This will probably NOT be my most popular blogpost, but life can’t always be about popularity so here it goes. This is a deeper dive into the incidents that have happened when carrying/babywearing. Why? Because it rarely discussed, therefore rarely analysed and because there have been some recent cases (indicating that we haven’t solved this problem). I’ve started in the medical literature but will end with some other sources.
I have decided to put a trigger warning (TW) here, since the incidents will include both injuries as well as lethal incidents. If you are new to babywearing/carrying, or just feel that you might be scared or triggered of this subject I would strongly recommend first reading other blogposts such as “Airways, airways, airways” (also available in Swedish here: “Luftvägar, luftvägar, luftvägar”), or simply not read this. You are very welcome to contact me if you want to discuss or ask something and if you worry about your or your baby’s safety when carrying do not hesitate to ask for help from someone with sufficient knowledge! I would strongly recommend seeing a trained carrying consultant (if you’re from Sweden you can locate a consultant or peer supporter here: SREB – Svensk Riksorganisation för Ergonomiskt Barnbärande).
So, brace yourselves and here we go!
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The first article I can identify is published in 2000 and contains data of reported incidents from Jan 1990- Sept 1998. The authors, Frisbee & Hennes, had a similar approach as I would have undertaken and vigorously searched the medical literature as well as other web-based sources. In this case the “other sources” was NEISS (National Electronic Injury Surveillance System), IPII (Injury/Potential Injury Incident File) and INDP (In-Depth Investigations File) both originating from CPSC (U.S. Consumer Product Safety Commission).
| Frisbee & Hennes, 2000. | NEISS = 51 cases 61% boys, mean age 7,6 months (95% CI, 5,7 – 9,4 m). 74,5% Head trauma 45,1% Lacerations & Abrasions 3,3% Concussions 15,7% Facial trauma 22% required hospitalization. (Med. Lit = 0 cases) |
| IPII = 34 cases “Cloth tearing, zippers coming undone or separating, hooks or fastening rings breaking, infants falling through leg openings, straps breaking, stitching unraveling, clasps or brackets breaking, and parents falling while carrying their child.” | |
| INDP = 6 cases “…most common type of injury investigated was a skull fracture sustained after an infant less than 6 months of age fell through the leg openings of a front style carrier, some despite using the restraining straps.” |
As pointed out by the authors this study was not intended to analyse the
incidents statistically, but rather to demonstrate what kind of injuries that
had happened. Looking at the incidents in the table above it seems pretty clear
that falling whilst carrying seems to be the big issue, either the child fell
out of the carrier or the adult/carer/parent falling. A lot of the other
factors described in the material from IPII has to do with the condition of the
carrier as well as how it is used, this highlights the need for always checking
the condition of your carrier and using it as it was intended. In the
discussion the authors state the following, which I would consider highly
important to keep in mind: “Most product
specific instructions include weight based guidelines. However, in young
infants especially, weight is only a crude proxy for size and strength.
Consequently, although caregivers may be using the product according to the
instructions, the infant may still not have sufficient size or strength to be
safely transported in a given model. On the other extreme, infants may be too
large, heavy, or strong for a specific model, leading to zippers, fasteners, or
straps that may break or come undone and the infant falling.”
Time wise I can’t identify any articles until 2008 when an article looking into
cases of SUID (Sudden Unexpected Infant Death) in the province of Quebec from
1991 to 2000 is published. They encountered 508 cases of SUID of which 17 of
them occurred in a “sitting device”, 1 of these devices being a “carrying
sling”. This article gives insight on how hard it can be to determine cause of
death but also how hard it can be to classify it, making it even harder to look
further into details like a potential relation to a certain product.
2012 a letter to the editor is published describing a mother breastfeeding her
baby in a sling during a car ride, but when reaching the intended destination
finding the infant unresponsive. The child received medical care but the
damages were too severe. The authors recommend that a wider knowledge on risks
as well as proper positioning should be addressed.
2014 Madré et al. publishes a case report from France were they describe two
infants being admitted after cardiorespiratory arrests whilst being carried. Both
of these babies were carried on their sides with their face towards the adult.
They were 22 respectively 63 days old when the incident occurred, time elapsed
since the parent had last checked on the infant was 15-30 minutes. The infants
received intensive care for 6 respectively 7 days before life support was
withdrawn, both infants were found to have severe damages in multiple organs
due to hypoxia/asphyxia.
2015 the article “Hazards
Associated with Sitting and Carrying Devices for Children Two Years and
Younger.” was published, the authors Batra, Midgett & Moon, had looked into
deadly incidents not only slings but also car seats, bouncers, swings and strollers.
