Injury Prevention 1995; 1: 76-80

ORIGINAL ARTICLES

Non-intentional asphyxiation deaths due to upperairway interference in children 0 to 14 years

Anne Altmann, Terry Nolan

AbstractObjective-This study was undertaken toidentify avoidable, contributing factorsassociated with non-intentional asphyx-iation deaths due to upper airwayinterference in children 0 to 14 years.

Design-Historical population basedincidence study.Methods-All postneonatal and child-hood deaths by asphyxiation from 1985 to1994, using appropriate ICD-9-CM codes,were compiled from the Victoriangovernment legislated paediatric mor-tality surveillance system. Recent caseswere identified from the State Coroner'sOffice. Case definition included childrenunder 15 years who died from upperairway interference such as facial occ-lusion, head and neck entrapment, ropeor cord strangulation, or foreign body.Results-Of the identified 42 deaths,eight (19%) were caused by a foreign bodyin the airway, five (12%) were due to facialocclusion, 16 (38%) were due to ropes andsimilar material (seven were homemaderope swings), and 13 (31%) were caused byentrapment (seven were in cots or beds).The average annual rate for asphyxiationdeaths by all causes for children 0 to 14years was 4-7 million. Infants under 1 yearhad a rate of 20-1/million, while the ratefor 10 to 14 year olds dropped to 2 0/million.

Conclusion-Rope swings and ropematerial are inherently dangerous andfrequently prove fatal, especially forolder children. For infants, environmen-tal factors are important; in particularfood and bedding. Prevention strategiesneed to be developed that includeobligatory standards for the design andmanufacture of products for children,appropriate labelling and warnings, andeducation for children, their carers, andhealth care professionals.(Injury Prevention 1995; 1: 76-80)

Keywords: asphyxia, suffocation, mortality,epidemiology.

Accidents, or non-intentional injury, are amajor cause of paediatric mortality andpremature years of life lost. In 1992, in Vic-toria, Australia there were 69 non-intentional

injury deaths in a total of 308 postneonatalinfant and childhood deaths (29 days to 14years). In the main categories of death, injuriesranked fourth after birth related deaths (94),acquired disease (75), and cot deaths (70),although injuries were the leading cause ofdeath after 1 year. Of the injury deaths therewere 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 deathsdue to non-intentional injury in the 0 to 14 yearage group.2Of these 11 (2 9%) and four (1 0%)were due to asphyxiation by food and otherobjects respectively, and 14 (3 7%) were due tosuffocation, giving a total of 7-6% due to thesetypes of asphyxiation.2During routine prospective statewide

surveillance of injury related deaths in Vic-torian children a cluster ofrope related asphyx-iations was noted. As a result it was decided toreview all such and similar asphyxiation deathsin children over the 9 5 years that the surveil-lance system has been active.Although non-intentional asphyxiation is a

relatively rare cause of death, there have been47 fatalities in children from this cause in thelast 9-5 years in Victoria. In this study only theasphyxiation deaths due to upper airwayinterference were included. These weredivided into four mechanism groups as follows:facial occlusion, entrapment of the neck, stran-gulation from any type of rope material orclothing, and foreign body aspiration. Deathsfrom involvement of the lower airway wereexcluded, such as chest compression or drown-ing. Although many of these 'accidents' mayappear to be random mishaps, closer inspectionreveals several consistent mechanisms andpredictable outcomes.

Subjects and methodsSince 1985, a statewide government legislatedpaediatric mortality surveillance system hasexisted in Victoria, Australia under the aus-pices of the Consultative Council on Obstetricand Paediatric Mortality and Morbidity. Thecouncil is notified of every death in the stateunder the age of 15 years directly from theVictorian registry of births, deaths, and mar-riages. The council compiles confidential casehistories from a variety of sources which arethen reviewed by specialist committees so thatany potentially avoidable factors can beidentified.

Public Health Branch,Department ofHealthand CommunityServices, Melbourne,Victoria, AustraliaA Altmann

Clinical Epidemiologyand Biostatistics Unit,Melbourne UniversityDepartment ofPaediatrics, RoyalChildren's Hospital,Parkville, Victoria,AustraliaT Nolan

Correspondence to:Associate Professor T Nolan,Clinical Epidemiology andBiostatistics Unit, RoyalChildren's Hospital,Parkville, Victoria 3052,Australia.

