terested in helping reduce playground hazards in their communities. In Canada, injuries account for more deaths among children and adolescents than all other ...
-case reports
*
etudes de r's o
Fatal asphyxations
children involving drawstrings on clothing in
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 admissions among children and adolescents than all diseases combined. The authors report two deaths by asphyxiation that resulted from drawstrings on the children's clothing becoming entangled on slides. Although such incidents are not common, they are preventable. The authors urge physicians to counsel parents and guardians to remove drawstrings from children's clothing, and they call upon the government and the clothing industry to work toward improving the safety standards for the design, manufacture and importation of children's clothing and banning the sale of children's clothing with drawstrings in Canada. In addition, they provide several resources for readers interested in helping reduce playground hazards in their communities.
In Canada, injuries account for more deaths among children and adolescents than all other causes combined.' Most deaths that result from injuries are deemed to be preventable.2 Many incidents of minor and major injury occur in playgrounds and on play equipment. Most of these injuries are due to falls and result in lacerations, abrasions, contusions, sprains and fractures.3 Head injuries account for about 75% of deaths related to playground falls.4 Although incidents involving clothing are far less common, they can cause major trauma and death, such as burns from flammable materials and strangulation from entanglement of clotiing.5 6 The Product Safety Bureau of the Health Protection Branch, Health Canada, reported 14 cases involving children 2 to 11 years old who died from injuries at playgrounds between 1982 and 1993.6 In seven cases the child's clothing or drawstring got caught on playground
Les blessures sont la cause de plus de deces et d'admissions k l'hopital chez les enfants et les adolescents que toutes les autres maladies ensemble. Les auteurs signalent le cas de deux enfants qui sont morts par asphyxie lorsque le cordon de serrage de leur vetement s'est emmele pendant qu'ils s'amusaient sur des glissoires. Bien que de tels incidents soient rares, on peut les eviter. Les auteurs incitent les medecins 'a conseiller aux parents et aux gardiens d'enlever les cordons de serrage des vetements de leurs enfants et ils invitent le gouvernement et l'industrie du vetement a renforcer les normes de scurite dans la conception, la fabrication et l'importation de vetements pour enfants et 'a interdire la vente de vetements pour enfants qui comportent ce genre de cordon. En outre, ils offrent
plusieurs ressources 'a ceux qui s'int6ressent a re6duire les dangers associes aux terrains de jeu dans leur collectivit6. equipment or a fence. The US Consumer Product Safety Commission reported 276 deaths related to playground equipment between 1973 and 1989.4 Strangulation was the cause in 131 cases, at least 25 of which involved clothing. Drawstrings on children's jackets and sweatshirts, hooded T-shirts and capes that caught on playground equipment, an escalator, a fence, cribs and other items were associated with at least 12 deaths and 27 near strangulations in the United States between 1985 and 1994.7 In Sweden, of 73 cases of accidental mechanical asphyxiation during a 10-year period, 5 involved clothing and children less than 16 years old.8 We describe two cases of fatal asphyxiation involving children that occurred within 4 months of each other. In both cases drawstrings were caught on a slide. One occurred in a day-care centre and the other at a public playground.
Ms. Petruk is with Alberta SAFE KIDS, Children's Health Centre, Capital Health Authority, Edmonton, Alta. Drs. Francescutti and Cummings are with the Department of Emergency Medicine and Trauma Centre at the Royal Alexandra Hospital, Edmonton, Alta. Ms. Shields was with Alberta SAFE KIDS and is now with the Office of Health Promotion, Virginia Department of Health, Richmond, Va.
