Infant Strangulation

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Case 4

DISCUSSION

Case 2

Case 3

NEONATOLOGY SUPPLEMENT 1043

EXPERIENCE

AND

REASON-Briefly

Recorded

“In Medicine one must pay attention not to plausible theorizing but to experience and reason together. ...I agree that theorizing is to be approved. provided that it is based on facts,

and systematically makes its deductions from what is observed. ...But conclusions drawn

from unaided reason can hardly be serviceable; only those drawn from observed fact.”

Hippocrates: Precepts. (Short communications offactual material are published here. Comments and criticisms appear as Letters to the Editor.)

Infant Strangulation

The purpose of this article is to report four cases of infant strangulation that have taken place in Phoenix during the past five years and to review the literature on this subject. To our knowledge, only two articles have appeared previously in the English literature regarding this problem,12 whereas the subject has been treated rather extensively in European literature.12 Additionally, the United States Consumer

Prod-uct Safety Commission (USCPSC) has done

considerable work in this

CASE REPORTS Case 1

A 7-month-old white male was found suspended b the neck on a retaining string to a toy mobile. The child was leaning forward with the neck placed over the sagging string. He had only recently learned to pull himself up and had apparently fallen forward, draping his neck over the string. A linear mark was found over the anterior part of the neck. Following emergency resuscitation, he was maintained on a ventilator for two days before his death.

A 4-month-old white male infant was found in his crib

with his head caught between the crib bars and mattress. lie

was taken to a nearby hospital and pronounced dead on

arrival about 20 minutes after the incident. He was found to have ecchynioses on the crown of the head and posterior to the left ear.

A 7-month-old white male was found in his crib hanging between the mattress and side rails. A screw had come loose, allowing the side rail to move away from the mattress a distance of 1 1 cm. The infant’s chin was resting on the mattress, and the occiput was wedged against the side rails. He was pronounced dead on arrival at a nearby hospital. Abrasions were noted under the chin. There were 26-cm vertical indentations posterior to the ears biIateraIl’.

A 6-month-old black female was found by her father hanging by her neck between the mattress and side rails. The head was wedged at mattress level. She was pronounced dead on arrival at a nearby hospital about 15 minutes after

having been discovered. Depressed marks on the skin were noted on both sides of the occiput.

Autopsies were performed in each case and no other cause of death was found. There were no indications suggestive of child abuse.

Several important observations may be made

oh the basis of the foregoing cases and the reports of others.’2#{176} Death of the infant in case 1 in this report and three others13’ resulted from strings

or cords attached to a plaything. Toys are

comnionly suspended by a horizontal string across the top of the crib tied to the crossbars on each side. In two cases the string sagged in such a way that the child who had learned to stand could fall

forward over it. The children were thus

suspended by the throat. In another case a string was fastened across a bassinet. A child sat tip in the bassinet and slumped forward over the string. The USCPSC reports eight cases that involved ribbons or strings attached to a pacifier. Conimonly, the pacifier was hung around the infant’s neck by a ribbon that became entangled

on part of the crib such as a corner 21

Apparently, the relatively large head and poor

niuscle control characteristic of young children made it impossible for them to free themselves.

Kleint’s case involved a string tied to a teething ring that created a loop in which the infant’s neck was inadvertently caught. Kleint’s group suggests that no straps or strings should be

used in cribs. They propose the use of a wooden bar lengthwise across the top of the crib with any

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1044 INFANT STRANGULATION

toys suspended from short vertical bars attached to the horizontal piece. This arrangement avoids any loose strings or cords in the proximity of an

infant.

Three cases in the present report involved an

infant slipping between the mattress and side

rails. One crib was broken, allowing the side rail

to slip outward. In the present cases as well as Schollnieyer’s case, the body slipped through the space between the crib structures, but the head

became jamnied, thus resulting in strangulation.

In our case 2 and, perhaps in some others, one should consider the possibility that death was due to sudden infant death syndrome and the chil-dren, while dying, got into peculiar positions. Nevertheless, the most common situation in-volving strangulation is entrapment between the crib mattress and slats. The USCPSC reviewed

126 death certificates of crib-related deaths that

occurred in the United States between January 1970 and August 1972. In 50 of these, this space was large enough for the infant’s head to become lodged therein. In four of these cases a missing slat

was contributory. In one the mattress was folded and in another a slide rod securing the bottom of the crib was out of its hole.2’

Mattresses are priced separately from cribs and max’ not be purchased at the same time as the crib. The mattress may, therefore, not fit tightly against the headboard or crib sides. Current law

requires strict warnings on the crib’s headboard, assembly instructions, and packing carton

advis-ing the owner to use only a mattress that fits snuglv.22 Unfortunately, cribs manufactured

under the present law were not marketed until

earI 1974.

