The airway obstruction injury death rate among children ages 14 and under declined 15 percent between 1987 and 1997. However, the airway obstruction injury death rate among children under age 1 has shown no decline in the past decade. Airway obstruction injury (suffocation, choking, and strangulation) is the leading cause of unintentional injury-related death among children in this age group. These injuries occur when children are unable to breathe normally because food or objects block their internal airways (choking); materials block or cover their external airways (suffocation); or items become wrapped around their necks and interfere with breathing (strangulation). Children, especially those under age 3, are particularly vulnerable to airway obstruction death and injury due to the small size of their upper airways, their relative inexperience with chewing, and their natural tendency to put objects in their mouths. Additionally, infants' inability to lift their heads or extricate themselves from tight places puts them at greater risk.

AIRWAY OBSTRUCTION DEATHS AND INJURIES

• In 1997, 659 children ages 14 and under died from airway obstruction injuries. Of these children, nearly 80 percent were ages 4 and under.
• In 1997, more than 470 children ages 14 and under died from suffocation, strangulation, and entrapment in household appliances and toy chests. Of these children, nearly two-thirds were under age 1 and more than 80 percent were ages 4 and under.
• In 1997, 185 children ages 14 and under died from choking (food and nonfood). Of these children, nearly 80 percent were ages 4 and under.
• In 1998, eight children ages 8 and under died from choking on a toy or toy part. Balloons were involved in half of these incidents. In addition, one child died from toy-related suffocation. These deaths account for nearly 65 percent of all toy-related fatalities.
• Approximately 5,000 children ages 14 and under are treated in hospital emergency rooms for aspirating and ingesting toys and toy parts each year. More than 75 percent of these children are ages 4 and under.

WHEN AND WHERE AIRWAY OBSTRUCTION DEATHS AND INJURIES OCCUR

The majority of childhood suffocation, strangulation and choking occur in the home. Children are more likely to suffocate during the summer months and choke during the winter months.

Suffocation

• Sixty percent of infant suffocation occurs in the sleeping environment. Infants can suffocate when their faces become wedged against or buried in a mattress, pillow, infant cushion or other soft bedding, or when someone in the same bed rolls over onto them. Infants can also suffocate when their mouths and noses are covered by or pressed against a plastic bag.
• Children can suffocate when they become trapped in household appliances, such as refrigerators or dryers, and toy chests.
• Each year, cribs are involved in more than 70 percent of all nursery product-related deaths among infants. Cribs are responsible for about 40 strangulation and suffocation deaths each year (primarily older, used cribs).
• It is estimated that as many as 900 infants whose deaths are attributed to Sudden Infant Death Syndrome (SIDS) each year are found in potentially suffocating environments, frequently on their stomachs, with their noses and mouths covered by soft bedding.

Choking

• The majority of childhood choking injuries and deaths are associated with food items.
• Children are at risk from choking on small, round foods such as hot dogs, candies, nuts, grapes, carrots and popcorn. Nonfood items tend to be round or conforming objects, including coins, small balls and balloons.
• Balloons are the most common cause of toy-related choking death among children. Unlike other causes of choking death, balloon-related deaths are as common among children ages 3 and older as among younger children.

Strangulation

• Strangulation occurs among children when consumer products become wrapped around their necks. Common items include clothing drawstrings, ribbons or other decorations, necklaces, pacifier strings, and window blind and drapery cords.
• Since 1981, more than 350 children have strangled on window covering cords. The majority of deaths occurred when the cord was hanging near the floor or crib, or when furniture was placed near the cord. Nearly 95 percent of these children were ages 3 and under.
• Since 1985, 22 children have died and at least 48 were injured from entangled children's clothing drawstrings, most often the hood/neck drawstrings. In addition, more than half of drawstring entanglement incidents involved playground slides.
• Children strangle in openings that permit the passage of their bodies, yet are too small for, and entrap, their heads. These include spaces in bunk beds, cribs, playground equipment, baby strollers, carriages and high chairs. Since 1990, at least 57 children, nearly all ages 3 and under, have died due to entrapment in bunk beds alone.

WHO IS AT RISK

• Children ages 4 and under, especially under age 1, are at greatest risk for all forms of airway obstruction injury.
• Male, low-income and non-white children are at increased risk from suffocation, choking and strangulation.
• Black infants are more likely than white infants to be placed to sleep on their stomachs and on softer bedding.
• Children placed in adult beds are at increased risk for airway obstruction injury. Since 1990, at least 121 children ages 2 and under have died in adult beds from smothering as a result of being overlain by another person. Additionally, 296 children in this age group died in adult beds as a result of entrapment in the bed structure.

AIRWAY OBSTRUCTION PREVENTION LAWS AND REGULATIONS

• The Child Safety Protection Act requires choking hazard warning labels on packaging for small balls, balloons, marbles, and certain toys and games having small parts that are intended for use by children ages 3 to 6. This Act also bans any toy intended for use by children under age 3 that may pose a choking, aspiration or ingestion hazard.
• The U.S. Consumer Product Safety Commission (CPSC) has issued voluntary guidelines for drawstrings on children's clothing to prevent children from strangling in the neck and waist drawstrings of upper outerwear garments, such as jackets and sweatshirts.
• The CPSC has combined voluntary standards development with mandatory regulations to prevent an estimated 200 crib-related deaths among young children each year.
• In 1999, the CPSC voted to issue a mandatory standard for bunk beds to address entrapment hazards. The new standard will restrict opening sizes and require company identification and age-specific warning labeling on all new bunk beds.

HEALTH CARE COSTS AND SAVINGS

• The total annual cost of airway obstruction injury among children ages 14 and under exceeds $1.5 billion. Children ages 4 and under account for more than 60 percent of these costs.

PREVENTION TIPS

• Place infants on their backs on a firm, flat crib mattress in a crib that meets national safety standards -- look for a Juvenile Products Manufacturers Association certification label. Remove pillows, comforters, toys and other soft products from the crib.
• Always supervise young children while they are eating and playing. Do not allow children under age 6 to eat round or hard foods like peanuts and other nuts, raw carrots, popcorn, seeds, or hard candy. Children under age 6 should not eat hot dogs or grapes unless the skin is removed and the food is chopped into small, non-round pieces. Keep small items such as coins, safety pins, jewelry and buttons out of children's reach. Learn First Aid and CPR.
• Consider purchasing a small parts tester to determine whether or not small toys and objects in your home may present a choking hazard to young children. Ensure that children play with age-appropriate toys according to safety labels. Inspect old and new toys regularly for damage. Make any necessary repairs or discard damaged toys.
• Remove hood and neck drawstrings from all children's outerwear. To prevent strangulation, never allow children to wear necklaces, purses, scarves or clothing with drawstrings while on playgrounds.
• Tie up all window blind and drapery cords or cut the ends and retrofit with safety tassels. Never hang anything on or above a crib with string or ribbon longer than seven inches.
• Do not allow children under age 6 to sleep on the top bunk of a bunk bed. Ensure that all spaces between the guardrail and bed frame and all spaces in the head and foot boards are less than 3.5 inches.

12/99 This information was compiled by the National SAFE KIDS Campaign.