The nanny checked on Madison Morr twice during her afternoon nap. The second time, Madison's skin was blue — her face was pressed against the bumper pad that lined the inside of her crib.
A medical examiner found the 5-month-old baby had suffocated, and federal regulators received a death certificate that said she had been trapped against padding in the corner of the crib.
The baby's death in 2006 is one of at least 17 cases where the Consumer Product Safety Commission did not investigate a child's death, even though the agency had reports on file suggesting bumper pads played roles in the fatalities, the Tribune found.
The Tribune looked into some of the cases and found that medical examiners and coroners said bumper pads were involved in the suffocations.
Now the safety agency is in the midst of trying to decide if the popular nursery products are safe, yet is doing so without having investigated all deaths that involved bumpers, which tie around crib slats.
The agency has been hesitant to take a stand on the products' safety despite warnings from the American Academy of Pediatrics and other groups urging parents not to use bumpers because they present a suffocation risk.
Commission spokesman Scott Wolfson said officials are examining if there is a scientific link between bumper pads and suffocations, or if factors such as blankets, pillows or medical issues played a primary role in the babies' deaths.
That reasoning worries leaders at children's health and safety groups who believe bumpers shouldn't be in cribs.
"If the baby was found with the face smushed up against the bumper pad, then I don't understand the relevance of the pillow or the blanket," said Dr. Rachel Moon, a pediatrician at Children's National Medical Center and researcher for the American Academy of Pediatrics.
In addition to the 17 cases the agency didn't look into, the Tribune found that officials have investigated at least a dozen deaths where bumpers appeared to play a role. In those fatalities, the safety agency has said bumpers were not clearly the culprit because other factors, such as blankets or pillows, were in the crib too.
But the Tribune found that in many of those cases, the babies had their faces pressed into bumper pads.
For instance, in 2007, a 2-month-old baby in Florida was found with her face pressed against a bumper pad, with one of her arms stuck between the pad and crib railing. The medical examiner said she suffocated. A detective who responded to the scene noted that other items were in the crib, but the baby's face was against the bumper.
Pinpointing the sole cause of death can be difficult because death scenes are complicated and often involve various products. But Dr. Marion Burton, president of the American Academy of Pediatrics, said federal regulators don't need to base safety considerations on "cause and effect," a high bar to meet scientifically, when there is a strong association between bumper pads and suffocations.
"It's a potential hazard, so don't have it in the child's environment," he said. "I can't think of any reason to have them."
Wolfson said babies have been injured from getting limbs stuck in crib slats, but no deaths have been reported.
Bumpers were originally made to cover space between crib slats that were too far apart. Regulations changed in the 1970s, mandating less space between slats so babies wouldn't fall out or get their heads caught. Bumpers are still widely sold, often as part of coordinated bedding sets.
For years, regulators and safety groups have promoted "safe sleep" environments, recommending that babies be put to sleep on their backs in cribs without pillows or soft bedding.
Safety experts argue that bumpers are problematic, too, because they are marketed to parents as a nursery staple and don't display warnings that babies can suffocate against them.
"It is possible for babies to suffocate against a lot of things," said Moon, with Children's National Medical Center. "I'm not sure why bumper pads would be an exception to that."
Three years ago, Washington University pediatrician Bradley Thach published a report that concluded at least 27 babies' deaths over two decades were attributable to bumper pads.
Wolfson said an outside panel of scientists will review the agency's own assessment of bumper pads but wouldn't say who will sit on the panel.
The children's bedding industry, through its lobbying trade group, has said bumpers are safe and is doing its own study.
No warning for parents
The Tribune reported in December that for years, federal regulators have received reports of babies suffocating against bumpers but have failed to warn parents or investigate all deaths. In response, the agency said it would reopen files on babies' deaths and assess the safety of bumper pads on store shelves.
Under the Freedom of Information Act, the Tribune requested from the agency all infant death files where bumper pads were mentioned. After 3 1/2 months, the agency turned over 42 of 52 cases since 1990. Officials provided one- or two-sentence summaries for the missing files, which they said are still in archives.
The Tribune found 17 cases in which the files contained few details on how the child died, yet the agency failed to ask for further information that could explain what happened. Some deaths are documented only by a death certificate or a brief report from a medical examiner.
Wolfson said some cases that weren't investigated came to the agency's attention years after the tragedies occurred, making it difficult to re-create death scenes, interview parents and analyze products.
