Unintentional Suffocation draft report
Engagement and feedback document
Authors: Hayman, RM1 and Dalziel, SR2
1
Fellow and 2Paediatric Emergency Specialist and Director of Emergency Medicine Research, Children’s Emergency
Department, Starship Children’s Hospital, Auckland.
Published in September 2012 by the Health Quality & Safety Commission, PO Box 25496, Wellington 6146
This document is available on the Health Quality & Safety Commission website: www.hqsc.govt.nz
For information on this report please contact info@hqsc.govt.nz
CYMRC Unintentional Suffocation website consultation document – September 2012
1
Executive Summary
The Child and Youth Mortality Review Committee (CYMRC) is requesting feedback on the development of
recommendations to prevent unintentional suffocation of children under 25 years of age.
In New Zealand, unintentional injury is the second leading cause of death in those aged between one month and 24
years (34.5% for 2002-2008)(4). Previous CYMRC reports have indicated that within the unintentional injury category,
death from suffocation is the third leading cause. Death from suffocation encompasses a heterogeneous collection of
causes that end in death due to asphyxia. This includes unintentional strangulation from cords or ropes, foreign body
inhalation, oro-nasal occlusion, chest compression and head and neck entrapment. Previous CYMRC reports have not
explored the contributions that various conditions make to the wider classification of death from suffocation. As a
result, this report provides information on the mechanisms and circumstances of death by suffocation in New Zealand
children and young people aged less than 25 years. The data in in part A of the report is from the Ministry of Health’s
National Mortality Collection, while the data in part B is from the New Zealand Mortality Review database.
Towards the end of this report, readers will find where the CYMRC has begun to develop recommendations – aimed at
government, service providers, and families – to prevent unintentional suffocation in children under 25 years of age.
In order to develop sound recommendations, the CYMRC is now inviting feedback on these recommendations. If you
wish to provide feedback on the recommendations, you can send an email with your feedback to info@hqsc.govt.nz
with ‘CYMRC suffocation report’ in the subject line.
While the CYMRC is particularly interested in feedback on the proposed recommendations to prevent unintentional
suffocation in children under 25 years of age, reviewers are welcome to provide feedback on any part of the
document.
All feedback provided to CYMRC will be analysed as part of the feedback process. In order to be included in the initial
analysis, please provide your feedback by Friday, 26th October.
CYMRC Unintentional Suffocation website consultation document – September 2012
2
Introduction
Suffocation and strangulation are well recognised as a cause of death in the paediatric age group. Data from the
United States and United Kingdom show a significant burden of death due to unintentional suffocation, strangulation
or choking(1, 2).
Prevention of these deaths can be achieved with a “best practice” model(3). Best practice incorporates
surveillance of New Zealand issues and uses a three way approach: Safe product design and use, effective legislation
and parent and professional education.
In New Zealand, unintentional injury is the second leading cause of death in those aged between one month and 24
years (34.5% for 2002-2008)(4). Previous Child Youth Mortality Review Committee (CYMRC) reports have indicated
that within the unintentional injury category, death from suffocation is the third leading cause. Death from suffocation
encompasses a heterogeneous collection of causes that end in death due to asphyxia. This includes unintentional
strangulation from cords or ropes, foreign body inhalation, oro-nasal occlusion, chest compression and head and neck
entrapment. Previous CYMRC reports have not explored the contributions that various conditions make to the wider
classification of death from suffocation. For this reason detailed knowledge of the New Zealand cases will be provided
in this chapter. This will provide essential information on deaths due to suffocation such as cause, trends and
preventable factors.
Furthermore, unintentional suffocation is increasingly being recognised as a significant contributing factor to
Sudden Infant Death Syndrome (SIDS) and Sudden Unexpected Death in Infancy (SUDI) in those aged less than one
year.1 As more information becomes available from death scene investigations, it is becoming clear that a
considerable proportion of these deaths are attributable to unsafe sleeping situations. These situations lead to
suffocation from becoming wedged between parts of bedding or being overlain by a co-sleeping partner(5, 6). Analysis
of such detailed scene data may in part explain the proportional increase of reported infant death due to accidental
suffocation in bed(7, 8) as this could be due to diagnostic transfer. Location of infant sleep has also been shown to be
an important contributor. A case control study over two decades showed an eight-fold increase in deaths in adult beds
or on sofas over the time studied. Concurrently deaths in cribs decreased over this time period(8).
Other mechanisms of unintentional suffocation include strangulation from cords or ropes and choking on food or
other objects(1, 9). Children in the 1-5 year age range are more likely to become tangled in hanging cords, such as
curtain cords, bibs or pacifier cords and be unable to extract themselves from these situations. Older children are at
risk during dangerous or experimental play with ropes, such as climbing trees with ropes and rope swings(2, 9).
Trachea size in children is smaller than adults with trachea being of similar size to the size of the child’s little finger.
Furthermore, children younger than 3 years of age are more likely to put things in their mouth as part of normal
development. Together these factors increase the risk of young children choking on both food and non-food items.
Hard round foods, such as peanuts and beans, are the most likely causes of death due to choking, although items with
elasticity and lubricity, such as hot dogs and balloons, also contribute to childhood choking deaths internationally(1012).While this report focuses on mortality, mortality remains only a small proportion of the overall health burden
associated with unintentional suffocation. For example, for every child that dies from foreign body inhalation another
ten are seen in hospital(11). This does not include those children who choke who are successfully treated at home.
In this chapter we will provide information on the mechanisms and circumstances of death by suffocation in New
Zealand children and young people aged <25 years, from the New Zealand Mortality Review database. With this
information we hope that effective prevention strategies can be put in place that are developmentally appropriate,
culturally acceptable and provide effective information using health promotion principles.
11
Please see the text box on page 19 entitled Preventing the Unexpected - How Does Suffocation and Strangulation in Bed Relate to Sudden
Unexpected Death in Infancy (SUDI) and Sudden Infant Death Syndrome (SIDS)?
CYMRC Unintentional Suffocation website consultation document – September 2012
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Methods
Cause(s) of Death and Sample Selection
A. Main Underlying Cause of Death as Assigned in National Mortality Collection 2: In the National Mortality Collection all
deaths are assigned a single main Underlying Cause of Death (ICD-10-AM), plus as many Contributory Causes (ICD-10-AM) as
required. The initial analyses in this section include only cases with a main Underlying Cause of Death in the ranges outlined
below, in order to ensure that each individual is allocated a single cause, and so that the totals in tables and graphs sum to
100%.
The initial analysis thus includes all children and young people aged 0 days to less than 25 years who died in New Zealand
between January 1st 2002 and December 31st 2009 and where the main underlying cause of death identified in the National
Mortality Collection was in the following range:
*Accidental Suffocation and Strangulation in Bed (ICD-10-AM W75)
*Other Accidental Suffocation, Strangulation and Threats to Breathing (ICD-10-AM W76, W77, W83)
*Inhalation of Food or Other Objects Causing Obstruction of Respiratory Tract (ICD-10-AM W79-80)
Cases selected using these criteria were then used to explore the distribution of suffocation in children and young people by
year, gender, age and ethnicity.
B. Cause(s) of Death Assigned after Additional Review of Information from the New Zealand Mortality Review Database:
The CYMRC and the Perinatal and Maternal Mortality Review Committee (PMMRC) 3 store data in the New Zealand Mortality
Review database, which contains information from a variety of sources, many of which could be used to assign a cause(s) of
death. On occasion, the New Zealand Mortality Review database holds additional information, not available to Ministry of
Health coders when assigning official causes of death in the National Mortality Collection. Thus, in addition to using National
Mortality Collection cause of death data, this section contains additional analyses where the main underlying cause of death
has been assigned following individual case review of CYMRC and PMMRC data. Benefits of the detailed analysis include
providing further information on the mechanisms of injury leading to unintentional death from suffocation and information
concerning the location in which these deaths occurred. Further, the possibility remained that a number of similar deaths
had been coded to other causes (e.g. SIDS) potentially masking the magnitude of the problem. The methodology used to
