Computerized Tomography Analysis of Young Children for Prevention of Aspiration Injuries.

OBJECTIVE: The Small Parts Test Fixture (SPTF) (16 CFR 1501) was developed from cadavers of young children and foreign body (FB) data. Recent FB studies reveal that the SPTF misses outliers. Computerized tomography (CT) provides detailed dimensional data for young children. Our null hypothesis is that the SPTF (31.75 mm) is smaller than relevant portions of the aerodigestive tract. METHODS: A 3-year retrospective review (2011-2014) of head/neck CT data for infants and children (N = 106) aged 6 months to 6 years was completed. Six measurements (mm) were recorded: 1) maxillary incisors to posterior edge of hard palate (MI/HP); 2) posterior edge of hard palate to first cervical (C1) vertebra (HP/C1); 3) soft palate to posterior pharyngeal wall; and 4) interpalatine tonsillar distance; 5, 6) larynx diameter, and width. Two ratios were calculated: 1) ratio of lengths (hard palate to soft palate), and 2) laryngeal dimensional ratio. RESULTS: A linear trend of increasing dimensions with increased age was noted. The length measured MI/HP best correlates with known data of potential FBs causing injury or death. This MI/HP length can range from 33.8 to 45.8 mm for all children younger than 3 years of age and exceeds the SPTF diameter (31.75 mm). There were no statistical anatomical differences by gender in any of the age groups. CONCLUSION: Computed tomography measurements appear larger than SPTF values developed from cadavers. These CT data support enlargement of the SPTF to enhance safety for choking hazards in children. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1468-1476, 2019.

Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal.

OBJECTIVES/HYPOTHESIS: Button battery (BB) injuries continue to be a significant source of morbidity and mortality, and there is a need to confirm the mechanism of injury for development of additional mitigation strategies. STUDY DESIGN: Cadaveric piglet esophageal model. METHODS: Lithium, silver oxide, alkaline, and zinc-air BBs were placed in thawed sections of cadaveric piglet esophagus, bathed in normal saline. Severity of gross visual burn, pH, and temperature were recorded every 30 minutes for 6 hours. In other esophageal tissue specimens, the lithium BB was removed after 24, 36, and 48 hours and the site was irrigated with either 0.25% or 3% acetic acid. Separately, ReaLemon® juice, orange juice, Coke®, Dasani® water, Pepsi®, and saline were infused over a vertically suspended esophagus with a CR2032 lithium battery every 5 minutes for 2 hours while tissue temperature and pH were measured. RESULTS: A gradual rise in tissue pH and minimal change in temperature was noted for all BBs. ReaLemon® and orange juice applied every 5 minutes were most effective at neutralization of tissue pH with minimal change in tissue temperature. After BB removal (24, 36, 48 hours), irrigation of esophageal tissue specimens with 50-150 mL 0.25% acetic acid neutralized the highly alkaline tissue pH. CONCLUSIONS: BB appear to cause an isothermic hydrolysis reaction resulting in an alkaline caustic injury. Potential new mitigation strategies include application of neutralizing weakly acidic solutions that may reduce esophageal injury progression. LEVEL OF EVIDENCE: NA Laryngoscope, 127:1276-1282, 2017.

Development of the small parts cylinder: lessons learned.

OBJECTIVES/HYPOTHESIS: The Consumer Product Safety Commission mandates federal child choking prevention standards in the United States. Consumer Product Safety Commission utilizes the small parts cylinder (SPC), a 31.75-mm inside-diameter cylinder with a slanted bottom and depth ranging from 25.4 to 57.1 mm. The SPC was developed with very limited clinical data, and the effectiveness of the SPC remains controversial. Small parts ingestions remain among the most common causes of injury and fatality to preschool children. This study reviews the history, medical basis, and effectiveness of the SPC and provides recommendations for prevention of choking and airway fatalities. STUDY DESIGN: Retrospective case series, 48 tertiary care pediatric hospitals (1989-2004) and historical review (1972-2007). METHODS: American Academy of Pediatrics and Consumer Product Safety Commission documents and published reports. Forty-eight children's hospital medical records were reviewed by ICD-9 and current procedural terminology codes for injury or fatality data from foreign bodies (FBs) involved in airway obstruction or esophageal injury. All FBs dimensions were measured and statistically analyzed. RESULTS: Twenty-three percent of fatalities resulting from small parts over the study period involve objects that pass SPC evaluation and over 90% of FBs between 27.9 and 30.5 mm involved in nonfatal incidents pass SPC evaluation. Many objects involved in fatal and nonfatal injury pass because of the slanted bottom. CONCLUSIONS: Over one-fifth of injuries and fatalities to children could be prevented if a standard more stringent than the SPC were in use. Alternative gauges and broader age guidelines are recommended. We propose a 38.1-mm diameter open-bottom gauge for nonspherical FBs and a similar 44.5 mm gauge for spherical FBs. We suggest that this new standard would have prevented all small-parts fatalities to children (including children 3 years of age and older) and the overwhelming majority of nonfatal injuries.

