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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 4  |  Page : 197-202

Nonnatural deaths of children under the age of 5 years in Ontario, Canada: A retrospective autopsy analysis of 10 years (2006-2015)

1 Department of Public Health, Lakehead University, Thunder Bay; Provincial Forensic Pathology Unit, Forensic Pathology Service, Toronto, Ontario, Canada
2 Provincial Forensic Pathology Unit, Forensic Pathology Service; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada

Date of Web Publication11-Jan-2018

Correspondence Address:
Dr. Jayantha C Herath
2nd Floor, 25 Morton Shulman Avenue, Toronto, Ontario, M3M 0b1
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfsm.jfsm_64_17

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The goal of this study is to unravel the common patterns observed among nonnatural deaths of children under 5 years and suggest ways to prevent such unnecessary deaths. The study was confined to the province of Ontario to allow the identification of regional specific patterns. The database at the Office of the Chief Coroner of Ontario was searched for all pediatric deaths from the years 2006-2015. All nonnatural deaths for children under the age of 5 years, including sudden infant death syndrome, were selected for the study. Manner and cause of death along with the corresponding year were recorded in tables. In the 10-year period, 940 nonnatural deaths were identified in Ontario through autopsy records which are equal to approximately 36.7% of the total childhood deaths. There were 295 accidental cases (11.6%) and 71 homicides (2.8%). The leading causes of nonnatural childhood deaths in Ontario were drowning, traffic accidents, blunt trauma, and asphyxia. Nonnatural deaths are preventable through education and training of parents. Implementation of educational interventions can significantly reduce nonnatural deaths of children in Ontario.

Keywords: Accidental, death, drowning, homicide, trauma

How to cite this article:
Rizvi SS, Herath JC. Nonnatural deaths of children under the age of 5 years in Ontario, Canada: A retrospective autopsy analysis of 10 years (2006-2015). J Forensic Sci Med 2017;3:197-202

How to cite this URL:
Rizvi SS, Herath JC. Nonnatural deaths of children under the age of 5 years in Ontario, Canada: A retrospective autopsy analysis of 10 years (2006-2015). J Forensic Sci Med [serial online] 2017 [cited 2022 May 28];3:197-202. Available from: https://www.jfsmonline.com/text.asp?2017/3/4/197/222893

  Introduction Top

A reduction in child mortality rate is imperative for the success of any nation.[1] Death in children can occur naturally or due to external factors that are usually preventable.[2] In developed nations, injuries are a leading cause of mortality in children under 5 years of age. During the period of 2006-2008, Statistics Canada reported that congenital malformations, chromosomal abnormalities, disorders related to short gestation period, low birth weight, and other maternal complications of pregnancy are the significant causes of death in infants. Statistics Canada identified accidental injuries, malignant neoplasms, and congenital conditions to be the top three leading causes of death for children aged 1-5 years. After identifying the common causes of fatal injuries, public health practitioners can develop child survival and death prevention interventions that aim to prevent these tragic deaths.

In Ontario, the Forensic Pathology Service uses a centralized system to record all pediatric death investigations that were subjected to autopsies in the province. Coroners investigate the cases of sudden deaths and order autopsies appropriately. Under the supervision of the chief forensic pathologist, autopsies are performed by registered forensic pathologists. This study employed a retrospective autopsy review approach to investigate the patterns of death observed in young children residing in Ontario. Autopsy reviews provide accurate information that is medically proven.[3] However, it is important to note that not all deaths are subjected to autopsies; therefore, all nonnatural deaths that occurred during the study period will not be incorporated in data analysis. Statistics Canada reported that the province has a population of 13.9 million and a death rate of 4.7 deaths per 1000 population.[3] The rate of autopsies, including children and adults, in Ontario is 1.6% which is relatively low compared to that of other provinces.[4] The autopsy rate is relatively lower in Ontario due to the expertise of coroners. In Ontario, coroners are medical doctors with specialized training in death investigations. They can determine the cause of death by external examination of the body; therefore, autopsies are only performed for more complicated cases where the cause of death is unclear.[5]