assign cause(s) of death in this context is outlined below.
Search Strategy for Additional Case Review: A wide search of the New Zealand Mortality Review database (using an
additional eight ICD-10-AM codes, as well as those deaths awaiting ICD-10-AM coding which were considered to be due to
suffocation by CYMRC and PMMRC data group staff) was conducted, in order to find additional cases not identified by the
search strategy above. The methodology used was intentionally broad, in order to capture as many additional cases as
possible. Detailed analysis of these cases was then undertaken, in order to identify the mechanism and location of death.
Sample Selection for Detailed Case Review: The detailed case review included children and young people aged 0 days to less
than 25 years who died in New Zealand between January 1st 2002 and December 31st 2009 and where the ICD-10-AM main
underlying cause of death identified in the National Mortality Collection was in the following range:
*Pneumonitis due to food and vomit (ICD-10-AM J690)
*Asphyxia (ICD-10-AM R090)
*Unattended death (ICD-10-AM R98)
*Other ill defined and unspecified causes of mortality (ICD-10-AM R99)
*Accidental suffocation and strangulation in bed (ICD-10-AM W75)
2
The National Mortality Collection is maintained by Ministry of Health coders who classify the underlying cause of death for all deaths registered in
New Zealand. More information can be found at: http://www.health.govt.nz/nz-health-statistics/national-collections-andsurveys/collections/mortality-collection.
3 The CYMRC acknowledges collaboration with the PMMRC to access information about infants under 28 days of age.
CYMRC Unintentional Suffocation website consultation document – September 2012
4
*Other accidental hanging and strangulation (ICD-10-AM W76)
*Threat to breathing due to cave-in, falling earth and other substances (ICD-10-AM W77)
*Inhalation of gastric contents (ICD-10-AM W78)
*Inhalation and ingestion of food causing obstruction of respiratory tract (ICD-10-AM W79)
*Inhalation and ingestion of other objects causing obstruction of respiratory tract (ICD-10-AM W80, W808)
*Other specified threats to breathing (ICD-10-AM W83)
*Unspecified threat to breathing (ICD-10-AM W84)
*Hanging, strangulation and suffocation, undetermined intent (ICD-10-AM Y20)
*Sudden Infant Death Syndrome (SIDS) (ICD-10-AM R95)
Each case was then reviewed by a single reviewer and assigned to one of nine sub-groups; unintentional strangulation,
foreign body inhalation, death in a place of sleep with suffocation, suicide or purposeful strangulation with unclear intent to
die, Sudden Unexpected Death in Infancy (SUDI), medical cause, aspiration of vomit, suspicious death and unknown cause.
Information used to support subgroup allocation included local CYMR group review, police reporting (POL47 and POL47A
forms), and post mortem and Coroner’s reports. If insufficient information was available from the New Zealand Mortality
Review database, the Coroner’s office provided further information where possible. The deaths assigned into the sub-group
of death in a place of sleep with suffocation were further independently checked by two additional reviewers to confirm that
they fulfilled the inclusion criteria below. Discrepancies were resolved by consensus discussion.
Inclusion Criteria: Cases were included in the analysis if they were clearly unintentional, and were; 1) due to external
compression of the neck leading to strangulation, 2) external compression of the chest leading to suffocation, 3) oro-nasal
compression, or 4) blockage of the airway with an object other than vomit.
Exclusion Criteria: Cases were excluded if it was unclear that they were unintentional. Cases with the ICD-10-AM code of
“Y20: Hanging, strangulation and suffocation, unclear intent” were excluded when there was clear intent to cause
strangulation or suffocation, but no clear intent to die, or if there had been prior suicidal behaviour. Deaths classified as
SUDI that had no clear evidence of accidental suffocation or entrapment, were excluded. In some cases there was a strong
suspicion that accidental suffocation due to overlay by a co-sleeping partner was the cause of death, but only those cases
found in compromising situations (such as under a co-sleeping partner) were included. Deaths with post mortem findings
consistent with a cause other than suffocation, or evidence of vomit in the airway assigned as cause of death were also
excluded, as it was hypothesised that vomit in the airway may have been an agonal event rather than a terminal event.
Suspicious cases and cases due to a medical cause, such as sepsis or asthma, were excluded. Cases with insufficient
information to permit further classification were also excluded as unknown cause.
Demographic data, risk factors for SUDI, potential risk factors for unintentional overlay, potential risk factors for
entrapment/wedging in bed and a narrative account surrounding the death were recorded for all cases. A descriptive
analysis of the cases was also undertaken.
Notes on Interpretation: The actual number of deaths from unintentional suffocation / overlay / wedging is probably
underestimated in this analysis, as only cases where clear evidence that a suffocation event had occurred were included.
Further, while the search terms were made as broad as possible, so as to include any potential cause of suffocation, the
possibility remains that some cases may have been overlooked. In addition, the CYMRC dataset was not complete for all
cases, and in a number of cases, there was conflict between data from different sources. In such cases the reviewer took all
findings in to consideration when making a decision.
Ethnicity classifications were undertaken using a prioritised classification.4
4
The CYMRC ethnicity protocol
www.otago.ac.nz/nzmrdg/reports.html.
can
be
found
on
the
NZ
Mortality
Review
Database
website
CYMRC Unintentional Suffocation website consultation document – September 2012
5
at:
https://secure-
A. Analysis of Data from National Mortality Collection
Main Underlying Cause of Death
The following section uses the main underlying cause of death (ICD-10-AM), as assigned in the National Mortality
Collection, to review deaths from unintentional suffocation in New Zealand children and young people aged 0 days to
less than 25 years during January 1st 2002 to December 31st 2009.
Distribution by Year
In New Zealand during 2002-2009, on average, 24 children or young people per year died from unintentional
suffocation, with this equating to a rate of 1.63 per 100,000. The largest subgroup was deaths due to suffocation and
strangulation in bed (78.4% of total deaths) (Table 1).
Table 1. Mortality from unintentional suffocation in children and young people aged 0 Days to 24 Years, New Zealand
2002-2009.
2003
2004
2005
2006
2007
2008
2009
2002–2009 rate
per 100,000
2002
Total
(%)
Total
13
13
18
13
23
27
29
16
152
78.4
1.28
Other accidental suffocation,
strangulation and threats to
breathing
1
4
4
3
1
6
6
2
27
13.9
0.23
Inhalation of food or other objects
causing obstruction of respiratory
tracts
2
2
-
2
-
6
3
-
15
7.7
0.13
Total
16
19
22
18
24
39
38
18
194
100.0
1.63
ICD-10-AM Cause of death
Accidental suffocation
and strangulation in bed
Source: Numerator: CYMRC and PMMRC Cases by ICD-10-AM Main Underlying Cause of Death as assigned in National Mortality
Collection; Denominator Statistics NZ Estimated Resident Population.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Figure 1. Mortality from unintentional suffocation in children and young people aged 0 days to 24 years, New
Zealand 2002–2009 (n=194).
Inhalation of food or
other objects
causing obstruction
of respiratory tracts
7.7%
Accidental
suffocation and
strangulation in bed
78.4%
Other accidental
suffocation,
strangulation and
threats to breathing
13.9%
Source: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in the National Mortality Collection
Distribution by Age and Cause
In New Zealand during 2002-2009, deaths from suffocation and strangulation in bed were highest during the first
year of life, with only one death occurring after 24 months of age. In contrast, deaths from other suffocation,
strangulation or threats to breathing were more evenly distributed across the age range. Mortality from inhalation
of food or other objects was highest in preschool age children, with the highest rates being seen in those 12 to 24
months of age. Males were more likely to die from unintentional suffocation than females in each of the categories
reviewed (Figure 2, Figure 3, Figure 4 and Figure 5).
CYMRC Unintentional Suffocation website consultation document – September 2012
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Figure 2. Mortality from all unintentional suffocation in children and young people aged 0 days to 24 years by age
and gender, New Zealand 2002-2009 (n=194).
90
Number of deaths
Male
80
Female
70
60
50
40
30
20
10
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age in years
Source: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in National Mortality Collection.
Figure 3. Mortality from accidental suffocation and strangulation in bed in children and young people aged 0 days to
23 months by age and gender, New Zealand 2002-2009 (n=152).
25
Mortality from unintentional suffocation and strangulation in
Number of deaths
children and young people aged 0 days to 24 years by age and
gender, New Zealand 2002-2009 (n=194)
Male
Female
20
15
10
5
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23
Age in months
Source: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in National Mortality Collection.
CYMRC Unintentional Suffocation website consultation document – September 2012
Figure 3a. Mortality from accidental suffocation and strangulation in bed in
children and young people aged 80 days to 24 months by age (in months) and
