CASE REPORT
Strangulation by Feeding Tube in a 23-Month-Old With Down Syndrome Case Report and Review of Literature Paige C. Woodham, MD,* James W. Fulcher, MD,†‡§ and Michael E. Ward, MD†‡§
Abstract: Ligature strangulation, although typically homicidal in nature, has been reported as accidental in both the pediatric and adult populations. The unique mode of accidental strangulation with a gastric feeding tube in a 23-month-old with Down syndrome is currently unreported in the literature and has prompted us to report this case and look into safety modifications that can be made to these common medical devices. Given the number of children with gastric feeding tubes and concern over this exact scenario brought up by parents, it is unusual that a similar case has not been reported. Key Words: accidental, down syndrome, feeding tube, strangulation (Am J Forensic Med Pathol 2016;37: 245–247)
G
astric feeding tubes are medical devices inserted through the skin of the abdomen into the stomach to supply nutrition for both adults and children. Indications for these devices are vast and include failure to thrive or malnutrition, inability to swallow, neurologic disorders, and anatomic disruptions of the alimentary tract, just to name a few. Down syndrome is a common condition in which children may require the assistance of a feeding tube for nutrition because of hypotonia of the oral muscles causing difficulty with the suckling reflex.1 Approximately 40% of children with Down syndrome may also suffer from cardiac defects that make breathing more difficult, thus affecting feeding by mouth.2 When it is determined that a patient qualifies for a gastric feeding tube, also known as g-tube, the procedure is typically performed endoscopically, and the tube is inserted into the stomach through a small incision, where it is held in place by a balloon. After the procedure is performed, the device is ready for use, and a feeding regimen is typically agreed upon by the patient, clinician, and nutritionist to ensure proper nutrition and growth.3 In the pediatric population, tube feedings are typically given at night while the patient sleeps, for ease of use by the parent. There are many pump systems available that ensure adequate delivery of formulas in a continuous fashion, and these pumps come with tubing of varying lengths that hooks into the g-tube site on the patient’s abdomen. Some parents have reported pinning the tubing to the child’s clothing to prevent the child from pulling on it and causing tube feed to spill out. Most pumps also have alarm systems that sound when there is an issue with pulling or
Manuscript received April 24, 2016; accepted September 2, 2016. From the *University of South Carolina School of Medicine Greenville; †Office of the Medical Examiner; ‡Pathology Associates of Greenville; and the §Greenville Health System University Medical Center, Greenville, SC. The authors report no conflict of interest. Reprints: Paige C. Woodham, MD, 317 Lantana Dr, Charleston, SC 29407. E-mail: [email protected]. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0195-7910/16/3704–0245 DOI: 10.1097/PAF.0000000000000278
Am J Forensic Med Pathol • Volume 37, Number 4, December 2016
kinking of the tubing or if for some reason the device is not delivering the formula.
CASE REPORT We report the case of a 23-month-old white boy with Down syndrome who was found deceased in his crib with the plastic tubing from his feeding tube wrapped at least once around his neck. The patient’s medical history is significant for an arteriovenous canal defect diagnosed prenatally at 26 weeks’ gestation and Down syndrome diagnosed at 30 weeks’ gestation. He was delivered at 39 weeks’ gestation and was hospitalized for 8 weeks after birth, during which time he was treated for failure to thrive and hypothyroidism, and a feeding tube was placed. At about a year old, the patient underwent heart surgery to repair his arteriovenous canal defect, and after that, he experienced no issues other than continued feeding difficulty; therefore, the gastric feeding tube was continued. His feeding regimen was 50 mL Compleat Pediatric formula per hour throughout the night, and he typically slept between the hours of 9:00 PM and 9:00 AM. At baseline, the patient could not walk but was very active and could pull himself up in the crib and play with his surroundings. On the evening of the accident, the patient was in his usual state of health and was put down for bed around 10:00 PM, at which point his pump was turned on and feeding was started. His mother checked on him around 3:30 AM the following morning and found nothing out of the ordinary. Around 10:00 AM, when his father checked on him, he found the patient lying against the rails of the crib on his right side. He noticed that the feeding machine had been turned sideways and that the tubing was tight (Fig. 1). He also noted that the patient’s skin was discolored, he was not breathing, and he had several loops of the tubing wrapped around his neck. At this time, his father removed the tubing and carried him to another room to begin cardiopulmonary resuscitation and call 911. The patient vomited during cardiopulmonary resuscitation, but upon EMS arrival, he was noted to be asystolic and was pronounced dead. The autopsy findings included prominent petechial hemorrhages over the anterior face, as well as an abraded halfinch-wide ligature mark completely encircling the neck (Fig. 2). There was no upward or downward sloping noted, and the mark lied directly between the hyoid bone and the thyroid cartilage anteriorly, with horizontal orientation. The periodicity and width of the abraded mark compared with the diameter of the tube suggested that the tube was wrapped at least twice around the neck. No significant natural disease or injuries were noted at autopsy including a stepwise dry neck dissection. Pertinent findings during microscopic examination of tissue revealed chronic inflammation of the epidermis at the site of the feeding tube and acute neuronal hypoxic change in the cerebellum and hippocampus. Postmortem toxicology was negative. Findings of both the external and internal examinations coupled with microscopic www.amjforensicmedicine.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
245
Am J Forensic Med Pathol • Volume 37, Number 4, December 2016
Woodham et al
FIGURE 3. Looped tubing; circle is around the safety pin. Figure 3 can be viewed online in color at www.amjforensicmedicine.com.
