Non-intentional asphyxiation deaths due to upper

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Injury Prevention 1995; 1: 76-80
Non-intentional asphyxiation deaths due to upper
airway interference in children 0 to 14 years
Anne Altmann, Terry Nolan
Public Health Branch,
Department ofHealth
and Community
Services, Melbourne,
Victoria, Australia
A Altmann
Clinical Epidemiology
and Biostatistics Unit,
Melbourne University
Department of
Paediatrics, Royal
Children's Hospital,
Parkville, Victoria,
T Nolan
Correspondence to:
Associate Professor T Nolan,
Clinical Epidemiology and
Biostatistics Unit, Royal
Children's Hospital,
Parkville, Victoria 3052,
Objective-This study was undertaken to
identify avoidable, contributing factors
associated with non-intentional asphyxiation deaths due to upper airway
interference in children 0 to 14 years.
Design-Historical population based
incidence study.
Methods-All postneonatal and childhood deaths by asphyxiation from 1985 to
1994, using appropriate ICD-9-CM codes,
were compiled from the Victorian
government legislated paediatric mortality surveillance system. Recent cases
were identified from the State Coroner's
Office. Case definition included children
under 15 years who died from upper
airway interference such as facial occlusion, head and neck entrapment, rope
or cord strangulation, or foreign body.
Results-Of the identified 42 deaths,
eight (19%) were caused by a foreign body
in the airway, five (12%) were due to facial
occlusion, 16 (38%) were due to ropes and
similar material (seven were homemade
rope swings), and 13 (31%) were caused by
entrapment (seven were in cots or beds).
The average annual rate for asphyxiation
deaths by all causes for children 0 to 14
years was 4-7 million. Infants under 1 year
had a rate of 20-1/million, while the rate
for 10 to 14 year olds dropped to 2 0/
Conclusion-Rope swings and rope
material are inherently dangerous and
frequently prove fatal, especially for
older children. For infants, environmental factors are important; in particular
food and bedding. Prevention strategies
need to be developed that include
obligatory standards for the design and
manufacture of products for children,
appropriate labelling and warnings, and
education for children, their carers, and
health care professionals.
(Injury Prevention 1995; 1: 76-80)
injury deaths in a total of 308 postneonatal
infant and childhood deaths (29 days to 14
years). In the main categories of death, injuries
ranked fourth after birth related deaths (94),
acquired disease (75), and cot deaths (70),
although injuries were the leading cause of
death after 1 year. Of the injury deaths there
were 32 due to motor vehicles, 16 drownings,
11 fire related, two train accidents, and five
(7-2%), due to accidental asphyxiation.'
In Australia in 1992 there were 380 deaths
due to non-intentional injury in the 0 to 14 year
age group.2 Of these 11 (2 9%) and four (1 0%)
were due to asphyxiation by food and other
objects respectively, and 14 (3 7 %) were due to
suffocation, giving a total of 7-6% due to these
types of asphyxiation.2
During routine prospective statewide
surveillance of injury related deaths in Victorian children a cluster of rope related asphyxiations was noted. As a result it was decided to
review all such and similar asphyxiation deaths
in children over the 9 5 years that the surveillance system has been active.
Although non-intentional asphyxiation is a
relatively rare cause of death, there have been
47 fatalities in children from this cause in the
last 9-5 years in Victoria. In this study only the
asphyxiation deaths due to upper airway
interference were included. These were
divided into four mechanism groups as follows:
facial occlusion, entrapment of the neck, strangulation from any type of rope material or
clothing, and foreign body aspiration. Deaths
from involvement of the lower airway were
excluded, such as chest compression or drowning. Although many of these 'accidents' may
appear to be random mishaps, closer inspection
reveals several consistent mechanisms and
predictable outcomes.
