This article is Part 1 of “Death by Delay,” a series on how consumer product hazards have cost lives.
BETHESDA, Md. — In September 2021, federal officials grew so alarmed by the number of babies who had suffocated after being laid down on a popular infant lounger that they issued an urgent notice to parents: Stop using it immediately.
The padded, pillowy Boppy Newborn Lounger — sold to exhausted caregivers who relied on it as a safe place to put their infants — was linked to the deaths of eight babies, the Consumer Product Safety Commission warned. The federal agency announced a recall of more than 3 million of the loungers, which had been a mainstay of baby registries for years.
CPSC staff members then wanted to go a step further. It wasn’t just one manufacturer’s infant lounger that posed a potentially lethal threat; the agency next planned to consider sweeping regulation of other cushioned infant loungers, which some experts and officials believed were just as unsafe as the Boppy lounger. The move could have forced manufacturers to redesign their loungers or stop selling them, according to interviews with current and former CPSC employees, industry representatives and safety advocates.
But one day after the Boppy recall was announced, the CPSC’s two Republican commissioners — who at the time held a majority — scrapped that more comprehensive action, approving an annual operating plan that removed a proposal for regulating infant pillows, according to interviews and a review of the documents.
Since then, babies have continued to die.
NBC News has found that at least five babies have died in incidents linked to infant loungers since late September 2021, based on CPSC records and reports made to the agency. Four days after the CPSC’s vote and less than a week after the Boppy recall, a 3-month-old boy from Texas died while sleeping in the company’s lounger; his father had fallen asleep and woke up to find his child lying facedown, according to a report that local officials submitted to the CPSC.
The following spring, according to another report, a 4-month-old died from asphyxiation on a lounger produced in China that was advertised on Amazon as “perfect for co-sleeping.”
In addition to those five deaths, NBC News determined that at least 21 other babies died in infant loungers from December 2015 through September 2021, more than twice as many deaths as the CPSC cited in public warnings about specific brands of loungers. This count is based on an examination of government data, court documents, public reports reviewed by the CPSC, medical examiners’ reports, and records obtained through a Freedom of Information Act request. (See the full methodology below.)
Many of the incident reports cited suffocation, asphyxiation or a loss of oxygen as the cause of death, and seven lawsuits accused the loungers of causing the babies’ deaths. In some of the reports to the CPSC, the loungers were listed as one of multiple factors contributing to an unsafe sleep environment, while in others, no cause of death was listed. In one instance, after an 11-day-old baby died of Covid in a lounger, a local government agency identified “unsafe sleep” as a potential factor in the death. All of the babies were under a year old; the youngest was 4 days old.
“It is infuriating, and it’s senseless,” said Megan Parker, of Alton, Illinois, whose 2-month-old daughter, Layla, died in a Boppy lounger in 2019. “I don’t understand why they wouldn’t push that information out there, knowing that there are more deaths that are not reported. It could save lives.”
The 26 deaths tallied by NBC News are almost certainly an undercount, according to product safety experts, as autopsies do not always mention specific consumer products.
“The death certificate is not clear, and if it doesn’t list the product, then you don’t know,” said NJ Scheers, a statistician and former CPSC staff member who reviewed NBC News’ methodology.
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Before it was recalled, the Boppy Newborn Lounger was beloved by many parents who discovered that even the fussiest of newborns tended to relax in the round, slightly recessed cushion. Other loungers are rectangular or oval-shaped, with a raised perimeter surrounding a cushioned pad.
More than 3 million baby lounger cushions recalled after 8 deathsSept. 24, 202100:30
While the CPSC closely oversees infant sleep products, loungers have largely escaped regulation because they are described as a place for babies to lay while they’re awake. That means that most loungers are not subject to a new federal rule that bans inclined surfaces and other potential hazards in infant sleep products.
Yet newborns can quickly fall asleep at any time. Some companies explicitly advise customers to “transition” their babies to a crib or bassinet if they fall asleep on a lounger, but that does not always happen. And for years, photos of infants peacefully snoozing in loungers have proliferated on social media, muddying the message that the product should not be used for sleep.