examination of tissues point to accidental asphyxia secondary to strangulation by feeding tube as the manner and cause of death, respectively.
DISCUSSION
FIGURE 1. Disruption of feeding pump. Figure 1 can be viewed online in color at www.amjforensicmedicine.com.
FIGURE 2. Ligature mark. Figure 2 can be viewed online in color at www.amjforensicmedicine.com.
246
www.amjforensicmedicine.com
According to the Centers for Disease Control and Prevention, unintentional or accidental injuries are the leading cause of death in children aged 1 to 19 years.4 Review of literature reveals that accidental hanging deaths have been reported among children worldwide, with a variety of ligatures ranging from balcony railings to jump ropes to high-chair straps.5–7 In contrast to hangings, most ligature strangulations are homicidal in nature.8 Accidental ligature strangulations are much less frequently reported in both pediatric and adult populations, especially by medical devices designed to support life. As mentioned in the first part of this article, all of these feeding pump systems have audible alarms that sound under certain conditions. Alarms go off when the battery is low, when the feed containers are empty, and when the tubing becomes occluded between the bag and the pump or between the pump and the patient. Occlusions may be caused by kinking of the tubing or disruption
FIGURE 4. Arrow denotes area of potential breakaway. Figure 4 can be viewed online in color at www.amjforensicmedicine.com. © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Am J Forensic Med Pathol • Volume 37, Number 4, December 2016
of flow for any reason; however, none of these manuals state whether there is any certain amount of pressure that is required to set off the alarm. In our case, there was no alarm that sounded on the evening or morning of the accident according to the child’s parents. Of note, they also mentioned that it was not uncommon for the child to get the tubing wrapped around his neck during sleeping, but that it had never been tightly wrapped. An area of concern voiced by many parents regarding feeding tube devices is prevention of spills. Because the flow sensor does not distinguish between flow into the stomach and flow onto the child’s clothes and surroundings, when the tubing becomes detached, the pump continues to work, dumping feeds everywhere. Thus, many parents pin the tubing to their child’s clothing to prevent it from disconnecting and causing a spill. However, when pinned, the tube is then attached to the body, potentially increasing the risk of entanglement and strangulation. In our case, the child’s tubing was pinned to his diaper as photographed (Fig. 3). This unfortunate accident brings up important issues that can hopefully be points of discussion to prevent future deaths of similar nature. Although these pump systems have a breakaway area in the tubing (Fig. 4), the amount of force that it takes to break the tubing away from the points of insertion is unclear. It would be worthwhile for companies that manufacture these systems to look at engineering design and force applied in order to come up with the safest possible devices; however, with an easier breakaway, there may be more potential for spills, leading to greater potential for pinning. Therefore, there is a fine line between functionality and safety. Modifications can also be made to the alarm systems to sense when the tubing is detached at any location, which will hopefully prevent large spills. Although pinning of the tubing may be helpful in preventing spills, parents and caregivers should be cautioned about this as it may likely increase the risk of entanglement and strangulation. Finally, it is important to note that while some older children may be able to self-rescue in a similar grave situation, infants, young children, and children with developmental delay may lack the ability to do so. Accidental deaths have been attributed to devices such as boards and cots attached to beds that have been used to prevent injury in children with mental and physical disability. These modifications may not be dangerous to children of the same age without developmental delays; therefore, parents should
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Strangulation by Feeding Tube
exercise extreme precautions when assessing the safety of their children’s surroundings.9