Subjects and methods
Since 1985, a statewide government legislated
paediatric mortality surveillance system has
existed in Victoria, Australia under the auspices of the Consultative Council on Obstetric
and Paediatric Mortality and Morbidity. The
council is notified of every death in the state
mortality, under the age of 15 years directly from the
Victorian registry of births, deaths, and marriages. The council compiles confidential case
Accidents, or non-intentional injury, are a histories from a variety of sources which are
major cause of paediatric mortality and then reviewed by specialist committees so that
premature years of life lost. In 1992, in Vic- any potentially avoidable factors can be
toria, Australia there were 69 non-intentional identified.
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Non-intentional asphyxiation deaths due to upper airway interference in children 0 to 14 years
The council's records on accidental postneonatal infancy and child deaths (29 days to 14
years) were searched. All deaths by asphyxiation from 1985 to June 1994 were drawn using
the International Classification of Diseases, 9th
revision, clinical modification (ICD-9-CM).
The codes used were: 994.7-suffocation by
bedclothes, cave in, constriction, mechanical,
plastic, pressure, and strangulation; 933934-foreign body in pharynx, larynx, trachea,
bronchus, and lung; E911-912-inhalation or
ingestion of food or other object causing obstruction of the respiratory tract or suffocation;
and E913-accidental mechanical suffocation:
in bed/cradle, by plastic bag, by falling earth or
other substance, by accidental hanging, due to
lack of air (in closed space), or by unspecified
The Coroner's Act 1985 in Victoria states
that certain deaths must be reported. These
include those that were unexpected, unnatural,
or violent, that resulted from an accident or
injury; that occurred during an anaesthetic; or
where a person was held in care. Cases occurring in 1993 and the first half of 1994 were also
searched for on the State Coroner's Office's
computer system by age and cause of death.
All the cases were verified using information
in the files on the investigations undertaken by
the state coroner. The information reviewed
for each case included: age, date of death,
circumstances of the death, results of postmortem examination if carried out, and
identification, if possible, of any avoidable
All cases due to lower airway interference
were excluded. This included five asphyxial
deaths caused by crushing or burying. Other
asphyxial deaths excluded were those due to
aspiration of vomit, drowning, fires, associated
with motor vehicle accidents, suicides,
homicides, and sudden infant death syndrome
(SIDS). SIDS is classified by a combination of
a centralised postmortem examination and a
death scene investigation. These deaths are not
classified as asphyxiation unless there is unequivocal evidence of such from the investigations.
The asphyxial deaths were divided into
groups according to the anatomic level of upper
airway involvement. The groups were: facial
occlusion; entrapment of head of neck; rope or
cord strangulation; and airway obstruction due
to a foreign body (food or other object).
to crushing or burying were excluded. The
remaining 42 deaths are tabulated by the
mechanism causing death (table 1).
Of the 42 deaths, eight (19%) were caused by
a foreign body in the airway, six of which were
due to food and two due to objects. Five (12%)
were caused by facial occlusion, one of which
involved plastic material.
Of the 29 strangulation deaths, 16 (38%)
were due to ropes, cords, and other such
material, and 13 (31%) were due to head or
neck entrapment. Seven of the 13 deaths by
entrapment were caused by cots or beds, seven
of the 16 rope or cord associated deaths were
due to homemade rope swings, and three were
due to blind or curtain cords.
There were 12 deaths in infants under the age
of 1 year. Of the four due to facial occlusion,
two were related to couches and one involved
plastic material. Another four became entrapped, two in the cot and one whose cardigan
caught on the cot. One infant strangled on a
rattle cord suspended over the cot and three
inhaled a foreign body. Half were associated
with an unsafe sleeping environment, for example, an inadequately sized mattress, inappropriate type of bed for the child's age, or objects
attached to the cot.
The average annual rate for asphyxiation
deaths by all causes in children 0 to 14 years was
4-7/million (table 2). However, the age group
most at risk is that of infants under 1 year with a
rate of 20- 1/million/year. The rates then drop
off with increasing age to a rate of 2-0/million
year for the 10 to 14 year olds. In the infants, all
mechanisms feature prominently except strangulation by ropes. In contrast, ropes are the
most common cause of asphyxial death for
children over 1 year of age.