Reprint requests to: Dr. Louis Hugo Francescutti, Department of Public Health Sciences, University of Alberta, CSB 13-106 J, Edmonton AB T6G 2C3; fax 403 492-0364 © 1996 Canadian Medical Association (text and abstract/r6sum6) .-
For
prescribing information see page 1498
CAN MED ASSOC J * NOV. 15, 1996; 155 (10)
Case reports Case 1 A 2%-year-old girl was playing on a slide at a day-care centre. Although the required number of supervisors were present in the play area, no one noticed when the toggle of a drawstring on the hood of the girl's jacket was caught in a V-shaped gap at the top of the slide. The gap had apparently been created from fatigue that separated two pieces of the slide at a joining point. The weight of the child's body pulled the drawstring tautly around her neck. When the supervisors noticed her, they freed her immediately and initiated cardiopulmonary resuscitation (CPR). Upon arrival, the paramedics found that the girl was unconscious and markedly cyanotic and that her airway was blocked by vomitus. At a local hospital the girl was further resuscitated and stabilized and then transferred to a regional pediatric intensive care unit. Despite medical efforts she did not regain consciousness and died 3 days after admission. The cause of death was reported as asphyxia by strangulation.
Case 2 Four months later an almost identical, unwitnessed incident occurred involving a 6-year-old girl at a public playground. The drawstring on the hood of her garment was caught at the top of a slide, between the support rail and the handrail. She was removed from the slide by a neighbour. She had no pulse and was not breathing. Mouth-to-mouth resuscitation was attempted by bystanders. The girl was transported by ambulance to a local hospital, resuscitated and placed on life support for 2 days but subsequently died. The cause of death was reported as asphyxia by strangulation.
Comments
lated standards to address safety in the design of children's clothing. In 1993 the Product Safety Bureau of Health Canada informed clothing manufacturers and retailers of the hazards of drawstrings on children's clothing and encouraged voluntary changes. This positive step was the catalyst for several manufacturers to make changes in their garment designs. However, there is currently no process to monitor industry compliance. The importation of clothing manufactured abroad is an additional and far-reaching problem. Many imported garments are inexpensive and thus popular with consumers. Monitoring the activities of importers is a huge and complex challenge. After being made aware of several drawstring-related deaths, in 1994 the Canadian Children's Apparel Manufacturers' Association (CAMA) urged its 80 members to remove drawstrings from children's clothing. Several major manufacturers have complied. According to CAMA Executive Director Murray Schwartz, a concerted effort by all stakeholders to publicize the dangers of drawstrings and toggles is needed to help educate consumers (personal communication, 1996). Redesigning the items should be a simple process for manufacturers - consumers are likely not concerned with the lack of drawstrings as long as the hoods are fimctional. Although some clothing hazards are difficult to correct without altering function or aesthetic appeal, this is not so for drawstrings. On many children's garments drawstrings are rarely used for their intended purpose and have often become a decorative item. Aside from entanglement in play equipment, fences, vehicle doors and bicycle spokes, drawstrings and toggles have been responsible for injuries from falls and have been chewed and inhaled.6'9 In July 1994 the US Consumer Product Safety Commission announced a major cooperative effort with clothing manufacturers and retailers to remove drawstrings from the hoods and necks of children's clothing.7 In 1976 British safety advocates promoted the enactment of a statute banning the sale of children's clothing with drawstrings.'0 Although the regulation is far from comprehensive, there apparently have been no known deaths from drawstring-related injuries since its enactment (Dr. Sara Levene, pediatrician and epidemiologist, Child Accident Prevention Trust, London, England: personal communication, 1996).