CONCLUSIONS This case, albeit rare because of the few accidental ligature strangulations that happen in general, is important because of the common nature of gastric feeding tubes in the pediatric population and the inability for some children to release themselves from tubing should something serious occur. It is our hope that through this case parents understand the dangers that can happen with a seemingly harmless medical device and take the proper precautions. We also hope that companies that manufacture these pump devices and tubing take a look at design methods to make them safer and more functional. REFERENCES 1. Kumin L, Goodman M, Councill C. Comprehensive communication intervention for infants and toddlers with Down syndrome. Infant Toddler Interv Transdiscip J. 1991;1(4):275–283. 2. Cousineau AJ, Lauer RM. Heart disease and children with Down syndrome. In: van Dyke DC, Mattheis P, Eberly SS, et al., eds. Medical & Surgical Care for Children With Down syndrome. A Guide for Parents. Bethesda, MD: Woodbine House; 1995. 3. Friginal-Ruiz AB, Lucendo AJ. Percutaneous Endoscopic Gastrostomy. Gastroenterol Nurs. 2015;38(5):367–368. 4. National Action Plan for Child Injury Prevention—Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/safechild/NAP/. Accessed January 18, 2016. 5. Muthukrishnan L, Raman R, Nagaraju K. An unusual cause of accidental hanging in a toddler. Pediatr Emerg Care. 2012;28(9):924–925. 6. Souheil M, Audrey F, Anny G, et al. Fatal accidental hanging by a high-chair waist strap in a 2-year-old girl. J Forensic Sci. 2011;56(2):534–536. 7. Gok E, Cetin S, Baduroglu E, et al. Two accidental hanging cases of children. J Pak Med Assoc. 2015;65(7):790–792. 8. Arun M, Kumar RH, Kumar GP, et al. Accidental strangulation by a hot belt: an occupational medico-legal case report. Med Leg J. 2013;81(3):132–134. 9. Amanuel B, Byard R. Accidental asphyxia in bed in severely disabled children. J Paediatr Child Health. 2000;36(1):66–68.
www.amjforensicmedicine.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
247
Strangulation by Feeding Tube in a 23-Month-Old With Down Syndrome Case Report and Review of Literature Paige C. Woodham, MD,* James W. Fulcher, MD,†‡§ and Michael E. Ward, MD†‡§
Abstract: Ligature strangulation, although typically homicidal in nature, has been reported as accidental in both the pediatric and adult populations. The unique mode of accidental strangulation with a gastric feeding tube in a 23-month-old with Down syndrome is currently unreported in the literature and has prompted us to report this case and look into safety modifications that can be made to these common medical devices. Given the number of children with gastric feeding tubes and concern over this exact scenario brought up by parents, it is unusual that a similar case has not been reported. Key Words: accidental, down syndrome, feeding tube, strangulation (Am J Forensic Med Pathol 2016;37: 245–247)
G
astric feeding tubes are medical devices inserted through the skin of the abdomen into the stomach to supply nutrition for both adults and children. Indications for these devices are vast and include failure to thrive or malnutrition, inability to swallow, neurologic disorders, and anatomic disruptions of the alimentary tract, just to name a few. Down syndrome is a common condition in which children may require the assistance of a feeding tube for nutrition because of hypotonia of the oral muscles causing difficulty with the suckling reflex.1 Approximately 40% of children with Down syndrome may also suffer from cardiac defects that make breathing more difficult, thus affecting feeding by mouth.2 When it is determined that a patient qualifies for a gastric feeding tube, also known as g-tube, the procedure is typically performed endoscopically, and the tube is inserted into the stomach through a small incision, where it is held in place by a balloon. After the procedure is performed, the device is ready for use, and a feeding regimen is typically agreed upon by the patient, clinician, and nutritionist to ensure proper nutrition and growth.3 In the pediatric population, tube feedings are typically given at night while the patient sleeps, for ease of use by the parent. There are many pump systems available that ensure adequate delivery of formulas in a continuous fashion, and these pumps come with tubing of varying lengths that hooks into the g-tube site on the patient’s abdomen. Some parents have reported pinning the tubing to the child’s clothing to prevent the child from pulling on it and causing tube feed to spill out. Most pumps also have alarm systems that sound when there is an issue with pulling or
Manuscript received April 24, 2016; accepted September 2, 2016. From the *University of South Carolina School of Medicine Greenville; †Office of the Medical Examiner; ‡Pathology Associates of Greenville; and the §Greenville Health System University Medical Center, Greenville, SC. The authors report no conflict of interest. Reprints: Paige C. Woodham, MD, 317 Lantana Dr, Charleston, SC 29407. E-mail: [email protected]. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0195-7910/16/3704–0245 DOI: 10.1097/PAF.0000000000000278
Am J Forensic Med Pathol • Volume 37, Number 4, December 2016
kinking of the tubing or if for some reason the device is not delivering the formula.