The results indicate two main risk groups for
asphyxiation: infants, who were at risk from
facial occlusion, neck entrapment, and foreign
body aspiration and children over 1 year who
were at risk from strangulation by ropes. The
main mechanisms of asphyxiation are noticeably consistent and repetitive, and virtually all
these deaths could have been prevented.
The excellent surveillance system in place in
Victoria for paediatric mortality made it possible to identify the entire defined population in
the selected time period. Although a preceding
primary cause is not annotated on the death
certificate (for example asphyxiation with
anoxia resulting in cerebral palsy with death at
Data on the Victorian population figures was a later date), misclassification would be
obtained from the Australian Bureau of Statis- unlikely due to statutory investigations undertics estimated resident population by sex and taken on all paediatric deaths by the council.
age from 1985 to 1993. Death rates were The coroner's records provided much addicalculated by dividing the number of deaths tional information on intent and circumstances.
observed by the number of children in the age After reviewing available evidence there were
group at risk. Because the annual number of no indications to suspect suicide, for example,
deaths in each subgroup of asphyxiation was depression or prior disputes - in any of our
small, average annual rates were derived for the cases. Due to the conservative classification of
total study period (9 5 years).
SIDS, and exclusion of these cases from the
study, some underestimation of the true
incidence of asphyxiation may have resulted.
From 1985 to June 1994 there were 47 deaths
The rate for asphyxiation deaths in Victoria
due to non-intentional asphyxiation. Five due over the study period, excluding deaths due to
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Altmann, Nolan
Table 1 Non-intentional asphyxiation deaths in children O to 14years, by mechanism of asphyxiation
Facial occlusion
Plastic (n = 1)
Other material
(n = 4)
Cot/bed related
(n = 7)
Occlusive plastic dressing (shower cap), to scalp to treat seborrhoea. Cap
dislodged to cover face leading to asphyxiation
Left on couch during night after night feed by father. Suffocated between
two couch cushions
Fell off couch during night, caught between mattress on floor and base of
Put into cot for afternoon sleep. Found face down in 1 m high, clothes filled,
linen basket next to cot
Undetected intussusception of transverse colon during night. Suffocation by
Improper product usage
Arm of woollen cardigan caught on wingnut on top rail of cot, causing neck
to be pulled tight, strangling infant
Hospitalised for ear infection. Fell feet first between cot side and mattress
(10 cm gap) entrapping face against mattress causing asphyxiation
Playing with brothers. Head caught between notch in cot bedhead and
ladder of bunk bed above
Found hanged as neck caught between top of cot and wooden rail nailed to
cot to prevent child from getting out. Distance between top edge of cot and
rail = 13 5 cm
Intellectually disabled child, epilepsy. Sleeping in protected bed, caught
between guard rail and mattress (12 cm gap), hanged
Severe cerebral palsy. Head caught between protective bars of bed during
night, neck compression
Put down for sleep in single bed. Fell through bars of bedhead into 20 cm
gap between bedhead and wall. Throat constricted over edge of cardboard
box under bed and in this gap
Head in toilet, heavy timber toilet seat came down trapping infant's neck
against rim of toilet bowl
Early morning, parents in bed. Found with head caught between two tiers of
a coffee table
Caught head in 11 cm gap between changing table and support bar while
attempting to climb up and subsequently losing her footing
Playing 'hide and seek'. Head caught between iron grill lid and edge of
concrete pit in park, neck compression
Epilepsy. Left alone after recovering from fit and had second fit unattended.