A variety of reasons can cause nonnatural deaths in children. For instance, asphyxiation is a condition that results in low oxygen supply to organs due to abnormal breathing.[6] Asphyxia in children can be caused by choking, strangulation, neck or chest compression, airway obstruction, or a kind of positional restraint. Furthermore, children are especially vulnerable to various forms of physical trauma due to their smaller body size. Traumatic injuries from road accidents can cause lacerations, concussions, fractures, and even death in some cases.[7] Globally, drowning is the third leading cause of unintentional injury death, with rates highest among children under 5 years of age.[1] In Canada, the total annual cost associated with drowning injury is estimated to be US $173 million.[1] Even nonfatal drowning can cause severe brain damage that may lead to long-term disabilities such as loss of brain functioning, memory problems, and learning disabilities.[1],[4] In addition, a significant amount of deaths in children occur due to fire or the inhalation of smoke. Death can be caused by inhaling toxic gases such as carbon monoxide or the rapid effects of intense heat. Some children also lose their lives after falling from heights and due to drug toxicity and hyperthermia. Thus, several reasons can lead to the untimely deaths of children. Findings of this study will provide substantial evidence to highlight the most common trends observed in nonnatural deaths of children. Appropriate policies and interventions can be targeted toward specific causes, ultimately lowering the rate of nonnatural deaths of children in Ontario. Child survival efforts are successful if accurate information regarding the cause of death is available. Regional patterns of Ontario closely resemble the overall death patterns of children in Canada. Other developed nations can utilize these findings to compare death patterns and possibly adopt similar death prevention strategies used in Ontario.

  Methods Top

A retrospective quantitative study was conducted to discover the common causes of nonnatural deaths in children under the age of 5 years. The study was inclusive for children who were residents of the province of Ontario. The study was approved by the Research Ethics Board at The Office of the Chief Coroner of Ontario. The data used in the study were retrieved from pediatric autopsy records and Coroner's Information System files at the Office of the Chief Coroner of Ontario.

Data were extracted from coroner's summary reports and transferred onto an Excel file. The information provided included name, dates of birth and death, age, sex, region, manner of death, the environment at the time of death, and the primary death factor and the immediate cause of death. After intensive police investigations and examination of medical reports, the manner of death was classified as natural, accident, suicide, homicide, or undetermined and recorded in the files of the deceased children. Whereas, the primary death factor was recorded as an event (drowning, motor vehicle accident, burning, etc.) that led to the child's death. Finally, the biological cause of death was revealed through autopsies, genetic testing, and toxicology results. Only nonnatural deaths were analyzed for the purposes of this study. All the natural deaths, undetermined cases of stillbirths, and aborted fetuses were excluded. Each case was manually reviewed to record the cause of death. Appropriate formulas were used on Excel to determine the number of accidents, homicides, undetermined cases as well as male and female ratios.

Tables were generated to record the number of cases for each nonnatural cause of death. Asphyxiation cases were further divided into various categories including strangulation, choking due to food bolus or another foreign body, airway obstruction, neck compression, positional restraints, chest compression, hanging, and environmental asphyxia. Trauma cases were also divided into specific categories including vehicle accident, sharp force (stabbing), gunshot wound, blunt, farming, beating/assault, and animal bites. The category of sudden and unexplained deaths (SUD) described deaths, usually during sleep, of apparently healthy infants. Deaths by sudden infant death syndrome (SIDS) were also incorporated in the study. Finally, the numbers were utilized to generate percentages and ultimately analyze the data to determine the leading causes of nonnatural deaths in children residing in Ontario.

  Results Top

Exactly 2560 cases of deaths of children under the age of 5 years were analyzed from 2006 to 2015. There were 940 deaths due to nonnatural causes as well as SIDS, which make up approximately 36.7% of the total childhood deaths in Ontario from 2006 to 2015. The manner of death was undetermined for the majority of nonnatural cases, but accidental deaths (11.6%) and homicidal deaths (2.8%) were also observed. The total accidental cases comprised of 167 males and 128 females while the total homicides included 39 males and 32 females.

The results were mostly compatible with a similar study conducted for the province of Manitoba. Both studies showed similar patterns in nonnatural deaths of children. The accidental cases generally declined over the years, with an unusual rise in 2009 and 2010. The peak of accidental cases was in 2006 with a total of 43 deaths. In Manitoba, the accidental death rate increased initially, peaked in 1999, but showed reduction since then. On the other hand, homicidal cases showed variability and the highest number of homicides, 13 deaths, were observed in 2010. Generally, the rate of homicides was found to be significantly lower than the rate of accidental cases, which was similar to the province of Manitoba. In Manitoba, the top major causes of nonnatural deaths were road accidents, suicide by hanging, accidental drowning, and house fires. Whereas, the top major causes of nonnatural deaths in Ontario were drowning, traffic accidents, blunt trauma, asphyxia, and fire [Figure 1]. It is important to note that the study conducted in Manitoba used data for all nonnatural deaths of children under 18 years of age while the Ontario study is based on data from children under the age of 5 years. Thus, some causes of nonnatural deaths, including suicides and road accidents where the deceased was the driver, were exclusive to the Manitoba study.
Figure 1: Distribution of common causes of childhood deaths in Ontario over a period of 10 years

