-case reports * etudes der'so

Fatal asphyxations in children

involving drawstrings on clothing

Jackie Petruk, RN, BScN; Erima Shields, MPH;Garnet E. Cummings, MD, MSc, FRCPC, FACEP; Louis Hugo Francescutti, MD, PhD, MPH

Injuries account for more deaths and hospital admissionsamong children and adolescents than all diseases com-bined. The authors report two deaths by asphyxiation thatresulted from drawstrings on the children's clothing be-coming entangled on slides. Although such incidents arenot common, they are preventable. The authors urgephysicians to counsel parents and guardians to removedrawstrings from children's clothing, and they call uponthe government and the clothing industry to work towardimproving the safety standards for the design, manufac-ture and importation of children's clothing and banningthe sale of children's clothing with drawstrings in Canada.In addition, they provide several resources for readers in-terested in helping reduce playground hazards in theircommunities.

In Canada, injuries account for more deaths amongchildren and adolescents than all other causes com-

bined.' Most deaths that result from injuries are deemedto be preventable.2 Many incidents of minor and majorinjury occur in playgrounds and on play equipment.Most of these injuries are due to falls and result in lacer-ations, abrasions, contusions, sprains and fractures.3Head injuries account for about 75% of deaths relatedto playground falls.4 Although incidents involving cloth-ing are far less common, they can cause major traumaand death, such as burns from flammable materials andstrangulation from entanglement of clotiing.5 6The Product Safety Bureau of the Health Protection

Branch, Health Canada, reported 14 cases involvingchildren 2 to 11 years old who died from injuries at play-grounds between 1982 and 1993.6 In seven cases thechild's clothing or drawstring got caught on playground

Les blessures sont la cause de plus de deces et d'admis-sions k l'hopital chez les enfants et les adolescents quetoutes les autres maladies ensemble. Les auteurs signalentle cas de deux enfants qui sont morts par asphyxie lorsquele cordon de serrage de leur vetement s'est emmele pen-dant qu'ils s'amusaient sur des glissoires. Bien que de telsincidents soient rares, on peut les eviter. Les auteurs in-citent les medecins 'a conseiller aux parents et aux gardiensd'enlever les cordons de serrage des vetements de leursenfants et ils invitent le gouvernement et l'industrie duvetement a renforcer les normes de scurite dans la con-ception, la fabrication et l'importation de vetements pourenfants et 'a interdire la vente de vetements pour enfantsqui comportent ce genre de cordon. En outre, ils offrentplusieurs ressources 'a ceux qui s'int6ressent a re6duire lesdangers associes aux terrains de jeu dans leur collectivit6.

equipment or a fence. The US Consumer ProductSafety Commission reported 276 deaths related to play-ground equipment between 1973 and 1989.4 Strangula-tion was the cause in 131 cases, at least 25 of which in-volved clothing. Drawstrings on children's jackets andsweatshirts, hooded T-shirts and capes that caught onplayground equipment, an escalator, a fence, cribs andother items were associated with at least 12 deaths and27 near strangulations in the United States between1985 and 1994.7 In Sweden, of 73 cases of accidental me-chanical asphyxiation during a 10-year period, 5 in-volved clothing and children less than 16 years old.8We describe two cases of fatal asphyxiation involving

children that occurred within 4 months of each other. Inboth cases drawstrings were caught on a slide. One oc-curred in a day-care centre and the other at a publicplayground.

Ms. Petruk is with Alberta SAFE KIDS, Children's Health Centre, Capital Health Authority, Edmonton, Alta. Drs. Francescutti and Cummings are with the Department ofEmergency Medicine and Trauma Centre at the Royal Alexandra Hospital, Edmonton, Alta. Ms. Shields was with Alberta SAFE KIDS and is now with the Office ofHealth Promotion, Virginia Department of Health, Richmond, Va.

Reprint requests to: Dr. Louis Hugo Francescutti, Department of Public Health Sciences, University ofAlberta, CSB 13-106 J, Edmonton AB T6G 2C3; fax 403 492-0364

© 1996 Canadian Medical Association (text and abstract/r6sum6)

CAN MED ASSOC J * NOV. 15, 1996; 155 (10).- For prescribing information see page 1498

Case reports

Case 1

A 2%-year-old girl was playing on a slide at a day-carecentre. Although the required number of supervisorswere present in the play area, no one noticed when thetoggle of a drawstring on the hood of the girl's jacketwas caught in a V-shaped gap at the top of the slide. Thegap had apparently been created from fatigue that sepa-rated two pieces of the slide at a joining point. Theweight of the child's body pulled the drawstring tautlyaround her neck. When the supervisors noticed her,they freed her immediately and initiated cardiopul-monary resuscitation (CPR). Upon arrival, the paramed-ics found that the girl was unconscious and markedlycyanotic and that her airway was blocked by vomitus.