Found wedged across kitchen floor, neck hyperextended against stove, airway obstruction
18 m
(n =8)
preventable factors
Put down for sleep, chest caught between bars and base of cot
21 m
11 m
14 m
22 m
14 y
Strangulation by ropes and cords
Blind cord (n = 3)
16 m
16 m
21 m
Other string near
(n = 2)
Rope swing
(n = 7)
11 m
15 m
13 y
12 y
Unsafe play
with ropes (n = 4)
11 y
13 y
in airway
Foreign body
Food (n = 6)
14 m
13 y
Other objects
(n = 2)
10 m
14 m
Comments and
13 m
Furniture and
other objects
Description of
Cord of venetian blind hanging down next to cot placed beside window.
Found strangulated with this cord around neck
Head of cot beside window. Neck entangled in loop of curtain cord while
in cot
Found kneeling in bed with blind cord around neck. Bed beside window,
parents claim to have tied cord up out of reach
Elastic string with row of rattles attached across cot. Found face down with
head entangled in the elastic
Bead necklace hanging on wardrobe handle 20 cm from end of cot. Put
down for sleep. Found strangled by necklace around throat and still attached
to wardrobe door handle
Rope swing in garden with tied loop in end 1-2 m off ground. Wooden step
ladder climbed, knocked to ground. Neck caught in rope, hanged
Family visiting friend's house. Found hanging from looped rope used as a
swing, end of loop 1 m off ground
Child made rope swing with knotted end of rotary clothes line. Found
hanging beside chair, feet off ground
Child attached rope to clothes line and tied in a loop as swing. Found
Playing with rope hanging from tree, two ends knotted, found hanging by
older sister
Rope swing with loop in end in hayshed. Found hanging with loop over
Child made rope swing in garden. Found hanging with noose around neck.
Died 5 days later in hospital
Playing in lounge room with belt around neck as 'stethoscope'. Found
suspended from door handle by belt, hanged
Child came home unsupervised from school. Found hanged by dressing
gown cord from clothes hook behind bedroom door
History of overactivity, aggression, learning difficulties, attention deficit
disorder, taking dexamphetamine. Found strangled by nylon cord tied to
end of bed. Actions thought to be impulsive, reckless, and experimental
behaviour rather than suicide
Playing on top bunk. Cord tied to guard rail, and around neck. Fell face
downward from bunk, hanged
Inappropriate sleeping environment
Inappropriate sleeping environment
Side rail of cot broken, remains set, halfway up, at about 2 feet above mattress
Old cot with thin mattress causing unsafe
sleeping environment
Unsafe cot with protruding screw on
Unsafe sleeping environment poorly
fitting mattress
Unsafe placement of furniture
Unsafe addition by parents to cot
Unsafe sleeping environment
Unsafe sleeping environment
Inappropriate sleeping environment and
unsafe placement of furniture
Unsafe width of bars on nursery furniture
Inadequate maintenance of park by local
Very large child: 113 kg, 1 89 cm tall.
Unsupervised epileptic fit. Medication
Blind cord, cot placement
Blind cord, cot placement
Blind cord, cot placement
Cord string attached to cot, cord on toys
Strings and cords near cot and accessible
to infants and children
Rope swing
Rope swing
Rope swing. Flying-fox at school
Rope swing, ropes accessible to children
Ropes and swings
Rope swing
Rope swing, rope accessible to children
Unsafe play with ropes and cords
Unsafe play with ropes and cords
Unsafe play with ropes and cords
Training dog at home with choker, unsafe
play with rope
Inhaled spaghetti meat sauce
Aspiration of biscuit fragments, unsupervised, may have been fed by sibling
aged 2-5 years
At children's party. Inhaled small frankfurter
Aspiration of chick peas when 22 m old causing tracheal obstruction at
carina and subsequent severe cerebral damage. Remained in hospital 2-5
years until died
At children's party. Small frankfurter lodged in pharynx at tonsils
Down's syndrome. At restaurant, choked on cut up steak. Piece of meat
found in larynx
Inhaled snail shell causing laryngeal damage and obstruction. Found with
snails in hands
Fell over hitting face. Inhaled stone, presumably in mouth, causing obstruction at carina
Potential danger of infants being fed by
older siblings
Inappropriate food for child's age
Inappropriate food for child's age
Obese child, tonsils very enlarged. Inappropriate food for child's age
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Non-intentional asphyxiation deaths due to upper airway interference in children 0 to 14 years
Table 2 Total No (%) and average annual rate* ofasphyxiation deaths by cause and
age group in children 0 to 14 years in Victoria, Australia, 1985-J7une 1994
<I year
0-14 years
Facial occlusion
Foreign body
All causes
No (%J
5 (12)
13 (31)
16 (38)
8 (19)
42 (100)
*Average annual death
1 7t
1-4 years
5-9 years
10-14 years
rate/i 000 000/year. tRate for 0-4 years.
