Can we Stick to the Message of Safe Sleep and Prevent Infant Deaths?

Unintentional suffocation is the leading cause of injury and death among infants < 1 year old in the United States with 82% being attributable to accidental suffocation and strangulation in bed.  Understanding the circumstances surrounding these deaths may inform prevention strategies. 

Pediatrics; May 2019

Understanding the circumstances of infant and child deaths has been prominent in my work as the executive director of a Child Advocacy Center, the director of a victims services organization and as a public health consultant.  Over the past 15 years, I have served on a national expert Child Fatality Review Team, a member of a local county team, an advisor to the New York City Council as they developed legislation requiring child death reviews which was signed into law by Mayor Michael Bloomberg, and as a consultant for a developing Fetal/Infant Mortality Review Team.  The mission of all of these initiatives has been to understand the circumstances of infant and child deaths to prevent future deaths.  Reviews are often excruciatingly detailed including the brief lives and relationships, and tragic losses of lives; the understanding never ceases to be heartbreaking.

Reviews I have participated in over the years have included babies who had died from suffocation while in the care of family members, neighbors, friends of the parents.   I have often found myself wide awake late into the night and early morning hours struggling with how these tragic deaths could be prevented.  The American Academy of Pediatrics, the CDC, state departments of health, hospitals and health care providers provide information and training for parents.  The A, B, C’s of Safe Sleep has been promoted in videos, brochures, and on bus stop kiosks.  New parents receive information in hospitals after the birth of their baby; perhaps not the most teachable moment as parents celebrate their baby’s birth, but also adjust to many life changes.  These forms of Safe Sleep education have had varying degrees of success.  But how does this education reach other people who will care for babies?  Grandparents, aunts, uncles, cousins, babysitters, neighbors, friends?  There have been cases of babies placed on a soft sofa, a babies in a bed with another child, babies who died with their faces against a teddy bear or other soft toy.  

In the early morning hours of a recent sleepless night, I came downstairs to my computer and started researching articles and statistics and mostly just thinking about how we as public health professionals could provide education for anyone who would ever care for a baby.  It seemed overwhelming.  At some point I realized that general information, public service announcements, social media, those bus kiosks might not be the answer.  I had the thought that parents needed a tool to educate, remind, inform caregivers and as I glanced around my own desk, my own office and in various places in my house I realized how I remind myself and provide information to others:  sticky notes.  I had several on my desk about bills to pay and other “to do”s, on my refrigerator as a reminder that I was low on milk, and one on the front door to remind visitors to not let the cats out.  Sticky notes with Safe Sleep information could be stuck on a refrigerator, on a wall near where the baby would be sleeping, on a diaper bag.  I had a pang of embarrassment that I was thinking about a tool for parents to protect their babies by using something so simplistic as sticky notes to share Safe Sleep information, but I pushed through that and went to an online print service and bullet pointed the basics, organized the information on a 3×4 sticky note and placed the order.  When they arrived I shared them with several public health colleagues.  Good idea, too small.  I increased the size to 4×6 and organized the information in the A, B, C’s of Safe Sleep and sent it off to where David, the company president not only cleaned up my format removing extraneous punctuation, but gave me a discount on printing.

Besides the basics of Safe Sleep parents leaving their baby will want to assure that the baby is not exposed to second hand smoke, that there is a fire exit, that there are no drugs, weapons, or other dangers in the home.  The Safe Sleep stickies cannot protect against all dangers.  Certainly from my participation in infant death reviews too many and too tragic, I know that saving lives can be complex and requires large scale interventions, medical science and technology, but I also know that saving lives can be accomplished by simple behavioral changes: wearing a seat belt, wearing a mask, throwing away that pack of cigarettes, applying sunscreen, washing our hands for 20 seconds singing Happy First Birthday twice to all babies.  Hopefully a caregiver having a sticky note with the A, B, C’s reminding them to put a baby to sleep alone, on their back and in a crib or firm surface can save lives.  

The bottom of the message on the sticky note states:  

My baby will grow to be a happy, healthy child with your love and kindness.

