Infant Suffocation Guidelines

OMB Control Number 3041-0029

Appendix 108
April 12, 1993
INFANT SUFFOCATIONS
I.

INTRODUCTION
A.

Background Information

Each year about 200 infants die of suffocation on consumer
products. Some suffocation deaths may not be identified because
they are diagnosed as Sudden Infant Death Syndrome (SIDS). There
are about 6,000 SIDS deaths reported annually.
Investigations of SIDS and suffocation deaths may help to
identify soft bedding and other products that could be involved
in suffocating infants under one year of age, and the mechanisms
causing the suffocation. Knowledge of such factors can serve as
a valuable tool in the evaluation of sleeping/resting surfaces
and other nursery-related items so that appropriate actions can
be taken.
B.

Product Class Description

Definitions and General Description
Includes all sleeping/resting surfaces and items used on
these surfaces. Products in contact with the infant's face or
head are of interest.
The term "bedding" includes such items as mattress pads,
sheets, blankets, quilts, etc. The term "mattress" includes such
items as adult mattresses, youth mattresses, crib mattresses
including portable crib mattresses, day bed mattresses, trundle
bed mattresses, and convertible sofa bed mattresses.
C.

Specific Items of Interest
1.

Of primary interest is the victim's head and body
position, specifically in relation to the sleeping
surface, bedding items, or other products that may
have been involved. A detailed description of the
products involved is also extremely important.

2.

Remember that no guideline can cover all pertinent
factors that may apply to a particular death. Be
sure to include an explanation of any such factors
in your narrative, even if we have not
specifically mentioned them in the guidelines. As
a supplement to the narrative, a data recording
sheet has been included to record specific items
of interest.

3.

D.

See Section IV, Instructions for Obtaining Samples
and Documents Related to the Investigation for
specific instructions particular to this study.

Headquarters Contacts
Dr. N.J. Scheers, EPHA - (301) 504-0470
Manon Boudreault, EPHA - (301) 504-0470

II. INSTRUCTIONS FOR COLLECTING SPECIFIC INFORMATION
Note: Complete and attach a data recording sheet with each
investigation conducted. The data recording sheet is not to be
used in lieu of an in-depth investigation format. Rather it is
intended to enhance the investigation, and provide guidance for
the investigator. Answer all questions using appropriate
unknowns or not applicable responses as needed.
A.

Synopsis

Provide a brief description of the circumstances in which
the infant was found dead or unresponsive. Include a description
of the infant's head and body position, particularly in relation
to the sleeping surface, bedding items, or other items that may
have been involved. Specify the type of product (e.g., crib,
adult mattress, infant pillow, etc.) upon which the infant was
found. Note any product failures or deficiencies in design that
may have contributed to the incident.
For data retrieval from the computer, please make sure that
the following key words are used in the summary as appropriate:
face into, covering face, covering mouth, covering nose, face
straight down, face up, over infant, under infant, pocket,
bedding, broken, restraint.
B.

Description of the Incident Environment

·

Describe type of housing or other structure (e.g.,
mobile home, single family detached, apartment) where
incident occurred.

·

Indicate whether there were any other children or
adults present at the time of the incident and describe
what they were doing.

·

Describe the ventilation conditions of the room,
residence, or other site where the incident occurred,
as well as the approximate temperature inside at the
time the infant was found. Report the temperature
setting of the thermostat at the time of the incident
and the approximate size of the room where the heater

or ventilator outlet was located.
·

Specify energy source and heating appliance or air
conditioning source in use at the time of death (use
source and appliance terminology listed in the attached
data recording sheet).

·

Indicate number of individuals who smoke cigarettes,
pipes, or cigars as well as amount in the home or other
location where infant spends most of his/her time.

·

Include in the investigation any pertinent information
not covered by the foregoing.

C.

Description of the Infant and Product Interaction
1.

The following information should be collected
(note source).

