Co-sleepers (n = 6).
Particular model involved in case recalled in 2008.
Similar to model recalled in 2008 but not included in recall.
Injuries Associated With Co-sleepers (n = 20).
Abbreviations: F, female; M, male.
Deaths Associated With Co-sleepers
There were 6 infant deaths associated with co-sleepers. Four of the infants were female (67%), and 2 were male (33%). The mean age of death was 3.1 months, and the median age was 2.3 months. Two infants were white, 2 were black, and 2 were of unknown race. The cause of death was determined to be asphyxia for 5 infants (83%) and SIDS for 1 infant (17%). Half of the deaths were associated with the same model of an in-bed co-sleeper. The other half of the deaths were associated with bedside co-sleepers from a single manufacturer. In the bedside co-sleeper deaths, it is presumed that the co-sleeper was being used as a portable crib because all 3 infants were found in a space that would have been connected to the adult bed if the co-sleeper had been used as such.
In 2 infant death cases, there were no known risk factors for sudden and unexpected infant death documented. In the remaining 4 cases of infant deaths, the infant was placed and/or found in the prone position. In 1 case, the mother stated that she had placed the infant in a supine position but later said that she might have placed the infant on the side; this infant was found in a prone position. Three cases had blankets, clothes, pillows, or other loose bedding in the sleeping area, and 1 case had bumper pads in the sleeping area. Parental risk factors included 2 cases that were associated with young maternal age and 1 case that involved known smokers in the home. With regard to infant risk factors, 1 infant was born prematurely, and 1 infant was unvaccinated. Although not specifically known to be risk factors for sudden and unexpected infant death, 2 cases had complex social situations that possibly contributed to an increased risk of an adverse event. In 1 case, the infant was HIV positive, and the other case involved reports of possible mental retardation in the infant and abuse among family members.
The bedside co-sleeper involved in one of the cases was recalled in 2008 because even proper use resulted in a hazardous gap that imposed an entrapment or suffocation risk. The infant death occurred approximately 1 month after the recall was announced by the CPSC.
Injuries Associated With Co-sleepers
There were 20 injuries reported to be associated with co-sleepers. More than two-thirds (14, 70%) were associated with bedside co-sleepers, with the remaining 6 (30%) associated with in-bed co-sleepers. Less demographic and environmental information was available for these incidents than for the reported infant deaths. Demographic information was available for 15 infants with injuries; 9 (60%) were female and 6 (40%) were male. The mean age was 4.8 months, and the median age was 5 months, with a range of 5 days to 8 months.
Entrapment hazard was the most common injury, found in 12 cases (60%), with suffocation hazard the second most common, found in 7 cases (35%). In 9 cases (45%), the infant was found hanging off or having fallen out of the co-sleeper, thought to likely be a result of the infant rolling over. However, in 2 of these cases, parents specifically noted that the infant was unable to roll or otherwise move. Another 9 cases involved the infant becoming trapped in gaps and spaces created by the co-sleeper (45%). In 1 case, the parent’s pillow could cover the infant even when the co-sleeper was correctly placed in the bed. Another case involved a large amount of mold found underneath the pillow cover. Nine cases (45%) were associated with improper use or assembly of the co-sleeper. Several of the reports indicated that injuries could have been fatal if the infant had not been under close supervision at the time of the incident.
Discussion
In this article, we describe details of 6 infant deaths and 20 infant injuries associated with bedside and in-bed co-sleepers, as reported to the CPSC, to illustrate potential hazards of these environments. Overall, infant deaths and injuries associated with co-sleepers are rare, but these cases illustrate that there are suffocation and entrapment risks associated with these products.
Two-thirds of the deaths reported in this study were also associated with known risks for sudden and unexpected infant death. 1 Caregivers should be aware that the risks of prone sleep position and soft or loose bedding in the sleep area are also risk factors when using a co-sleeper. In addition, co-sleepers, in particular in-bed co-sleepers, may share some of the risks of bed-sharing, because one reported injury involved the infant being covered by the father’s pillow, and another case involved the infant somehow ending up next to the father in bed.
Furthermore, health care providers should also advise caregivers to use these and other infant care products as directed. This includes proper assembly of co-sleepers; 45% of infant injuries and 2 deaths were associated with improper assembly or use of the product, and the infants were found in a gap in the bedside co-sleeper that should have been closed off by being attached to the bed or by a fabric covering. However, it should be noted that one of the models associated with an infant death was recalled in 2008 because of an exposed gap, even with proper assembly. Use of previously owned baby products should also be discouraged because assembly instructions and complete parts may not be provided.
We acknowledge that this study is limited by the data source. Because CPSC investigations are conducted in response to specific incidents involving a product, this creates bias. Reports are anecdotal, with much variability in the type and amount of information available for each case. In addition, this review encompassed various manufacturers and models for these products. Furthermore, because reporting is voluntary and ongoing, this should be considered an underestimate of the deaths and injuries associated with co-sleepers and not a statistical sample. Finally, because there are no data about the total number of consumers who use co-sleepers and because this review represents an unknown proportion of adverse events, this study cannot calculate rates of death or injury associated with these products.
In 2014, in response to these and other incidents, the CPSC issued a mandatory safety standard for bedside sleepers, 10 which stipulates testing to ensure a minimal gap between the adult bed and the co-sleeper, so that entrapment dangers are minimized. In addition, bedside sleepers should meet the mandatory safety standard for bassinets, 11 which includes requirements for stability, structural integrity, mattress flatness performance, and side heights.
It is hoped that improved engineering of these products will result in fewer incidents. In addition, health care providers should continue to advise caregivers to follow the AAP safe sleep guidelines for all infants in all sleep environments. 1
Author Contributions
ELT acquired and analyzed the data and drafted the manuscript. RYM conceived of and designed the study, interpreted the data, and revised the manuscript critically.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.