Safe Sleep (and CRs) Back in the News

This article originated in the September/October 2021 issue of Safe Ride News.

Although it’s apparent from this image of an inclined sleeper that these devices are very different from CRs, CPSTs should know about the rules governing sleep-related products for children and provide safe sleep guidance to caregivers.

The topic of safe sleep has been in regulatory and legal news lately as the risk of infant death in products called “inclined sleepers” has begun to spur action (see box below). Inclined sleepers are portable sleep devices that put a baby’s back at an angle of up to about 30 degrees. Over the past 15 or so years, these devices have been linked to infant airway obstruction (from head flopping) or suffocation (from rolling into the padding or partially out of the device). These incidents have led to dozens of infant deaths, with 74 reported to the Consumer Product Safety Commission (CPSC) in 2019 alone.

New Rules to Address Risks of Inclined Sleepers

Recalls of some inclined sleepers*over the past few years have not done enough to prevent infant deaths, so in June, the Consumer Product Safety Commission (CPSC) approved a final rule to establish a mandatory standard for all infant sleep products. Beginning in June 2022, these products will be required to meet the formerly voluntary CPSC infant sleep standard or be tested to ensure an incline of less than 10 degrees and compliance with CPSC’s standard for bassinets and cradles.
Separately, the Safe Sleep for Babies Act, which would forbid the sale of inclined sleepers (as well as padded crib bumpers) for infants, was passed by the U.S. House of Representatives this summer. The bill is now in committee awaiting Senate approval, though it’s unclear whether it will advance to a vote. Last year, a similar bill passed in the House and stalled in the Senate.
Although neither the new regulation nor the potential law affects CRs, these news stories mean CPSTs should be prepared, when asked, to explain to caregivers that CRs are essential safety devices that are different from inclined sleepers, despite certain positional similarities.

To be clear, CRs are not inclined sleepers, even though rear-facing CR models are semi-reclined, and sometimes children fall asleep in the car. Unlike inclined sleepers, CRs are essential safety devices that are not specifically made nor marketed for infant sleep. If asked, CPSTs can reassure caregivers that they needn’t be alarmed when infants happen to fall asleep while riding in a properly installed and used CR. And caregivers must know that safe sleep concerns should never be used to justify not using a CR or removing a child from one during travel.
However, despite CR instructions that say a CR should not be used as a sleeping device, there is a perpetual need to educate caregivers about the topic of safe sleep with respect to CRs. Virtually all caregivers will, at times, be inclined to keep their infant in a CR after travel, whether to allow them to remain asleep or to ease transfer to another environment, like daycare or a stroller. Therefore, caregivers should be warned that it is best to move sleeping infants to an appropriate sleep environment after travel and be taught how to ensure a CR is used safely for occasional sleep during travel.
When it comes to the latter, some established safe sleep guidelines can be applied while a child rides in a CR. For instance, children should wear comfortable, close-fitted clothing that is not likely to cause them to overheat. Also, as in a crib, no padding should be around or near the face.
However, the basic safe sleep rule of lying a baby flat on his/her back cannot be followed in a rear-facing CR. As CPSTs know, an over-reclined rear-facing infant is at risk during a crash because too much force would be applied to the shoulders rather than to the whole back. Yet, being too upright could result in the head flopping forward into an airway-obstructing, chin-to-chest position. All babies are vulnerable to this problem due to their underdeveloped musculature, but the risk is heightened for infants under 4 or 5 months, as these newborns haven’t yet developed the neurological impulse to readjust their heads when they’re in a position that inhibits proper breathing.
Careful adherence to CR instructions should prevent head flopping, so if a caregiver reports this problem, return to the instructions to check for oversights, including in the details of installation angle, padding use, and harness adjustment.
Installation angle is a common contributor to head flopping, so the recline angle instructions aim to prevent this problem. However, even a CR that is installed at an allowed angle may have instructions that specify a range of approved angles, so if head-flopping is occurring or a potential concern, check to see if the CR or base can be installed at an even more reclined angle that better allows gravity to keep the head back.
Improper use of padding can be another cause of head flopping. Check the various infant pads that came with the CR as well as any aftermarket padding. The padding that comes with today’s CRs can be instrumental in safely positioning a child, but when improperly used, it can contribute to problems. It is very important to read instructions (and, increasingly often, related product labeling) on the use of today’s padding inserts, which tend to be more sophisticated than those that came with older CR models. Often, various pads are provided, each designated only for certain CR modes or stages of child growth. Instructions typically provide guidance on when padding parts must be used and when use is optional or prohibited.
Adding padding that did not come with the CR is typically not recommended and/or necessary. Some exceptions exist, however. Most CR models permit optional use of padding rolls alongside the body (but never under the harness), and some models also allow or specify placing a cloth roll behind the crotch strap if needed to prevent an infant from slouching. In the interest of safety (while a child is asleep or otherwise), padding should not be placed near the face and never wrapped over the top of the head, where it can work its way behind the head and push it forward.
Proper harness securement also plays a role in noncrash infant safety in CRs. A properly fitted and snugged harness will keep baby’s body trued (center aligned) and prevent active babies from squirming into an unsafe position. Don’t overlook the crotch strap as part of the harness system, as it can affect overall positioning if it is either too far forward or back relative to the front of baby’s diaper. Following instructions, a crotch strap should be close to, but not under, a child.
It’s important to remember that in the vast majority of sleep-related deaths involving CRs, the CR was outside of a vehicle and/or the harness was not worn properly. Therefore, caregivers must understand that harness use remains important even when the CR is taken outside the vehicle. Too often, caregivers loosen or even unbuckle the harness when a CR is carried or used in a stroller. This behavior is so risky that the CPSC requires RF-only CRs to bear a prominent label on the top of the seating area to warn caregivers that infants have been strangled by loose or partially unbuckled harness straps and advise them to keep infants fully restrained whenever they’re in the carrier.