·

Height (inches) and weight pounds/ounces) at
birth.
Whether infant was breast-fed or formula-fed.
Whether infant was carried to full term or if
birth was premature.
Most recent vaccination.
If infant had been ill within the past two weeks
and any medical treatment received for this, or if
it had any injury or major illness since birth.
Any behavioral characteristics which might be
relevant to the death (see data recording sheet).
Any known physical handicaps or adverse health
conditions prior to death.

·
·
·
·
·
·
2.

Description of the Mother
The following may have had an impact on the
infant's development or will be used in the data
analysis and should be included in the report.
·
·
·
·
·

Mother's age.
Whether mother ingested prescribed or
over-the-counter medication or any other
drugs during pregnancy and type.
Maternal tobacco use during pregnancy.
Highest level of education completed by the
mother.
Annual household income from all sources.

3.

Description of the Death Sequence

·

Provide a full, detailed, step-by-step description
of the death sequence.
Describe how the infant's interaction with the
product may have led to death.

·

·
·
·

·

·
·
·

·

Specify if any other individuals were resting or
sleeping on the same unit.
Describe infant's face and body position when last
seen alive. Note if the infant's head was
pressed/tucked towards his chest.
If infant's nose and/or mouth was in contact with
any it describe item and its location. Describe
and give dimensions of any visible pock-t or cup
that had formed in item around infants face.
Describe any fluid/substance on the infant's face,
the bedding, or on any other item in close
proximity to the infant. Specify location of the
fluid in relation to the infant and indicate if it
was foamy, mucus, bloody, colored, etc.
Describe infant's face and body position when
found dead or unresponsive.
List all articles of clothing and other
accessories (e.g., jewelry) on infant when found.
List any items (blanket, pillow, toys) under,
over, or in close proximity to the infant when
found. Describe from closest to furthest from
infant. If the item was on the infant's face or
the infant's face was straight down into this
item, collect information on manufacturer, model,
size (if relevant), fiber contents, where
obtained, and age of product.
Indicate if there were any vinyl or other plastic
products present that the infant may have come in
contact with.

D.

Description of the Product

·

Describe sleeping/resting unit (e.g., crib, crib
mattress, adult mattress, bassinet, etc.) where infant
was found, include information on product dimensions,
construction materials or sleeping surface, etc. Note
any visible damage to surface or accessories and any
failures or defects of the sleeping/resting unit.

·

Indicate if a depression (sag, indent, or pocket) was
observable on the sleeping/resting surface when no
object was on it in any area. Indicate location of
depression in relation to the infant, and its
approximate width, depth, and length.

·

Place weighted doll in position found in relation to
products and measure width, depth, and length of any
pocket or sag that forms under the doll.

·

Indicate if the sleeping/resting surface was tilted and
its relation to the infant's head.

·

Indicate manufacturer, model, size (if relevant),
brand, fiber contents, where obtained, and age of

product.
·

Report any labeling on the product and photograph it.
Describe location, how affixed, colors of lettering and
background.

·

Describe condition of product(s).

·

Provide a description of the part or features of the
product which may have contributed to (not necessarily
caused or inflicted) the death.

·

Identify any labeling indicating certification, testing
or conformance with mandatory or voluntary standards.
Of particular interest are labels certifying
conformance with standards of the Juvenile Products
Manufacturers Association (JPMA).
This guideline covers a large group of products. Many
of the concerns are generic to the group, but there are
some product-specific concerns. These are as follows:
1.

2.

Mattresses
a.

Indicate content material (foam, innerspring,
other--specify).

b.

Indicate surface material (fabric, vinyl,
other-specify) of mattress.

c.

Indicate if any other material was used as a
mattress protector or cover, or for
cushioning purposes. Give mattress, pad,
and/or cushioning material dimensions.
Indicate how well it fits in the crib, bed
frame, or other structure.

Cribs
a.

Determine if the crib is in compliance with
the mandatory crib regulation. Be sure to
check dimensions and fit of mattress,
construction of end panels, slat spacing,
etc. A copy of the crib regulation is
attached for reference.

b.

