Choking, Aspiration, and Suffocation Interventions



In general, legislation goes hand-in-hand with product modification in that the measures introduced have largely required manufacturers to change the style or design of their products to decrease children’s risk (i.e., exposure) of suffocation. Examples of current legislation are the Federal Refrigerator Safety Act (enacted in 1958) and the California state statute requiring written warnings of suffocation hazard on plastic bags. Legislation is a passive intervention that can be at the local, state, or national level.

Review of legislation studies:


Kraus, 1985

Study design and target population

Before and after design

All deaths due to suffocation or asphyxiation among California residents aged 0-14 years, between January 1, 1960, and December 31, 1981.


California statute making it illegal to discard refrigerator or freezer in a place accessible to children (effective 1951; amended 1953 to require door and/or latch removal). Federal Refrigerator Safety Act (FRSA) prohibiting sale of refrigerators or freezers > 2.0 cubic feet that cannot be opened from inside with exertion of 15 lb. on closed door latch (effective October 30, 1958).

California statute requiring all plastic bags with thickness less than 0.001 inch to have printed warning on bag (effective July 6, 1959; amended 1961 to restrict usage of cartoons and pictures on warning labels).

Consumer Product Safety Commission regulation on crib design standards (enacted 1973), mainly affecting slat spacing.


Mortality rates (averages over two-year intervals) for deaths from refrigerator and freezer entrapments, plastic bags, and crib strangulations.


Refrigerators: death rates per million children declined from 1.3 in 1960 to 0.9 in 1963, increased to 1.8 in 1966, then decreased to less than 0.50 by 1977. Significant decrease in deaths per million children from 1968 to 1982 (p=0.025).

Plastic bags: death rates per million children decreased significantly between 1969-1971 and 1975-1977 (p=0.005). Deaths rates due to plastic sheeting (e.g., mattress covers) declined from 0.90 to 0.20 between 1971-1977, but not significantly.

Cribs: death rates per million children (ages 0-4) have not shown any significant decreases since law enacted in 1973, although trend was downward.

Study quality and conclusions

Thorough attempt at assessing death rates for California residents.

Uncertain whether refrigerator entrapments declined from design statute, enforcement of refrigerator abandonment, parental supervision, or some combination of these factors. However, no entrapments seen between 1972 and end of study period involved a refrigerator built after 1958, probably reflecting 15-year appliance life expectancy and FRSA. Suggestion that minimum force needed to open door be lowered.

Printed warning (directed at parents) on plastic bags seems to have worked. However, plastic sheeting still presents a problem. Suggestion that small holes be placed in sheeting, rendering it non-airtight.

Crib strangulation data not conclusive; more recent data should be reviewed. Suggestion that older models be removed from homes.

Summary of legislation interventions

The one study that evaluated several legislative interventions on choking and suffocation found significant reductions in death rates (per million children) from suffocation due to entrapment in refrigerators and suffocation from plastic bags. It is unclear the degree to which the legislation was responsible for the significant reduction in deaths. However, it is reasonable to assume that product changes through legislation rather than parental supervision remove (permanently) a larger portion of existing risk. Clearly, no upward trends in suffocation events are present between pre-law and post-law periods. Lastly, a study by Bain and colleagues4 in 1958 showed that an exertion of 15 pounds of force (per the 1958 FRSA) was not within the capacity of a significant proportion of children tested (53% of the 30 children tested–ages 2 through 5–failed to exert the minimum horizontal force from within the simulated enclosure).

Recommendations on legislation interventions

Legislation that removes the risk of choking and asphyxiation should be implemented wherever possible. Several suggestions of legislative measures that might remove the risk of suffocation have been discussed, such as lowering the minimum force required to open a refrigerator or freezer door from the inside. Legislation that requires that warning labels should be placed on products should require that the specific hazard be explained; a label merely stating, "For children ages 3 and up," doesn’t adequately explain the risk to the parent.

Recommendations for future research

More research on the effectiveness of legislation in the prevention of suffocation is needed, not only on the state level but also at the national level. A study examining, for example, national death rates due to suffocation from plastic bags both before and after introduction of legislation requiring written warnings is needed to determine the success of such laws. Consideration of regional laws and their effective dates should be taken into account with such studies. For example, one might examine the effectiveness of regulations forbidding latex balloons.