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.