Overlay (Suffocation)

Child deaths due to suffocation result when the child is in a place or position where he or she is unable to breathe. In 2000, there were 1,580 suffocations, including 842 unintentional deaths, 568 suicides, 107 homicides and 63 deaths of undetermined manner in the United States.

Most of the unintentional suffocations are caused by:

  • Overlay: a person who is sleeping with a child rolls onto the child and unintentionally smothers the child.
  • Positional asphyxia: a child’s face becomes trapped in soft bedding or wedged in a small space such as between a mattress and a wall or between couch cushions.
  • 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.

The majority of these suffocations happen to infants while they are in unsafe sleeping environments. These infants suffocate when another person lays over them or when they smother in bedding or furniture. This is the fourth leading type of accidental death for all children, following motor vehicle crashes, fires and drowning. Infants who suffocate often have no clinical findings at autopsy. It is only through a comprehensive scene investigation that unintentional suffocation can be distinguished from SIDS or intentional suffocations (homicides). Yet, even with complete investigations, a large number of suffocation deaths are still reported as manner undetermined, further highlighting the difficulty investigators have in determining how the infants died.

Overlay deaths are most often caused when an infant sleeps with adults or older siblings (bed-sharing). Bedding deaths occur when infants sleep with too much bedding or when they sleep in beds other than cribs. They suffocate because the bedding is usually too bulky or soft for infants. Hazardous sleeping surfaces include waterbeds, couches, large pillows, or soft or heavy comforters.

Researchers from the CPSC and the National Institute of Child Health and Human Development are now reporting that infants sleeping in adult beds are 20 times more likely to suffocate than infants who sleep alone in cribs. Some proponents of bed- sharing argue that it promotes breastfeeding. However, researchers have shown that many of the benefits received from bed-sharing can be derived from the practice of having the infant sleep on a separate, firm surface, but in the same room with the mother. The majority of infants suffocate when another person lays over them or when they smother in bedding or furniture. For choking and strangulation deaths, toddlers and preschoolers are at highest risk. Because they are active, they be-come entangled in cords and gain access to small objects. Food and uninflated balloons remain the number 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 draws rings from children’s clothing and safety cord hangers for window blinds have reduced the number of these types of suffocations in recent years.

Major Risk Factors

  • Infants sharing sleep surfaces with other persons.
  • Unsafe infant bedding: may include couches, waterbeds, poor-fitting crib mattresses, infant beds filled with clutter, heavy or numerous blankets and soft mattresses.
  • Easy access by infants and toddlers to small objects, balloons and toys with small parts.
  • Easy access by infants and toddlers to cords and ropes.
  • Toy chests without safety latches and heavy furniture not secured to floors or walls.
  • Place where child was sleeping or playing.
  • Position of child when found.
  • Type of bedding, blankets and other objects near child.
  • Faulty design of cribs, beds or other hazards.
  • Number of and ages of persons sleeping with child.
  • Obesity, fatigue, or drug or alcohol use by persons supervising or sleeping with child.
  • Quality of supervision at time of death.
  • Child’s ability to gain access to objects causing choking or confinement.
  • If hanging, child’s developmental age consistent with activity causing strangulation.
  • Family’s ability to provide safe sleep or play environment for child.
  • Prior child deaths or repeated reports of apnea episodes by caregiver.
  • 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



  • Education at childbirth classes and in hospitals to expectant and new parents on safe infant sleep environments.
  • In-hospital assessments by nurses with parents to assess babies’ sleep environments.
  • Culturally competent public education campaigns and coordination with the “Back to Sleep” campaign.
  • Crib distribution programs for needy families.
  • Education to professionals on risks of infant suffocation.
  • Notification to CPSC and continued product safety recalls on choking and strangulation hazards.
  • Licensing requirements for daycare providers on safe sleep environments and infant sleep positions.
National Center for Child Death Review Policy and Practice
c/o Michigan Public Health Institute, Keeping Kids Alive, Fact Sheet, 2009, http://www.childdeathreview.org/causesSUF.htm