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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 post-neonatal infancy and child deaths (29 days to 14years) were searched. All deaths by asphyxia-tion from 1985 to June 1994 were drawn usingthe International Classification of Diseases, 9threvision, clinical modification (ICD-9-CM).The codes used were: 994.7-suffocation bybedclothes, cave in, constriction, mechanical,plastic, pressure, and strangulation; 933-934-foreign body in pharynx, larynx, trachea,bronchus, and lung; E911-912-inhalation oringestion of food or other object causing obs-truction of the respiratory tract or suffocation;and E913-accidental mechanical suffocation:in bed/cradle, by plastic bag, by falling earth orother substance, by accidental hanging, due tolack of air (in closed space), or by unspecifiedmeans.The Coroner's Act 1985 in Victoria states

that certain deaths must be reported. Theseinclude those that were unexpected, unnatural,or violent, that resulted from an accident orinjury; that occurred during an anaesthetic; orwhere a person was held in care. Cases occurr-ing in 1993 and the first half of 1994 were alsosearched for on the State Coroner's Office'scomputer system by age and cause of death.

All the cases were verified using informationin the files on the investigations undertaken bythe state coroner. The information reviewedfor each case included: age, date of death,circumstances of the death, results of post-mortem examination if carried out, andidentification, if possible, of any avoidablefactors.

All cases due to lower airway interferencewere excluded. This included five asphyxialdeaths caused by crushing or burying. Otherasphyxial deaths excluded were those due toaspiration of vomit, drowning, fires, associatedwith motor vehicle accidents, suicides,homicides, and sudden infant death syndrome(SIDS). SIDS is classified by a combination ofa centralised postmortem examination and adeath scene investigation. These deaths are notclassified as asphyxiation unless there is une-quivocal evidence of such from the investiga-tions.The asphyxial deaths were divided into

groups according to the anatomic level ofupperairway involvement. The groups were: facialocclusion; entrapment of head of neck; rope orcord strangulation; and airway obstruction dueto a foreign body (food or other object).

STATISTICAL ANALYSISData on the Victorian population figures wasobtained from the Australian Bureau of Statis-tics estimated resident population by sex andage from 1985 to 1993. Death rates werecalculated by dividing the number of deathsobserved by the number of children in the agegroup at risk. Because the annual number ofdeaths in each subgroup of asphyxiation wassmall, average annual rates were derived for thetotal study period (9 5 years).

ResultsFrom 1985 to June 1994 there were 47 deathsdue to non-intentional asphyxiation. Five due

to crushing or burying were excluded. Theremaining 42 deaths are tabulated by themechanism causing death (table 1).Ofthe 42 deaths, eight (19%) were caused by

a foreign body in the airway, six of which weredue to food and two due to objects. Five (12%)were caused by facial occlusion, one of whichinvolved plastic material.Of the 29 strangulation deaths, 16 (38%)

were due to ropes, cords, and other suchmaterial, and 13 (31%) were due to head orneck entrapment. Seven of the 13 deaths byentrapment were caused by cots or beds, sevenof the 16 rope or cord associated deaths weredue to homemade rope swings, and three weredue 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 involvedplastic material. Another four became entrap-ped, two in the cot and one whose cardigancaught on the cot. One infant strangled on arattle cord suspended over the cot and threeinhaled a foreign body. Half were associatedwith an unsafe sleeping environment, for exam-ple, an inadequately sized mattress, inapprop-riate type of bed for the child's age, or objectsattached to the cot.The average annual rate for asphyxiation

deaths by all causes in children 0 to 14 years was4-7/million (table 2). However, the age groupmost at risk is that ofinfants under 1 year with arate of 20- 1/million/year. The rates then dropoff with increasing age to a rate of 2-0/millionyear for the 10 to 14 year olds. In the infants, allmechanisms feature prominently except stran-gulation by ropes. In contrast, ropes are themost common cause of asphyxial death forchildren over 1 year of age.

