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Infant Suffocation Prevention Models

Suffocation deaths are the result of an airway obstruction from a foreign object that hampers breathing and deprives the lungs of oxygen. Deaths from suffocation may include strangulation or asphyxiation from foreign objects, such as bedding and bed clothing, as well as choking on or breathing in food or other objects.

In 2018-2019, suffocation was the leading cause of unintentional injury death among children younger than 1 year in both urban and rural areas. However, suffocation deaths among children aged under 1 year are much higher in rural areas (42.1 per 100,000) than in urban (24.9). Rural rates of suffocation deaths are also higher than urban rates among children ages 1 to 13. Because suffocation is more common in infants than in adults, most suffocation prevention efforts focus on creating safe sleep environments for infants.

Health Messaging and Educational Tools

In June 2022, the American Academy of Pediatrics (AAP) issued Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. The AAP recommendations for a safe sleep environment to reduce infant sleep-related deaths include:

  • Placing infants on their backs to sleep
  • Using a firm, flat sleep surface
  • Having infants sleep in the same room as caregivers, but on a separate surface (room sharing without bed sharing)
  • Keeping soft objects away from the infant sleep area
  • Avoiding overheating

The AAP recommends that healthcare providers and childcare providers encourage and model guidelines for safe infant sleep, that media and manufacturers follow safe sleep guidelines in their messaging and advertising, and that the National Institute of Child Health and Human Development (NICHD) continues its “Safe to Sleep” campaign.

Education campaigns and health messaging usually focus on caregivers of infants. However, some interventions focus on training healthcare or childcare professionals about safe sleep to educate and model safe sleep environments to caregivers.

Legislation and Regulation Efforts

Legislation and regulation increase the likelihood of adherence to guidelines by making safe sleep activities required by law. About 20% of sudden infant death syndrome (SIDS) deaths in the United States happen in a childcare facility. Accidental suffocation during sleep is thought to be a potential cause of SIDS. In the 1990s, many states began to implement regulations on infant sleep positioning and sleep environments in child care. The requirements included in these regulations vary widely between states. Most states regulate infant sleep position in licensed childcare facilities, but fewer than half require safe sleep training for childcare providers.

In June 2022, the Safety Standard for Infant Sleep Products went into effect. The federal rule makes it unlawful to sell non-compliant sleep products for infants as of June 23, 2022. The new rule is meant to remove potentially dangerous sleep products from the marketplace, including products that do not comply with the Consumer Product Safety Commission's safety standard for bassinets and cradles.

Examples of Health Messaging and Education Programs for Caregivers

  • Tennessee's Safe Sleep Diaper Bag Project builds upon evidence-based home visiting and care coordination programs to offer safe sleep education and resources to caregivers. To improve adherence to the AAP safe sleep guidelines, home visitors provide caregivers with safe sleep education and a diaper bag including a sleep sack, a onesie, safe sleep books, and other safe sleep promotional materials.
  • There is evidence that mobile health (mHealth) messaging may improve caregiver adherence to safe sleep practices. mHealth interventions distribute health messages by text message or email. Health messages may include educational videos, parent testimonials, answers to frequently asked questions, and solutions to common barriers to creating safe sleep environments. The SIDS Center of New Jersey has developed two safe infant sleep mobile apps that present safe sleep guidance, tips, and links to resources. The apps are free, with one app available in both English and Spanish.
  • The Injury Prevention Center at Arkansas Children's partners with local communities to provide “Safety Baby Showers” for expectant mothers. Caregivers who attend the shower receive education about safe sleep, as well as home and motor vehicle safety.

Examples of Health Messaging and Education Programs for Healthcare and Childcare Professionals

  • The Cribs for Kids' National Safe Sleep Hospital Certification program recognizes hospitals that teach and model the AAP recommendations for infant safe sleep. Certification is awarded at three levels — bronze, silver, and gold — based on the number of activities the hospital demonstrates. All levels require the implementation of a site-wide safe sleep policy and education for nursing staff. The silver level requires the implementation of quality improvement initiatives, and the gold level requires providing education to at-risk caregivers in need of safe sleep assistance as well as engagement in community outreach initiatives.
  • As a part of the state's larger safe sleep campaign, the Tennessee safe sleep hospital project was launched by the Tennessee Department of Health (TDH) to increase awareness of safe sleep practices within hospitals. By participating in the project, hospitals agree to develop and implement a hospital safe sleep policy that requires annual education for perinatal staff, modeling of safe sleep recommendations by staff, conducting quarterly compliance audits, and submitting activity reports to the TDH. In return, hospitals receive educational materials to distribute to new parents and statewide recognition.
  • The Baby Sleep Basics Program in rural Sumter County, Florida distributes playards to parents meeting income requirements upon completion of an educational training. The educational program teaches parents, grandparents, and caregivers about how to create a safe sleep environment to avoid unintentional asphyxiation. An analysis of Bedtime Basics for Babies, a program that distributed free cribs and safe sleep education to families with low incomes, found that program participation led to a reduction in bedsharing and increased maternal knowledge of safe sleep recommendations.

Implementation Considerations

Health messaging and education are an important method for disseminating information to new parents and other caregivers on providing safe sleep environments. However, health messages are frequently reduced to short sound bites that do not convey the reasons behind the safe sleep recommendations. For example, some caregivers worry about their infant choking if placed on their back to sleep. Healthcare providers and childcare providers should be equipped to explain the rationale for safe sleep recommendations, including information about how babies' anatomy and gag reflex can prevent this from happening when on their back.

Removing known barriers to safe sleep. A safe sleep environment consists of a firm sleep surface in the parents' room without blankets or other soft items, but not in the parents' bed. However, finances may not allow a new parent to afford a crib or bassinet which may lead to bedsharing. Incorporating crib distributions into safe sleep programs improve both knowledge and practice about safe sleep practices.

Recognizing cultural traditions. When implementing educational programs to caregivers, educators — including healthcare providers — should present information in a culturally appropriate and respectful manner. NICHD has adapted its Safe to Sleep campaign to deliver culturally sensitive messages about safe sleep to American Indian and Alaska Native families. The Healthy Native Babies Project offers a six-part video series including train-the-trainer sessions, as well as a workbook, toolkit, and facilitator's guides.

Program Clearinghouse Examples

Resources to Learn More

First Candle
A collection of safe sleep resources to prevent Sudden Infant Death Syndrome (SIDS) including tips, recommendations, and frequently asked questions.
Organization(s): First Candle

Safe to Sleep
A collection of safe sleep information and resources for parents, families, healthcare providers, childcare providers, and other caregivers.
Organization(s): Eunice Kennedy Shriver National Institute of Child Health and Human Development

Safe Sleep Practices and SIDS/Suffocation Risk Reduction
A compilation of national safe sleep standards for all individuals involved with childcare from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs.
Citation: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education.
Date: 2012