NSW child deaths are at the lowest level since statistics started being reported.
But there are concerns that too many children are taking their own lives and being unnecessarily killed on quad bikes, motorbikes and go-karts.
The annual review into child deaths in the state, released on Wednesday, found that of the 493 kids who died in 2012, 357 were due to natural causes.
While those figures are the lowest since recording began in 1996, NSW Ombudsman Bruce Barbour said there had been no apparent change in the rate of suicides.
"It is very disappointing that yet again there was quite a large number," he told AAP.
Of the 16 young people who committed suicide in 2012, 11 had been reported to community services as being at risk of harm or significant harm within three years prior to their deaths.
The report also states that the majority had experienced some stress associated with schooling, including bullying, behavioural problems, academic failure and a history of suspension.
A total of 245 children have taken their own lives in the last 15 years.
Another concern was the number of children dying in off-road vehicle accidents, Mr Barbour said.
In the decade to 2012, 25 children had been killed in off-road accidents involving quad bikes, motorcycles, side-by-side vehicles, tractors and go-karts.
"Every single death we reviewed was preventable," he said, with children not wearing a helmet or being without adult supervision.
Some of the children were aged under 10.
Six children were killed riding quad bikes.
The report has recommended that the Department of Premier and Cabinet should consider a number of measures to reduce the off-road deaths, including implementing regulation and licensing of vehicles on private property.
* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Kids Helpline 1800 55 1800.
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