Safe Sleep is an investigative series examining what risk factors were present in more than 1,300 incidents of infant death over an 11-year span in Canada.
Early one morning in 2018 inside a home in British Columbia, a fussing baby was placed to sleep on their stomach on the chest of a family member.
The relative, who was lying on a couch, fell asleep, too. When they awoke, the one-month-old was unresponsive and not breathing.
It’s a tragic scenario that’s occurred for multiple families across Canada, as detailed in records obtained as part of a CBC News investigation into infant deaths during sleep, which found at least 1,338 infants died with unsafe sleep risk factors present between 2009 and the end of 2019.
The infant in B.C. died a natural death from pneumonia, according to a coroner’s report, but bed sharing with the relative on a couch was listed as a contributing factor.
“Perinatal [Services] BC recommends that a baby be placed to sleep alone on a firm mattress such as a crib, cradle or bassinet,” the report says.
“A safe sleep surface reduces the risk of suffocation which can be increased in infants with compromised breathing due to a respiratory infection.”
When the infant was born a month earlier, the family asked the province for help “as an appropriate sleep surface was not available” for the baby. A crib was provided, but it hadn’t been set up at the time of the baby’s death.
Some experts who talked to CBC say such societal inequities and systemic issues must be addressed, and that safe sleep should be a higher priority both federally and provincially. They include Dr. Ian Mitchell, a pediatric respirologist at Alberta Children’s Hospital.
“This is not a new problem,” said Mitchell, who also teaches at the University of Calgary.
“Every death of a child is a tragedy. These are, as far as we can tell, otherwise healthy children who would be productive citizens of our society and contribute to society.”
Health Canada’s infant safe sleep guidelines spell out actions and environments that can put an infant at higher risk of death. Risk factors include a baby being placed to sleep in a position that increases the risk of suffocation or asphyxiation, such as on their stomach instead of their back.
It also includes infants sleeping on a surface that can contribute to suffocation, such as a soft mattress or pillows or a surface cluttered with items, or sharing a sleep space with an adult or another infant.
Bed sharing puts the baby at risk of suffocation and other hazards, according to the federal health agency.
61 per cent of infants were bed sharing
In each province and territory, CBC requested reports from coroners and medical examiners that detail the deaths of children who were younger than 12 months, where there were unsafe sleep risk factors present.
Some jurisdictions provided full coroner or medical examiner reports, while others provided statistics, summaries or heavily redacted reports. Some jurisdictions didn’t provide enough detailed information to include those cases in the analysis.
CBC had enough information to analyze about one-third of the 1,338 deaths — specifically, 476 infant deaths in five provinces and three territories.
At least 61 per cent of the 476 infants who died had been bed sharing, the information provided to CBC shows.
The records show that in at least 77 per cent of cases, the infant had been sleeping on a surface not recommended as safe by health officials, including an adult bed and a couch.
In some cases, whole families slept together on a mattress on the floor. In others, the baby was placed to sleep in an adult bed or on a couch after feeding. In all, the details were difficult, describing parents, over and over again, waking up to find their baby was no longer breathing.
The findings are similar to data published by Statistics Canada last year that showed more than 90 per cent of infants who died in their sleep between 2015 and 2020 were “in an unsafe sleep environment.”
The researchers found more than half (53 per cent) of the infants who died suddenly in their sleep during that time frame were sharing a bed with one or more people.
“There may be factors involved in a sudden and unexpected sleep-related infant death other than those discussed here, such as underlying genetic, metabolic or other biological factors,” the Statistics Canada study says.
“In addition, the full circumstances surrounding infant sleep-related deaths is not always known, as the event is not often witnessed.”
‘I wish I had known’
Dr. Rachel Moon has spent decades researching Sudden Infant Death Syndrome, or SIDS, and trying to promote safe sleep.
It’s a difficult topic to study, but the professor of pediatrics at the University of Virginia’s medical school does it for the families she’s met.
“Almost every week, I talk to a family who’s lost the baby, and it’s heart-wrenching,” Moon said. “And many times, it doesn’t have to have happened.”
For Moon, prevention starts with understanding why parents do what they do.
Parents often bed share because it’s easier for breastfeeding, Moon said. Health Canada guidelines say parents can minimize risk by putting the baby back to sleep in a crib, bassinet or cradle after their feeding, instead of allowing them to sleep in an adult bed.
Other times, parents see unsafe sleep practices being shared on social media. While images of children sleeping with an adult on a couch might seem cute, Moon said it’s also very dangerous.