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The majority of undetermined cases were sleep-related infant deaths that may have occurred due to bed sharing and/or unsafe sleeping conditions. The primary death factor was unascertained or classified as SUD for all the undetermined cases. Cases that had no association with sleeping conditions were recorded as SIDS in coroner's summary reports. Seventeen cases of SIDS were also included in the study [Table 1]. Cases of SIDS are unclear; although most SIDS deaths are natural, a few nonnatural deaths can also be classified under the category of SIDS.
Table 1: Distribution of the various causes of deaths in children under the age of 5 years

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The research revealed that drowning incidents make up a significant portion of nonnatural deaths among children (9.0%). Out of the 85 drowning deaths, most children drowned in bathtubs/whirlpools/hot tubs (n = 31) or private pools (n = 31), but there were quite a few cases of drowning in open water bodies such as ponds/lakes/casual water (n = 21) as well. Most drowning cases occurred in children who were 2-5 years old (n = 48) and toddlers (n = 30) who were 7-23 months old. Road traffic accidents contributed to about 8.1% of deaths or 76 cases [Table 2]. Due to road traffic accidents, there were 11 cases of stillborn babies. The age distribution of the other 65 cases included 14 infants (0-6 months), 21 toddlers (7-23 months), and 30 children (2-5 years old). Over the years, there was no apparent pattern, and casualties occurred randomly every year for traffic accidents and drowning incidents [Table 1] and [Table 2], respectively]. The highest number of deaths due to drowning (n = 16) occurred in 2010 while the highest number of traffic accident cases (n = 12) occurred in 2006. Blunt trauma (7.4%) was the third major cause of death among children [Table 2]. Blunt trauma cases had two major categories including 31 cases of beating/assault and 39 cases of accidental deaths. The majority of accidental blunt trauma cases included severe head injuries (n = 24) and some abdominal injuries (n = 15). Of the 39 accidental blunt trauma cases, only 4 deaths occurred on the spot and 35 children died while receiving treatment in Intensive Care Unit, emergency departments, or acute care wards at hospitals. Children who were killed by beating/assault had multiple injuries all over the body. Furthermore, inhalation of smoke and deaths from intense burning caused 3.7% of nonnatural deaths [Table 1].
Table 2: The total number of trauma cases, from the study period of 2006–2015, divided into specific categories

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Almost half of the traumatic deaths were due to vehicle accidents (48%). There were a couple of traumatic cases due to gunshot wound and animal bites [Table 2]. In Ontario, farming deaths due to machine runovers and/or being crushed under heavy objects are also observed among children [Table 2]. The remaining causes of deaths were falls from height, drug toxicity, and hyperthermia [Table 1]. Disturbingly, the study revealed that complications during medical procedures at the hospital are also a cause of death among children [Table 1]. Many of the aforementioned causes included cases of accidental deaths as well as homicidal deaths. Brutal cases of homicides included 39 males and 32 females. Children were murdered in a variety of ways including drowning, stabbing, burying, strangulation, and beating/assault.

Different types of asphyxiation were also responsible for about 7.2% of the total deaths [Table 3]. The three most common types of asphyxiation were airway obstruction (27.9%), choking (17.6%), and positional restraint (19.1%).
Table 3: The total number of asphyxia cases, from the study period of 2006–2015, divided into specific categories

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  Discussion Top

The study analyzed nonnatural deaths of children under the age of 5 years in Ontario. The 10-year study period, 2006-2015, revealed that the major causes of nonnatural deaths among children in Ontario are drowning, road traffic accidents, asphyxiation, and burning or inhalation of smoke from fire. Studies conducted in other developed nations show similar death patterns in children. For instance, an Australian study found that the three most common causes of deaths among children aged under 16 years were motor vehicle accidents, drowning, and fire/burns.[7] Preventative initiatives can be developed once the patterns of child death and all the contributing factors are clearly understood.[8] This research provides valuable knowledge about the main causes of death among children which can be useful in driving the development of preventative initiatives.

