In Kansas, more children die from sleep-related deaths before their first birthdays than die from any other non-natural cause – motor-vehicle accidents, homicides, suicides, drugs and drownings – between birth and age 17.

The tally – 221 infants lost to largely preventable sleep deaths between 2019 and 2023, the most recent data – drives the work of the Center for Research for Infant Birth & Survival at KU School of Medicine-Wichita, and its director, Cari Schmidt, Ph.D. Recently, drawing on her expertise and research, the research professor contributed a chapter on “Firm and Flat Sleep Surfaces” to a book on safe sleep best practices.

Edited by Rachel Moon, M.D., a nationally known infant sleep expert from the University of Virginia, “Infant Safe Sleep” is the second edition of a book designed to be an easily at hand, white-coat-ready resource for doctors and others working with infants and their parents. As the subtitle says, it’s a “Pocket Guide for Clinicians” just a tad bigger than a mass market paperback.

“I really do think the invitation to write this reflects the incredible work in Kansas over the last 20 years,” says Schmidt, noting the collaborative efforts of physicians, researchers and other advocates.

One collaborator is Christy Schunn, a CRIBS board member and executive director of the KIDS Network (Kansas Infant Death and SIDS Network), which offers grief support, safe sleep training and community baby showers providing education and sleep-safe equipment statewide.

“The fact that Dr. Moon asked Dr. Schmidt to write this chapter, that’s a gold star,” Schunn says. “We need to shine a light on sleep-related deaths and shine a light on these methods that work, and this book contributes to that.”

Firm, flat and the ABCs of Safe Sleep

Schmidt’s chapter and others draw on research and elaborate on safe sleep guidelines from the American Academy of Pediatrics, with topics that include “Parent Decision-Making and How to Influence Decisions,” “Room-Sharing Without Bed-Sharing” and “Baby Products: How to Evaluate Them for Potential Safety.”

For clinicians, it’s intended to help them understand and explain the evidence-based guidelines, which can be distilled to the ABCs of Safe Sleep:

• Alone and not with a parent or caregiver.
• On the Back, because infants, particularly in the first six months, have trouble turning themselves over, which can lead to smothering.
• And in a Crib, without blankets or loose sheets, bumpers and toys or other hazards which can lead to suffocation.

Firm and flat may seem straightforward terms but are often misunderstood. For adults shopping for a baby mattress, firm means something different than it does for infants, who should sleep on a mattress more comparable to a pool table, because their nose and mouth could be trapped in a suffocating “pocket” if they roll on their bellies. Babies, after all, are delightfully squishy and quite comfortable sleeping on a surface that would make mom and dad toss and turn.

As for “flat,” it means a slope of less than 10 percent, because otherwise an infant can leverage the incline and dangerously turn onto their stomach, a frightening revelation to any parent who, uninformed of the dangers, let a child sleep in a car seat for extended periods.

Like other chapters, Schmidt’s opens with examples of safe sleep challenges, such as the young couple working different shifts and the father takes their infant to sleep on the couch so the mother can rest. Schmidt then discusses sleep surfaces good (a Consumer Product Safety Commission-approved crib, bassinet or portable crib) and bad (sofas, cushioned armchairs, adult beds). There are tips for assessing mattress firmness – firm means hard – and a list of frequently asked questions. The goal is to enable productive clinician-parent conversations and clarify misperceptions.

“As adults, we're very used to having pillow-top and memory foam mattresses and really sinking into our beds, and that’s what we perceive as comfortable. But infants don't have the capacity to move themselves and shift themselves on a soft surface,” Schmidt says. “With the head being the heaviest part of the body, it's very easy for them to get in a compromising position.”

Bringing best practices from many directions

CRIBS, part of the KU School of Medicine-Wichita Department of Pediatrics, has a mission of eradicating infant death in Kansas, where mortality is slightly above the national rate and more pronounced among Black and Hispanic children. Its grant-supported programs include Baby Talk, which delivers prenatal education, and LYFTE, Lifting Young Families Toward Excellence, which provides home visitation and one-on-one counseling on health, positive parenting, and education and career goals.

Many KUSM-Wichita faculty play roles in safe sleep advocacy. KUSM-Wichita Associate Professor Stephanie Kuhlmann, D.O., serves on the Kansas State Child Death Review Board, as does retired faculty member Katherine Melhorn, M.D., while clinical professor and OB-GYN Zachary Kuhlmann, D.O., serves on CRIBS’ board. Both Kuhlmanns, pediatrician Kari Harris, M.D., and OB-GYN Darren Farley, M.D., serve on the KIDS Network board or committees.

Both Schmidt and Schunn say addressing infant mortality requires coming at the issue from multiple directions and ensuring parents receive information multiple times. Meeting parents where they’re at is valuable, because after birth they are often tired and frazzled.

“Parents can come home from the hospital with information, and pediatricians can discuss safe practices as well,” Schunn says. “But then they go home and do the best they can with what they have,” says Schunn, who says home visitation and prenatal education like what CRIBS provides can “help caregivers morph their infant’s sleep space into a safe sleep environment.”

Schmidt notes that providing clear, accurate information is particularly important these days, as many programs promoting safe sleep have suffered funding cuts.

“Pediatricians and children’s health advocates have so much ground to cover, so many recommendations to know. No single person can be an expert in it all,” says Schunn. “This book gives the pediatrician who may have only two to four infant patients a quick resource they can flip through and find the information they need.”

Schmidt is drawn to safe sleep work for reasons professional and personal.

“I have always been passionate about prevention. Let's not wait until a problem arises. Let's try and give people the information and tools they need to prevent having adverse outcomes occur. Having a baby can be scary and overwhelming. When I became pregnant with my first child, I was like, ‘Where's my manual to tell me what I'm supposed to do?’ And no one gave me one of those. So I think through my work, I've inadvertently been trying to develop that for others.”

Above, right: Cari Schmidt, Ph.D., research professor and CRIBS director at KU School of Medicine-Wichita.

Get the book

“Infant Safe Sleep: A Pocket Guide for Clinicians” is available in print and e-book versions from the publisher and Amazon.com.

Learn more

• The Kansas State Child Death Review Board examines child mortality and is the source of statistics for this article. See its annual reports.
• Find out more about CRIBS, the KIDS Network and their programs.