“If you have a product that looks like it’s good for sleep, you can’t claim that it’s not a sleep product.”
CPSC Chair Alex Hoehn-Saric
“You can’t put that burden on parents,” CPSC Chair Alex Hoehn-Saric said in a recent interview. “If you have a product that looks like it’s good for sleep, you can’t claim that it’s not a sleep product.”
In some of the cases reviewed by NBC News, caregivers placed the loungers inside a crib. Other cases involved co-sleeping with the baby in a lounger on a bed beside the caregiver. The American Academy of Pediatrics’ safe sleep guidelines recommend babies sleep alone on their backs on a firm, flat mattress in a crib or bassinet with no loose blankets, pillows, crib bumpers or other soft items.
Industry representatives argue that loungers are not hazardous if used as intended: on the floor as a place to lay down babies who are awake and closely monitored.
“Boppy products, including the Newborn Lounger, have never been marketed as infant sleep products,” Amy St. Germain, a spokesperson for The Boppy Company, said in a statement. “They are intended to aid parents during awake time only and include warnings against unsupervised use.”
The Boppy lounger is distinct from the company’s popular, horseshoe-shaped nursing pillow, which has not been recalled. Nursing pillows have also been tied to reports of deaths, prompting the CPSC to investigate and warn caregivers against using them for sleep.
The decision to put off new regulations for baby loungers in 2021 was part of a series of amendments that the CPSC Office of Inspector General later criticized as violating rules requiring advance notice to the commission of major proposed changes. In a statement to NBC News, CPSC Commissioner Richard Trumka Jr., a Democratic appointee who joined the commission in December 2021, called the delay a “grave error” by the prior commission that put babies’ lives at risk.
“It delayed meaningful change that could have started protecting infants,” Trumka said. “It set us back and delayed safety benefits to the public.”
Instead of pursuing a hard rule, the CPSC took a piecemeal approach to address the issue: The agency commissioned a research study on infant pillows, a category that includes both infant loungers and nursing pillows; worked with the industry to develop voluntary safety standards for loungers; and took enforcement action against individual manufacturers.
“CPSC has long warned of the dangers of putting infants to sleep in products not intended for sleep, including soft, pillow-like products,” the CPSC said in a statement to NBC News. “When we develop evidence of hazards — especially that a product is associated with infant deaths — we can and have prioritized these risks and taken action to warn and protect consumers from products posing such risks.”
CPSC Commissioner Peter Feldman, one of the Republicans who removed infant pillow regulations from the 2022 operating plan, said that the agency “simply had not yet laid the required groundwork” necessary to move forward at the time, and that taking shortcuts could have made any new requirements vulnerable to being overturned in court.
“The Commission cannot act rashly. A rule that is stayed or overturned offers zero consumer protection.”
CPSC Commissioner Peter Feldman
“The Commission cannot act rashly,” Feldman said in a statement. “A rule that is stayed or overturned offers zero consumer protection.”
Dana Baiocco, the other Republican commissioner at the time, declined to comment.
The CPSC will begin considering a rule on infant loungers as soon as next month, according to two agency employees, having secured a Democratic majority last summer.
But any action is too late for families who have already lost children.
“This thing was defective as designed,” said Joe Zarzaur, a Florida-based attorney representing a family whose baby died in a Boppy lounger in 2020 just before she turned 5 months old. “It should have never been available as a product at any point in time.”
On the night that 2-month-old Layla died in December 2019, Parker, her husband and their 1-year-old twins were out of town visiting relatives. Layla was staying at Parker’s mother’s house in Missouri.
At around 4 a.m., Parker was awoken by a panicked call from her mom. Layla was not breathing, Parker’s mother screamed through the phone.
The baby had fallen asleep on a Boppy lounger, where she endured “horrific suffering and death by suffocation,” attorneys for Parker and her husband allege in an ongoing wrongful death lawsuit against The Boppy Company and Parker’s mother. The lawsuit accuses Parker’s mother of negligence and argues that Boppy should have recognized that the “unreasonably dangerous design” of the lounger could cause infants to suffocate.