Other cases of infant strangulation have involved the crib side rails. In one instance the baby’s head “protruded between two of the side

bars and his body arched into the crib and then

out between two adjacent side bars with the legs and lower trunk dangling outside the bed. The weight of the child’s body was thus borne by his neck.” One crib was repaired with wires placed horizontally between the side rails so that the neck was compressed between them.’

Recorded in the work of the USCPSC are 42 cases of entrapment of an infant’s head between slats ili the sides or foot of a crib. It was noted that one child worked his body through a 1 1 .43-cm

opening at the head of the bed, and another died

as a result of slipping through slats that were 7.94

to 8.57 ciii apart. In three cases a slat was missing, and in another the child became entangled in a cord used to replace a missing slat. In another

instance the victim caught his neck between the

headboard and a vertical guide bar that had

become detached at the top. Two others involved loose or detached guide 21

A study done by the University of Michigan indicates that a distance of 6.03 cm between crib slats is appropriate. The study was done primarily of infants who were 2#{189}to 6#{189}months of age. It was believed that this group is most susceptible to slipping feet first through the slats. Information

from head measurements was used to make the foregoing recommendation, which has become law.2

Two cases have been reported in which infants were hanged to death by means of a protruding screw in a crib. The collar on the infants’ clothes had become entangled on the screw.4” It has been suggested that all screws should be placed on the outside of cribs to avoid proximity to the baby.’ The same should hold trite for nails or other fastening devices.

The dangers of strap-type restraining devices

used in cribs have been pointed out, especially by

European authors.5 ‘ L’Hirondel7 mentions two

fatalities that occurred in hospitals. Such restrain-ing devices are especially popular in some foreign

countries and involve straps usually attached to both sides of the crib. They are especially

dan-gerous when the straps become unattached on

one side, are too long, or are, applied too loosely. Although supposedly safer models have been proposed,3 some authors have discouraged their

use altogether.’5 Still another case3 involved a child who was tied in bed with a 1.3-m elastic band bound to the right ankle. The band became tangled around the neck. When the child climbed over the side of the crib, he was hanged by the neck and died.

Several deaths has been associated with items in close proximity to cribs. One child became wedged between two cribs placed side by side.3

Another child was suspended between the

crossbar of his crib and a chair.’” Mallach reported two nearly identical cases of children who tipped their cribs over as they attempted to clinib out. They were strangled as their cribs

clamped them against 2 A near death

was caused as a 13-month-old fell out of bed and hanged herself on the cord of a venetian blind.2 The USCPSC found eight deaths in which the child was wedged between the crib and a window sill and another between the crib and a

dress-21

Two episodes of fatal strangulation involved

high chairs.1 In one case the safety strap was not fastened and the child slid beneath the tray and caught her head between the seat and tray. In the

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NEONATOLOGY SUPPLEMENT 1045 other case the tray was not in place, but a single

safety strap was secured. The child slipped tinder

the loose strap and was found hanging by the

neck. Ostensibly, some of the same dangers exist

with high chair restraints as with crib restraints.

SUMMARY

All the tragedies described in this paper were avoidable and all involved healthy children. The

ages ranged from 17 days to 2 years, bitt the

majority were 2 to 9 months. In this age range

children become increasingly agile bitt may lack

the ability to extricate themselves from

poten-tially dangerous situations. The head is large,

relative to the body, and may become entrapped

if a child’s body slides through an opening. Cribs

and high chairs should be constructed with this

concept in niind. There should be no existing or

potential space large enough for the baby’s body

to slide through. No screws or nails should

protrude on which a baby could become

suspended. Repairs may be dangerous and must

be done carefully; however, cribs and high chairs

must be kept in good condition, especially in

regard to loose parts. Homemade items may be

dangerous. Restraining devices have been

respon-sible for many fatalities as described and should

generally be avoided. Ribbons and strings used to

hang a pacifier around a child’s neck should be

strictly avoided as should strings and cords

attached to playthings in the crib.