CASE REPORT We report the case of a 23-month-old white boy with Down syndrome who was found deceased in his crib with the plastic tubing from his feeding tube wrapped at least once around his neck. The patient’s medical history is significant for an arteriovenous canal defect diagnosed prenatally at 26 weeks’ gestation and Down syndrome diagnosed at 30 weeks’ gestation. He was delivered at 39 weeks’ gestation and was hospitalized for 8 weeks after birth, during which time he was treated for failure to thrive and hypothyroidism, and a feeding tube was placed. At about a year old, the patient underwent heart surgery to repair his arteriovenous canal defect, and after that, he experienced no issues other than continued feeding difficulty; therefore, the gastric feeding tube was continued. His feeding regimen was 50 mL Compleat Pediatric formula per hour throughout the night, and he typically slept between the hours of 9:00 PM and 9:00 AM. At baseline, the patient could not walk but was very active and could pull himself up in the crib and play with his surroundings. On the evening of the accident, the patient was in his usual state of health and was put down for bed around 10:00 PM, at which point his pump was turned on and feeding was started. His mother checked on him around 3:30 AM the following morning and found nothing out of the ordinary. Around 10:00 AM, when his father checked on him, he found the patient lying against the rails of the crib on his right side. He noticed that the feeding machine had been turned sideways and that the tubing was tight (Fig. 1). He also noted that the patient’s skin was discolored, he was not breathing, and he had several loops of the tubing wrapped around his neck. At this time, his father removed the tubing and carried him to another room to begin cardiopulmonary resuscitation and call 911. The patient vomited during cardiopulmonary resuscitation, but upon EMS arrival, he was noted to be asystolic and was pronounced dead. The autopsy findings included prominent petechial hemorrhages over the anterior face, as well as an abraded halfinch-wide ligature mark completely encircling the neck (Fig. 2). There was no upward or downward sloping noted, and the mark lied directly between the hyoid bone and the thyroid cartilage anteriorly, with horizontal orientation. The periodicity and width of the abraded mark compared with the diameter of the tube suggested that the tube was wrapped at least twice around the neck. No significant natural disease or injuries were noted at autopsy including a stepwise dry neck dissection. Pertinent findings during microscopic examination of tissue revealed chronic inflammation of the epidermis at the site of the feeding tube and acute neuronal hypoxic change in the cerebellum and hippocampus. Postmortem toxicology was negative. Findings of both the external and internal examinations coupled with microscopic www.amjforensicmedicine.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
245
Am J Forensic Med Pathol • Volume 37, Number 4, December 2016
Woodham et al
FIGURE 3. Looped tubing; circle is around the safety pin. Figure 3 can be viewed online in color at www.amjforensicmedicine.com.
examination of tissues point to accidental asphyxia secondary to strangulation by feeding tube as the manner and cause of death, respectively.
DISCUSSION
FIGURE 1. Disruption of feeding pump. Figure 1 can be viewed online in color at www.amjforensicmedicine.com.
FIGURE 2. Ligature mark. Figure 2 can be viewed online in color at www.amjforensicmedicine.com.