Boppy and an attorney for Parker’s mother denied the allegations in court filings and declined to comment further.
In responses sent to the CPSC about other deaths reported to the federal government, the company wrote, “At Boppy, our collective hearts ache for any parent who has lost a child,” and added that its products “are safe when used properly.”
Layla had just started smiling and was adored by her older sisters, who had proudly held her when she was born. The girls, now 4, don’t know how their baby sister died.
“I think about how she’d be interacting now with her siblings,” Parker said. “It’s kind of heartbreaking to know that I’m going to have to tell them one day.”
Other death reports involving loungers reviewed by NBC News included a 4-day-old baby in New Jersey, born with a full head of black hair, whose obituary described her as “beyond loved, and wanted more than anything.” In another case, the obituary for a nearly 5-month-old girl who died in Florida a few weeks after the 2019 winter holidays shows her wearing a Santa hat that reads “Baby’s 1st Christmas.”
In some of the cases discovered by NBC News, families had received the loungers as gifts off of their baby registries. Others had purchased the loungers from major retailers, including Amazon, which declined to comment, and Walmart, which didn’t respond. Many of the babies died at home, while at least two died at day care.
In most cases, the infants were found by their parents. Some desperately performed chest compressions as they waited for an ambulance to arrive, incident reports show.
The threat from loungers can emerge quickly, according to the lead researcher of a study commissioned by the CPSC and released by the agency in October 2022. The study found that babies died in loungers and other pillow products in two main ways: They suffocated when they rolled over or turned their face against the plush surface, or they died from positional asphyxia, when they slouched forward or arched backward, putting their bodies at an angle that inhibited their breathing. Babies also sometimes rolled off the loungers and then suffocated.
“It’s kind of a scary death trap for a baby that doesn’t know how to move very well, or a baby that’s asleep and isn’t moving very well in their sleep,” said Andrea De La Torre, owner and founder of sleep consulting company Baby Sleep Answers. “We need to be very, very strict about saying, ‘No, sleep is not OK, even if you’re right next to them.’”
Further confusing the issue, some products currently marketed as newborn loungers were previously sold as in-bed co-sleepers, like the DockATot Deluxe+. The CPSC issued the company a notice of violation last year after new rules on infant sleep products went into effect.
DockATot denied wrongdoing and said its loungers are not unsafe if used while babies are awake. “The agency has continued to single out our Deluxe+ docks despite taking no action on several similar products currently on the market,” the company said in a statement. DockATot agreed to phase out its Deluxe+ model lounger after the CPSC’s enforcement action, but the product is still available for purchase, and a larger version of the lounger is also for sale.
Brandon Movitz’s 10-week-old son Pierce died while sleeping in a DockATot Deluxe+ in July 2020 in the family’s Bloomfield Hills, Michigan, home. Pierce was the “most calm, peaceful, loving baby,” who was doted on by his big brother, Jude, now 5, Movitz said. Jude often talks about how much he wishes he could go to heaven so he could visit his little brother.
Movitz has since started a foundation to help families who have lost infants cover the cost of their funerals and has connected with other parents whose babies died in loungers.
He said it is “ludicrous” that loungers are still sold.
“If babies are dying, why are we allowing this?” he said.
Lounger manufacturers maintain that the most effective way to prevent such tragedies is to educate parents and caregivers about safe sleep practices.
If baby loungers weren’t available, then caregivers could end up resorting to far more hazardous places to put down their infants, such as adult pillows, said Carol Pollack-Nelson, a product safety consultant who has worked on behalf of industry and consumers.
Getting rid of products like loungers “does not fix the problem,” Pollack-Nelson said. “It does not change how the baby is put to sleep, just where the baby is put to sleep.”