If the incident involved a crib corner post
or some sort of catch point on the crib
structure or hardware, describe the corner
post or catch point and provide dimensions.

c.

If the incident involved head entrapment in
the crib structure, provide the dimensions of

the area of entrapment.
3.

4.

Crib Bumpers
a.

Indicate if the bumper pads fit around the
entire crib and if they tie or snap on to the
crib.

b.

Specify how many ties or snaps are in place
and the length of the ties.

c.

Specify type of surface material (fabric,
vinyl, other--specify) covering bumper pads
and inner content material of the pad (foam,
batting, other--specify).

Bassinets and Cradles
a.

Describe the material from which the bassinet
or cradle is made.

III. INSTRUCTIONS FOR PHOTOGRAPHING AND/OR DIAGRAMING
FACTORS RELATED TO THE INVESTIGATION SEQUENCE
Photographs desired, in order of preference:
1.

Undisturbed infant,

2.

Doll or mannequin in position occupied by infant,

3.
Arrow or marker indicating where the infant was found,
emphasizing presence or absence of wedging, cupping, or other
entrapment of the head and/or face.
·

Simulate the positioning of the infant and surrounding
items using a doll. Photograph the product involved in
the death, be sure to include a clear and labeled view
of any components which are defective or improperly
installed or maintained. Also, photograph any labeling
present on the product such as certification emblems,
warnings, or instructions for use or installation.

·

Include a diagram or sketch of the floor plan of the
incident location, including the location of the
product(s), area where the infant was found and
location of doors, windows, or other openings that may
normally provide some ventilation for the residence.

·

Photograph all features of the physical environment
directly involved in the incident.

·

Diagram the position of the infant and product(s) when
found. If multiple products are involved, describe

position from closest to furthest from infant.
Describe layered products in the order found, from
closest to furthest from infant.

IV.

·

Provide a photograph, diagram and/or description of the
product, sufficient that Compliance or Engineering
might identify it if necessary.

·

If the scene was re-created for photographs, indicate
who helped recreate the scene.

INSTRUCTIONS FOR OBTAINING SAMPLES AND DOCUMENTS
RELATED TO THE INVESTIGATION

Samples should be obtained for those cases in which the
infant's face was found straight down into a product, the
product was on the infant's face, or if the infant's face
was turned to the side (nose and mouth need not be obstructed).
Products that are very close to, or near the infant's face that
may have been involved should also be collected. If the sample
has been discarded or the individual does not want to give, sell,
or loan the sample to CPSC, investigators should purchase an
exemplar sample only if it is an exact replica.
If there is a layering of products, collect all products
above a non-permeable surface or above an intact mattress.
Collect non-permeable products if the surface is damaged or torn.
Collect crib mattress in addition to other products if the
surface material is damaged, or if there was any observable
sagging under the infant. If the infant was found in a bassinet
or other small item, collect the entire product.
Products (e.g., crib mattress and/or bedding items) should
be sent if the following criteria are met:
1. The owner voluntarily agrees to provide the product for
testing,
2.
The cost of the product sample does not exceed $75.00
for regional offices,
3.
The condition of the product is the same as it was at
the time of death.
·

Sofas, adult size beds/mattresses, and cribs should not
be collected.

·

Samples may be borrowed from individuals. Please make
sure to note that the sample is "Borrowed" in Block 1
(Flag) of the Sample Collection Report included with
the sample. In Block 26 (Remarks), include the name
and mailing address.

V.

·

Samples collected for this study should be sent to the
attention of Warren Porter, Health Sciences Laboratory
through the Sample Custodian.

·

Medical examiner, police, and autopsy reports should be
obtained, when possible. This is especially important
in cases where the police or medical examiner has the
product.

ADDITIONAL INSTRUCTIONS
·

Identify clearly the source of the information you
provide; i.e., the persons with whom you spoke or
corresponded about the death. Indicate who provided
most of the information for the interview. If the
parent is not the actual witness, then the actual
witness should be interviewed in addition to the
parent.