Legislation has been passed which addresses

itself to the problems of distance between crib

slats and space between the mattress and side

iails.2224 We commend the work butt point out

that cribs manufactured before the present law

becanie active will be in use for many years. A

crib safety education campaign has been

launched that provides excellent advice on

purchasing new cribs and reconditioning old

ones.5 We only regret that the information has

tiot been further disseminated. Infant

strangula-tion is a poorly publicized problem that warrants

attention of physicians, parents, and

nianutfac-turers to help avoid further needless tragedies.

PAUL S. BERGESON, M.D.

LUCY S. HERNRIED, M.D.

PAUL L. SONNTAG, M.D. Department of Pediatrics, Good Samaritan Hospital

1 03.3 East McDowell Road Phoenix, Arizona 85006

ADDRESS FOR REPRINTS: (P.S.B.) Good Samaritan

Hospital, 1033 East McDowell Road, Phoenix. Arizona 85006.

REFERENCES

1. Greendyke RM: Accidental strangulations in infancy. Pediatrics :36:275, 1965.

2. Keniper M, Gibson 5: Accidental hanging with

recov-ery. A report of two cases in children. J Pediatr

26:401, 1945.

3. Kleint \V, Gruner G, Hupfer I: Selbsterdrosselung eines

Sauglings durch Spielzeug-Aufhangeband. Dtsch Gesund 21:1125, 1966.

4. Krahl P: Selbsterdrosselung durch Kinderrassel. Munch

Med Wochenschr 102:1281, 1960.

5. Schollmeyer W: Verhinderung von Strangulationstodes-fallen bei Sauglingen und Kleinkindern. Z Aerztl Fortbild (Jena) 60:368, 1966.

6. L’Hirondel J: On the safety of the infant in crib and high

chairs. Pediatrie 15:595, 1960.

7. L’Hirondel J: La s#{233}curit#{233}de l’enfant asi berceau et dans les chaises hautes: Ia strangulation par les moyens de contention et les chutes. Rev Hg Med Soc 9:653, 1961.

8. Zachau-Christensen B, Jensen J: Death by suffocation in

children during the first three years of life. With

special reference to suffocation in children’s

harnesses. Ugeskr Laeger 123:1049, 1961.

9. Bundschuh C: Uber zufalliges Erdrosselii l)ei Kleinkin-dern. Das Med Bud 6:30, 1963.

10. Duimond G, D#{233}robert L: Strangulation par attache b#{233}b#{233}.Arm Med Leg 42:475, 1962.

11. Elbel H, Schulte M: Uber die Gefahrdung des Kindes

dutch Kinderschutzgurtel. Dtsch Zschr Gerichtl Med 36:210, 1942.

12. Fog J: Wieder em Fall von Erwurgen durch Kinderz#{252}-gel. Ugeskr Laeger 86:40, 739, 1924.

13. Folger C: T#{246}dliche Unglucksfalle bei Sauglingen tind Kleinkindern durch Selbststrangulation . Krim

13:243, 1959.

14. Hallermann \V, Hehmann-Ch rist: Uber eigenartige Strangulations-befunde. Dtsch Asch r Gerich tI Med

38:97, 1943-44.

15. Lyss S: tJber zufallige Erdrosselung von S#{228}uglingen. Munch Med Wochenschr 85:1708, 1938.

16. Marcusson H, Oehmisch W: Der t#{246}dliche Unfall im Kindes- illid Jugendalter in der Deutschen

Demo-kratischen Republik im Jahre 1962. Dtsch Gesulid

\Ved 19:1038, 1964.

17. Muller-Rudat D: Uber t#{246}dliche Unf#{228}lleim Sauglinsalter.

z Aerztl Fortbild (Jena) 59:159, 1965.

18. Weh L, Neumann S. Ocklitz Fl W, et al: Padiatrische Arbeitsrichtlinien: 39. Unf#{228}lle in Krippen tiiid

Heimen. Z Aerztl Fortbild (Jena) 64:988, 1970. 19. Hofmann-Haberda: Lehrbuch der gerichtlichen

Medi-zin. 11 Aufi, S 704, Berlin-Wien, Urban & Schwar-zenberg, 1927.

20. Mallach HJ: Uber einen ungewohnlichen

Strangtila-tionsmechanisnu,s nu Kindesalter. Beitr Gerichtl

Med 2:3:21:3, 1964.