Despite the findings of the study the CPSC commissioned, the agency has yet to issue any broad warnings about the use of baby loungers — and is highly constrained by a federal law that requires it to consult with manufacturers before publicly disclosing hazards or deaths tied to specific products.
When Trumka, the CPSC commissioner, announced the agency’s enforcement action against DockATot in November, he did not provide any specifics about deaths. Instead, he directed the public to search the CPSC’s SaferProducts.gov database for the company’s name.
At least six babies have died in incidents involving DockATot loungers from 2020 to 2023, according to those reports — and some are easy to miss because the company’s name is misspelled.
‘Too many children have died’
More than 30 years ago, the CPSC took decisive action to ban infant cushions filled with foam pellets or beads — a beanbag-like design — after reports that 36 infants died.
Then, as now, infants were found facedown on the cushions, having suffocated on the soft material that conformed to their bodies.
Decades later, amid mounting reports of infant deaths, some at the CPSC became convinced that modern-day loungers posed a similar hazard — and wanted to consider expanding the 1992 cushion ban to account for them, according to interviews with current and former agency employees.
So staff members included a proposed expansion of the infant pillow ban on the operating plan submitted to the agency’s commissioners for approval in mid-September 2021, just as the CPSC was preparing to announce the recall of the Boppy Newborn Lounger.
But at the time that the plan was coming up for a vote, Senate Republicans were blocking President Joe Biden’s three Democratic nominees for the five-member commission, which had two vacant seats. That gave the CPSC’s two Republican commissioners an opening to make a raft of changes to the operating plan, which the CPSC’s sole Democratic commissioner, Robert Adler, denounced as “government by ambush.”
“This is not something that CPSC staff has requested nor has anyone shown any reason to halt these rulemaking packages,” Adler said in a statement after the Sept. 24, 2021, vote. “This postponement of consumer safety is extremely improper.”
In the following months, the agency received reports of fatalities in loungers produced by manufacturers across the world, including a $300 high-end product from Europe and a cheap knock-off from China, according to NBC News’ review.
In the absence of broad regulations, the agency has instead attempted to target individual companies.
In January 2022, the agency tried to recall the Leachco Podster, which the CPSC linked to the deaths of two infants. Unlike Boppy, however, the manufacturer refused to cooperate with a recall, insisting that its products were safe.
The agency is now suing Leachco for refusing to recall its loungers and issued a rare unilateral warning to consumers to stop using them, over the company’s objections.
“Warning consumers was our top priority,” the CPSC said in its statement to NBC News.
The company has sued the agency back, accusing the CPSC of overreach.
Leachco blames misuse of its products for the two deaths that the CPSC publicly tied to its loungers: One infant was left unsupervised on the Podster inside a crib, and another was in a Podster placed between two parents on a bed, its complaint said. In January, the agency alerted the company to a third death that it had linked to its product, of an infant who had been “put down for a nap and left unattended for a while” in 2021, said Oliver Dunford, a senior attorney for the Pacific Legal Foundation, a conservative group representing the company.
“The agency claims the Podster® is defective because it’s ‘reasonably foreseeable’ that parents and caregivers will ignore express warnings and fail to use common sense,” the Pacific Legal Foundation said in a statement. “The claim is absurd: Consumers can ignore the warnings on any product.”
Pacific Legal Foundation and Leachco declined further comment.
It wasn’t until June 2022 — nearly a year after Biden made the nomination — that the third and final new CPSC commissioner, who had faced Senate Republican opposition, was confirmed. That gave Democrats the majority for the first time in the Biden administration.
The commission’s new Democratic leadership has described loungers as a deadly and looming hazard that the agency must address through regulation, and added the task to the CPSC’s operating plan for 2023.
“There is a long history here — too many children have died,” said Hoehn-Saric, the CPSC chair.
The agency cannot produce a new rule overnight: Under federal law, staff must undertake a painstaking process of gathering and analyzing relevant data, researching incident reports, and justifying the need for regulation, which the commission will then vote on.
Feldman, the Republican commissioner, said the 2021 decision to slow new regulations will ultimately help produce a convincing, evidence-based proposal.