·

If several respondents are available, all should be
interviewed regarding position of the infant in
relation to the products when last seen alive and
position of the infant in relation to the products when
found dead or unresponsive.

·

There may be conflicting statements from the parents
and other observers or investigators. State clearly
any conflicting opinions. If you have reason to
believe that statements made by any parties are
inaccurate, please note and document observed facts
that may help to address and resolve questionable
opinions.

·

Contact the local police department and medical
examiners office to obtain a written report. Autopsy
and pathology reports should be included in the medical
examiner report.

·

List other documents obtained and appended (Police
Report, Medical Examiner Report).

·

To reduce interviewing time, some information may be
answered from medical examiner reports, police reports,
and/or autopsy reports. The following information may
be obtained from the above reports.
-age (in weeks)
-date of birth
-race
-approximate time of death
-weight at time of death
-address and phone number of parents/witnesses

DATA RECORD SHEET
IDI __________________________
DATE WITNESS
INTERVIEWED_________________

DEATH SCENE INVESTIGATION OF INFANTS LESS THAN 12 MONTH5 OF AGE
DYING SUDDENLY AND UNEXPECTEDLY
I.

Description of the Product/Infant Interaction
Pre-Death
1.

What is the date and time infant was last seen alive
(use 24 hour clock)?
date __________

2.

time__________

Immediately (within one hour) prior to death, had the
infant been in a car seat/carrier for any length of
time?
No _____
Yes ____ (approximate time)

Refused ________
Don't Know _____

If yes, give manufacturer, brand, and size.
_______________________________________________________
3.

At the time the infant was last seen alive, on what
type of product (e.g., sofa, crib, bassinet, adult bed,
etc.) had the infant been placed?
_______________________________________________________

4.

At the time of death, was this the usual resting place
(usual location and product) of the infant?
Yes _____
No ______

Refused ________
Don't Know _____

If no, specify usual place (location and product).
_______________________________________________________
5.

What was the infant's body position when last seen
alive?
On stomach _____
On infant's side _____
Don't Know _____

Other (specify) _____
On back _____
Refused _____

6.

What was the infant's face position when last seen
alive?
Face up _____
Face "straight" down _____
Face to infant's side ______

7.

Other (specify) _____
Don't Know _____
Refused _____

Were there any other individuals resting or sleeping on
the same unit as the infant?
No _____
Yes _____

Don't Know _____
Refused _____

If yes, how many individuals? ________
8.

When was the infant last fed?
Time _____

Type of food (liquid or
solid) __________________

Don't Know _____
Refused _____
9.

Is the type of food listed in question number 8 the
infant's regular diet?
No _____
Don't Know _____
Yes _____
Refused ________
Not applicable (food not known)_______________

Death
10.

What is the date and time infant was found dead or
unconscious (use 24 hour clock)?
date __________

11.

time__________

Were there any resuscitation attempts?
No _____
Yes _____

Don't Know _____
Refused ________

If yes, by whom?
______________________________________________________
12.

What was the infant's body position when found?
On stomach ________
On infant's left side _______
On infant's right side _______
On back _______
Other (specify) _______________________________________
Don't Know _______
Refused _______

13.

What was the infant's face position when found?
Face up _______
Face to infant's right side _______
Face down _______
Refused _______
Other (specify)________________________________________
Don't Know _______

14.

Was the infant's head pressed forward towards the
chest?
No _______
Yes _______

15.

Don't Know _______
Refused __________

Were there any marks, creases, or impressions from
bedding or other materials present on the infant's face
or head?
No _______
Yes _______

Don't Know _______
Refused __________

If yes, describe location and approximate size.
_______________________________________________________
_______________________________________________________
16.

When found, was the infant's nose and/or mouth in
contact with any item?
No _______
Yes, nose _______
Yes, mouth _______
Yes, both mouth and nose _______

Don't Know _______
Refused __________

If yes, describe location of contact and item. Include
any label information on manufacturer, brand, and
fiber/material contents (in the absence of label
information, describe material).
_______________________________________________________
_______________________________________________________
17.