DiscussionThe results indicate two main risk groups forasphyxiation: infants, who were at risk fromfacial occlusion, neck entrapment, and foreignbody aspiration and children over 1 year whowere at risk from strangulation by ropes. Themain mechanisms of asphyxiation are notice-ably consistent and repetitive, and virtually allthese deaths could have been prevented.The excellent surveillance system in place in

Victoria for paediatric mortality made it possi-ble to identify the entire defined population inthe selected time period. Although a precedingprimary cause is not annotated on the deathcertificate (for example asphyxiation withanoxia resulting in cerebral palsy with death ata later date), misclassification would beunlikely due to statutory investigations under-taken on all paediatric deaths by the council.The coroner's records provided much addi-tional information on intent and circumstances.After reviewing available evidence there wereno indications to suspect suicide, for example,depression or prior disputes - in any of ourcases. Due to the conservative classification ofSIDS, and exclusion of these cases from thestudy, some underestimation of the trueincidence of asphyxiation may have resulted.The rate for asphyxiation deaths in Victoria

over the study period, excluding deaths due to

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Table 1 Non-intentional asphyxiation deaths in children O to 14years, by mechanism of asphyxiation

Description ofClassification Age circumstancesFacial occlusion

Plastic (n= 1) 4 m Occlusive plastic dressing (shower cap), to scalp to treat seborrhoea. Capdislodged to cover face leading to asphyxiation

Other material 3 m Left on couch during night after night feed by father. Suffocated between(n = 4) two couch cushions

3 m Fell off couch during night, caught between mattress on floor and base ofcouch

1 y Put into cot for afternoon sleep. Found face down in 1 m high, clothes filled,linen basket next to cot

7 m Undetected intussusception of transverse colon during night. Suffocation bybedclothes

EntrapmentCot/bed related 8 m Put down for sleep, chest caught between bars and base of cot(n = 7)

9 m Arm of woollen cardigan caught on wingnut on top rail of cot, causing neckto be pulled tight, strangling infant

13 m Hospitalised for ear infection. Fell feet first between cot side and mattress(10 cm gap) entrapping face against mattress causing asphyxiation

18 m Playing with brothers. Head caught between notch in cot bedhead andladder of bunk bed above

21 m Found hanged as neck caught between top of cot and wooden rail nailed tocot to prevent child from getting out. Distance between top edge of cot andrail = 13 5 cm

4 y Intellectually disabled child, epilepsy. Sleeping in protected bed, caughtbetween guard rail and mattress (12 cm gap), hanged

8 y Severe cerebral palsy. Head caught between protective bars of bed duringnight, neck compression

Furniture and 6 m Put down for sleep in single bed. Fell through bars of bedhead into 20 cmother objects gap between bedhead and wall. Throat constricted over edge of cardboard(n =8) box under bed and in this gap

11 m Head in toilet, heavy timber toilet seat came down trapping infant's neckagainst rim of toilet bowl

14 m Early morning, parents in bed. Found with head caught between two tiers ofa coffee table

22 m Caught head in 11 cm gap between changing table and support bar whileattempting to climb up and subsequently losing her footing

8 y Playing 'hide and seek'. Head caught between iron grill lid and edge ofconcrete pit in park, neck compression

14 y Epilepsy. Left alone after recovering from fit and had second fit unattended.Found wedged across kitchen floor, neck hyperextended against stove, air-way obstruction

Strangulation by ropes and cordsBlind cord (n = 3) 16 m Cord of venetian blind hanging down next to cot placed beside window.

Found strangulated with this cord around neck16 m Head of cot beside window. Neck entangled in loop of curtain cord while

in cot21 m Found kneeling in bed with blind cord around neck. Bed beside window,

parents claim to have tied cord up out of reachOther string near 11 m Elastic string with row of rattles attached across cot. Found face down withcot (n = 2) head entangled in the elastic

15 m Bead necklace hanging on wardrobe handle 20 cm from end of cot. Putdown for sleep. Found strangled by necklace around throat and still attachedto wardrobe door handle

Rope swing 4 y Rope swing in garden with tied loop in end 1-2 m off ground. Wooden step(n = 7) ladder climbed, knocked to ground. Neck caught in rope, hanged

4 y Family visiting friend's house. Found hanging from looped rope used as aswing, end of loop 1 m off ground

6 y Child made rope swing with knotted end of rotary clothes line. Foundhanging beside chair, feet off ground

6 y Child attached rope to clothes line and tied in a loop as swing. Foundhanged

8 y Playing with rope hanging from tree, two ends knotted, found hanging byolder sister

13 y Rope swing with loop in end in hayshed. Found hanging with loop overhead

12 y Child made rope swing in garden. Found hanging with noose around neck.Died 5 days later in hospital

Unsafe play 4 y Playing in lounge room with belt around neck as 'stethoscope'. Foundwith ropes (n = 4) suspended from door handle by belt, hanged