Others believe that the work could have begun sooner.
“There’s a good possibility that further deaths would have been limited if the commission had been freer to take more decisive action,” said Adler, the former Democratic commissioner.
Manufacturers say that the time has been put to good use: They point to the voluntary safety standards that are currently under development, which could include design guidelines and warning labels.
“It’s a proven process. It’s collaborative, and it brings together all the voices of everyone involved,” said Rachael Shagott, an industry consultant who is leading the effort through ASTM International, an independent standards organization.
Work on those standards began in early 2022 and is expected to wrap up by the end of this year, Shagott said. The process is open to the public and includes consumer advocates, parents of infants who died in loungers and CPSC officials. But advocates point out that industry representatives significantly outnumber the rest — and the standards would not be binding.
“Waiting for that process to play itself out is ignoring what we already know,” said Nancy Cowles, executive director of Kids In Danger, a consumer advocacy group.
‘This could happen to any family’
While the federal process inches forward, baby loungers are still readily available for sale in stores nationwide, and recalled models are easy to find secondhand. Listings for used Boppy loungers abound on Facebook Marketplace, even though the platform’s rules prohibit the sale of recalled items.
Boppy said it is “frustrated” that its recalled product is so easily found and that Facebook has failed to respond to takedown requests. In a statement, Facebook’s parent company Meta said it takes the issue seriously: “When we find listings that violate our rules, we remove them.”
“If we can’t make them safer, we’ve got to get rid of them.”
Dr. Warren Seigel
Some state lawmakers say infant loungers are so dangerous, they need to be banned immediately. In New York, legislators introduced a bill that would prohibit the sale of baby loungers statewide. The bipartisan bill — which appears to be the first of its kind — would fine retailers and secondhand dealers that list loungers for sale up to $500.
“If we can’t make them safer, we’ve got to get rid of them,” said Dr. Warren Seigel, district chair of the American Academy of Pediatrics’ New York chapter, which advised lawmakers on the bill.
Democratic Assemblymember Amy Paulin drafted the bill after two mothers on her staff learned of the Boppy lounger recall. She hopes it will help pave the way for a nationwide ban.
“I do think the federal government moves a lot slower than the states, which is why we introduced the bill,” Paulin said. “The fact that New York will pass something will give impetus for the federal government to do the same.”
The window to act this year is closing: Paulin’s bill passed the Assembly in March but is awaiting action by the state Senate, whose last day in session is June 8.
Parker, Layla’s mom, hopes her daughter’s story will help save other babies.
“I want people to know her name,” she said. “I want people to know that this could happen to any family.”
And she believes federal regulators need to be more forthcoming about the danger.
“I just want this information to be pushed out there,” she said. “It seems kind of hushed to me.”
Suzy Khimm reported from Bethesda, Maryland, and West Conshohocken, Pennsylvania. Elizabeth Chuck reported from New York.
Methodology: To compile the list of 26 deaths involving infant loungers, NBC News relied on autopsy reports; lawsuits and other court records; interviews with attorneys; the CPSC’s Clearinghouse data, which draws from death certificates, medical examiner reports, news articles and reports from local government agencies; and the CPSC’s SaferProducts.gov database, which compiles reports from consumers, local health and government officials, and others. The Clearinghouse data and SaferProducts.gov reports are vetted by the CPSC before being posted online, though the agency does not guarantee their accuracy or completeness.
NBC News' list includes deaths caused by suffocation and positional asphyxiation in which babies were placed on infant loungers, as well as deaths in which the lounger is mentioned in a CPSC database as a contributing factor. It also includes fatal incidents for which no cause of death was listed, but which involved a lounger, according to CPSC data and product safety reports to the agency. The list excludes deaths in which the cause was clearly unrelated to the lounger, such as deaths caused by blunt-force trauma. This list also excludes any potentially duplicative cases, based on the available information. Cases involving loungers were identified through the product name, manufacturer’s name, and/or description of an incident involving a “newborn lounger” or “baby lounger.”