The agency relies in part on medical examiners and coroners to alert it to product-related deaths. But the process is voluntary, and many officials don't participate. As a result, the agency buys death certificates from states to try to find relevant cases. Wolfson said the time delay in getting death certificates can make investigations a challenge.
But it is still possible.
By requesting police and medical examiners' reports as well as talking with families and officials, the Tribune could determine that five of the 17 deaths were linked to bumper pads, although other factors were sometimes also present.
A few deaths did not turn out to involve bumpers, or there wasn't enough information available to determine what happened. Federal authorities, however, would likely have greater access to information.
The newspaper was unable to follow up on nine deaths because the agency provided only short summaries of each case and would not release the public documents it has on file. The brief descriptions of each death, however, mention the child's face being against a bumper pad or the child being wedged between a bumper and something else.
Madison Morr's death in Michigan was among those not investigated by federal officials. Records show that the baby was put to sleep on her back with a wedge placed to one side of her, presumably to prevent her from rolling over.
During her nap, the baby rolled away from the wedge, flipped onto her stomach and became trapped with her face in the bumper, the medical examiner found.
In 2003, Alexis Ferguson, 2 months old, was found dead in her crib with her face in a bumper pad, according to the Cass County coroner's office in Indiana. That same year, Jacent Jackson, of Detroit, was found with his face buried in a bumper pad. The 2-month-old baby's nose and mouth were completely blocked, according to a medical examiner's report.
Pat Tackitt, a pediatric mortality investigator, said Jacent had scooted to the top of his crib after being put to sleep on his stomach. The safety agency has discounted deaths of babies put to sleep on their stomachs because that position is considered a risk factor for sudden infant death syndrome, but it's unclear if officials classified Jacent's death that way.
'It needs attention'
Experts agree that thorough death-scene investigations are critical to determine how someone died. But the quality and consistency of investigations vary.
Distraught parents often don't want to talk about what happened or can't remember exactly how they found their baby before taking him or her out of the crib. Police reports sometimes do not explicitly explain how a child was found or what was in the crib.
Thach and other experts believe bumper-related suffocations are underreported because they can be wrongly attributed to sudden infant death syndrome if the death is not thoroughly investigated.
Statistics from the National Center for Child Death Review suggest bumper pads play a role in more deaths than the safety agency knows about. Since 2008, the federally funded group has received 14 reports where a bumper pad was relevant in the suffocation of a baby, though other products were sometimes relevant too. Death review teams in about 33 states reported to the group.
That many deaths tied to a product is cause for concern, said director Theresa Covington. "I really think it needs attention and study," she said.
Last year, the Consumer Product Safety Commission told the Tribune it had reports of 28 infant deaths over two decades that were associated with bumper pads, meaning the product played a role in the death.
The agency then backpedaled on that number earlier this year, stating that in all cases "confounding factors were more likely to have been primary contributors."
But the Tribune found several cases investigated by the agency where bumpers do appear to be primary contributors to the deaths, even though other products were also mentioned.
In 1998, the baby sitter of a 7-month-old Missouri boy found him with his face pressed into a bumper pad. Police photos of the baby's crib show a stuffed animal and blankets at one end of the crib, but a re-enactment with a doll shows that the baby was found in another corner of the crib with his face in the bumper pad.
Tyler Baker was found pitched forward with his face in a bumper pad at his baby sitter's house in 2007. The 5-month-old baby from Wenona, Ill., was put to sleep on his stomach but somehow worked his way to a corner of the crib and ended up, face down, in the bumper pad.
Photos of the crib show a musical toy, blanket and stuffed animal at one end of the crib, but Tyler was found at the other end. Part of a blanket hanging over the crib edge was under his head as well, according to a police report.
His mother, Michelle Bobinski, said the baby's bed at home had bumper pads too. "I'd never heard about a child suffocating on anything in a crib," she said.
Safe sleeping tips for infants
•Place babies to sleep on their backs.
•Use a baby crib or bassinet with a firm mattress.
•Do not put anything in the crib besides the baby and a fitted sheet over the mattress.
Agency fails to probe deaths linked to popular baby product
Yet same regulators are trying to decide if crib bumpers pose a suffocation risk
Michelle Bobinski with her son, Tyler Baker, who died at 5 months old.