gender, New Zealand 2002-2009 (n=121)
Figure 4. Mortality from other suffocation, strangulation or threats to breathing in children and young people aged 0
days to 24 years by age and gender, New Zealand 2002-2009 (n=27).
3.5
Number of deaths
Male
3
Female
2.5
2
1.5
1
0.5
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age in years
Source: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in National Mortality Collection.
Figure 5. Mortality from inhalation of food or other objects in children and young people aged 0 days to 24 years by
age and gender, New Zealand 2002-2009 (n=15).
Number of deaths
6
Figure 3. Mortality from other suffocation, strangulation or threats to
breathing in children and young people aged 0 days to 24 years by age and
Male
gender, New Zealand 2002-2009 (n=27)
5
Female
4
3
2
1
0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age in years
Source: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in National Mortality Collection
Figure 2. Mortality from inhalation of food or other objects in children and young
people aged 0 days to 24 years by age and gender, New Zealand 2002-2009 (n=15)
CYMRC Unintentional Suffocation website consultation document – September 2012
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Distribution by Ethnicity
In New Zealand during 2002-2009, using the Prioritised Ethnicity Classification, mortality from suffocation and
strangulation in bed (W75) was significantly higher for Māori children and young people (Rate Ratio 9.71, 95% CI
6.35 -14.84) than for European children and young people (Table 2).
Due to the small number of deaths from inhalation of food or other objects (W79-80) and other suffocation,
strangulation or threats to breathing (W76, W77, W83) these two categories were combined for review by ethnicity.
There were no significant differences between Māori and European children and young people for these (combined)
categories of death. The small numbers preclude a more meaningful analysis for children of other ethnic groups
(Table 2).
Table 2. Mortality from unintentional suffocation in children and young people aged 0 days to 24 years by ethnicity,
New Zealand 2002–2009.
Ethnic
group
2002
2003
2004
2005
2006
2007
2008
2009
Total
2002–
2009 rate
per
100,000
Rate
ratio
RR Confidence
interval (95%)
Accidental suffocation and strangulation in bed
European
3
3
4
2
5
2
5
3
27
0.40
1.00
-
Māori
7
8
12
10
13
21
20
11
102
3.85
9.71
6.35 – 14.84
Pacific
3
1
2
1
3
4
3
1
18
1.72
4.34
2.39 – 7.89
Asian
-
1
-
-
2
-
1
1
5
0.38
0.97
0.37 – 2.51
MELAA
-
-
-
-
-
-
-
-
-
-
-
-
Subtotal
13
13
18
13
23
27
29
16
152
1.27
Inhalation of food or other objects and other suffocation, strangulation or threats to breathing
European
1
3
2
2
1
8
5
2
24
0.35
1.00
-
Māori
2
2
2
2
-
2
3
-
13
0.49
1.39
0.71 – 2.73
Pacific
-
-
-
1
-
1
1
-
3
0.29
0.81
0.25 – 2.70
Asian
-
1
-
-
-
-
-
-
1
0.08
0.22
0.03 – 1.61
MELAA
-
-
-
-
-
1
-
-
1
0.76
2.17
0.29 – 16.04
Subtotal
3
6
4
5
1
12
9
2
42
0.35
Total
16
19
22
18
24
39
38
18
194
1.62
Source: Numerator: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in National Mortality
Collection; Denominator Statistics NZ Estimated Resident Population.
CYMRC Unintentional Suffocation website consultation document – September 2012
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B. Analysis Following Additional Review of Information from the New
Zealand Mortality Review Database
Introduction
Further to the 194 cases identified above, 427 extra cases were identified from a search of the eight additional ICD10-AM codes. All 621 cases subsequently underwent a detailed case review of the information contained in the New
Zealand Mortality Review database to classify deaths as unintentional suffocation or unrelated to unintentional
suffocation, as detailed in the methods section. Cases classified as unintentional strangulation, foreign body inhalation
and death in place of sleep with suffocation (n=79 cases) were then included in the following analysis, while the
remaining cases (n=542 cases) were excluded (Table 3).
Distribution of Included Cases by Category of Death
In New Zealand during 2002-2009, 79 children and young people died from unintentional suffocation as
determined by case review, with these deaths being broken into three categories: unintentional strangulation (13
deaths); foreign body inhalation (16 deaths); and death in a place of sleep with suffocation (50 deaths)(Table 3).
Table 3. Classification of unintentional suffocation deaths from additional analysis of the CYMRC and PMMRC
Datasets, New Zealand 2002-2009.
2005
2006
2007
2008
2009
2002–2009 rate
per 100,000
2004
Total cases reviewed and excluded
Total
(%)
2003
Unintentional strangulation
Foreign body inhalation
Death in place of sleep with suffocation
Total cases included as unintentional
suffocation
Suicide / purposeful strangulation intent
to die unclear
Sudden unexpected death in infancy
Medical causes
Aspiration of vomit
Suspicious death
Unknown cause
Total
2002
Cause of death
2
4
4
1
9
1
7
2
5
5
1
5
8
4
3
9
3
3
3
13
16
50
16.5
20.3
63.3
0.11
0.13
0.42
6
14
8
7
5
14
16
9
79
100
0.66
3
1
5
4
4
5
12
21
55
10.1
0.46
49
1
1
2
5
57
1
2
1
55
1
1
1
1
46
1
1
3
71
1
2
58
2
2
2
58
4
4
38
3
1
12
432
13
7
5
30
79.7
2.4
1.3
0.9
5.5
3.64
0.11
0.06
0.04
0.25
61
62
64
55
78
69
78
75
542
100
4.56
Source: CYMRC and PMMRC Data Collections; Numerator: Cause of Death assigned following individual case review of CYMRC and
PMMRC data. Denominator: Statistics NZ Estimated Resident Population.
Excluded Cases by Cause of Death
Of the 542 cases that were excluded from further review, the majority 432 (79.7%) were classified as SUDI, with
most, 292 cases (67.6% of those classified as SUDI), being coded as ICD-10-AM R95: SIDS. Fifty-five (10.1%) of the 542
excluded cases were classified as suicide or purposeful strangulation with unclear intent to die. Thirty (54.5%) of
these 55 excluded cases had an ICD-10-AM Y20: Hanging, Strangulation and Suffocation, Undetermined Intent code.
Thirty (5.5%) of the total 542 cases were excluded as there was insufficient information to assign them to an
appropriate category. The majority of this latter group was from 2009, with a high proportion having Coroners’
reports and local group reviews outstanding.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Unintentional Strangulation
In New Zealand during 2002-2009, thirteen children and young people died from unintentional strangulation,
equating to a rate of 0.11 per 100,000. There were eight male and five female deaths. The deaths fell into two broad
categories, those in infants (6 cases, range 7-24 months) and those in older children and young people (7 cases, range
6-24 years).
The deaths in infants younger than 2 years of age were due to strangulation with loose cords such as a curtain cord,
mosquito net, evening bag strap and a commercially available product to ensure supine sleeping by securing an infant
to the bed with a wide band across the abdomen. Infants in these situations did not have the developmental ability to
extract themselves from a dangerous situation.
Deaths in the older children were due to collapse of sand/dirt (3 cases) or due to dangerous play with ropes or
cords such as a homemade flying fox, climbing with rope/cord, or riding a skateboard with a rope.
Foreign Body Inhalation
In New Zealand during 2002-2009, 16 children and young people died from foreign body inhalation, equating to
a rate of 0.13 per 100,000. There were thirteen male and three female deaths. The median age of death was 4.9 years
(range 1-20 years). Thirteen deaths were in children under 6 years of age, with the remaining three young people
being over 15 years (with one case complicated by alcohol intoxication and the other two by severe developmental
delay).
Deaths occurred as a result of the inhalation of food; meat/sausage n=5 (31.3%), peanuts n=2 (12.5%), apple n=1
(6.3%), grapes n=1 (6.3%), or other objects like drawing pins n=2 (12.5%), plastic food wrapping n=2 (12.5%), beads
n=2 (12.5%) and tablets n=1 (6.3%) (Figure 6). Seven of the 16 deaths (43.8%) occurred away from the normal eating
routine at home, e.g. at a family or social event.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Figure 6. Mortality from foreign body inhalation in children and young people aged 0 days to 24 years, by type of
object inhaled, New Zealand 2002–2009 (n=16).
6
Number of deaths
5
5
4
3
2
2
2
2
2
1
1
1
1
0
Object inhaled
Source: CYMRC and PMMRC Data Collections; Cause of Death assigned following individual case review of CYMRC and PMMRC
data.
Death in Place of Sleep with Suffocation
In New Zealand during 2002-2009, 50 children or young people died from suffocation in a place of sleep, equating
to a rate of 0.42 per 100,000.
Forty-eight (96.0%) of the deaths were in infants under 12 months of age. Amongst this group the average age of
death was 3.4 months (range 3 days-10 months, median 3 months) with the most common age at death being 1
month or under (n=21). Both children aged over 12 months had developmental delay.
Using prioritised ethnicity, mortality from death in a place of sleep with suffocation was significantly higher for
Māori (RR 8.22, 95% CI 4.04-16.73) and Pacific (RR 4.56, 95% CI 1.74-11.98) children and young people than for
European children and young people (Table 4).
Deaths were due to overlay (60.0%, n=30) or wedging (40.0%, n=20). Overlay consisted of overlay by mother while
breast feeding (16.0%, n=8), overlay by sibling in a co-sleeping situation (8.0%, n=4), and overlay by mother or father
in a co-sleeping situation (34.0%, n=17), with mechanism unknown in one case. Wedging deaths occurred due to
entrapment between a hard sleeping surface and bedding, i.e. mattress and cot/bed/couch (20.0%, n=10), sleeping
surface and wall (10.0%, n=5), and couch/cushions (10.0%, n=5) (Table 5).