According to Health Canada, the target age for death prevention efforts is the first 4 years of life.[5] Different causes of deaths can provide suggestions to prevent future deaths of children. For instance, considering the large amounts of infant deaths due to unsafe sleeping conditions, it is apparent that there is a dire need to provide education and training to parents. Educational programs must inform parents about the dangers of bed sharing and provide appropriate instructions for creating a safe sleeping environment for their children. A randomized controlled trial showed the high efficacy of promoting safe sleeping practices through children's books.[9] The study involved families of low socioeconomic status and revealed that adherence to crib use was high among the group of parents who were taught about safe sleeping conditions through children's books.[9] Thus, various strategies can be employed to educate parents about creating a safe environment for their infants. The annual report by Pediatric Death Review Committee (2015) defines SIDS as a sudden death of an infant, under 1 year of age, that cannot be explained even after a thorough investigation including full autopsy and detailed review of the circumstances of death.[5] These cases emphasize the importance of metabolic and genetic testing. If a fatal genetic abnormality is discovered in time, living family members as well as future siblings can be screened and receive proper treatment. Similarly, metabolic testing can also provide a better understanding of metabolism in infants and prevent deaths in the future.

As discussed earlier, drowning accidents are the top cause of nonnatural deaths among children. Drowning can occur in familiar swimming pools or in an unfamiliar setting with poor access to resuscitation. In Ontario, most drowning cases occur in bathtubs/whirlpools or private pools as well as lakes and ponds. Deaths due to drowning can be prevented by building fencing around swimming pools, providing children with floatation devices such as a life jacket, draining unnecessary accumulations of water (baths, buckets, etc.), and training the community in cardiopulmonary resuscitation procedures.[2],[10] The second major cause of nonnatural deaths was accidental road traffic incidents. Almost all young children who died in traffic incidents were passengers in the vehicle, suggesting the possibility of improper use of seatbelts and child seats as well as intoxicated driving. According to the Centers for Disease Control and Prevention (CDC), the proper use of car seats reduces the risk of infant deaths by 54% for toddlers.[11] The CDC also reported that sometimes car seats are incorrectly used in such a way that in fact increases the risk of injury rather than protecting the child.[2],[11] An Ontario-based study conducted by Lapner et al. (2001) suggested that proper seat belt restraint will significantly reduce childhood morbidity in motor vehicle crashes. Thus, it is crucial to provide detailed instructions to parents when choosing and installing a car seat.

Blunt trauma is also a leading cause of mortality in the pediatric population of Ontario. The results indicated that most children affected by accidental blunt trauma died in hospitals while receiving treatment. This information suggests that an enhancement in trauma management and care can possibly increase survival rates in children affected by trauma.[12] Future studies should focus on trauma prevention interventions as well as improved medical procedures to treat young trauma patients. There were 31 cases of beating/assault that produced the fatal effects of blunt trauma in children. In Ontario, the rate of homicides related to child assault was reported to be 0.3 cases/million/year in a previous study.[12] Child assault can be reduced if the abusers are punished accordingly and a fear of punishment is instilled in the minds of people.[12],[13] Child assault and maltreatment investigations demand a multidisciplinary approach requiring the coordination of several involved parties.[14] In addition, lifesaving interventions can be implemented if abusive injuries are properly identified. A study indicated that 30% of children who died due to abuse had irregular health-care visits, for reasons other than natural illnesses, in the year before their death.[13] This alarming discovery demands serious action from public health professionals who must make appropriate policies to ensure the safety of children.

Asphyxiation, oxygen deprivation, or the inability of cells to utilize the available oxygen also caused a significant number of childhood deaths in Ontario. A noteworthy fact is that intentional asphyxiation in infants is almost impossible to distinguish from SIDS or accidental asphyxiation.[15] Therefore, some infant deaths may actually have been homicides but would be classified as SIDS or accidental asphyxiation in this study. Deaths by asphyxia are significantly more common than other unexpected or dramatic events such as deaths by fires, falls, drug toxicity, and errors in hospital treatment. In Germany, a retrospective analysis of autopsy reports reported that the three main causes of accidental asphyxia in children are strangulation, positional asphyxia, and choking.[15] Similarly, the top major causes of asphyxiation in Ontario included positional asphyxia and choking. Asphyxiation accidents can be prevented through parental education and improved legislation/standards to increase product safety.[16] A randomized controlled trial of a home visit combined with providing an injury prevention kit showed a significant reduction in choking and suffocation hazards found in the home.[16] Public health programs should distribute asphyxia prevention information to parents and include instructions about choking treatment protocols in babysitting courses. Toys intended for young children must have modified designs to prevent choking incidents along with detailed instructions for parents.[14],[16] Finally, burning and smoke inhalation were another significant causes of death among children. Most of the accidental residential fire-related deaths in children result from fire play. Appropriate interventions should aim to prevent fire play among children and even adults who live with children.[17]