Once experts understand the reasoning behind parents’ actions, it’s easier to tweak the message about what is actually safe and ensure it reaches parents.
“We’re trying to explain to parents why some of the things that they believe are not true,” Moon said.
Moon doesn’t believe it’s possible to prevent every infant from dying in their sleep because she said there are genetic components that researchers still don’t understand. But she believes “the vast majority” of deaths could be prevented.
“I think that for many of the families, it’s just that they didn’t understand,” Moon said.
She said some parents might have thought bed sharing was OK because they’d done it before and it turned out fine.
“And that’s the thing that the parents keep telling me: I wish I had known.”
Cause of death language a concern, experts say
In some cases analyzed by CBC, the unsafe sleep risk factor was listed as a contributing factor in the baby’s death. In others, death investigators couldn’t be sure of the significance.
It’s a familiar dilemma for Ontario’s chief coroner, Dr. Dirk Huyer.
In Ontario, at least 539 infants died in unsafe sleep environments between 2009 and January 2021, according to data provided by the coroner’s office.
When describing those cases, Huyer is careful to say the infants died in unsafe sleep environments, but not necessarily from the unsafe sleeping arrangement. In many cases, the manner and cause of death are marked as undetermined.
“We don’t know why their babies died, despite multiple efforts and multiple tests and multiple ways to try and figure it out,” he said.
Huyer does see bed sharing as a risk, but said that given how many people share a bed with their infants at some point, if there was a more direct correlation between bed sharing and infant death, “we would likely be seeing many more children dying.”
Mitchell sees safe sleep practices as being similar to wearing a seatbelt in a car — it may not prevent car crashes, but it can prevent deaths.
“Many of our medical problems, we never have the last word,” he said.
“We have to go on the information we have and do what we can to save lives.”
New sleep guidelines issued in 2021
Last fall, Health Canada and the Public Health Agency of Canada released an updated joint statement on safe sleep, written with the Canadian Paediatric Society and Baby’s Breath, a national charitable organization with a focus on SIDS.
“Sharing a sleeping surface increases the risk of SIDS, suffocation from overlay or entrapment, and overheating,” the new guidelines say, noting that children born pre-term are more at risk, as are those sharing with a parent or caregiver who is a smoker, has been drinking or using drugs or is “overly tired.”
But the guidelines don’t explicitly say parents shouldn’t share beds with infants.
“Although bed sharing is not advised, parents/caregivers should be aware of the factors that put infants at greatest risk when bed sharing so they can take steps to avoid them,” the guidelines say.
The federal health agency declined a request for an interview about the guidelines.
In an emailed statement, a spokesperson cited data that shows bed sharing is common among parents, “despite over a decade of advising parents not to bed share.”
“This may indicate the need for new messages/approaches, such as those that help parents make informed decisions — which is the direction [the Public Health Agency of Canada] took with its latest updates to its safe sleep resources.”
‘They don’t have to die’
Decades of work have been done in Alberta, Mitchell said, to make sure health-care professionals are giving the same messages to parents about safe sleep.
It’s also crucial that messages don’t blame parents but deliver key facts, he said.
“We have to be very careful we’re not so reassuring that we deny the undeniable facts: That taking the baby into bed with you increases the risk.”
Beyond changing behaviour, Moon sees sleep-related deaths as a systemic issue that requires fixing inequities in society, such as access to safe housing and drinking water. It’s addressing what leads to a whole family sleeping on a mattress on the floor.
“There are huge disparities and I think that that’s been reported, wherever there are minority populations, disparities have been reported,” she said.
Over her career, Moon has watched the Back to Sleep campaign dramatically decrease infant deaths in the 1990s, when health professionals started advising parents to place their babies to sleep on their backs. The SIDS rate in the U.S. dropped by more than 50 per cent during a five-year period between 1994, when the campaign began, and 1999, according to federal health data.
In Canada, the SIDS rate decreased by 50 per cent between 1999 and 2004, also coinciding with recommendations for parents to place their babies on their backs to sleep, Health Canada says.
But Moon feels momentum has been stalling.
She thinks more infants could be saved if governments made it a priority
“There are still babies dying, and they don’t have to die,” Moon said.
“And if we made changes in how we take care of these babies in terms of how they sleep, where they sleep … I think that … more of them would live to see their first birthday.”
In the next part of the series, CBC looks at why some provinces are reporting an over-representation of Indigenous infants in sleep-related deaths, and why other regions aren’t keeping track at all.