A quarter of deaths (24.0%, n=12) in place of sleep with suffocation occurred away from home, all in make-shift
bedding arrangements.
CYMRC Unintentional Suffocation website consultation document – September 2012
13
2009
2008
2007
2006
2005
2004
2003
Ethnic
group
2002
Table 4. Mortality from unintentional suffocation in children and young people aged 0 days to 24 years by ethnicity,
New Zealand 2002-2009.
Total
2002–2009
rate
per 100,000
Rate
ratio
RR Confidence
interval (95%)
Accidental suffocation and strangulation in bed
European
2
4
1
1
Māori
2
3
6
4
Pacific
1
Asian
1
1
1
3
6
7
2
1
1
10
0.15
1.00
-
1
32
1.21
8.22
4.04 - 16.73
2
7
0.67
4.56
1.74 - 11.98
1
0.08
0.52
0.07 - 4.07
0
0.00
0.00
-
50
0.42
MELAA
Subtotal
4
9
7
5
5
8
9
3
Inhalation of food or other objects and other suffocation, strangulation or threats to breathing
European
-
3
-
-
-
5
4
2
14
0.21
1.00
-
Māori
2
1
1
2
-
-
2
2
10
0.38
1.84
0.82 - 4.13
Pacific
-
-
-
-
-
-
1
1
2
0.19
0.93
0.21 – 4.10
Asian
-
1
-
-
-
-
-
1
2
0.15
0.75
0.17 – 3.28
MELAA
-
-
-
-
-
1
-
-
1
0.76
3.72
0.49 – 28.29
Subtotal
2
5
1
2
-
6
7
6
29
0.24
Total
6
14
8
7
5
14
16
9
79
0.66
Source: CYMRC and PMMRC Data Collections; Numerator: Cause of Death assigned following individual case review of CYMRC and
PMMRC data. Denominator: Statistics NZ Estimated Resident Population.
Information regarding co-sleeping was available in 46 of the 50 deaths (92.0%). All of the overlay deaths, and four
(20.0%) of the 20 wedging deaths, were in a co-sleeping situation. Overall 34 out of the 50 cases of suffocation in
place of sleep (68.0%) occurred in a co-sleeping situation.
Information regarding where the children and young people were put to sleep was available in 48 of the 50 cases
(96.0%). Seven were placed to sleep in a cot (17.0%), 32 in a bed (62.3%), and 9 in a couch or chair (20.8%). Six of the
seven deaths in cots were due to faulty cots, and there was insufficient information regarding the condition of the cot
in the remaining death. Cots commonly had an inappropriate sized mattress that could allow wedging between the
mattress and the base of the cot. Alternatively the sides of the cot were faulty and allowed infants to slip through and
become trapped. Two of the infants were found under pillows and eight died at the breast when their mother fell
asleep while feeding, most of whom were <1 month old.
Unfortunately information was not consistently available for known risk factors for SUDI (particularly absence of a
risk factor). However, the CYMRC and PMMRC datasets indicate that at least two (4.0%) infants were placed to sleep
prone, nine (18.0%) were exposed to a smoking environment, eight (16.0%) were noted to have an illness at the time
of death (most commonly an upper respiratory tract infection), three (6.0%) were premature and in four (8.0%) cases
alcohol use by care-givers was noted to be a significant contributing factor.
CYMRC Unintentional Suffocation website consultation document – September 2012
14
Table 5. Death in place of sleep with suffocation in children and young people aged 0 days to 24 years, number and
rate per 100 000 population, by location found, New Zealand 2002–2009.
Frequency
Percentage of
category
Percentage of total
2002–2009 rate
per 100,000
Trapped between sleep surface and bedding
10
50.0
20.0
0.08
Trapped between sleep surface and wall
5
25.0
10.0
0.04
Trapped between cushions and couch
5
25.0
10.0
0.04
Total
20
100.0
40.0
0.17
8
26.7
16.0
0.07
by sibling co-sleeping
4
13.3
8.0
0.03
by parent co-sleeping
17
56.7
34.0
0.14
Unknown
1
3.3
2.0
0.01
Total
30
100.0
60.0
0.25
Grand Total
50
100
0.42
Death in place of sleep with suffocation
Wedging
Overlay
While feeding
Source: CYMRC and PMMRC Data Collections; Numerator: Cause of Death assigned following individual case review of CYMRC and
PMMRC data. Denominator: Statistics NZ Estimated Resident Population.
Wedging refers to an infant who was found with face, neck or chest trapped in a manner that would impede breathing and
compromise the airway. Wedging had to occur between two sleeping surfaces, such as a mattress and a cot.
Overlay refers to the situation where a co-sleeping partner has caused suffocation.
Suffocation in place of sleep includes situations where the whole or part of a body, such as a limb or breast, can cover the
face, flex the neck or apply pressure to the chest or abdomen of an infant making it harder to breath. Infants have few
mechanisms to protect their own airway because of soft flexible tissues so even slight pressure on the nose or face or neck
flexing can lead to suffocation.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Issues and Recommendations
Issues Identified and Recommendations Made by Guest Authors5
We report the detailed case review of 79 deaths from unintentional suffocation during 2002-2009, and the
identified elements that contributed to these deaths. While official data such as that provided by the National
Mortality Collection, and reported on in the first section of this chapter, is useful for understanding the distribution of
suffocation in broad terms, the detailed case reviews by the numerous local mortality review groups across the
country provide invaluable information specific to New Zealand communities and it is these findings that are most
relevant for comment and to identify future recommendations.
Death in Place of Sleep with Suffocation
Fifty of the 79 deaths in this report arose from unintentional suffocation in bed, particularly among infants. The 50
deaths classified as death in a place of sleeping with suffocation differ from the 152 cases in the National Mortality
Collection coded as ICD-10-AM W75: Accidental suffocation and strangulation in bed as the main cause of death. One
hundred and thirteen of these deaths were excluded from the detailed analysis as there was no clear evidence of
death from suffocation, as described in the methods. Of the 113 cases excluded, 77 (68.0%) were co-sleeping and 22
(19.5%) infants were found prone. Furthermore, 54 (47.8%) out of the 113 cases had an additional risk factor for
SIDS/SUDI. The tight definition for death in place of sleep with suffocation used in this report attempted to highlight
mechanisms and location for such deaths in New Zealand, beyond information that was already available from
previous SIDS/SUDI data. In utilising such a tight definition, the report is likely to have underestimated the burden of
disease from suffocation or strangulation in bed.
The 50 deaths reinforce the importance of safe places to sleep. The message “safe sleep, every sleep, every place”
must be given correctly and consistently by all health professionals. It is concerning to see that the rate of death in
Māori and Pacific infants is significantly higher than for European infants (RR 8.22, 95% CI 4.04-16.73, RR 4.56, 95% CI
1.74-11.98, respectively). We were not able to determine the cause of this marked difference.
Hutchinson et al have previously demonstrated a high rate of co-sleeping in Māori (21%) and Pacific (39%) infants.
There is debate regarding the safety of bed sharing, which is a frequent practice in New Zealand, particularly among
Māori and Pacific people(14, 15). The promotion of breast feeding and infant parent bonding is cited as a benefit of
bed sharing(15, 16). However, during bed sharing an infant may spend a proportion of their sleep with their face
covered(16). Furthermore, there is evidence that if infants are exposed to a smoking environment they may not be
able to respond appropriately to this stressor. In Hutchinson’s study, 22% of both Māori and Pacific infants were also
exposed to cigarette smoke(13), a considerable risk factor for SIDS. Regardless of the underlying cause, the increased
risk in these infants needs to be highlighted to the parents, whānau and professionals who care for them.
The data in this analysis, while not adjusted for smoking, highlight that a number of New Zealand infants die each
year in co-sleeping situations from suffocation often related to overlying by the co-sleeping partner.
5
The CYMRC would like to thank guest authors, Dr Rebecca Hayman and Dr Stuart Dalziel. The CYMRC would also like to thank reviewers who
provided feedback early on in the report, including: Martin Rushton and Lou Parker from the Ministry of Consumer Affairs; Dr Marewa Glover and
Dr David Tipene Leach from the Mortality Review Committees’ Māori Caucus; Stephanie Cowan from Change for Our Children; Anne Weaver and
Moses Alatini from Safekids New Zealand; and Erin Beatson and Sue Campbell from Plunket.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Attributes of a Safe Sleep Space
This Chapter has highlighted that a substantial number of infants suffocate or are strangled during sleep every year. Much is known
about what constitutes a dangerous sleep environment, often based on death scene review. It is much harder to specify the
attributes of a safe sleep environment. It is suggested that the attributes below are used in assessing any sleeping arrangement
from first principles to support families to implement safe sleep practices.
A safe sleep space should be:
1.
Free from other people who might overlay the infant – sleep arrangements need to make sure that if someone else
moves in sleep the infant will still be able to breathe easily with a clear airway.
2.
Free of gaps that could trap or wedge – there should be no gaps which might trap an infant, wedge them and make
breathing hard or impossible.
3.
Firm – so the infants neck does not flex and block breathing and the face cannot get buried in the surface
4.
Flat - so the infant does not suffer compromise to the airway or breathing by rolling over, tipping out, inversion of sleep
space or becoming wedged.
5.
Free from objects that might cover the face – nothing should be put near that could cover the face during sleep. This
could include sleep restraint apparatus or low-hanging mobiles.
In safe sleep spaces infants should be:

Back to sleep – infants should always sleep on their backs.

Smokefree – always allow babies to breathe air free of smoke.

In parents’ room - when parents are asleep for the first six months of life.

At a comfortable temperature avoiding overheating – too many layers or too much heat from others can distress babies.
This study has highlighted that infants still die in unsafe bassinettes and cots. There are no NZ safety standards for bassinettes. All
cots and bassinettes should be checked against the points above to make sure they are safe, especially those that are second hand
or make shift.
Problems with make shift sleeping arrangements may occur because people often think infants need to be “snugly” or tightly
wrapped or cocooned. However such situations will also increase the risk of suffocation or strangulation with face covering,
overheating, neck flexing, or wedging as can occur on a couch, bean bag or adult bed.
Beds designed for adults are often too soft, have spaces to wedge an infant or coverings that can cover the face. Infants all need a
space designed for them to sleep safely. If an adult or another child is in the same bed as an infant, risks of suffocation occur as the
other person may accidently move and compromise the ability of the infant to breathe, which is overlaying.
Because safe sleep is so important, much work is being done to find better ways to keep infants safe.
The wahakura6 is a woven flax basket designed to meet all the points 1-5 above. In addition, the wahakura can sit in the family
sleeping place and provide the benefits of bed sharing, such as ease of breast feeding and bonding. Furthermore, the wahakura is a
culturally appropriate solution and easily transportable, a potential solution to deaths away from the home occurring in makeshift
bedding arrangements and deaths in faulty cots.
The Pepi-Pod 7and various clip-on cots and “side car” cots are also being trialled in New Zealand.
As new solutions are being considered, it is crucial that any unforeseen consequences relating to their use or misuse are identified
and addressed. Research is currently occurring in which families and whānau will be given a wahakura and then followed over time
to allow understanding of practical issues related to its use and how families and whānau can be best supported to keep infants
safe.
6
7
Contact http://www.maorisids.org.nz/ for more information.
Contact http://www.changeforourchildren.co.nz/safe_start_programme/pepi-pod for more information.
CYMRC Unintentional Suffocation website consultation document – September 2012
17
All sleeps should be safe sleeps. Parents need to be aware of the risks associated with make-shift bedding.
Recommendations to sleep infants in a cot must include the importance of a secure cot with a tightly fitting mattress
that can’t move during sleep. Cots that have been purchased second hand, or passed down from generation to
generation, are at risk of having ill-fitting mattresses or being broken. A practical solution provided by a local CYMRC
group was to have a pop-up window on internet sites such as Trade Me providing recommendations for safe cot
features at the point of sale for second hand goods. Furthermore, parents and caregivers need to be aware of the
risks of reduced awareness associated with their own alcohol and drug use – all babies should have a sober carer at all
times. These messages need to be disseminated widely to the community, and reinforced at all levels.
Messages regarding safe sleeping do change practice(13). Von Kohorn demonstrated that advice regarding safe
sleep position given from multiple sources to high risk mothers does make a difference to child care practices(18).
Mothers’ beliefs regarding comfort and risk of choking in the supine position influenced their decision, and safe sleep
messages should reassure mothers regarding these issues(18). All health practitioners need to ensure that the
messages given are consistent and ensure best practice is implemented.
Safe sleep messages need to be given from before birth and health care professionals, including midwives, Well
Child providers and GP practice nurses, have a responsibility to reinforce messages that are current, scientifically
proven and consistent across all spheres. This is especially important as infants under two months represent the
largest single group at risk of suffocation while in a place of sleeping.
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Preventing the Unexpected - How Does Suffocation and Strangulation in Bed Relate to Sudden Unexpected Death in
Infancy (SUDI) and Sudden Infant Death Syndrome (SIDS)?
Sudden Unexpected Death in Infancy (SUDI) is an umbrella term that describes the death of an infant which was not
anticipated as a significant possibility 24 hours before the death or where there was a similarly unexpected collapse leading
to or precipitating the events which led to the death. Deaths due to overlaying and wedging are included as SUDI cases yet
deaths due to motor vehicle crashes or assaults are not. Within the group of deaths designated as SUDI, there is a spectrum
of cases ranging from those that are unexplained following full investigation (SIDS) to cases which are fully explained
(explained SUDI). Between these two ends of the spectrum are cases where a pathologist or coroner cannot be certain as to
whether it’s explained or not; these are often labelled “unascertained.” The unexpected nature of SUDI can lead to the
acceptance that these deaths “just happen” and cannot be prevented. In fact, a substantial proportion of SUDI are
preventable.
As SUDI is defined with “unexpected” being considered from the point of view of parents or caregivers it is important to
review the whole of the SUDI spectrum so preventive efforts can be aimed at all causes of SUDI. Unfortunately coding of
deaths and even the definitions used is not a precise science and pathologists, coroners and researchers around the world
and in New Zealand include and exclude different categories. For instance some do not include cases of suffocation or
strangulation in bed within SUDI; this means any international comparisons need to be viewed with extreme caution.
Exclusion of any cases from the SUDI group may mask the importance of some preventive strategies.
A critical feature of the first year of life is that infants can exhibit the particular trait of dying without sufficient warning signs
or distress to alert parents or caregivers. It has been defined that a group of infants exist in which “intrinsic vulnerabilities”
may make them more susceptible to sudden death. For some these intrinsic vulnerabilities are sufficient to cause death
without any external factor or illness contributing. There are also cases which are clearly attributable to external factors that
on their own would be sufficient to cause death. These include suffocation and strangulation in bed or overwhelming
infection. Between these two extremes a spectrum exists where the degree of contribution of infant factors and
environmental factors varies. It appears that infant factors and external factors conspire together with risk accumulating.
Where un-modifiable risk factors in the infant exist, it is especially important that environmental factors are as favourable as
possible.
Infants’ vulnerabilities include:

smoke exposure during pregnancy

smoke exposure after birth

prematurity

small for gestational age

illness or congenital conditions that may affect the ability to breathe.
The sleeping environment is crucial with regard to SUDI prevention (see earlier text box). A key message from the Chapter is
that everyone needs to be aware of the circumstances that lead to infants suffocating or being strangled in bed so they can
be avoided. Furthermore there are common themes between SIDS prevention messages and the actions needed to prevent
suffocation and strangulation in bed so good uptake of prevention is likely to have benefits for the prevention of other parts
of the SUDI spectrum as well.
Foreign Body Inhalation
Sixteen children died as a result of choking in New Zealand during 2002-2009. Foreign body inhalation leading to
death in children is well recognised internationally(1, 9). The majority of deaths that we report here occurred in
children younger than 2 years of age. Sausage/meat and peanuts were the cause of death in approximately half of the
cases. Literature supports the finding that hard round foods (such as peanuts and beans) are the most likely causes of
death due to choking. Items with elasticity and lubricity, such as hot dogs and balloons, are also often cited as high
risk(10-12).
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19
Death from choking is just the tip of the iceberg, for every child that dies from foreign body inhalation another ten
are seen in hospital(12). Tragically almost half of the deaths in this series occurred at a gathering or communal place
of eating and during a special event such as a party. While the reasons for the contribution that such environments
make to mortality rates was not available from the CYMRC dataset, it is not unreasonable to suggest that during such
gatherings special foods are more likely to be available (such as nuts, small round lollies, small sausages), children are
less likely to be supervised, and children are more likely to be running around while eating and not following the
normal eating routine of sitting still and focussing on eating alone. All of these factors may contribute to an increase
in choking related deaths at such events.
In 2010 the American Academy of Pediatrics (AAP) published a policy statement on prevention of choking which
highlighted the risk of latex balloons (responsible for 29% of deaths in one case series) and hot dogs (responsible for
17% of deaths). The AAP recommended foods and toys to have mandatory choking hazard warnings and a call to
redesign high risk foods such as hot dogs(19).
The New Zealand Ministry of Health has recently developed guidelines on the prevention of choking by food in
children(30) . Increasing the awareness of the importance of supervised eating times is important, and a focus on one
activity at a time should be emphasised. In addition awareness should be encouraged of potential household choking
risks, such as small objects and toys. These need to be kept out of the reach of young children. Interestingly, there
were no deaths from small toys or small parts incorporated into toys in the cases reviewed.
In New Zealand(20), children’s toys must comply with a standard related to mechanical and physical properties
which is a common legal requirement in most developed jurisdictions around the world. This provision makes it a
mandatory requirement that small parts that are choking hazards be illegal in toys for children under 36 months. The
adoption of this provision may be reflected in our results. Furthermore, there has been a focus on providing health
promotion messages over a number of years to highlight to parents the importance of age appropriate toys and
avoiding toys with small removable parts or small toys that may cause choking.
What to do with a Choking Child (21)
If a foreign body is easily visible in the mouth then remove it, but be careful not to push it further into the airway. Do not perform
blind finger sweep of the mouth.
Are they coughing? Encourage coughing, support and assess continuously.
Do they have severe airway obstruction or an ineffective cough? An ineffective cough is recognised by the child’s inability to
speak, cry or take breaths between coughs.
If they are conscious:
1.
5 back blows – lying the child or infant with head down, deliver blows with the heel of your hand to the back of the child.
2.
5 chest thrusts – turn the child over, still in head down position and placing heel of hand on the lower third of the sternum
deliver thrusts at a rate of one per second.
3.
Assess the mouth for a foreign body and repeat if the foreign body has not be expelled.
If they are unconscious:
1.
Open the airway - head tilt/chin lift and jaw thrust.
2.
Give 5 rescue breaths.
3.
Commence CPR.
4.
Call for help.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Unintentional Strangulation
Thirteen children died from unintentional strangulation in New Zealand during 2002-2009. Six of them were under
2 years of age, and lacked the developmental ability to extract themselves from a dangerous situation. Altman in
Victoria, Australia reviewed 16 deaths in a 10-year period due to unintentional cord strangulation. Age and
developmental ability of the child influenced the mechanism of death. Infants not yet mobile became tangled in cords
on objects, as in a rattle on a string or a hanging necklace(9). Other studies have shown dummy cords and bibs to also
pose risk in this age group(1, 5). As children become more mobile they encounter danger in the form of hanging cords
or ropes such as curtain cords. The danger of curtain cord strangulation is widely recognised in the literature with 168
deaths reported in the United States over a 15-year period(22). Internationally, there has been advocacy and
legislation created to prevent unintentional strangulation in this age group(23-26).
Older children are at risk from dangerous play with ropes or cords. Six children over the age of 6 years died in New
Zealand from dangerous play with ropes. Homemade rope swings have caused deaths in Australia(9). Children need
to be educated about safe play with ropes. This message should be reinforced by parents, teachers, caregivers and the
media.
The prevention of unintentional suffocation requires consistent and clear messages, provided through education
and professional advice and with media support. In addition, high-risk families could be targeted with an intensive
home visiting programme aimed at increasing awareness of safety at home. Tertinger et al. developed and tested a
home accident prevention inventory package, which introduced and reinforced safety messages over multiple visits.
At the end of the intervention, homes were safer from known risk factors leading to childhood injury(27). Although
intensive, for families identified at high risk, such as those with Child Youth and Family involvement, a package similar
to this may be useful.
In Austria a free home safety pack was provided to all families with children less than 6 years of age. Items
included a smoke alarm, safety plugs and window barriers to prevent falls(3). The box was popular and most items
had good uptake in terms of use in the house. However, it was an expensive project to run and Eurosafe
recommended integration of the products into housing standards so that safety features are already part of the house
that a family rents or buys. Currently some regional initiatives produce a home safety pack, “Reach Me”, and this
model could be distributed to a wider community and have additional items such as curtain cord coverings or cleats,
and a choking guide to the size/type of food objects suitable for varying age groups. Housing New Zealand could
incorporate safety features recommended by this report into homes under its jurisdiction.
Issues and Recommendations from Local Mortality Review Groups
During 2002-2009, a total of 62 cases (37% of the cases identified by a ICD-10-AM J690, R090, R98, R99, W75-79,
W84, Y20 search) underwent local group review. The proportion undergoing review increased progressively as the
number of local review groups operating around the country increased. Thus, in interpreting the issues and
recommendations highlighted below, it should be remembered that these recommendations were made on the basis
of review of only a subset of the unintentional suffocation deaths that occurred during this period.
Local groups identified three consistent themes when reviewing suffocation cases: the need for after death care
pathways, the need for education and consistency of messages, and the need for improved interagency
communication.
CYMRC Unintentional Suffocation website consultation document – September 2012
21
After Death Care Pathways
Care after death can have a significant impact on the ongoing grief process for the family and whānau. Local group
recommendations included more victim support services that are culturally and language appropriate. They also
noted that people with disabilities need more support and that in some cases there is a lack of understanding of police
and medical processes and more support needs to be provided regarding communicating with these services. One
group suggested a follow up medical appointment after the death to provide preventative messages for the remaining
children could be helpful.
Consistency of Information Given to Caregivers
Some groups noted the inconsistency of information provided by neonatal intensive care units, Lead Maternity
Carers (LMCs) and Well Child providers. In some cases, the significance of risk factors appears not to have been
recognised, or these risk factors were not communicated to families. Recommendations included further education of
LMCs and Well Child providers regarding how to make consistent assessments of risk, provide appropriate referrals,
and provide correct and consistent messages for prevention. In addition to education, an audit or regular review of
