KANSAS CITY, Mo. - In May, a 29-year-old Kansas City woman fell asleep in her bed with her three children, including a 6-month-old boy. When she awoke about six hours later, she found his lifeless body at the foot of her bed, under a cover.
Police who arrived at her doorstep saw her cuddling the baby. Tears streaked her face.
"He's dead!" she screamed.
It marked the sixth time this year that a baby died while sleeping at home in Kansas City. None of the babies, who ranged from 11 days to 10 months old, was in his or her own bed.
The tragedies put the city on pace for a deadlier-than-usual year for bed-sharing infants.
"It is such an overlooked topic," said Amanda Pickman, whose 7-month-old son, Madden, died in 2012 while sleeping in Pickman's bed in Kansas City. "You don't know until it happens to you."
The deaths continue to increase nationally despite a campaign by the American Academy of Pediatrics to avoid bed-sharing and efforts by advocates to promote safe-sleeping guidelines for infants. The academy came out against the practice of bed-sharing in 2005, but other experts continue to defend it under specific circumstances, including, most important, if the mother is breast-feeding.
The rift between the academy's directive to always avoid bed-sharing and the other experts who think bed-sharing is beneficial and biologically based can confuse parents. Plus, guilt, shame and embarrassment often prevent open discussions of the topic, leaving more parents even more in the dark.
"The bed-sharing issue is contentious," said Pete Potts, the Western region program and bereavement coordinator with Missouri's SIDS Resources. "It is fraught with controversy."
Most experts agree there are ways to minimize the risks, no matter where the babies sleep, by putting them on their backs and avoiding soft bedding, heavy blankets, pillows and maternal smoking.
But sometimes even those precautions aren't enough.
One night in April 2012, little Madden Pickman acted particularly fussy.
Amanda Pickman had taken her two older children into her bed without problems. Comfortable with the practice, she thought it might help soothe Madden.
To be safe, she removed the bed pillows and pushed her blankets to the bottom of the bed. Then she put him on his back.
Her husband was out of town, so they had the bed to themselves. She fell asleep. During the night, she rolled away from Madden, leaving her back to him.
More than five hours later, the sun came up and her 4-year-old son bounded into the room, wanting to help change his little brother's diaper.
As her preschooler chattered away, Pickman realized the baby hadn't made a sound. She rolled over to check him.
Madden remained on his back, just as she had left him. But his lips were blue, his flesh cold.
She scooped him up and blew into his mouth. The air just blew back against her cheeks.
It was too late.
Every year, more than 4,000 infants die suddenly and unexpectedly in the United States.
Barring an undiagnosed medical or criminal cause, these deaths are filed in three categories: suffocation; sudden infant death syndrome, when a medical examiner has ruled out other causes; and undetermined, used when authorities didn't conduct a scene investigation and autopsy.
Advocates launched a national "Back to Sleep" campaign in 1994 urging parents to put their babies to sleep on their backs.
Parents responded. Deaths from SIDS dropped by more than half between 1992 and 2001.
Meanwhile, deaths from other sleep-related incidents, including suffocation, entrapment and asphyxia, increased, according to the academy's journal. Better awareness and reporting might have contributed to the higher numbers, they said.
Advocates expanded their message in 2011, hoping to reduce all sleep-related infant deaths. They launched a "Safe to Sleep" campaign the next year.
The ability to track national statistics on bed-sharing deaths is limited because death certificates don't include the circumstances and events leading to death. The Centers for Disease Control and Prevention has started a case registry that should provide more data in the future.
But 70 percent of infants who died from 2005 to 2008 had been on a surface not intended for infant sleep, according to a nine-state study published in the American Journal of Public Health. Sixty-four percent had been sharing a sleep surface, including almost half sleeping with an adult, the study noted.
Sixty-one children died in Missouri in 2012 because of unintentional suffocation, according to Missouri Child Fatality Review data. Of those, 90 percent were younger than 1, and more than 90 percent died from bedding, from soft items or while sharing a sleep surface.