If you want to reach me or have questions, please call me at_____________________


If you would like a sample of the Safe Sleep Sticky you may contact me at 

Karel R. Amaranth, MPH, MA

Amaranth Advocates for Public Health

Of Health and War

Last Monday was Memorial Day, the day that extends a weekend to three days, celebrates the beginning of summer and commemorates those who have died in wars with ceremonies, parades and poppies sold at grocery stores.  In my small town USA village of Piermont, New York, there was the annual parade through our little town to the Veterans Monument.  I had played tennis early in the morning and was returning just as our Piermont Police Department was starting to close the main street with saw horse barricades diverting cars through the pier parking lot.  After a quick handshake through my car window with my favorite Piermont cop, I took the detour, arrived up the hill at my house and grabbed my bicycle (oh, yes, got out of my sweaty tennis clothes and slipped into biking shorts.)  I cycled down to the Veteran’s Monument and got a good spot for the parade which consisted of the Fire Department volunteers in their uniforms, the very impressive Piermont (“on-the-Hudson”) fire trucks, our Mayor, and the Yonkers Pipe and Drums Band wearing kilts.  And, there were several veterans of wars marching, elderly gentleman who I would guess had been in WWII.  There were a few speeches and prayers, the band played “God Bless America,” it was over, and the crowd dispersed.

There was also another Memorial Day event that was taking place out at the end of the pier.  Every year on Memorial Day a huge bonfire constructed with enormous tree trunks is built right on the river.  It is lit at midnight and burns through Memorial Day until midnight and then is bulldozed into the river.  It’s a pretty impressive site for our little town.  It’s called a Watchfire, a homecoming fire.  It is a blazing light in the dark night to welcome back all of the souls lost far away and to bring them back home.

While all this was going on, and people were stoking their barbeques, I was thinking about all of those wars, all of the lost and damaged lives.  In fact I Googled “US in Wars” and opened up a chart that you can access on Wikipedia.  There was much more information than I expected.   In the meantime I couldn’t help thinking about other “wars.”  The war on poverty…who and what are we exactly fighting?  Was there a beginning?  Will we win or will poverty win?  The war on drugs.  The war on crime.

The war on cancer was declared 40 years ago by Richard Nixon.   Here is an interesting commentary.

And in an updated report from 2010:

Declaring a “war on cancer,” President Richard Nixon signed the National Cancer Act on Dec. 23, 1971, in a White House room full of happy scientists and proud politicians. The bellicose metaphor implied that cancer was one enemy and that victory was possible. Nobody believes that anymore. It would have been no less naive if Nixon had declared a “war on bad government” that day, ignoring the fact that there are a hundred ways to govern poorly and no single way to do it right.   For the full article:

There of course has been a war on AIDS:

Brian Lehrer on WNYC has been conducting a survey called “End of War” asking the question “Is War Inevitable?”

Many responses indicated that if more women were in power that more wars would be prevented because women are more inclined to negotiation, conflict resolution, and a focus on health and well-being for themselves and their families.

Former Chilean President Michelle Bachelet, the first Under-Secretary-General and Executive Director of UN Women, discussed the role of women and war–and the importance of having more women in power to lessen conflicts around the world.

An interesting connection, or perhaps it is the disconnection, of war and health is in the little Central American country of Costa Rica.  In 1991, after having researched the substantial decrease in infant and maternal mortality and increased health and well being of children and families based on the Costa Rican home visiting program, I traveled to San Jose and had a meeting with Dr. Lenin Saenz, one of the architects of the government-funded health care program.  The program included visits to every family in Costa Rica four times a year to assure that all children had their vaccinations, that pregnant women were receiving prenatal care, that the family had clean running water and everyone was in good health.  The visits were done by community health workers who had been soldiers in the war against mosquitoes.  Yes, the war against mosquitoes was mounted by a collaboration between the United Fruit Company and the Costa Rican government.  So many farm workers were dying of malaria that the fruit export business was suffering.  Literally armies of mosquito eradicators were employed in the joint effort.  By the late 1960’s, the mosquito was defeated and Costa Rica was free of the tyranny of malaria.  But now what to do with all of these people who had visited every part of the country spraying and removing breeding areas?  Dr. Saenz and his colleagues in the Costa Rican government decided to fight on…this time against infant mortality, maternal mortality, water borne diseases, and just for good measure, illiteracy.  They retained the army of workers and re-educated them to be home health visitors.  Within 10 years between 1970 and 1980, the health status of Costa Rica dramatically improved as indicated by the drop infant mortality by 69 percent from 61.5/1,000 to 18.6/1,000. How did they finance this one might ask?  All those health workers fighting disease.  Well, they used money that other countries use to pay for their military.  Costa Rica in 1948 had decided not to fight their own people or other countries; they disbanded their army.  Since the mid 1980’s there have been financial challenges that have impacted the success of the Costa Rican war against disease, but there is still no military and the health status far exceeds that of most countries in the world.

So Is War Inevitable?

This post does not have neat clever ending or political message or even health prescription.  I just find myself wondering if the question needs to be shifted from “Is War Inevitable?” to “Who or What Are We Fighting?” or more importantly,  “Who Are We Fighting For?”

As for Memorial Day, I continue to think about the Watchfires bringing everyone home.