  Conclusion Top

Nonnatural deaths among children continue to be a major public health concern in Ontario. Future studies should analyze preventable deaths that occurred due to natural causes as well. A study revealed that 10% of pediatric deaths are preventable as they are a result of treatable natural acute illnesses such as sepsis and pneumonia.[18] As discussed earlier, most of the accidental deaths are preventable if appropriate safety measures are taken. This can be achieved by educating and empowering parents with valuable knowledge. Public health practitioners and policymakers can utilize the findings of this research to design efficient interventions and ultimately reduce the number of nonnatural deaths among children in Ontario. Further studies should focus on analyzing the effectiveness of various death prevention interventions.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Beaulne G; Health Canada. For the Safety of Canadian Children and Youth: From Injury Data to Preventive Measures. Ottawa: Government of Canada; 1997.  Back to cited text no. 1
Diamond IR, Parkin PC, Wales PW, Bohn D, Kreller MA, Dykes EH, et al. Preventable pediatric trauma deaths in Ontario: A comparative population-based study. J Trauma 2009;66:1189-94.  Back to cited text no. 2
Statistics Canada. CANSIM Database [Table 102] and 0561 - Leading Causes of Death, Total Population, by Age Group and Sex, Canada, Annual; 2009.  Back to cited text no. 3
Herath JC, Kalikias S, Phillips SM, Del Bigio MR. Traumatic and other non-natural childhood deaths in Manitoba, Canada: A retrospective autopsy analysis (1989-2010). Can J Public Health 2014;105:e103-8.  Back to cited text no. 4
Pediatric Death Review Committee and Deaths under Five Committee 2015 Annual Report. Office of the Chief Coroner of Ontario; February, 2016.  Back to cited text no. 5
Baker AM. Pediatric asphyxial deaths. In: Byard M, Collins B, Roger W, Kim A, editors. Forensic Pathology of Infancy and Childhood. New York, USA: Springer; 2014. p. 207-28.  Back to cited text no. 6
Byard RW. Accidental childhood death and the role of the pathologist. Pediatr Dev Pathol 2000;3:405-18.  Back to cited text no. 7
Sidebotham P, Fraser J, Fleming P, Ward-Platt M, Hain R. Patterns of child death in England and wales. Lancet 2014;384:904-14.  Back to cited text no. 8
Hutton JS, Gupta R, Gruber R, Berndsen J, DeWitt T, Ollberding NJ, et al. Randomized trial of a children's book versus brochures for safe sleep knowledge and adherence in a High-Risk population. Acad Pediatr 2017;17:879-86.  Back to cited text no. 9
Cyr C, Canadian Paediatric Society, Injury Prevention Committee. Preventing choking and suffocation in children. Paediatr Child Health 2012;17:91-4.  Back to cited text no. 10
Lapner P, McKay M, Howard A, Gardner B, German A, Letts M. Children in crashes: Mechanisms of injury and restraint systems. Can J Surg 2001;44:445-9.  Back to cited text no. 11
Pollanen MS, Smith CR, Chiasson DA, Cairns JT, Young J. Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990-1995. Forensic Sci Int 2002;126:101-4.  Back to cited text no. 12
King WK. Child abuse fatalities: Are we missing opportunities for intervention? Acad Emerg Med 2004;11:594.  Back to cited text no. 13
Ross AH, Juarez CA. A brief history of fatal child maltreatment and neglect. Forensic Sci Med Pathol 2014;10:413-22.  Back to cited text no. 14
Meyer FS, Trübner K, Schöpfer J, Zimmer G, Schmidt E, Püschel K, et al. Accidental mechanical asphyxia of children in Germany between 2000 and 2008. Int J Legal Med 2012;126:765-71.  Back to cited text no. 15
Sznajder M, Leduc S, Janvrin MP, Bonnin MH, Aegerter P, Baudier F, et al. Home delivery of an injury prevention kit for children in four French cities: A controlled randomized trial. Inj Prev 2003;9:261-5.  Back to cited text no. 16
Istre GR, McCoy M, Carlin DK, McClain J. Residential fire related deaths and injuries among children: Fireplay, smoke alarms, and prevention. Inj Prev 2002;8:128-32.  Back to cited text no. 17
Bamber AR, Mifsud W, Wolfe I, Cass H, Pryce J, Malone M, et al. Potentially preventable infant and child deaths identified at autopsy; findings and implications. Forensic Sci Med Pathol 2015;11:358-64.  Back to cited text no. 18


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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