Object-Related Aspiration Deaths in Children and Adolescents in the United States, 1968 to 2017 | Adolescent Medicine | JAMA | JAMA Network
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Figure 1.  Mortality Rate From Aspiration of Objects Among Children in the United States
Mortality Rate From Aspiration of Objects Among Children in the United States

AAP indicates American Academy of Pediatrics; CPTSA, Child Protection and Toy Safety Act; ICD-8, International Classification of Diseases, Eighth Revision; ICD-9, International Classification of Diseases, Ninth Revision; ICD-10, International Classification of Diseases, Tenth Revision. Data markers indicate age-standardized observed rates. Solid colored lines indicate best-fitting log-linear regression modeled rates to identify the years (ie, joinpoints) when the annual percentage changed significantly. Data in parentheses are 95% CIs. Dates of protective legislation and guidelines to prevent mortality from aspiration of objects in children are included.

aThe annual percentage change is statistically different from zero (2-sided P < .05).

Figure 2.  Annual Percentage Change in Object-Related Mortality Rate Based on Age Among Children in the United States
Annual Percentage Change in Object-Related Mortality Rate Based on Age Among Children in the United States

Data markers indicate age-stratified observed rates. Solid colored lines indicate best-fitting log-linear regression–modeled rates to identify the years (ie, joinpoints) when the annual percentage changed significantly. Data in parentheses are 95% CIs. This analysis allowed up to 5 joinpoints.

aThe annual percentage change is statistically different from zero (2-sided P < .05).

1.
 American Academy of Pediatrics Committee on Accident and Poison Prevention: first aid for the choking child, 1988.  Pediatrics. 1988;81(5):740-742.PubMedGoogle Scholar
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Milkovich  SM, Altkorn  R, Chen  X,  et al.  Development of the small parts cylinder: lessons learned.  Laryngoscope. 2008;118(11):2082-2086. doi:10.1097/MLG.0b013e31818173d5PubMedGoogle ScholarCrossref
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US Public Interest Research Group Educational Fund. Trouble in toyland: the 33rd annual survey of toy safety. https://uspirg.org/sites/pirg/files/reports/WEB_USP_Toyland-Report_Nov18_2-1.pdf. Accessed July 16, 2019.
4.
Committee on Injury, Violence, and Poison Prevention.  Prevention of choking among children.  Pediatrics. 2010;125(3):601-607. doi:10.1542/peds.2009-2862PubMedGoogle ScholarCrossref
5.
National Center for Health Statistics. National Vital Statistics System: multiple cause of death data file, 1968-2017. https://www.cdc.gov/nchs/nvss/deaths.htm. Accessed February 1, 2019.
6.
Harris  CS, Baker  SP, Smith  GA, Harris  RM.  Childhood asphyxiation by food: a national analysis and overview.  JAMA. 1984;251(17):2231-2235. doi:10.1001/jama.1984.03340410039029PubMedGoogle ScholarCrossref
Research Letter
November 26, 2019

Object-Related Aspiration Deaths in Children and Adolescents in the United States, 1968 to 2017

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
  • 2Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
  • 3Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA. 2019;322(20):2020-2022. doi:10.1001/jama.2019.15375

During the last 50 years, efforts to prevent aspiration in children have been led by the US Consumer Product Safety Commission, the American Academy of Pediatrics, and the US Public Interest Research Group.1-4 Beginning in 1969 with the Child Protection and Toy Safety Act, regulations on the size of parts in products designed for children, choking hazard warning labels, and public awareness campaigns have been instituted. For example, products designed for young children were prohibited in 1979 from containing small parts that can fit into a test cylinder approximately the size of the upper aerodigestive tract of a child younger than 3 years.

In 1994, products designed for older children containing small parts were required to display a warning label that states “WARNING: CHOKING HAZARD—Small parts. Not for children under 3 years.” In 2010, the American Academy of Pediatrics proposed adding warning labels to vending machines and internet sites that sell toys, and improving the effectiveness of product recalls.4 Whether the incidence of aspiration deaths has changed since 1969 has not been examined.

Methods

We analyzed deaths in children and adolescents aged 0 to 17 years caused by object-related aspiration in the National Vital Statistics System.5 Object-related aspiration deaths were identified using codes from the eighth through tenth revisions of the International Classification of Diseases (ICD-8 and ICD-9: E912; ICD-10: W80). Deaths caused by food-related aspiration were excluded because these codes are prone to errors.6 We examined deaths beginning in 1968 (when rigorously verified data started to be collected) through 2017, the most recent year of data available.