At a local hospital the girl was further resuscitatedand stabilized and then transferred to a regional pedi-atric intensive care unit. Despite medical efforts she didnot regain consciousness and died 3 days after admis-sion. The cause of death was reported as asphyxia bystrangulation.

Case 2

Four months later an almost identical, unwitnessedincident occurred involving a 6-year-old girl at a publicplayground. The drawstring on the hood of her garmentwas caught at the top of a slide, between the support railand the handrail. She was removed from the slide by aneighbour. She had no pulse and was not breathing.Mouth-to-mouth resuscitation was attempted by by-standers. The girl was transported by ambulance to a lo-cal hospital, resuscitated and placed on life support for 2days but subsequently died. The cause of death was re-ported as asphyxia by strangulation.

Comments

Multiple factors (clotiing design, equipment fatigue,infrequent equipment maintenance, lack of supervision,delayed initiation of CPR) contributed to the two deathsdescribed here. To prevent such deaths in other children,implementation ofthe following measures is required:* Legislated standards that ban the use of drawstrings

and toggles on children's clotiing.* Improved design of playground equipment, with

eradication of catch points and fatigue hazards.* Improved maintenance schedules for checking and

correcting equipment hazards.* Increased active supervision of children by care-

givers.* Earlier intervention with CPR.

In reviewing the Canadian literature we found that,aside from flammability standards, there are no regu-

lated standards to address safety in the design of chil-dren's clothing. In 1993 the Product Safety Bureau ofHealth Canada informed clothing manufacturers and re-tailers of the hazards of drawstrings on children's cloth-ing and encouraged voluntary changes. This positivestep was the catalyst for several manufacturers to makechanges in their garment designs. However, there is cur-rently no process to monitor industry compliance.The importation of clothing manufactured abroad is

an additional and far-reaching problem. Many importedgarments are inexpensive and thus popular with con-sumers. Monitoring the activities of importers is a hugeand complex challenge.

After being made aware of several drawstring-relateddeaths, in 1994 the Canadian Children's Apparel Manu-facturers' Association (CAMA) urged its 80 members toremove drawstrings from children's clothing. Severalmajor manufacturers have complied. According toCAMA Executive Director Murray Schwartz, a con-certed effort by all stakeholders to publicize the dangersof drawstrings and toggles is needed to help educateconsumers (personal communication, 1996). Redesign-ing the items should be a simple process for manufactur-ers- consumers are likely not concerned with the lackof drawstrings as long as the hoods are fimctional.

Although some clothing hazards are difficult to cor-rect without altering function or aesthetic appeal, this isnot so for drawstrings. On many children's garmentsdrawstrings are rarely used for their intended purposeand have often become a decorative item. Aside fromentanglement in play equipment, fences, vehicle doorsand bicycle spokes, drawstrings and toggles have beenresponsible for injuries from falls and have been chewedand inhaled.6'9

In July 1994 the US Consumer Product Safety Com-mission announced a major cooperative effort withclothing manufacturers and retailers to remove draw-strings from the hoods and necks of children's clothing.7In 1976 British safety advocates promoted the enact-ment of a statute banning the sale of children's clothingwith drawstrings.'0 Although the regulation is far fromcomprehensive, there apparently have been no knowndeaths from drawstring-related injuries since its enact-ment (Dr. Sara Levene, pediatrician and epidemiologist,Child Accident Prevention Trust, London, England:personal communication, 1996).

Injury prevention

Government agencies, health care professionals,clothing manufacturers, the media and consumers allhave a role to play in preventing drawstring-related in-juries. Given the present deregulatory mood of govern-ments and the fact that changing regulations is slow,cumbersome and expensive, immediate benefit can befound in education and preventive counselling. Physi-

1418 CAN MED ASSOC J * 15 NOV. 1996; 155 (10)

cians and other health care workers have an importantrole to play in educating patients and increasing thepublic's awareness of hazards. Recent literature supportsthe effectiveness of physician counselling in injury pre-vention."'2 Physicians and related professional organiza-tions have been powerful in creating positive changes inthe market place. The elimination of baby walkers andthe improvement in flammability standards for children'ssleepwear are two examples.

Multiple factors were involved in the two deaths wehave described here. In seeking a solution it will take amultifaceted approach- through technology (redesignof clotiing and play equipment), education and aware-ness (of clothing manufacturers, retailers, health careprofessionals, the media and consumers) and regulation(voluntary or legislated standards)- before real changecan occur and be sustained over time.We suggest that health care professionals take the fol-

lowing steps to help prevent injuries associated withplayground equipment and children's clothing:* Counsel parents and guardians to remove draw-

strings from existing children's clotfiing and to pur-chase only clothing without drawstrings.