foreign body inhalation was 3-8/million/year,
with the Australian rate for suffocation, in
1992, comparable at 3.7/million/year.2 A
national analysis of childhood injury deaths in
the USA, over a five year period, 1980-5,
reported higher rates for childhood suffocation
- 7/million/year population of children 0 to 14
A total of 17 deaths (40%) related to the
child's own bed or bed furnishings, an inappropriate sleeping place for the child's age, or
to furniture, cords, or other articles within
close proximity of the cot. Despite the publicity
and the design standards regarding infant cots,
deaths continue to occur in this environment.
The importance of using a cot with the appropriate design standards needs to be
emphasised, along with using an appropriately
fitting mattress. Design standards must also
apply to special beds for the disabled.
The risk of death as a direct result of the
sleeping environment, and in particular the
infant cot, has been stressed by numerous
authors.4-'0 Regulations regarding infant cribs
were first set in the USA in 1974, and reports
since then have varied as to whether there has
been a reduction in the number of associated
crib deaths. Feldman and Simms quote a US
Consumer Product Safety Commission (USCPSC) report claiming that there was approximately a 50% reduction in the number of crib
strangulations since the introduction of legislation.8 In contrast Kraus, after reviewing deaths
in Californian children due to suffocation and
strangulation from 1960 to 1981, found no
evidence of a statistically significant decline.4
These differing findings may well be due to a
lag time in discarding of old cribs after introduction of regulations.
Cots and beds should be placed firmly
against the wall, and proximity to blind cords
and other potentially dangerous articles
avoided. Restraining devices fitted to the bed or
cot are hazardous, as illustrated by one death
that was a direct consequence of a bar over the
cot. Although Australian standards on cots
make provision against any protrusion into the
cot, injuries are still likely to arise from broken
or repaired cots that are outside the set safety
standards. The death of a child in our series due
to a cardigan catching on a wingnut in the cot
was not an isolated incident."I These dangers of
restraining devices, protrusions, and repairs
were emphasised by Bergeson et al 18 years
A couch is not a safe sleeping environment
for infants because of its inability to prevent
facial smothering due to poor head control.
There were no deaths in our series associated
with waterbeds, sheepskin rugs, or polystyrene
bead filled cushions, each of which have been
noted to pose a risk to infants.9 The importance
of age appropriate bedding cannot be overemphasised.
The largest cause of death in our series was
strangulation due to ropes and cords, in children aged 11 months to 13 years, the majority of
whom were male. For infants who are not
mobile, the risk of strangulation was from cords
on objects, both within and outside the cot for example, strings attached to toys, harnesses,
and clothing that can pull tight around the
neck. The danger of infant strangulation due to
cords has been raised in several case reports and
the avoidance of these is strictly advised.6"I
Three toddlers were strangled by blind or
curtain cords, and one by a necklace left
hanging beside the cot. Two recent fatal case
reports highlight these dangers - the first of a
toddler by a corded light switch specifically
designed for use by children,'2 and the second
by a loose lamp flex during the night.'3 Toddlers become increasingly mobile, lack a sense of
danger, and are curious by nature and therefore
are at risk from a variety of objects around the
house and near the cot.