We calculated age-standardized rates based on US Census data. Trends in object-related aspiration mortality for all children and adolescents and for those younger than 3 years or aged 3 years or older were calculated using version 4.7.0 of the Joinpoint Regression Analysis software (National Cancer Institute). A 2-sided P < .05 was considered significant. The Wayne State University institutional review board waived the need for informed consent because data were deidentified.

Results

We identified 20 629 object-related aspiration deaths in children and adolescents. Over 50 years, object-related aspiration deaths decreased from 1.02 per 100 000 children (719 deaths) in 1968 to 0.25 per 100 000 children (184 deaths) in 2017. The annual percentage change was −2.0% (95% CI, −1.6% to −2.3%) in 1968-1990; −6.1% (95% CI, −4.9% to −7.2%) in 1990-2003; and −2.5% (95% CI, −1.3% to −3.7%) in 2003-2017 (Figure 1).

For children younger than 3 years, the annual percentage change was −2.8% (95% CI, −2.4% to −3.3%) in 1968-1991; −8.4% (95% CI, −4.8% to −11.8%) in 1991-1999; and −2.4% (95% CI, −1.3% to −3.5%) in 1999-2017 (Figure 2). In children aged 3 years or older, mortality was stable in 1968-1976 and declined thereafter (annual percentage change, −2.1% [95% CI, −1.2% to −3.1%] in 1976-1992 and −4.5% [95% CI, −3.9% to −5.1%] in 1992-2017).

Discussion

Object-related aspiration deaths in children and adolescents declined between 1968 and 2017, especially among children younger than 3 years, the target population of restrictive labeling. The declines occurred across all years, but slowed among children younger than 3 years after 1999.

A number of laws, regulations, and guidelines were adopted during this period; however, the individual and cumulative effect of these actions was not determined. Whether other factors contributed to the decline is not known. Another limitation is that death certificate data do not specify the type of object that contributed to deaths.

Although object-related aspiration deaths among children and adolescents have declined, 184 children died of this cause in 2017. Additional prevention strategies should be considered such as redesigning the small parts test cylinder because 23% of object-related aspiration deaths result from objects that passed the evaluation2 using the small parts test cylinder, and reducing exposure of vulnerable children to objects already restricted with warning labels.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: September 4, 2019.

Corresponding Author: John D. Cramer, MD, Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, 4201 St Antoine St, Ste 5E, Detroit, MI 48201 (jdcramer@med.wayne.edu).

Author Contributions: Drs Cramer and Meraj had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cramer, Meraj.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cramer, Meraj.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cramer, Meraj, Lavin.

Administrative, technical, or material support: Cramer.

Supervision: Cramer, Boss.

Conflict of Interest Disclosures: None reported.

References
1.
 American Academy of Pediatrics Committee on Accident and Poison Prevention: first aid for the choking child, 1988.  Pediatrics. 1988;81(5):740-742.PubMedGoogle Scholar
2.
Milkovich  SM, Altkorn  R, Chen  X,  et al.  Development of the small parts cylinder: lessons learned.  Laryngoscope. 2008;118(11):2082-2086. doi:10.1097/MLG.0b013e31818173d5PubMedGoogle ScholarCrossref
3.
US Public Interest Research Group Educational Fund. Trouble in toyland: the 33rd annual survey of toy safety. https://uspirg.org/sites/pirg/files/reports/WEB_USP_Toyland-Report_Nov18_2-1.pdf. Accessed July 16, 2019.
4.
Committee on Injury, Violence, and Poison Prevention.  Prevention of choking among children.  Pediatrics. 2010;125(3):601-607. doi:10.1542/peds.2009-2862PubMedGoogle ScholarCrossref
5.
National Center for Health Statistics. National Vital Statistics System: multiple cause of death data file, 1968-2017. https://www.cdc.gov/nchs/nvss/deaths.htm. Accessed February 1, 2019.
6.
Harris  CS, Baker  SP, Smith  GA, Harris  RM.  Childhood asphyxiation by food: a national analysis and overview.  JAMA. 1984;251(17):2231-2235. doi:10.1001/jama.1984.03340410039029PubMedGoogle ScholarCrossref
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