Tid I: Reors fo th prvnino lyrud:jreRemoving Playground Hazards for Our Children's Sake(Alberta SAFE KIDS and Alberta Medical Association, Edmonton, 1994)A user-friendly community resource (booklet and slides) that outlinesthe process of improving playground safety. Available from AlbertaSAFE KIDS, 4100, EDC, 8308-114 St., Edmonton AB T6G 2V2;tel. 403 492-9997

A Guideline on Children's Playspaces and Equipment(Canadian Standards Association, Etobicoke, Ont., 1990. Productdesignation no. CAN/CSA-Z-614-M90)A technical document that defines minimal voluntary standardsacceptable in the design and setup of playgrounds and playgroundequipment. Available from the Canadian Standards Association,178 Rexdale Blvd., Etobicoke ON M9W 1 R3; tel: 416 747-4000

Study ofConfonnity of Children's Playspaces and Equipment toVoluntary Canadian Standard CSA A614-M90(Montreal Public Health Unit, Montreal, 1993)Report of the results of research into injuries sustained on playgroundequipment in the Montreal area and conformity of playgrounds tothe Canadian standards. Available from the Montreal Public HealthUnit, 4835 Christophe Colomb St., Montreal QC H2J 3G8; tel. 514528-2400, ext. 3362 (Dominique Lesage)

When Child's Play Is Adult Business(Canadian Institute of Child Health, Ottawa, 1987)A booklet outlining how to guard against the inherent dangers ofplaygrounds. Available from the Canadian Institute of Child Health,512-885 Meadowlands Dr., Ottawa ON K2C 3N2; tel. 613 224-4144

.. ~~~~~~~~~~~~~~~~...

* Counsel parents and caregivers about the hazards ofplay equipment and playgrounds and stress the im-portance of active supervision.

* Encourage, support and work with the appropriateorganizations (e.g., the Product Safety Bureau,Health Protection Branch, Health Canada, AL0301B2, Ottawa ON KlAOK9; and the Children'sApparel Manufacturers' Association, Decarie Square,3110-6900 Decarie Blvd., Montreal QC H3X 2T8)to address the issue of lack of safety standards forchildren's clothing and to take positive steps to eradi-cate unnecessary hazards.

* Use available resource publications (Table 1) to workwith communities interested in preventing play-ground injuries.

* Work with manufacturers of playground equipmentto enhance their knowledge of hazards to children.Preventing childhood injuries requires the cooperative

efforts of many individuals and organizations. Westrongly urge physicians and other health care providersand their professional associations to act immediatelyto help prevent further needless injuries and deaths ofchildren.

1. Mackenzie SG. Childhood injury: deaths and hospitalizations in Canada.CHIRPP News [Canadian Hospitals Injury Reporting and Prevention Pro-gram News, Laboratory Centre for Disease Control, Health Canada]1994;Mar:4-5.

2. Rivara FP. Traumatic deaths of children in the United States: currently avail-able prevention strategies. Pediatrisa 1985;75:456-62.

3. Playground, amusement park and outdoor household hazards. In: Committeeon Accident Prevention, American Academy of Pediatrics. Injuy control forcbildren andyoutb. Elk Grove Village (IL): American Academy of Pediatrics,1987:194-201.

4. Tinswoth DK, Kramer JT. Playground equipment related inuries and deaths.Washington: Division of Hazard Analysis, Epidemiology Directorate, USConsumer Product Safety Commission, April 1990:1-31.

5. Stanwick RS. Clothing burns in Canadian children. Can Med Assoc J1985;132.1 143-9.

6. Deaths involving plyground equipment. Ottawa: Product Safety AccidentalDeath Systems, Product Safety Bureau, Health Protection Branch, HealthCanada, 1993.

7. Media release. Washington: US Consumer Product Safety Commission, 7July 1994. Release no. 94-103.

8. Flobecker P, Ottosson J, Johansson L, et al. Accidental deaths from asphyxia:a 10-year retrospective study from Sweden. Am i Forensic Med Patbol1993;14:74-9.

9. Levene S. The safety of children's cotbing. London (UK): Child Accident Pre-vention Trust, 1993.

10. Cbildren's Clotbing (Hood Cords) Regultions 1976, S.I. 1976/2.11. Bass JL, Christoffel OK, Widome M, et al. Childhood injury prevention

counseling in primary care settings: a critical review of the literature. Pedi-atric 1993;92:544-50.

12. Smith GS. The physician's role in injury prevention. J Gen Intern Med1990;5:S67-73.

CAN MED ASSOC J * NOV. 15, 1996; 155 (1 0) 1419