ABCs of putting babies to sleep:
A -- Alone. It's good for babies to sleep in the same room as their caregivers, but not in the same bed.
B -- Back. Babies should always be placed on their backs to sleep unless otherwise instructed by a pediatrician.
C -- Crib. Babies should be placed in a secure crib or bassinet with a firm mattress covered only by a fitted sheet. Remove any clutter like blankets, bumper pads, stuffed animals or toys.
Source: American Academy of Pediatrics, Tennessee Department of Health
Three years ago, six kindergarten classes' worth of Tennessee babies died in their sleep.
That's the unit of measurement Dr. Michael Warren has used while trying to draw more attention to a major factor in the state's bleak infant mortality rate: Unsafe sleeping conditions.
One in five infant deaths in Tennessee is due to preventable causes, such as suffocation or strangulation while sleeping, according to the Tennessee Department of Health.
"In a given year we have close to 600 overall infant deaths, and there are many causes for that," said Warren, director of maternal and child health for the department. "But about 20 percent of our infant deaths were preventable sleep-related deaths."
In Hamilton County, 20 babies died of sleep-related causes between 2009 and 2011, the department reported.
The numbers include babies who suffocated after being placed on their stomachs to sleep, or those placed in cribs cluttered with blankets or stuffed toys.
Some babies died sleeping on a bed or couch with a caregiver who may have accidentally rolled onto them; others were placed to sleep in chairs, on pillows, or on the floor.
The Tennessee Department of Health started tracking sleep-related deaths in 2010. That year, 131 babies died. The next year, it was 109. Statistics for 2012 will be available in a few months.
Of the sleep-related infant deaths, 84 percent had not been sleeping in a crib or a bassinet. Two-thirds of the babies were sleeping with someone else. Half the babies were not sleeping on their backs.
According to a report from The Tennessean, at least three dozen children whose deaths were investigated by the Department of Children's Services between 2009 and mid-2012 died after being put down to sleep.
That included a 10-month-old Hamilton County girl born with Down syndrome, who was found dead after being left to nap in a baby swing, covered in a blanket. An 11-month-old Bradley County boy suffocated after falling face forward from a baby pillow where he had been placed to sleep.
Tennessee ranks fifth in the nation in the number of infants dying before their first birthdays.
Just by eliminating the number of sleep-related deaths, that dial could be moved close to the national average, said Warren.
That's why a growing number of campaigns have sprung up to promote safe sleep practices and provide needy Tennessee parents with safe cribs.
The new Department of Children's Services commissioner, Jim Henry, has said safe sleep is now a priority for caseworkers interacting with families of infants.
"We don't want to leave any home without a crib in it," he told the Times Free Press.
Causes for infant sleep deaths have been difficult to pinpoint. Many are classified as "undetermined," or more generally as sudden infant death syndrome (SIDS).
Tennessee's child fatality review process has gotten progressively better at tracking specific causes of sleep-related deaths and contributing factors, said Warren.
Abuse and neglect can play a role, but a bigger problem may be well-intentioned parents who aren't aware of infant sleeping risks.
Some parents can't afford cribs since federal safety regulations passed in 2010 made them more expensive and difficult to buy secondhand.
But the problem isn't just with families in poverty, said Connie Gardner, the DCS hospital liaison in East Tennessee.
"A lot of these families had no intention of obtaining a crib because of [the] culture they've come from," she said. "When we explain it to the families, it is an eye-opener for them."
Parents often say they are abiding by advice passed down in families that it's safer when a baby sleeps on its stomach or beside a parent.
"Co-sleeping is a tough one to crack culturally, because if you don't have stories in your family of something going wrong, you will think it's fine," said Dr. Michael Cull, assistant professor at Vanderbilt University and director of the Center of Excellence for Children in State Custody.
It's the same challenge Lori Franklin Wheeler sees when she works with new parents. But Wheeler, who is the infant mortality program manager at the Chattanooga-Hamilton County Health Department, says she also is worried about the growing co-sleeping trend among new parents who say they want to raise their children more naturally.
"As much as we think we're conscientious, we lose total control when we're asleep," Wheeler said.
Preventing more sleep deaths means making sure parents are aware and equipped.
The health department and DCS have taken cues from a Knoxville group called the East Tennessee Safe Sleep Initiative, which has given away more than 50 cribs since May.
Using federal dollars, the health department bought 250 Pack 'n' Play cribs for regional health departments to give to needy families.
The Chattanooga-Hamilton County Health Department has a stock of cribs that are distributed in urgent circumstances, said Wheeler -- like when newly homeless women arrive at shelters with babies, or during the Patten Towers evacuation in May.
The DCS is piloting its own crib program in Knoxville, focused on drug-exposed infants at the East Tennessee Children's Hospital.
Within 24 hours of those babies returning home, a caseworker will visit to assess the baby's sleep environment. If there's no crib, they will put one in place that day.
But getting a crib in the home is only part of the picture, Cull emphasized.
"We don't want to just throw cribs at parents," he said. "We want to make sure we educate them."
The state hopes to eventually turn the pilot programs into something more permanent.
Meanwhile, Tennessee parents may find themselves the subject of revamped awareness campaigns.
The local health department is spreading the word at the Chattanooga Market and the county fair. They've put safe-sleep information in buses, and soon will be pasting it on the floors of grocery stores, Wheeler said.
So far, parents have been receptive, officials say.
"We still have a lot of work to do," Warren said. "But it has not been a tough sell."
Contact staff writer Kate Harrison at firstname.lastname@example.org or 423-757-6673.