practitioners’ practice could be made to ensure ongoing best practice is developed and followed consistently. Leaflets
or pop-up windows on internet sites such as Trade Me could be used to provide information regarding safe sleeping
and safe cots. Immunisation was noted by some groups to be erroneously associated with SUDI by some families and
whānau. In other cases, there was a delay in calling emergency services and there was concern expressed that there
was no credit on the phone to make the emergency call.
Need for Improved Interagency Communication
Many of the cases that were reviewed were complex and had multiagency involvement. In addition to multiple risk
factors, there were also occasions of previous child or young person deaths in the same family and whānau. Often
there was a breakdown in communication or a lack of a suitably resourced care co-ordination. Local groups suggested
more social work support in such cases was essential, as was the development of a service to co-ordinate care from
health, education, child protection and police perspectives. There is some confusion regarding the privacy laws and
what information could be shared between agencies and this was seen as needing to be clarified and formalised into
agreements between agencies. In addition, accidents involving products could be relayed to the Ministry of Consumer
Affairs to allow prevention initiatives. One group suggested that persistent follow up of families and whānau refusing
to engage with Well Child providers was critical to improve outcomes for children. They suggested that this could be
the responsibility of a formally assigned care co-ordinator.
Issues and Recommendations from CYMRC
Injury Prevention
The committee observes that New Zealand has a high rate of death from injury, particularly unintentional injury,
amongst its children and young people (29). In order to address this excess of deaths, a focus on childhood and
adolescent injury should remain a priority.
In the current classification of injury deaths in the first year of life, it is convention to include transport, drowning
and suffocation deaths (where a clear external agent applies force such as a blind cord) in the category of
unintentional injury. Such deaths only make up 2.4% of deaths in infants aged between 28 days and one year. The
injury prevention sector works hard to highlight and prevent risky situations which may contribute to these classes of
CYMRC Unintentional Suffocation website consultation document – September 2012
22
deaths. However, as highlighted by the above work, this is an under-representation of the risk of unintentional injury
death in infants as deaths due to suffocation or strangulation in place of sleep are, in contrast, classified as SUDI
deaths and not unintentional injury deaths. SUDI comprises 40.9% of deaths in infants aged between 28 days and one
year.
As deaths from suffocation or strangulation in the place of sleep are in fact injury deaths, successful preventive
work will have much in common with other types of injury prevention work. In the future, CYMRC will develop ways to
indicate the true burden of injury deaths in the first year of life. As suffocation and strangulation in bed will then be
overwhelmingly the most common cause of injury death in infants under one, it is hoped that preventive efforts will
grow in keeping with this tragic toll. The previous classification of suffocation and strangulation in place of sleep only
within the SUDI group may have tended to hide this condition. Preventive efforts from the injury prevention sector
have not been prominent and the community as a whole has at times tended to accept these deaths as something
that happens rather than something that can be prevented.
In many cases, infants who die of SUDI come from families where complex needs exist and vulnerability to a number
of adverse outcomes can be recognised before death. Early identification of vulnerable infants and families provides
an opportunity to implement inter-sectoral interventions and supports. Systems to ensure the ongoing assessment of
needs, from before birth, followed by planning and action to provide additional supports and interventions are
therefore recommended.
The committee observes that unintentional suffocation is the result of a heterogeneous collection of causes, of
which many aspects are totally preventable. The European child safety alliance(3) has created a report card of policy
interventions with evidence of positive effect for injury prevention strategies. European countries use this to
benchmark their progress and to implement evidence-based strategies. New Zealand can use this as an evidencebased guide to effective prevention strategies for unintentional suffocation and to assess progress toward the goal of
decreasing deaths.
With respect to the European child safety alliance report card for unintentional suffocation, positive features of the
current New Zealand climate include responsible government departments, leadership and interagency networking in
the area of child injury prevention, and surveillance in place to ensure strategies are valid within the New Zealand
context (28). Furthermore there are New Zealand laws to enable restriction and banning of unsafe products and to
require warning labels on toys and foods that are a choking hazard. In addition, New Zealand has appropriate
regulation regarding cot design and a chance to monitor the impact of an intervention such as the wahakura.
However, areas that New Zealand could improve on include more explicit warning labels outlining actual risk of
strangulation or choking. A warning label must explain what the risk is to be more effective. Secondly, specific curtain
cord legislation could be introduced reinforcing the production and importation of curtain cords that conform to
international safety legislation and have appropriate safety labels to prevent strangulation. Thirdly, although no
deaths were recorded from latex balloons or drawstrings on children’s clothing this is an area that has caused deaths
overseas. Approach to this issue requires further debate.
Finally, New Zealand could improve systems within the Well Child and social support systems around home injury
prevention across multiple developmental stages with assessment and education regarding home safety and provision
of consistent messages. Supportive home visits can be effective if information is provided at an age appropriate time
in the child’s development and combined with the provision of free safety equipment, if needed(3). Tools and
information resources could be created and key indicators recorded. These key indicators could be included in a
checklist of quality indicators, including every infant being registered with a General Practitioner by four weeks of
age.8 These resources could be used to ensure consistent safe messages are being disseminated, and to identify high
need families and whānau who require more intensive intervention.
8
The Committee is very pleased to note recent work to improve continuity of general practitioner and Well Child care with newborn enrolment.
CYMRC Unintentional Suffocation website consultation document – September 2012
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Preventing suffocation in place of sleep
The Committee notes that suffocation in place of sleep is the most common cause of death from unintentional injury
in the first year of life in New Zealand and is largely preventable. Prevention should therefore be a high priority for all
health and social service providers, including those who specialise in injury prevention.
Coroners frequently request that the health sector provide clear consistent advice about prevention, such clear advice
is becoming more important as additional sleep options become available to families. In the past mixed and conflicting
messages about the best safe sleep arrangements may have been a factor in the continuing death toll from SUDI. The
Committee has, therefore, developed the following points to provide to guide professionals, family and whānau.
1.
2.
3.
4.
5.
6.
7.
8.
Infants under three months of age (and especially in the first month of life) are most vulnerable to
suffocation in place of sleep.
Interventions which prevent circumstances that may compromise the airway or breathing of an infant will
reduce the risks of suffocation in place of sleep and have a significant impact on the incidence of SUDI in New
Zealand.
All places where infants sleep should be carefully assessed from first principles 9 to minimise risks of
suffocation.
Parents and caregivers have a right to know that a significant number of infants die every year because of
suffocation10 in the situation of sharing a sleep surface with an adult or child.
Current evidence suggests that the safest place to sleep for ALL infants is in their own cot or bassinette
designed for infant sleep, close to parents or caregivers and in the same room as parents or caregivers at
night.
Some families share a bed or other sleep surface with their baby routinely, occasionally or do so when away
from home. In these situations there are some new solutions (such as wahakura or pepi-pods) which may
provide the baby with some protection.
When the only available sleep spaces are hazardous11 providers of health and social services should all work
to support families in providing sleep spaces for infants. Preference should be given in obtaining a cot
compliant with the mandatory safety standard AS/NZS 2172:2003 or a safe bassinette. Where this is
impractical or impossible, a wahakura, pepi-pod or other arrangement that minimises the risk of suffocation
should be considered.
Where infants have additional factors leading to vulnerability, such as in-utero smoke exposure, prematurity,
low birth weight, or medical conditions, additional efforts should be made to reduce the risks of suffocation.