7 y Child came home unsupervised from school. Found hanged by dressinggown cord from clothes hook behind bedroom door

11 y History of overactivity, aggression, learning difficulties, attention deficitdisorder, taking dexamphetamine. Found strangled by nylon cord tied toend of bed. Actions thought to be impulsive, reckless, and experimentalbehaviour rather than suicide

13 y Playing on top bunk. Cord tied to guard rail, and around neck. Fell facedownward from bunk, hanged

Foreign body in airwayFood (n = 6) 8 m Inhaled spaghetti meat sauce

8 m Aspiration of biscuit fragments, unsupervised, may have been fed by siblingaged 2-5 years

14 m At children's party. Inhaled small frankfurter4 y Aspiration of chick peas when 22 m old causing tracheal obstruction at

carina and subsequent severe cerebral damage. Remained in hospital 2-5years until died

5 y At children's party. Small frankfurter lodged in pharynx at tonsils

13 y Down's syndrome. At restaurant, choked on cut up steak. Piece of meatfound in larynx

Other objects 10m Inhaled snail shell causing laryngeal damage and obstruction. Found with(n = 2) snails in hands

14 m Fell over hitting face. Inhaled stone, presumably in mouth, causing obstruc-tion at carina

Comments andpreventable factors

Improper product usage

Inappropriate sleeping environment

Inappropriate sleeping environment

Side rail of cot broken, remains set, half-way up, at about 2 feet above mattress

Old cot with thin mattress causing unsafesleeping environmentUnsafe cot with protruding screw oninsideUnsafe sleeping environment poorlyfitting mattressUnsafe placement of furniture

Unsafe addition by parents to cot

Unsafe sleeping environment

Unsafe sleeping environment

Inappropriate sleeping environment andunsafe placement of furniture

Unsafe width of bars on nursery furniture

Inadequate maintenance of park by localcouncilVery large child: 113 kg, 1 89 cm tall.Unsupervised epileptic fit. Medicationnon-compliance

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 accessibleto 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, unsafeplay with rope

Potential danger of infants being fed byolder siblingsInappropriate food for child's ageInappropriate food for child's age

Obese child, tonsils very enlarged. Inapp-ropriate 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 andage group in children 0 to 14 years in Victoria, Australia, 1985-J7une 1994

0-14 years <I year 1-4 years 5-9 years 10-14 years

Mechanism No (%J Rate No Rate No Rate No Rate No RateFacial occlusion 5 (12) 1 7t 4 6-7 1 0.4 0 - 0 -Entrapment 13 (31) 1 5 4 6-7 6 2-5 2 0 7 1 0 3Ropes 16 (38) 1 8 1 1-7 7 3-0 4 1-4 4 1-3Foreign body 8 (19) 0-9 3 5 0 3 1-3 1 0 3 1 0 3All causes 42 (100) 4-7 12 20-1 17 7-2 7 2-4 6 2-0

*Average annual death rate/i 000 000/year. tRate for 0-4 years.

foreign body inhalation was 3-8/million/year,with the Australian rate for suffocation, in1992, comparable at 3.7/million/year.2 Anational analysis of childhood injury deaths inthe USA, over a five year period, 1980-5,reported higher rates for childhood suffocation- 7/million/year population of children 0 to 14years.3A total of 17 deaths (40%) related to the

child's own bed or bed furnishings, an inap-propriate sleeping place for the child's age, orto furniture, cords, or other articles withinclose proximity ofthe cot. Despite the publicityand the design standards regarding infant cots,deaths continue to occur in this environment.The importance of using a cot with the appro-priate design standards needs to beemphasised, along with using an appropriatelyfitting mattress. Design standards must alsoapply to special beds for the disabled.The risk of death as a direct result of the

sleeping environment, and in particular theinfant cot, has been stressed by numerousauthors.4-'0 Regulations regarding infant cribswere first set in the USA in 1974, and reportssince then have varied as to whether there hasbeen a reduction in the number of associatedcrib deaths. Feldman and Simms quote a USConsumer Product Safety Commission (USC-PSC) report claiming that there was approx-imately a 50% reduction in the number of cribstrangulations since the introduction of legisla-tion.8 In contrast Kraus, after reviewing deathsin Californian children due to suffocation andstrangulation from 1960 to 1981, found noevidence of a statistically significant decline.4These differing findings may well be due to alag time in discarding of old cribs after int-roduction of regulations.

