During a six-week stretch in December and January, six infants died in their sleep in homes around Baltimore.
It was the worst spate of sleep-related infant fatalities since the city began a campaign in 2009 to teach new mothers how to avoid such a tragedy, and health officials say they are trying to understand what happened and how to bolster the program.
“We watch the trends really carefully and we know when there are any deaths,” said Rebecca Dineen, assistant health commissioner for the city’s Bureau of Maternal and Child Health. “It obviously alarmed us and we wanted to do something immediately.”
Dineen leads the B'more for Healthy Babies campaign, which promotes proper sleep practices so babies don’t suffocate, become strangled or inexplicably die before they are a year old. She said the latest deaths are especially devastating because they might have been prevented if caregivers better understood the risks.
Sleep-related deaths remain rare. In Baltimore, they trended down from a high of 27 in 2009 to a low of seven in 2016, before rising to 13 last year, according to department data. But the rash of recent deaths, occurring once a week for six weeks, was a rate not seen before.
By contrast, there were 17 juvenile homicides last year in Baltimore, about one every three weeks, police records show.
Health officials could not say definitively what caused the infant deaths, and there haven’t been any more sleep-related deaths this year.
But they said in a majority of homes babies were put down improperly in a crib and a member of the household was smoking tobacco, e-cigarettes or marijuana. The campaign calls for babies to be alone, on their backs, in a crib and in a home where caregivers don’t smoke — pitched as the A-B-C-D method, for alone, back, crib, don’t smoke.
The caregivers’ actions raised the risk of death and show the challenge in educating successive generations of parents about safe sleep, as well as how to address new risks such as vaping, said Dineen and Dr. Olufunke Pickering, a health department medical adviser in maternal and child health.
“Some people believe that vaping is a safer alternative to smoking cigarettes and it isn’t; it has a higher percentage of nicotine and is dangerous to that infant,” Pickering said. “And women may be getting mixed messages about using marijuana in pregnancy and after. That is also not safe.”
It’s not entirely clear why some of the safe sleep advice is effective, though data shows it is. For instance, they believe sleep-related deaths may be linked to harm caused by the chemicals in smoke to brain development during pregnancy and infancy, and smoke may reduce the oxygen in the air.
The key to the campaign is consistency, said Amber Summers, a senior program officer for the Johns Hopkins Center for Communication Programs, which helped craft B’more for Healthy Babies’ messaging.
The campaign will keep using A-B-C-D in messages, though in response to the recent deaths, officials plan to add a new hashtag, #NotOneMoreBaltimore. They also plan to enlist more messengers that are trusted in the community, including churches, dozens of which already participate in an April event called Precious Purple Sunday where leaders speak to their congregants about safe sleep.
“The more often people hear a message consistently the better,” Summers said. “And if they are hearing it from an established and trusted source, then that helps make message more powerful.”
The campaign will continue to push the message through a video shown to new mothers in area hospitals and other places new mothers visit such as the Baltimore Health Department offices for WIC, or Women, Infant & Children, which provides access to food, breastfeeding support, nutritional information and other services.
Crystal Pajardo sat next to her week-old daughter Dylan as she watched the video recently at a center in northeast Baltimore. It was her third time, having watched it already in the hospital after the birth of both her babies. She thinks the video, with teary testimonials from mothers who lost babies, is effective in dissuading women “who think it’s okay for their babies to be in bed with them.”
The Cedonia mother said she understands that new mothers are exhausted, up every couple of hours for feedings, and can fall asleep in bed with their babies or decide to leave them there.
“It makes it easier,” Pajardo said. “But if they stopped breathing there isn’t anything you can do.”
Nationally, the American Academy of Pediatrics promotes the same safe sleep habits as Baltimore. The group also emphasizes breast feeding, use of pacifiers and routine vaccinations, which appear to protect infants from sleep-related deaths.
The group reports that about 3,500 infants die a year around the country, a relatively constant statistic since the late 1990s. It’s the third leading cause of infant death behind congenital malformation and low birth weight, and the top killer after the first month.
The number would drop if every city adopted Baltimore’s campaign, said Dr. Michael H. Goodstein, division chief of neonatology at WellSpan, a York, Pa., health system. He’s also a member of the American Academy of Pediatrics’ task force on sudden infant death syndrome, the name for sleep-related deaths that are unexplained, largely because no one witnesses them.
He was surprised by the recent deaths in Baltimore, but said they show the importance of continuing the campaign to reach everyone, including baby sitters and grandparents who may have outdated information about sleeping with babies, covering them with blankets or using crib bumpers, or putting them on their bellies, all of which can constrict breathing.
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“It’s shocking,” he said about the deaths. “Maybe we should stay shocked all the time. One death is too many. If nationally 3,500 die a year, that’s a huge number, like one baby dying every two, three hours every day of the year.”
Goodstein noted Baltimore halved its death rate by making the message simple. Other cities are beginning to adopt the strategy, including Philadelphia. He shows the B’more for Healthy Babies video to his own patients.
He stressed that such deaths occur in families of all income levels, race and ethnicity, though there is a racial disparity that is not fully understood. Black infants are twice as likely to die as white babies. Some of the disparity may have to do with poverty, with poor black women facing more barriers to prenatal care, stable housing, obtaining a crib and breastfeeding.
In cities with high rates of opioid use, parents may be absent or too impaired to wake from sleep if they roll onto their babies.
High rates of both poverty and drug use may explain why, despite Baltimore’s successes, the city’s death rate remains more than twice the nation’s, Goodstein said.
Local officials recognize the challenges, said Khalilah Slater Harrington, the Family League of Baltimore’s chief program officer and co-lead of B’more for Health Babies. The program aims to get cribs to new mothers as well as links to other social services and health care. Workers go door-to-door to reach women in some neighborhoods, which can go years without an infant death.
“We need to continue the conversation to make sure every person in our community is aware, not just about the value of life but about reducing the social determinants of health and replicating those habits that work with infants and children,” Harrington said. “One baby gone is too much.”