Of the 131 infant deaths studied by Ontario's Office of the Chief Coroner last year, 37 per cent were found in unsafe sleeping environments, according the annual report of the Paediatric Death Review Committee and Deaths Under Five Committee.
The children died with no findings on autopsy, but were in an unsafe sleep environment, said Dr. Dirk Huyer, the committees' chairman and the regional coroner for Guelph, Ont.
"What we don't know is whether that directly caused the death, or whether it's specifically associated with it," he said.
"But we do know ... epidemiologically and through study that children have a greater risk of dying in unsafe sleeping environments."
Infants should sleep on their back in a crib, with nothing else in the crib except for a small blanket, he said.
Given that the rate hasn't changed in recent years, they've started to refine their approach in these deaths, he said. They've been collecting more data since Jan. 1 to see if there are certain risk factors associated with them, he said.
The additional information collected includes details of how the baby was sleeping and positioned, the temperature of the room and whether they were sleeping with a parent or adult, Huyer said. They're also trying to collect more information about the mother's pregnancy and the family's social characteristics.
"Hopefully that will allow us to provide more targeted prevention strategies in the area of sudden infant deaths in sleep environments," he said.
The report, obtained by The Canadian Press, also notes that the needs of critically ill children aren't met by the current Ontario transport system.
It caters very well to older children, but doesn't meet the unique needs of infants and younger kids, it said.
"The majority of the transports in this age group are for patients with acute viral respiratory illness or upper airway problems which require specialized skills in airway management and vascular access," the report said.
Toronto's Hospital for Sick Children's neonatal transport team, which cares for children up to age three, is a model that could be adopted across the province, it said.
The report also looks at youth suicide and whether some are linked to sexual orientation or gender identity issues. Youth who identify as gay, bisexual, transsexual or other are more vulnerable to suicidal behaviour than their heterosexual counterparts, the report said.
It's looking at recommendations to include questions of sexual orientation and gender identity when investigating deaths.
It could enhance their understanding of whether sexual or gender identity issues play a part in youth suicides and help them prevent such deaths, said Huyer.
The two committees are among seven that report to the Chief Coroner of Ontario. They assist the chief coroner's office in the investigation and review of deaths of children, as well as make recommendations to help prevent deaths.
The Deaths Under Five Committee reviews all deaths investigated by coroners involving kids under the age of five. The Paediatric Death Review Committee reviews cases with child welfare involvement and the deaths of children where issues or concerns have been identified pertaining to the medical diagnosis or provision of care.