Accidental infant death and stroller-prams

Shopping cart injuries, entrapment, and childhood fatality

Shopping carts may be associated with a variety of injuries, particularly in toddlers and young children. These usually relate to falls from carts or to tip-overs. Injuries that are sustained include hematomas/contusions, abrasions, lacerations, fractures, and fingertip amputations. Fatal episodes are uncommon and are usually due to blunt craniocerebral trauma from falls. A case involving a 19-month-old girl is reported who became entrapped when she inserted her head through the side frame of a cart that had been removed from a supermarket and left at her home address. Death was caused by neck compression. Although rare, the potential for lethal entrapment during unsupervised play means that the presence of stray shopping carts at private residences and in public places, including playgrounds and parks, is of concern. Strategies, such as coin deposits, should be encouraged to assist in the return of such carts to supermarkets.

Hazardous infant and early childhood sleeping environments and death scene examination

Infants and young children are at risk of accidental asphyxia from unsafe sleeping environments Specific dangers include wedging/entrapment and positional asphyxia when infants slide into gaps between mattresses and cot sides or between beds and walls. Faulty cot construction may result in defects through which infants may fall and become suspended, or in spaces which entrap the head. Projections on the inside of cots may ensnare clothing causing hanging, as may nearby curtain cords and restraining harnesses. The mouth and nose may be covered by plastic sheeting or by the mattress in partially filled waterbeds. Rocking cradles with excessive angles of tilt may also place infants' heads into positions where breathing is compromised. Finally, external pressure by adults in shared sleeping situations may result in fatal chest compression or airway occlusion. In many of these situations the autopsy findings are entirely nonspecific and do not help in establishing a cause of death. Thus, careful death scene examination with later formal review of findings may be the only way to accurately determine the manner of death.

Accidental hanging by a sweater: an unusual case

An accidental atypical hanging with the collar of a sweater is reported. A 67-year-old man was found dead in the sitting position with the collar of his sweater hanging off the brake handle of a motorcycle. Autopsy findings revealed a ligature mark on the surface of the neck; hemorrhages in the sternohyoid muscles; submucosal hemorrhages in the left greater horn of the hyoid bone; a large degree of submucosal petechial hemorrhages in the larynx, oral mucosa, and palpebral conjunctivae; and dark-red liquid blood with little clotting in the heart cavities. The alcohol levels in the blood and urine were 2.84 mg/ml and 3.52 mg/ml, respectively. It was concluded that the man had died from hanging by the sweater, and it was speculated that when he became inebriated, he might have lost consciousness and then fell with the collar of his sweater hanging from the brake handle of the motorcycle.

A review of the anatomy of the upper airway in early infancy and its possible relevance to SIDS

BACKGROUND

Since the danger of prone sleeping in the first 6 months of life has been publicised, there has been a dramatic and consistent reduction in the incidence of sudden infant death syndrome (SIDS). However, unexpected infant deaths and apparent life-threatening events (ALTEs) continue to occur that are clearly not associated with known epidemiological risk factors.

AIMS

To review the unique features of the anatomy and function of the upper airway of the young infant which contribute to increased vulnerability to hypoxia in this age group. We discuss the clinical identification of those infants at risk of obstruction or restriction of the upper airway and the management of the 'at risk' infant.

CONCLUSIONS

In the era after the "back to sleep" campaigns, it is likely that an increasing proportion of cases of ALTEs and SIDS will be related to obstruction or limitation of upper airway size leading to sleep hypoxia/asphyxia. This type of problem may be anticipated by evaluation and investigation of infants with signs or a clinical history consistent with possible upper respiratory tract compromise, including micrognathia.

Accidental childhood death and the role of the pathologist

The following study provides an overview of accidental childhood death. This study is based on a review of 369 cases of fatal childhood accidents taken from the records of the Department of Histopathology, Women's and Children's Hospital, Adelaide, Australia, over a 34-year period from 1963 to 1996. Data provide information on deaths due to motor vehicle accidents, drownings, accidental asphyxia, burns, poisonings, electrocution, and miscellaneous trauma. In addition, certain categories have undergone further examination, including asphyxial deaths due to unsafe sleeping environments and unsafe eating practices, drowning deaths, and deaths on farms, following identification of significant child safety problems in these areas as part of the "Keeping Your Baby and Child Safe" program. Previously unrecognized dangers to children detected through this program include mesh-sided cots, V-shaped pillows, and certain types of stroller-prams. The production of information pamphlets and packages for parents and the recall of certain dangerous products following recommendations made by pathologists demonstrate that pediatric and forensic pathologists have an important role to play in preventive medicine issues and in formulating public health strategies.

Accidental asphyxia in bed in severely disabled children

OBJECTIVE

To determine whether there are specific situations which may increase the risk of accidental asphyxia during sleep in children with physical and mental disabilities.

METHODOLOGY

Review of all cases where death was attributed to accidental asphyxia caused by unsafe sleeping situations in children listed in the Department of Histopathology database over a 10-year period from March 1989 to February 1999.

RESULTS

A total of 26 cases were found (M:F, 19:7; age range, 1-48 months; average age, 7.4 months). Of those cases, two involved children with significant mental and physical impairment. Case 1: A 4-year-old boy with Klippel-Trenaunay-Weber syndrome, macrocephaly and severe developmental delay, was found dead with his head hanging over a wooden board attached to the side of his bed. Case 2: A 4-year-old boy with lissencephaly and severe developmental delay was found dead wedged between a retractable mesh cot side and the side of his bed. In both cases the devices resulting in death had been put in place to prevent the boys from falling out of bed.

CONCLUSIONS

Accidental asphyxia in physically and mentally impaired children may be caused by devices that have been used to prevent injury from falling out of bed. Careful assessment of the specific developmental problems that children suffer should be undertaken before their beds are modified. It may be safer for these children either to have no barrier, or to have drop-sided cots/beds that meet recognized safety standards.

Hanging deaths in children

Relatively little is known about death in children following hanging. This 12-year retrospective study in southeast Scotland revealed 12 such deaths among children <15 years of age, involving 10 boys and 2 girls. The rate of hanging deaths was 0.7 deaths/100,000 children/year and was equal to that from falls in children during this time period. The children who died following hanging were aged between 4 and 14 years. All 12 children were in cardiac arrest when found, and 11 were declared dead at the scene, demonstrating the limited potential to reduce the death rate through improved treatment. Scrutiny of the circumstances surrounding each death suggested that 6 of the deaths were accidents and 6 were suicides. There appears to be some, albeit limited, potential to prevent some hanging deaths in children through increased parental supervision, education, and restriction of access to ligatures.

V-shaped pillows and unsafe infant sleeping

OBJECTIVE

To investigate the possibility that adult size V-shaped pillows may be associated with accidental asphyxial deaths in infants.

METHODOLOGY

Review was undertaken of all cases of sudden infant death presenting to the Women's and Children's Hospital in Adelaide involving infants who had been found on adult size V-shaped pillows.

RESULTS

Four cases of sudden infant death were found in which infants were found sleeping on V-shaped pillows. All of the deaths had occurred in 1995. In two of the cases the pillows were considered to be implicated in the cause of death as the potential for obstruction of the infants' airways could be demonstrated on death scene reconstruction.

CONCLUSION

Adult size V-shaped pillows may be unsafe for use in small infants who may accidentally suffocate if trapped between the two arms, or under, the pillow. The use of such pillows to maintain the body position of sleeping infants should be discouraged.