Cots and beds should be placed firmlyagainst the wall, and proximity to blind cordsand other potentially dangerous articlesavoided. Restraining devices fitted to the bed orcot are hazardous, as illustrated by one deaththat was a direct consequence of a bar over thecot. Although Australian standards on cotsmake provision against any protrusion into thecot, injuries are still likely to arise from brokenor repaired cots that are outside the set safetystandards. The death ofa child in our series dueto a cardigan catching on a wingnut in the cotwas not an isolated incident."I These dangers ofrestraining devices, protrusions, and repairswere emphasised by Bergeson et al 18 yearsago.6A 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 associatedwith waterbeds, sheepskin rugs, or polystyrenebead filled cushions, each of which have beennoted to pose a risk to infants.9 The importanceof age appropriate bedding cannot be over-emphasised.The largest cause of death in our series was

strangulation due to ropes and cords, in child-ren aged 11 months to 13 years, the majority ofwhom were male. For infants who are notmobile, the risk ofstrangulation was from cordson objects, both within and outside the cot-for example, strings attached to toys, harnesses,and clothing that can pull tight around theneck. The danger of infant strangulation due tocords has been raised in several case reports andthe avoidance of these is strictly advised.6"IThree toddlers were strangled by blind or

curtain cords, and one by a necklace lefthanging beside the cot. Two recent fatal casereports highlight these dangers- the first of atoddler by a corded light switch specificallydesigned for use by children,'2 and the secondby a loose lamp flex during the night.'3 Todd-lers become increasingly mobile, lack a sense ofdanger, and are curious by nature and thereforeare at risk from a variety of objects around thehouse and near the cot.There were 11 deaths in children 3 years and

over attributable to rope, belts, or cords. Playwith ropes is inherently dangerous even if thechild is thought old enough to be careful, asillustrated by the death of four children aged 1 1to 13 years. Seven deaths were due to home-made rope swings of varying types, usuallymade with a loop at the end or with the two endstied together. The risk of childhood strangula-tion due to unsafe play with such ropes must bestressed.8 11

In Australia in 1992 the rate for non-intentional death due to asphyxiation by food'was 2-9/million/year, and by other objects was1 1/million/year in children 0 to 14 years.2 TheVictorian average annual rate was less, at 0.9/million/year for foreign body aspiration, food,and other objects together. USA national ratesfor aspiration of food and other material were 4and 3/million/year respectively,3 similar to theAustralian rates.

Six of the eight deaths due to foreign bodyinhalation were in children under the age of 5years. Factors such as a younger age group, amore intense atmosphere, playing, laughing orshouting while eating, and lack of supervisionduring meals, may increase the risk of choking.These elements are likely to occur in the daycare setting,'4 or at children's parties.Hotdogs have been cited as a major cause of

fatal chokings in children.7 1516 Two Victorianchildren died after choking on a party frank-furter. Although not immediately evident as arisky foodstuff, the innocent and well-lovedfrankfurter is inherently dangerous for smallchildren due to its size, shape, and con-sistency. 6 Measures such as age appropriatefood, a supervised eating environment, and notallowing young siblings to feed an infant shouldbe adopted, together with promotion of correctresponses to aspiration emergencies.

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The prevention of asphyxiation deaths needstackling from a variety of angles. The failure ofvoluntary standards emphasises the need formore standards to be legislated."7 Australia hasmany voluntarily adopted standards that coverarticles with which children will come intocontact. However, legislation only exists regar-ding the size of toys for children under 3 yearswhere the toy may represent an inhalation or

ingestion risk.'8 In the USA, after a USCPSCreview of 126 crib related deaths,'9 legislationwas passed regulating the distance between cribslats and the space between the mattress andside rails.20 Currently in Australia standardsrelating to cots are under review, and legisla-tion is being contemplated.There are no codes or regulations in Aust-

ralia that cover the labelling of food regardingits age appropriateness, while these types oflabelling requirements on prepackaged food forinfants and children were introduced in 1979 inSweden,2' and are also seen in other Europeancountries. Labelling and warnings on products,in particular children's equipment, and hazar-dous foodstuffs need to be considered. Alldomestic market rope products, together withequipment that contains loose rope or cord (forexample skipping ropes and clothes lines),should carry product warnings, preferablynon-removable. Written warnings need to statethe potential hazard, rather than an age belowwhich the product is deemed inappropriate.Product labelling has the ability to reachmembers of the public not always targeted bypreventative campaigns and therefore is an

excellent mechanism for informationdissemination.Hazardous products for children are fre-

quently those available and marketed to thegeneral public. Education and anticipatoryguidance can address this problem, along withthe issue of access to age inappropriate food andtoys when there are older children in thehousehold. Parents, children, their carers, andhealth care professionals all need to be targeted.