21. Nelson T: Flazard Analysis of Injuries Relating to Cribs. %Vashington, United States Consuiiier Product Safety Commission Bureau of Epidemiology, 1975, pp 12-25.

22. Dunn SE: Title 16-Commercial Practices. Consumer

Product Safety Comm ission. Subchapter C-Fed-eral Hazardous Substances Act Regulations. Part

1500-hazardous Substances and Articles; Admiiiis-tration and Enforcement Regulations. Part

1508-Requirements for Full-Size Baby Cribs.

Banning of Hazardous Full-Sized Baby Cribs;

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1046 ENDOTRACHEAL INTUBATION

Establishment of Safety Requirements. Federal

Register, :38:32129, November 21, 1973.

23. Dunn SE: Title 16-Commercial Practices. Consumer Product Safety Commission ( 16 CFR Parts 1500. 1509) Non-Full-Size Baby Cribs. Banning of

Hazardous Articles and Establishment of Safety Requirements. Federal Register, 40:20293, May 9,

1975.

24. Nelson T: Hazard Analysis of Injuries Relating to Cribs.

Washington, United States Consunier Product

Safety Commission Bureau of Epidemiolog, 1975, pp 60-66.

25. Crib Safet-Keep Them on the Safe Side. Washington,

Ijliited States Consumer Product Safety Comm is-sion, 1974.

Oxygen

Supplement

During

Endotracheal

Intubation

of the

Infant

Endotracheal intubation is indicated for main-taming an efficient airway, for preventing aspira-tion and permitting pulmonary toilet, and for

prolonged administration of mechanical

ventila-tiOli or general anesthesia for many types of

.operations.’ Larngoscop and intubation may

result in ilijur to the lips, gums, tongue, nasal

passage, larynx, or trachea. Additional

complica-tions include niediastinal and subcutaneous emphysema and puenmothorax. : These

complica-tiOlis can l)e niinimized if hypoxia can be

prevented and larngoscop is performed in an

unhurried ilianner.

Patients who require a high ambient oxygen

concentration in order to maintain an adequate

Po2 usually react rapidly to an interruption of the

Fir.. 1. French No. 8 suctioii catheter taped to the top of a size 0 Miller blade.

oxygen suppI by developing bradycardia and

hypoxia. This frequently occurs during

conven-tional larngoscop and endotracheal intubation

without oxygen supplement. Infants, with their

smaller oxygen reserve, are more vulnerable than

older children and adults. It has been reported

that a combination of vagal stimulation caused by

endotracheal intuibation and hypoxia often results

iii cardiac

To avoid these untoward effects during

laryn-goscopy, we have made a simple modification of a

standard larngoscope which allows delivery of

supplemental oxygen continuously during

intuba-tion. A patient who is breathing spontaneously

and is exposed to this higher ambient oxygen can

maintain better oxygenation. The efficacy of this

niodification was demonstrated by a continuous

record of the transcutaneous Po2 obtained during

intubation.

METHOD

The niodification consists of taping a French No. 8 suction catheter to the top of a size 0 Miller

larngoscope blade (Fig. 1). The catheter is

connected to a flowmeter with 2 liters of oxygen

per minute flowing into the pharnx during

larngoscop. The position of the patient and

larngoscopic technique have been previously

r2

Au appropriately sized plastic endotracheal

tithe is prepared with the estimated length (from

naris to midpoint of trachea) determined

according to crown-heel length3 and marked with

a piece of tape. The distal end of the tube is

lubricated with a water-soluble surgical lubricant. Before intubation the ambient oxygen

concentra-tion is raised, and the nose and mouth are

suictioned thoroughly. The tube is introduced into

the nose with a gentle steady pressure with the

tube concavity downward and with the tube kept

snug against the floor of the nose. An alligator

clamp is usually used as a laryngeal forceps to guide the endotracheal tube into the trachea. If

cyanosis occurs during the procedure the infant

can be manually ventilated with a self-inflating

bag via the endotracheal tube provided the tip is

confirmed to be in the oropharynx dutring

laryn-goscop. Oxygen escape through the mouth

during the inspirator phase is prevented by

closing the mouth.

RESULTS

AND DISCUSSION

Figure 2 shows a continuous tracing of an infant’s Po2 during intubation recorded with a

transcutaneous Po2 electrode. The patient weighed 1,786 gm and was born after a 34-week

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1977;59;1043

Pediatrics

Paul S. Bergeson, Lucy S. Hernried and Paul L. Sonntag