In Kansas, nine children suffocated in 2010, the latest year for which statistics are available. Seven had been co-sleeping with an adult or sibling in an adult bed, according to the Kansas Child Death Review Board. Kansas also recorded 40 SIDS deaths that year, and in 33 cases, the possibility of overlay or asphyxia chest compression could not be ruled out.
After her baby's death, Pickman researched infant deaths. She was surprised to discover a mountain of unfamiliar information.
She became an advocate for safe sleep practices and started a Facebook page under the name Madd-Saac, combining the names of her son and another baby who died just weeks apart. The group sponsors an annual event in October to raise money for Missouri's SIDS Resources Center.
She believes parents should avoid bed-sharing. But changing parents' beliefs and habits is an uphill battle, Pickman said.
"So many women think (after a baby dies) that you're just doing it wrong," she said of bed-sharing. "They believe there's a safe way to do it. But there isn't."
The American Academy of Pediatrics recommends that babies sleep in the same room as their parents, but not in the same bed.
"I get a phone call or email every week," said Potts of Missouri's SIDS Resource Center. "And there's a pretty good chance what I'll be dealing with involves bed-sharing."
Babies can die in a bed even when nothing touches their face, Potts said. A baby can suffocate if a pillow, blanket or person creates a pocket of air rich in carbon dioxide.
When a baby breathes this in, "it's like flipping a switch," Potts said. "It's a sudden brain stem trigger," and the babies succumb quickly.
Even though many parents sleep with their babies without harm, that doesn't mean the practice is safe, Potts said. "They're the lucky ones," she said. "They beat the statistics."
Others, including James McKenna, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame and a renowned expert on the subject, counter that bed-sharing can be beneficial for babies and safe in specific circumstances if a mother is breast-feeding.
They believe that fatal co-sleeping death statistics are skewed and that most deaths could be avoided if parents mitigated known risks, such as co-sleeping with heavy blankets or pillows or when a parent is exhausted or under the influence of drugs or alcohol.
"My position is not the opposite of the AAP," said McKenna, who has researched co-sleeping for 30 years. "It's just nuanced."
He believes parents should be informed of the risks and benefits and allowed to make the final decision, he said.
"We're talking about biologically appropriate behavior," he said, adding that babies weren't meant to sleep alone in rooms.
Babies are designed to sleep in a light arousal state, which occurs when they are close to their mothers, not deep sleep in a room down the hall, he said.
"We propose when a baby is in deeper sleep, it's harder for the baby to wake to terminate apnea," McKenna said. "Babies born with arousal deficiencies should not be left alone at night."
The topic of bed-sharing shouldn't be a debate, he said, but rather a discussion about how to educate parents and minimize risks.
Still, parents must consider the blame they might face and the guilt they might feel if their infant dies of SIDS while in their bed, he said.
Homicide investigators for the Kansas City police get called to all baby deaths outside hospitals.
They "very rarely" find situations where babies die in cribs. In most instances, they said, parents have taken babies into an adult bed to cuddle or comfort the child and then the parent falls asleep.
"It's tragic," said homicide detective Mark Slater. "In an effort to do the right thing, they do the worst possible thing, because babies will just roll to the deepest indentation in the bed."
Of the 100 deaths investigated by the Jackson County medical examiner since 2004, most of the babies died from positional asphyxia, when the airway becomes obstructed by the abnormal position of the baby's neck or body.
SIDS rulings, in which the medical examiner eliminated all other causes of death, accounted for the second-highest number of deaths, followed by asphyxia, which includes suffocation and overlay.
The legal standard to file charges is criminal negligence, which means someone was aware of a substantial and unjustified risk and grossly deviated from the standard of care - a tough standard to meet when a recent national study showed 45 percent of parents admitted to sleeping with their baby at some point in the preceding two weeks.
In the case of Madden Pickman, the medical examiner ruled his death was from positional asphyxia. His mother believes she lost him to SIDS.