246
www.amjforensicmedicine.com
According to the Centers for Disease Control and Prevention, unintentional or accidental injuries are the leading cause of death in children aged 1 to 19 years.4 Review of literature reveals that accidental hanging deaths have been reported among children worldwide, with a variety of ligatures ranging from balcony railings to jump ropes to high-chair straps.5–7 In contrast to hangings, most ligature strangulations are homicidal in nature.8 Accidental ligature strangulations are much less frequently reported in both pediatric and adult populations, especially by medical devices designed to support life. As mentioned in the first part of this article, all of these feeding pump systems have audible alarms that sound under certain conditions. Alarms go off when the battery is low, when the feed containers are empty, and when the tubing becomes occluded between the bag and the pump or between the pump and the patient. Occlusions may be caused by kinking of the tubing or disruption
FIGURE 4. Arrow denotes area of potential breakaway. Figure 4 can be viewed online in color at www.amjforensicmedicine.com. © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Am J Forensic Med Pathol • Volume 37, Number 4, December 2016
of flow for any reason; however, none of these manuals state whether there is any certain amount of pressure that is required to set off the alarm. In our case, there was no alarm that sounded on the evening or morning of the accident according to the child’s parents. Of note, they also mentioned that it was not uncommon for the child to get the tubing wrapped around his neck during sleeping, but that it had never been tightly wrapped. An area of concern voiced by many parents regarding feeding tube devices is prevention of spills. Because the flow sensor does not distinguish between flow into the stomach and flow onto the child’s clothes and surroundings, when the tubing becomes detached, the pump continues to work, dumping feeds everywhere. Thus, many parents pin the tubing to their child’s clothing to prevent it from disconnecting and causing a spill. However, when pinned, the tube is then attached to the body, potentially increasing the risk of entanglement and strangulation. In our case, the child’s tubing was pinned to his diaper as photographed (Fig. 3). This unfortunate accident brings up important issues that can hopefully be points of discussion to prevent future deaths of similar nature. Although these pump systems have a breakaway area in the tubing (Fig. 4), the amount of force that it takes to break the tubing away from the points of insertion is unclear. It would be worthwhile for companies that manufacture these systems to look at engineering design and force applied in order to come up with the safest possible devices; however, with an easier breakaway, there may be more potential for spills, leading to greater potential for pinning. Therefore, there is a fine line between functionality and safety. Modifications can also be made to the alarm systems to sense when the tubing is detached at any location, which will hopefully prevent large spills. Although pinning of the tubing may be helpful in preventing spills, parents and caregivers should be cautioned about this as it may likely increase the risk of entanglement and strangulation. Finally, it is important to note that while some older children may be able to self-rescue in a similar grave situation, infants, young children, and children with developmental delay may lack the ability to do so. Accidental deaths have been attributed to devices such as boards and cots attached to beds that have been used to prevent injury in children with mental and physical disability. These modifications may not be dangerous to children of the same age without developmental delays; therefore, parents should
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Strangulation by Feeding Tube
exercise extreme precautions when assessing the safety of their children’s surroundings.9
CONCLUSIONS This case, albeit rare because of the few accidental ligature strangulations that happen in general, is important because of the common nature of gastric feeding tubes in the pediatric population and the inability for some children to release themselves from tubing should something serious occur. It is our hope that through this case parents understand the dangers that can happen with a seemingly harmless medical device and take the proper precautions. We also hope that companies that manufacture these pump devices and tubing take a look at design methods to make them safer and more functional. REFERENCES 1. Kumin L, Goodman M, Councill C. Comprehensive communication intervention for infants and toddlers with Down syndrome. Infant Toddler Interv Transdiscip J. 1991;1(4):275–283. 2. Cousineau AJ, Lauer RM. Heart disease and children with Down syndrome. In: van Dyke DC, Mattheis P, Eberly SS, et al., eds. Medical & Surgical Care for Children With Down syndrome. A Guide for Parents. Bethesda, MD: Woodbine House; 1995. 3. Friginal-Ruiz AB, Lucendo AJ. Percutaneous Endoscopic Gastrostomy. Gastroenterol Nurs. 2015;38(5):367–368. 4. National Action Plan for Child Injury Prevention—Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/safechild/NAP/. Accessed January 18, 2016. 5. Muthukrishnan L, Raman R, Nagaraju K. An unusual cause of accidental hanging in a toddler. Pediatr Emerg Care. 2012;28(9):924–925. 6. Souheil M, Audrey F, Anny G, et al. Fatal accidental hanging by a high-chair waist strap in a 2-year-old girl. J Forensic Sci. 2011;56(2):534–536. 7. Gok E, Cetin S, Baduroglu E, et al. Two accidental hanging cases of children. J Pak Med Assoc. 2015;65(7):790–792. 8. Arun M, Kumar RH, Kumar GP, et al. Accidental strangulation by a hot belt: an occupational medico-legal case report. Med Leg J. 2013;81(3):132–134. 9. Amanuel B, Byard R. Accidental asphyxia in bed in severely disabled children. J Paediatr Child Health. 2000;36(1):66–68.
www.amjforensicmedicine.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
247
