Face down on the floor, wedged between a bed and the wall, a 4-month-old Bell County boy died after falling off the mattress where he had been sleeping with an adult using opioids.

In Mason County, a 6-week-old girl was found blue and not breathing in bed with her uncomprehending mother who, when told the infant was dead, protested, "No way!" The baby had suffered at birth from drug withdrawal; after her death, the mother tested positive for marijuana, opioids, and methamphetamine.

And in Kenton County, a mother awoke next to her dead 6-month-old after a night of drinking and using drugs with no recollection of how she and the baby wound up sleeping on the couch together.

These deaths are among a growing group of Kentucky's smallest and largely unnoticed casualties of the state's substance abuse epidemic.

As opioids continue to claim more and more lives in Kentucky, experts say the epidemic is also increasingly ending the lives of infants put in "unsafe sleep" situations. That usually means impaired adults and babies who should never sleep anywhere other than alone, on their backs and in a crib free of blankets or pillows.

"It's not slowing down," said Dr. Melissa Currie, a forensic pediatrician at the University of Louisville and member of an outside panel that reviews cases where child abuse or neglect is suspected. "We have to get the message out about the dangers of this."

"We've got more and more women of childbearing age who are using opioids," said Dr. Lori Devlin, a neonatologist with Norton Children's Hospital and U of L. "It's making the whole thing a little bit scary."

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The infant deaths in Bell, Mason, and Kenton counties are among about 20 such cases examined over the past 12 months by the Child Fatality and Near Fatality External Review Panel on which Currie serves. It also includes police, prosecutors, judges, social services officials and others involved in child welfare.

Currie suspects there may be many more such deaths since as many as 100 Kentucky infants die each year from what's classified as Sudden Unexpected Infant Death, or SUID — often linked to suffocation when a sleeping infant's airway is obstructed. But most of such SUID deaths are not reported to or investigated by state social service officials as abuse or neglect and thus are never referred to the outside panel for review.

"We're only seeing a fraction of these at the panel," Currie said.

The panel, over the past 12 months, also reviewed about a dozen cases of "near fatalities" in which small children almost died after ingesting drugs found in their homes, including a toddler who had to be revived with the opioid overdose drug naloxone.

The information for this story is based on records of the panel's meetings and more detailed investigations of some deaths obtained under the state open records law by the Courier-Journal from the Cabinet for Health and Family Services.

The outside panel was formed in 2012 to review all cases of child deaths or severe injuries where abuse or neglect is suspected. Its findings for the past 12 months will be reported this year in its 2017 annual report; final conclusions about some of the cases it reviewed are still pending.

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Chairman Roger Crittenden, a retired Franklin Circuit Court judge, said this year's annual report must address the problem of addiction and drug abuse, factors the panel sees in nearly every case it examines.

"We have to talk in terms of substance abuse treatment," Crittenden said at the panel's June 19 meeting. "It seems like every case we've had, whether it be abusive head trauma, unsafe sleep or anything else, it seems like it has substance abuse involved in it."

Panel member Paula Sherlock, the chief family court judge in Jefferson County, said substance abuse appears to drive many of the child abuse and neglect cases the panel reviews, but she said its particularly alarming in sleep-related deaths of infants.

"Unsafe sleeping, that's the big uptick and it involves very small children," Sherlock said.

Education not enough

The panel has been highlighting the problem of infant deaths linked to unsafe sleep since its first annual report in 2014 cited nine such deaths and called for a "statewide public awareness campaign" to alert the public. The panel identified bed-sharing, or co-sleeping, as a concern, especially when an adult might be impaired by drugs, alcohol, prescription medication or just sheer exhaustion.

In 2015, the Kentucky Department of Public Health launched such a campaign, citing the "ABCs" of safe sleep for an infant: alone, on the back, in a crib.

Yet infant sleep deaths linked to abuse or neglect have doubled since 2014 with at least 20 identified this year by the outside panel and nearly all involving caregivers impaired by drugs or alcohol. Last year, the child fatality panel listed 17 infant deaths linked to unsafe sleep, according to its annual report in 2016 for the fiscal year that ended June 30, 2016.

Currie said she doesn't think educational efforts are enough, given the explosion of drug abuse in Kentucky.