If the infant's nose and/or mouth was covered or in
contact with any item, did a pocket or cup form around
its face?
No ________
Yes _______
Not Applicable _________

Don't Know _________
Refused ____________

If yes, describe item, give dimensions of pocket.
_______________________________________________________

18.

When found, was there any substance (e.g., blood or
other fluid) on the infant's face, especially around
the nose or mouth?
No ________
Yes _______

Don't Know _________
Refused ____________

If yes, specify location and whether substance is
foamy, mucus, bloody, colored, etc.
_______________________________________________________
_______________________________________________________
19.

Were there any fluids from the infant on clothing,
pillow, mattress, blanket, sheet, or other items when
found?
No _______
Yes ______

Don't Know _________
Refused ____________

If yes, describe (specify item and whether substance is
blood or other fluid).
_______________________________________________________
_______________________________________________________
20.

If yes to guestion number 19, was the infant's face in
contact with the wet items described in question 19?
No _______
Yes ______

Don't Know _________
Not Applicable
(no wet items)______

If yes, describe
_______________________________________________________
_______________________________________________________
21.

List all articles of clothing including jewelry, and
other accessories on infant when found (e.g., plastic
diaper, cloth diaper with plastic diaper pants, diaper
pins, hats, pierced earrings). Indicate any damage to
clothing (e.g., broken zipper, loose pieces, tears,
holes) or any missing items on clothing or accessories.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

22.

List any items under the infant when found (e.g.,
sheet, mattress pad, rug).
None _______
Refused _______

Don't Know _________

Describe (from closest to furthest from infant) and
specify if the infant's face was in contact with this
item. Include any label information on manufacturer,
brand, and material/fiber contents. In the absence of
label information, describe material.
_______________________________________________________
_______________________________________________________
_______________________________________________________
23.

List any items (e.g., blanket, quilt) over the infant
when found.
None _______
Refused _______

Don't Know _________

Describe (from closest to furthest from infant) and
specify if item was on the infant's head. Include any
label information on manufacturer, brand, and
material/fiber contents. In the absence of label
information, describe material.
_______________________________________________________
_______________________________________________________
_______________________________________________________
24.

List any other items (e.g., bottles, pacifiers, toys,
pillows, bumper pads, blankets, quilts, etc.) in close
proximity to the infant's face.
None _________
Refused ______

Don't Know _________

Describe (from closest to furthest from infant)
_______________________________________________________
_______________________________________________________
_______________________________________________________
25.

Was there any vinyl or other plastic product present
that the infant may have come in contact with?
None ________
Yes _________

Don't Know _________

If yes, specify product and describe.
_______________________________________________________
_______________________________________________________
_______________________________________________________

II.

Description of the Products
26.

Describe sleeping site (e.g., crib, crib mattress,
adult mattress, etc.) and other products involved
(e.g., blankets, quilts) where infant was found,
include information on product dimensions and materials
of construction of sleeping surface/site, etc.
·

Note any visible damage to sleeping surface or
accessories (e.g., ripped seams, exposed stuffing,
loose trim, etc.).

·

Note any failures or defects of sleeping/resting
unit (structural failure, broken or missing
hardware, etc.).
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
27.

Provide the following information for the above item(s)
listed in question 26:
Manufacturer __________________________________________
Size (if relevant) ____________________________________
Brand/Model/Style _____________________________________
How Obtained __________________________________________
Where Obtained ________________________________________
Age of Product_________________________________________
Surface material (e.g., fabric, vinyl, other, specify)
and filling contents (e.g., batting, foam, other,
specify) ______________________________________________
_______________________________________________________
Any recommendations or warnings listed on label
_______________________________________________________

28.

If the infant was found in a crib, were all four
mattress support hangers attached to the corner posts
and resting properly in the hooks at the time of death?
No ________
Don't Know _________
Yes _______
Refused ____________
N/A _______
(not found on a mattress/crib)
If no, describe
_______________________________________________________

29.