9
First principles of safe sleeping places for babies - A safe sleep space should be:
Free from other people who might overlay the infant – sleep arrangements need to make sure that if someone else moves in sleep the
infant will always be able to breathe easily with a clear airway.
•
Free of gaps that could trap or wedge – there should be no gaps which might trap an infant, wedge them and make breathing hard or
impossible.
•
Firm – so the infant’s neck does not flex and block breathing and the face cannot get buried in the surface;
•
Flat - so the infant does not suffer compromise to the airway or breathing by rolling over, tipping out, the sleep
space turning over
or becoming wedged.
•
Free from objects that might cover the face – nothing should be put near the baby that could cover the face during sleep.
10Suffocation in place of sleep includes all situations where the whole or part of a body, such as a limb or breast, can cover the face, flex the neck or
apply pressure to the chest or abdomen of an infant making it harder to breath. Infants have few mechanisms to protect their own airway because
of soft flexible tissues so even slight pressure on the nose or face or neck flexing can lead to suffocation.
11 Hazardous spaces would include couch, mattress or bed not designed for infant sleep (even if nobody is sharing the space), bean bags, cushions
or other make shift arrangements.
•
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Formal CYMRC Recommendations – These are in preliminary format and the Committee seeks
advice to develop targeted, effective recommendations.
I.
Policy Recommendations
A. At a National Level
1.
The CYMRC should display mortality data in ways that highlight that a large proportion of Sudden Unexpected
Deaths in Infancy are due to suffocation and so classified as unintentional injury.
2.
The provision of a safe place to sleep for every New Zealand infant should be a priority of government
departments and agencies (eg, Work and Income), District Health Boards, health providers and families and
whānau.
3.
Recommendations related to consumer products
a.
enforcement of the mandatory standard AS/NZS 2172 for cots
b.
information on a safe cots should be available to all purchasers at the point of sale, even when sales
are online
i.
A simple checklist of cot safety could be used to support the standards and be used by
health care providers and welfare agencies before and after birth as well as well by families,
whānau and sellers of used cots.
c.
development of a robust standard for bassinettes, portable cots and other commercially available
infant sleeping products
d.
consideration of legislation to ensure safe curtain cords are sold in New Zealand
e.
legislation to make hazard labels more informative and explicit, outlining actual risk of strangulation
or choking for products
4.
Specific recommendation about ways to improve information sharing between the Ministry of Health and
Ministry of Consumer Affairs to allow information regarding deaths and injury associated with products to be
monitored and acted on appropriately.
5.
Should we recommend in vivo observational studies of pepi-pod use, alongside parent reporting, so that we
are clear about the level (if any at all) of bed tilting or wedging and hypoxic events from any cause?
6.
Recommendations around the development of systems that identify needs before birth and ensure continuity
of care after birth, with high levels of coverage of general practitioner12 and Well Child services.
7.
Develop a targeted, inter-agency, strategic approach to the prevention of suffocation and strangulation.
What is the role of the Ministry of Social Development as the lead agency for child injury prevention within the
New Zealand? Should New Zealand have national guidelines on strangulation and choking prevention such as
those produced by the American Academy of Pediatrics and Eurosafe?
8.
Can the Ministry of Education, with input from the Ministry of Health, reinforce key messages regarding
suffocation in bed, choking and strangulation in their National Administration Guidelines provided to Early
Childhood Education providers and schools?
9.
Might we recommend a national health promotion campaign, direct to families, to promote safe sleep
messages (possibly through the Health Promotion Agency)?
Are any other recommendations needed? Furthermore, what might an implementation plan for any (or all)
of these recommendations look like? Which agencies would be involved?
12
The committee is very pleased to acknowledge recent work that supports the enrolment of new born babies with general practice.
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B. at a Local Level - District Health Boards, Primary Health Care Organisations and NonGovernmental Agencies
1.
All DHBs should have a safe infant sleeping policy13, which aims to ensure:
a.
staff who support families caring for infants receive mandatory training and updates about
prevention of SUDI and ways of communicating risks to families
b.
the modelling of safe sleeping practices for all infants14 within DHB facilities
c.
safe sleeping arrangements are available for all infants after they are discharged home
d.
families are provided with education and supports tailored to their level of need about the hazards
that arise in some sleeping situations
e.
advice on safe strategies for night feeds and settling infants is provided to parents
f.
safe infant sleep practices should be monitored as a quality indicator for maternity and child health
facilities.
2.
All DHBs should have “care pathways” in place that ensure early identification of vulnerable infants (before
birth) and make sure high quality, inter-sectoral interventions and supports are in place for those infants,
including those needed to support safe sleep.
3.
Health care providers should be assessing needs and planning with families to enable safe sleep through
interventions and supports that make safe sleep options easy to understand and practice. These actions
should start before birth and be reviewed at birth and again in the postnatal period(29).
4.
Appropriate monitoring and evaluation needs to be in place where pepi-pods and wahakura are used.
5.
Should New Zealand have a ‘home safe’ programme that provides practical information, injury prevention
packs and home visiting to either targeted families or all families and whānau concerning safe sleep,
strangulation and choking? Injury prevention packs could include curtain cord cleats or covers and
information on how to ensure that curtain cords do not create a risk of strangulation to babies, toddlers and
young children.
II.
Community Messages – These are in preliminary format. They need to be edited to
ensure the language used adheres to best practice health literacy guidelines and are
consistent with messages from other sources.
To prevent death in place of sleep by suffocation:
1.
Safe sleep for babies should be everyone’s priority.
2.
In the first year of life, always sleep baby on their back.
3.
In the first year of life, baby should sleep on a firm, flat and level surface with no pillow.
4.
In the first year of life, baby should have their own sleeping space.
5.
Parents have the right to know the risks from bed sharing.
6.
It is important that the sleeping environment is smoke free, alcohol and drug free, and free from the risk of
suffocation. Every baby needs a sober caregiver.
13
For a sample of a DHB safe sleep policy, see the CYMRC website at: http://www.hqsc.govt.nz/our-programmes/mrc/cymrc/publications-andresources/sudi/.
14 It is important to ensure this work extends beyond maternity services to include paediatric medical and surgical services and other services where
infants may be admitted with a parent such as adult medical, surgical and mental health services.
CYMRC Unintentional Suffocation website consultation document – September 2012
26
7.
Baby should never sleep on a sofa.
8.
Baby should not be left to sleep in car seats or capsules.
9.
Broken cots are dangerous cots.
10. Ensure that the mattress in the cot is the appropriate size and fits the cot snugly.
11. Ensure the cot is away from a wall and is free-standing in the room, or at least 10cm away from a wall.
12. When sleeping away from home, baby must have a safe sleeping place.
13. Do not use sleeping apparatus that confines the baby to a rigid sleeping position.
Foreign Body Inhalation:
1.
Toddlers should be supervised at all meal times, and encouraged to concentrate on the activity of eating
only.

2.
When children are eating, they shouldn’t be doing anything else.

3.
If toddlers are excited and running around they may choke.
If children are playing or running while they eat, they might choke.
Be cautious when feeding toddlers small, round, hard or elastic foods like sausage, grapes or apple.

Because these foods cause choking and death they need to be sliced or grated to make choking
unlikely
Unintentional Strangulation:
1.
Be aware of loose cords around the home and the risk of strangulation.

2.
Curtain cords should have a safety device to provide cover to keep the cords together so that they do not
form a noose, or they should be kept out of the reach of children.

3.
Cords that can fit around your child’s head could become entangled and cause suffocation.
Hanging curtain cords have caused deaths by strangulation.
If children are playing with ropes or cords, make sure they never put a rope around their own neck or chest
or someone else’s neck or chest.

Dangerous play with ropes or cords, such as homemade flying foxes or climbing with rope or cord,
can lead to unintentional strangulation.
4.
It is also important to be cautious when playing in sand or dirt.

Children or young people can become trapped in unsupported dirt or sand holes, e.g. while digging in
sand dunes or cliffs.
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