Multiple factors (clotiing design, equipment fatigue, infrequent equipment maintenance, lack of supervision, delayed initiation of CPR) contributed to the two deaths described 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 Injury prevention eradication of catch points and fatigue hazards. * Improved maintenance schedules for checking and Government agencies, health care professionals, correcting equipment hazards. clothing manufacturers, the media and consumers all * Increased active supervision of children by care- have a role to play in preventing drawstring-related ingivers. juries. Given the present deregulatory mood of govern* Earlier intervention with CPR. ments and the fact that changing regulations is slow, In reviewing the Canadian literature we found that, cumbersome and expensive, immediate benefit can be aside from flammability standards, there are no regu- found in education and preventive counselling. Physi1418
CAN MED ASSOC J * 15 NOV. 1996; 155 (10)
cians and other health care workers have an important role to play in educating patients and increasing the public's awareness of hazards. Recent literature supports the effectiveness of physician counselling in injury prevention."'2 Physicians and related professional organizations have been powerful in creating positive changes in the market place. The elimination of baby walkers and the improvement in flammability standards for children's sleepwear are two examples. Multiple factors were involved in the two deaths we have described here. In seeking a solution it will take a multifaceted approach - through technology (redesign of clotiing and play equipment), education and awareness (of clothing manufacturers, retailers, health care professionals, the media and consumers) and regulation (voluntary or legislated standards) - before real change can occur and be sustained over time. We suggest that health care professionals take the following steps to help prevent injuries associated with playground equipment and children's clothing: * Counsel parents and guardians to remove drawstrings from existing children's clotfiing and to purchase only clothing without drawstrings. fo th prvnino lyrud:jre Tid I: Reors Removing 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 outlines the process of improving playground safety. Available from Alberta SAFE 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. Product designation no. CAN/CSA-Z-614-M90) A technical document that defines minimal voluntary standards acceptable in the design and setup of playgrounds and playground equipment. Available from the Canadian Standards Association, 178 Rexdale Blvd., Etobicoke ON M9W 1 R3; tel: 416 747-4000 Study of Confonnity of Children's Playspaces and Equipment to Voluntary Canadian Standard CSA A614-M90 (Montreal Public Health Unit, Montreal, 1993) Report of the results of research into injuries sustained on playground equipment in the Montreal area and conformity of playgrounds to the Canadian standards. Available from the Montreal Public Health Unit, 4835 Christophe Colomb St., Montreal QC H2J 3G8; tel. 514 528-2400, 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 of playgrounds. Available from the Canadian Institute of Child Health, 512-885 Meadowlands Dr., Ottawa ON K2C 3N2; tel. 613 224-4144 ..
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* Counsel parents and caregivers about the hazards of play equipment and playgrounds and stress the importance of active supervision. * Encourage, support and work with the appropriate organizations (e.g., the Product Safety Bureau, Health Protection Branch, Health Canada, AL 0301B2, Ottawa ON KlAOK9; and the Children's Apparel Manufacturers' Association, Decarie Square, 3110-6900 Decarie Blvd., Montreal QC H3X 2T8) to address the issue of lack of safety standards for children's clothing and to take positive steps to eradicate unnecessary hazards. * Use available resource publications (Table 1) to work with communities interested in preventing playground injuries. * Work with manufacturers of playground equipment to enhance their knowledge of hazards to children. Preventing childhood injuries requires the cooperative efforts of many individuals and organizations. We strongly urge physicians and other health care providers and their professional associations to act immediately to help prevent further needless injuries and deaths of children.
1. Mackenzie SG. Childhood injury: deaths and hospitalizations in Canada. CHIRPP News [Canadian Hospitals Injury Reporting and Prevention Program News, Laboratory Centre for Disease Control, Health Canada]
1994;Mar:4-5. 2. Rivara FP. Traumatic deaths of children in the United States: currently available prevention strategies. Pediatrisa 1985;75:456-62. 3. Playground, amusement park and outdoor household hazards. In: Committee on Accident Prevention, American Academy of Pediatrics. Injuy control for cbildren 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, US Consumer Product Safety Commission, April 1990:1-31. 5. Stanwick RS. Clothing burns in Canadian children. Can Med Assoc J 1985;132.1 143-9. 6. Deaths involving plyground equipment. Ottawa: Product Safety Accidental Death Systems, Product Safety Bureau, Health Protection Branch, Health Canada, 1993. 7. Media release. Washington: US Consumer Product Safety Commission, 7 July 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 Patbol 1993;14:74-9. 9. Levene S. The safety of children's cotbing. London (UK): Child Accident Prevention 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. Pediatric 1993;92:544-50. 12. Smith GS. The physician's role in injury prevention. J Gen Intern Med
1990;5:S67-73.
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