There were 11 deaths in children 3 years and
over attributable to rope, belts, or cords. Play
with ropes is inherently dangerous even if the
child is thought old enough to be careful, as
illustrated by the death of four children aged 1 1
to 13 years. Seven deaths were due to homemade rope swings of varying types, usually
made with a loop at the end or with the two ends
tied together. The risk of childhood strangulation due to unsafe play with such ropes must be
stressed.8 11
In Australia in 1992 the rate for nonintentional death due to asphyxiation by food'
was 2-9/million/year, and by other objects was
1 1/million/year in children 0 to 14 years.2 The
Victorian average annual rate was less, at 0.9/
million/year for foreign body aspiration, food,
and other objects together. USA national rates
for aspiration of food and other material were 4
and 3/million/year respectively,3 similar to the
Australian rates.
Six of the eight deaths due to foreign body
inhalation were in children under the age of 5
years. Factors such as a younger age group, a
more intense atmosphere, playing, laughing or
shouting while eating, and lack of supervision
during meals, may increase the risk of choking.
These elements are likely to occur in the day
care setting,'4 or at children's parties.
Hotdogs have been cited as a major cause of
fatal chokings in children.7 1516 Two Victorian
children died after choking on a party frankfurter. Although not immediately evident as a
risky foodstuff, the innocent and well-loved
frankfurter is inherently dangerous for small
children due to its size, shape, and consistency. 6 Measures such as age appropriate
food, a supervised eating environment, and not
allowing young siblings to feed an infant should
be adopted, together with promotion of correct
responses to aspiration emergencies.
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Altmann, Nolan
The prevention of asphyxiation deaths needs
tackling from a variety of angles. The failure of
voluntary standards emphasises the need for
more standards to be legislated."7 Australia has
many voluntarily adopted standards that cover
articles with which children will come into
contact. However, legislation only exists regarding the size of toys for children under 3 years
where the toy may represent an inhalation or
ingestion risk.'8 In the USA, after a USCPSC
review of 126 crib related deaths,'9 legislation
was passed regulating the distance between crib
slats and the space between the mattress and
side rails.20 Currently in Australia standards
relating to cots are under review, and legislation is being contemplated.
There are no codes or regulations in Australia that cover the labelling of food regarding
its age appropriateness, while these types of
labelling requirements on prepackaged food for
infants and children were introduced in 1979 in
Sweden,2' and are also seen in other European
countries. Labelling and warnings on products,
in particular children's equipment, and hazardous foodstuffs need to be considered. All
domestic market rope products, together with
equipment that contains loose rope or cord (for
example skipping ropes and clothes lines),
should carry product warnings, preferably
non-removable. Written warnings need to state
the potential hazard, rather than an age below
which the product is deemed inappropriate.
Product labelling has the ability to reach
members of the public not always targeted by
preventative campaigns and therefore is an
excellent mechanism for information
Hazardous products for children are frequently those available and marketed to the
general public. Education and anticipatory
guidance can address this problem, along with
the issue of access to age inappropriate food and
toys when there are older children in the
household. Parents, children, their carers, and
health care professionals all need to be targeted.
Almost all the asphyxiation deaths reported
here could have been prevented by education,
supervision, or structural modification of
equipment. Preventable strategies need to include obligatory manufacturing standards,
product labelling and warnings, and specific
and targeted education of parents, child carers,
and health care professionals. Special attention
must be given firstly to ensuring a safe environment for infants, with respect in particular to
bedding and food, and secondly to warnings
and education about the dangers associated
with ropes, in particular rope swings.
The authors wish to acknowledge the invaluable help of the
Consultative Council on Obstetric and Paediatric Mortality and
Morbidity and its staff, in particular Dr Bill Kitchen, and also
the Victorian Coronial Service and its staff, especially the
principal registrar Mr David Stephens.
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Non-intentional asphyxiation deaths due to
upper airway interference in children 0 to 14
A. Altmann and T. Nolan
Inj Prev1995 1: 76-80
doi: 10.1136/ip.1.2.76
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