Suffocation, Choking and Strangulation

Fact Sheet

Child deaths due to suffocation result when the child is in a place or position where he or she is unable to breathe. In 2012, there were 239 unintentional suffocations of children 1-17, 617 suicide suffocations of children 1-17, and 53 homicide suffocations of children ages 1-17. There were 965 unintentional suffocations of infants less than 1 year of age and 26 homicide suffocations of infants.

Unintentional suffocation: Infant suffocation in sleep can happen as described in the SUID/SIDS section. Other ways that children suffocate accidentally are the following:

  • Covering of face or chest: an object covers a child’s face or compresses the chest, such as plastic bags, heavy blankets or furniture.
  • Choking: a child chokes on an object such as a piece of food or small toy.
  • Confinement: a child is trapped in an airtight place such as an unused refrigerator or toy chest.
  • Strangulation: a rope, cords, hands or other objects strangle a child.

Toddlers and preschoolers and children with special needs are at the highest risk for choking and strangulation deaths. Because they are active, they become entangled in cords and gain access to small objects. Food and uninflated balloons remain the numbers one and two choking hazards, again usually for toddlers. Product safety improvements including rigorous scrutiny and recalls by the CPSC on toys with choking hazards. Removal of drawstrings from children’s clothing and safety cord hangers for window blinds have reduced the number of these types of suffocations in recent years.

Older children have died accidentally while playing the “choking game.” In the CDC paper about the choking game cited below, most of the children who died from the game were boy ages 11-16. It is not always certain if death by hanging was intended or unintended. The CDC estimates that 83 youths died from the choking game from 1995-2007.

Intentional suffocation/strangulation:

In 2012, suffocation was the leading cause of suicide death among children ages 13-17 (558). Suffocation accounted for 9% of infant homicides in 2012 and for 4.3% of homicides of older children in the same year.

Major Risk Factors for suffocation/choking/strangulation

  • Easy access by infants and toddlers to small objects, balloons, plastic bags, and toys with small parts.
  • Food not properly cut into safely small pieces
  • Toy chests without safety latches
  • Family’s ability to provide safe sleep or play environment for child
  • Quality of supervision at time of death
  • Presence of unsafe window cords
  • Access by child to empty appliances
  • If hanging, child’s developmental age consistent with activity causing strangulation
  • For Suicide risk factors, see Suicide as a Cause of Death

Records Needed for Case Review

  • Autopsy reports
  • Scene investigation reports and photos
  • Interviews with family members
  • Day care licensing investigative reports, if occurred in day care setting
  • EMS run reports
  • Emergency Department reports
  • Prior CPS history on child, caregivers and person supervising child at time of death
  • Child’s health history
  • Criminal background checks on person supervising child at time of death
  • Reports of home visits from public health or other services
  • Any information on prior deaths of children in family
  • Any information on prior reports that child had difficulty breathing
  • Downloaded information from apnea monitors

Prevention

  • Notification to CPSC and continued product safety recalls on choking and strangulation hazards.
  • Education of parents about safe toys and safe environments, age-appropriate food items, and supervision.
  • Prevention of the choking game: “Parents, educators, and health-care providers should learn about the choking game and be able to recognize any of the following warning signs in youths: mention of the choking game (or the game by its other names); bloodshot eyes; marks on the neck; frequent, severe headaches; disorientation after spending time alone; and ropes, scarves, and belts tied to bedroom furniture or doorknobs or found knotted on the floor. Medical examiners and coroners should be aware of the choking game as a possible explanation for deaths from self-inflicted strangulation in this age group that otherwise might be miscategorized as suicides. In addition, better mortality surveillance is needed, and more research should be conducted (e.g., questions on youth-behavior surveys regarding awareness of and involvement in the choking game) to determine prevalence, risk factors, and protective factors that will lead to effective interventions aimed at reducing or eliminating choking-game participation and deaths.”
  • No evidence-based programs specifically targeting the choking game were found, but there are a number of evidence-based programs target parenting and supervision improvements.
  • Protecting Children as Feeding Skills Develop (limited access): This article examines the scope, intricacy, and complexity of reducing choking risk in the pediatric population and areas for further investigation to enrich evidence-based practice to enhance safety during feeding.

Resources