At least 30 babies have died of asphyxiation because they were placed in unsafe sleeping arrangements in the last five years, a coroner has found.
Another 19 babies who slept in an unsafe environment died in the same period, though their cause of death was not formally established.
Chief coroner Neil MacLean has released a recap of coronial findings into cases of Sudden Unexpected Death in Infancy (SUDI).
It shows there were 163 infant deaths attributed to SUDI since July 2007.
Unsafe sleeping, prone sleeping or sleeping with another person in the bed were highlighted as major preventable causes of death among infants.
Judge MacLean said the 30 babies who died of asphyxiation and many of the 19 others who died while in an unsafe sleeping environment could have been saved.
"This is a heartbreaking and unfortunately all too regular issue that comes before coroners.
"It is also a tragedy that, in many cases, these babies would still be alive if people had just followed established safe sleeping practices."
The report catalogued recommendations into preventing infant deaths in unsafe sleeping environments made in 41 coronial cases between October and December last year.
In one finding from December 2011, a seven-week-old boy died after going to sleep on an adult sofa bed shared with his mother and one-year-old sister.
Several blankets were pulled down over him and his head was on an adult pillow.
Coroners said the death and others highlighted the need for parents to be given "very explicit" messages about safe sleeping.
That included advice about the risk of lying babies on adult pillows in their first year of life.
Another case saw a six-week-old baby die after going to sleep in a stroller pram placed on a 45 degree angle.
A coroner found strollers were not an appropriate sleeping environment for young infants if placed on an angle.
One finding urged Auckland District Health Board to strengthen the advice it gives out about the risk of propping up babies with esophageal reflux on an adult pillow.
A second recap into deaths related to butane inhalation or "huffing" will be out in the coming weeks, Judge MacLean said.
- Herald OnlineBy Hayden Donnell Email Hayden