Did the sleeping surface have a visible depression (sag,
indent, or pocket) when no object was on it in any area?
No ________
Yes _______

Don't Know _________
Refused ____________

If yes, indicate area(s) and approximate width, depth,
and length.
_______________________________________________________
30.

Was the infant resting/sleeping on a tilted surface?
No ________
Yes _______

Don't Know _________
Refused ____________

If yes, describe where the infant's head was in
relation to the tilt.
_______________________________________________________
_______________________________________________________
III. Description of the Infant
31.

Birth Weight (lbs./oz.)

32.

Was the infant breast-fed?
No ________
Yes _______

33.

Was the infant carried to full term or was birth
premature?
Full Term ________
Premature ________

34.

Don't Know ________
Refused ___________

Don't Know _________
Refused ____________

Had the infant been ill within the past two weeks?
No _______
Yes ______

Don't Know _________
Refused ____________

If yes, describe illness, medical treatment received,
and give date of occurrence.
_______________________________________________________
35.

Has the infant had any injury or major illness since
birth?
No _______
Yes ______

Don't Know _________
Refused ____________

If yes, list all injuries and/or major illnesses and
date of occurrence.
_______________________________________________________

36.

Give a description of the infant's typical sleeping
position(s) including body and face position
(photograph of doll depicting infant or diagram).

37.

Was the infant able to lift his/her head?
No _______
Yes ______

38.

Was the infant able to roll from back to stomach and
stomach to back?
No _______
Yes ______

39.

Don't Know _________
Refused ____________

Don't Know _________
Refused ____________

Had the infant received any medication (prescribed,
over-the-counter, or home remedy) within the last 24
hours prior to death?
No _______
Yes ______

Don't Know _________
Refused ____________

If yes, give type, date, and time last given.
_______________________________________________________
40.

When was the infant's most recent vaccination?
None ever given _______
Refused _______________

Don't Know ________

Indicate if the vaccine was given orally or in a shot.
_______________________________________________________
41.

Had any changes occurred in the infant's behavior
(e.g., irritable, fussy) or functioning (e.g., ate
little, slept more/less, sweaty, diarrhea, etc.) within
the past 48 hours?
No _______
Yes ______

Don't Know _________
Refused ____________

If yes, describe
_______________________________________________________
_______________________________________________________
42.

Are there any other incidents of sudden infant death in
the family (other siblings)?
No _______
Yes ______

Don't Know _________
Refused ____________

If yes, specify
_______________________________________________________

IV.

Maternal History
43.

Mother's Age ____________

44.

Did mother take prescribed or over the counter
medication, or any other drugs during pregnancy?
No _______
Don't Know _________
Yes ______
Refused ____________
If yes, give type if known
_______________________________________________________

45.

Any maternal tobacco use during pregnancy?
No _______
Don't Know _________
Yes ______
Refused ____________
If yes, give duration and amount
_______________________________________________________

V.

Description of Environmental Factors
46.

Indicate number of individuals who smoke cigarettes,
pipes, or cigars in the home or other location where
infant spends most of his/her time.
Total number of cigarettes smoked in home or other
location per day
______________
Total number of pipes smoked in home or other location
per day
_______________
Total number of cigars smoked in home or other location
per day
_______________

47.

According to the parent's or care giver's perception,
was the room in which the infant was found at the time
of death:
Cold __________
Hot ___________
Refused _______

48.

Comfortable _____________
Don't Know ______________

Heating or cooling unit was set at what temperature
(Fahrenheit) at the time of death?
Heating __________
Don't Know _______
Turned Off _______

Cooling ______________
Refused ______________
Can't Control ________

49.

Energy source(s) in use at the time of death:
electric ____________
fuel oil _________
natural gas _________
kerosene _________
LP gas (propane) ____
wood/coal ________
don't know __________
refused _____________
none ________________
other(specify)_________________________________________