ConclusionAlmost all the asphyxiation deaths reportedhere could have been prevented by education,supervision, or structural modification ofequipment. Preventable strategies need to in-clude obligatory manufacturing standards,product labelling and warnings, and specific

and targeted education of parents, child carers,and health care professionals. Special attentionmust be given firstly to ensuring a safe environ-ment for infants, with respect in particular tobedding and food, and secondly to warningsand education about the dangers associatedwith ropes, in particular rope swings.

The authors wish to acknowledge the invaluable help of theConsultative Council on Obstetric and Paediatric Mortality andMorbidity and its staff, in particular Dr Bill Kitchen, and alsothe Victorian Coronial Service and its staff, especially theprincipal registrar Mr David Stephens.

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2 Harrison J, Cripps R. Injury mortality, Australia 1992.Australian injury prevention bulletin. Adelaide: NationalInjury Surveillance Unit. Issue 6, April 1994.

3 Waller AE, Baker SP, Szocka A. Childhood injury deaths:national analysis and geographic variations. Am J PublicHealth 1989; 79: 310-5.

4 Kraus JF. Effectiveness of measures to prevent uninten-tional deaths of infants and children from suffocation andstrangulation. Public Health Rep 1985; 100: 231-40.

5 Corey TS, McCloud LC, Nichols GR, Buchino JJ. Infantdeaths due to unintentional injury, an 11-year autopsyreview. Am J Dis Child 1992; 146: 968-71.

6 Bergeson PS, Hernried LS, Sonntag PL. Infant strangula-tion. Pediatrics 1977; 59 (suppl): 1043-6.

7 Baker SP, Fisher RS. Childhood asphyxiation by choking orsuffocation. JAMA 1980; 244: 1343-6.

8 Feldman KW, Simms RJ. Strangulation in childhood:epidemiology and clinical course. Pediatrics 1980; 65:1079-85.

9 Gilbert-Barness E, Hegstrand L, Chandra S, et al. Hazardsof mattresses, beds and bedding in deaths of infants. AmJForensic Med Pathol 1991; 12: 27-32.

10 Sturner WQ, Spruill FG, Smith RA, Lene WJ. Accidentalasphyxial deaths involving infants and young children. JForensic Sci 1976; 21: 483-7.

11 Cooke CT, Cadden GA, Hilton JMN. Hanging deaths inchildren. Am J Forensic Med Pathol 1989; 10: 98-104.

12 Hord JD, Anglin D. Accidental strangulation of a toddlerinvolving a wall light switch. Am J Dis Child 1993; 147:1038-9.

13 Shepard RT. Accidental self-strangulation in a young child:a case report and review. Med Sci Law 1990; 30: 119-23.

14 Byard RW. Unexpected death due to acute airway obstruc-tion in daycare centers. Pediatrics 1994; 94: 113-4.

15 Mittleman RE. Fatal choking in infants and children. AmJYForensic Med Pathol 1984; 5: 201-10.

16 Stallings Harris C, Baker SP, Smith GA, Harris RM.Childhood asphyxiation by food. A national analysis andoverview. JAMA 1984; 251: 2231-5.

17 Adams R. Protectingconsumers: unsafe products maim andkill. Journal of State Government 1989; 62: 104-6.

18 Office of Fair Trading. Consumer affairs (product safety)(children's toys) regulations, 1987. Victoria: Office of FairTrading, 1987.

19 Nelson T. Hazard analysis of injuries relation to cribs.Washington: United States Consumer Product SafetyCommission Bureau of Epidemiology, 1975: 12-25,60-6.

20 US Consumer Product Safety Commission. Federal code ofregulations: commercial practices. Bulletin 16, part 1000 toend. Washington, DC: US Government Printing Office,1978; 284-91.

21 Swedish National Food Administration. The National FoodAdministration's ordinance on food for infants and youngchildren. (SLV FS 1978:17, 15.) Uppsala, Sweden: FoodStandards Division, 1978.

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