"We can't educate our way out of this," she said. "At some point as a society, we are going to have to decide how serious we are about this and whether we are going to hold some folks accountable."

In some cases reviewed by the panel, infants were at increased risk of SUID because they were born experiencing withdrawal from drugs their mothers had used during pregnancy.

Such infants, diagnosed with Neonatal Abstinence Syndrome, or NAS, are at greater risk of sleep deaths in their first year. So are infants whose mothers smoked while pregnant or are exposed to cigarette smoke in the home.

Devlin, the neonatologist, said mothers who use opioids are more likely to smoke, putting infants born with NAS at increased risk when they go home.

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And mothers who are overwhelmed or impaired may be more likely to put their children in unsafe sleep situations, she said.

In the Mason County case of the 6-week-old infant born with drugs in her system, child protection officials allowed the mother to take the baby home only under the condition that she live with her parents under their supervision. After the infant died, the mother's father said he had repeatedly warned his daughter about the risk of sharing a bed with the newborn, to no avail.

"We have preached at her about sleeping with the baby," he told social service officials who investigated the case.

In another case, a 3-month-old from Boyd County died after her mother, who had a history of substance abuse, propped the baby in the corner of a couch to sleep. Both the mother and infant tested positive for drugs after the child's birth.

The infant died from "positional asphyxia," meaning she was in a position where she couldn't breathe properly.

Despite records from the hospital and the pediatrician's office that showed the mother had been counseled on safe sleep practices for infants, the mother insisted she had never received any such information, according to social service officials who investigated.

Overdose deaths rise

Meanwhile, drug overdose deaths in Kentucky rose again last year, with 1,404 people dying in 2016 compared to 1,248 in 2015, according to a report by the state Office of Drug Control Policy. Jefferson County had the most overdose deaths, with 364, with nearly all 120 counties recording at least one overdose death, the report said.

Heroin and opiate prescription painkillers have long been driving Kentucky overdose deaths, but in 2016 fentanyl, a powerful synthetic opioid, was the leading cause, the report said.

Devlin said the number of Kentucky babies born in withdrawal from opioids also has spiked, increasing from around 46 cases in 2001 to more than 1,200 in 2015.

Substance abuse by adults is flooding the state's foster care system with children removed from families who can't care for them. Adria Johnson, Kentucky's commissioner of social services, told state legislators in June that the number of children in state care has soared to 8,527, with about 500 children added in just the last few months.

Johnson, speaking before a legislative work group on foster care and adoption, said the surge is "directly attributed to the opioid crisis" in cases where it's not safe to leave children in homes with impaired adults, a trend seen in some of the cases the panel reviewed.

For example, after the death of the Bell County infant, three young children were removed from the home and placed in foster care after social service officials determined that neither parent — both with extensive histories of drug abuse — could care for them.

Risks of co-sleeping

Unsafe sleep for an infant is considered "co-sleeping" with a caregiver but also in a potentially dangerous setting such as on a couch or surrounded by pillows and blankets. Drug or alcohol use by the caregiver sharply raises the stakes, Currie said.

"Co-sleeping deaths have been happening forever," Currie said. "It was a problem even before the opiate epidemic. Add the opiates and that's the reason we're seeing so much more of it."

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The risk to any infant comes when the airway is obstructed by bedding, the body of an adult or other means that limit the supply of fresh air, Currie said. With the supply of fresh air reduced, a small or vulnerable infant essentially stops breathing and suffocates.

"Suffocation doesn't mean a pillow over the face," Currie said. "It can be from restricted air movement around the baby. They're not getting enough oxygen."

Sherlock, the Jefferson family court judge, said the escalating drug problems she sees in her courtroom and as a member of the panel don't bode well for Kentucky's children.

"I don't know where this is all going to end up," she said. "It's very sad."

Contact reporter Deborah Yetter at 502-582-4228 or at dyettter@courier-journal.com.

BY THE NUMBERS

Here's how many Kentucky infants have died in unsafe sleep situations over the past four fiscal years:

  • 2014: 9
  • 2015: 15
  • 2016: 17
  • 2017: 20*

*Some cases still pending

Source: Kentucky Child Fatality and Near Fatality External Review Panel