Fatal and non-fatal food injuries among children (aged 0-14 years).

OBJECTIVE: To identify and characterize food items with high risk of airway obstruction in children younger than 15 years. METHODS: This retrospective study collected injury data from 1989 to 1998 for 26 pediatric hospitals in the United States and Canada. Aspiration, choking, ingestion, and insertion injuries due to food items were analyzed. The data included 1429 infants and children. Results were compared with fatality data published by the American Association of Pediatrics in 1984. RESULTS: The 10 food objects with the highest frequency for both injuries and fatalities were identified. Peanuts caused the highest frequency of injury, and hot dogs were most often associated with fatal outcomes. The severity of respiratory distress prior to hospital evaluation varied for different foods. Age younger than 3 years was the highest-risk factor. Key characteristics such as bite size, shape, and texture were analyzed and found to demonstrate relationships with severity of clinical outcomes. CONCLUSIONS: Children younger than 3 years remain at greatest risk of food injury and death. We found that hard, round foods with high elasticity or lubricity properties, or both, pose a significant level of risk. Consideration of the key characteristics of the most hazardous foods may greatly decrease airway obstruction injuries. Food safety education can help pediatricians and parents select, process, and supervise appropriate foods for children younger than 3 years to make them safer for this highest-risk population.

Pediatric coin ingestion and aspiration.

OBJECTIVE: To determine the relationship between physical characteristics of the coin (size), age of the victim, the amount of coins in circulation, and the frequency and outcome of pediatric coin ingestion and aspiration injuries. METHODS: Records of coin related ingestion and aspiration injuries occurring to children 14 years of age or younger were acquired from the US Consumer Product Safety Commission (CPSC). Logistic regression was conducted to control for mutual confounding among variables. RESULTS: From 1994 to 2003, an estimated 252,338 children were treated in hospital emergency departments for non-fatal coin-related ingestion or aspiration, and additional 20 fatalities were reported during the same time span. Children 4 years of age or younger were at the highest risk. It is also observed that younger children are the most vulnerable victims of ingestion and/or aspiration of small coins (e.g., pennies), while older children are more likely to be treated due to ingestion and/or aspiration of larger coins (e.g., quarters). Pennies were involved in more incidents than all other coins combined. The hospitalization rate exhibited a negative correlation with the measure of the diameter and the weight of the coins. The overwhelming majority (94%) of the incidents were ingestion, whereas aspiration victims were more likely to encounter hospitalization. CONCLUSIONS: We hope that this study will raise public and health practitioners' awareness of the risk, and increase supervision, particular of the most vulnerable young children.

Accidental childhood strangulation by human hair.

A low-income mother is accused of child abuse after co-sleeping with, and then waking to find her 13-month-old daughter entangled and apparently strangling in the mother's hair. The baby was initially unconscious and cyanotic; revived by the time the parents reached the ER, clinical examination revealed a ligature mark on the neck and petechiae on the face. In a pro bono effort, her attorney teamed with RAM Consulting as an expert witness. RAM performed a six-part investigation including: (1) an anthropometric analysis, (2) determination of the strength of human hair, (3) characterization of the ligature mark, (4) an investigation into airway occlusion forces, (5) an investigation into the conditions required to initiate petechiae, and (6) a review of the literature. Our conclusion was that it is possible for a strangulation incident to occur when a young child is co-sleeping with a parent with long hair, and that this scenario may result in injury or death. Upon review of this report and RAM's deposition on this matter, the prosecuting attorney's expert witness withdrew her testimony and the judge dismissed the case.