The mean time elapsed from last checking in on the baby to the incident was 26
minutes for slings, the incident occoured between Apr 2004 and Dec 2008. The
data was collected from the INDP, IPII and the “Death Certificate file”. Out of
a total of 47 incidents 5 (11%) occurred in a sling.
| Batra, Midgett & Moon, 2015. |
N= 5 (Apr 2004 – Dec 2008) Mean age: 2 months Median age: 1 month Range: 10 days – 5 months Mean time: 26 min Median time: 18 min Range: 10 – 60 min |
None of the incidents in slings were directly during breastfeeding, one was in conjunction
with breastfeeding (the baby had nursed and fallen asleep, when the mother
checked on the baby approximately 10 minutes later the baby was unresponsive).
Cause of death was positional asphyxiation in all sling-related cases.
“Slings present a particular challenge
because, unless there is constant supervision of neck angle and airway patency,
it is very easy for an infant’s airway to be compromised in a short period of
time.”
“Slings are particularly hazardous because of their design and the ease with
which an infant’s airway can be collapsed. If used, the baby’s face should be
visible, not covered by any fabric, the chin should not be compressed into the
chest, and the face should be above the edge of the sling.”
“… this review should not be considered a comprehensive, but rather a minimum
accounting of deaths associated with sitting devices; nor is it intended to
represent a statistical sample of such deaths.”
In short one could argue that all sitting devices pose risks and hazards,
but that slings might need particular consideration. The presented material has
its limitations, which is usually something that we argue in relation to
statistical analysis and the strength of the findings, in this case however that
authors point out that they might not have included all incidents that occurred
during this period of time, which seems possible when considering the hardships
of classifying and identifying case of death in infants.
2015 Bergounioux et. al. reports on 19 lethal incidents from France and
Belgium. The incidents occurred during the years of 2003 to 2013, (so there
might be overlap with the article by Madré et al. from 2014 where there might
be two cases already reported on). Out of the 19 cases, 21% (4) had a low
birthweight (that’s under 2500 grams), 1 was born prematurely (at 34 weeks + 3
days).
| Bergounioux et. al. (2015) |
N = 19 (2003 – 2013) 47% boys Mean GA: 38 weeks Mean BW: 2990 grams Mean age of death: 40 days Median age of death: 32 days |
Of these incidents 10 were reported to have happened in a sling or wrap, and 9
in a carrier. Breastfeeding or positions in order to breastfeeding was reported
in 5 cases. In 2 cases the baby was older than 3 months, but not older than 4
months (108 respectively 115 days old when deceased). 8 of the babies returned
to spontaneous circulation by CPR at the site of the incident and were then
admitted to hospital, they had a median stay of 1.5 days (ranging from 1- 12
days) before being pronounced dead. The remaining 11 babies were pronounced
dead on the site of the incident. 13 were autopsied but the result was only
available for 11 of them. Suffocation was ruled to be the cause of death in 7
of the cases (63,6%), 2 (18,1%) had bilateral pneumonia (that’s infection in
both lungs), 1 (0,09%) had “massive gastric content aspiration” (that’s stomach
content in the lungs, lots of it) and the last one (1, 0,09%) had hypertrophic
cardiomyopathy (that’s thickening of a part of the heart muscle without explanation).
The authors reflect over the following (which to me is a very interesting
point): “The American Academy of
Pediatrics (AAP) reported a major decrease in SUDI since its 1992
recommendations on infant sleep position. However, the decrease has leveled off
in recent years, reflecting the role in SUDI of factors other than sleep
position.”
And also the following, pointing out how hard it actually is: “Deaths from suffocation are difficult to identify by autopsy alone, and close attention to the circumstances immediately before the death is crucial [9]. Suffocation is the most likely mechanism of death in infants in adult-worn soft carriers. The clinicians deemed that suffocation was clinically obvious in 6 of our 19 cases, obviating the need for an autopsy.”
The difficulties of terminology and identification of causes is addressed: “In 6 of our patients, the autopsy indicated asphyxial death, with intra-thoracic petechiae and diffuse hemorrhagic edema in the lungs. Two other patients had bilateral pneumonia that surely contributed to the occurrence of asphyxia. The massive gastric content aspiration seen in 1 patient may have been a consequence of asphyxia. Finally, in 2 patients, the autopsy showed cardiac abnormalities which probably were revealed by hypoxia related to the position of the infants (i.e., positional asphyxia) and contributed to death. Thus, all 19 cases were directly or indirectly ascribed to asphyxia.”
As in the other studies, this study has severe limitations due to the nature and collection of data, as the other studies it’s not really possible to draw any statistical conclusions since numbers on for example how much time children spend in slings are lacking, even for these 19 cases.
The last part of this study comes with strong recommendation: “Soft carriers should not be used until the baby can support his or her head alone; they are contraindicated before 4 months of age.”. For someone who is passionate about babywearing/carrying, I guess this is a really tough thing to even read (none the less take under consideration). But looking at the cases reported, their recommendation seems very understandable to me.
2016 Nguyen, Garcia, Wang, Friedlander & Krakowski reports on three cases of children experiencing “Rumpel Leed phenomenon” whilst or after being carried. Rumpel Leed phenomenon is a skin manifestation of bleeds in the skin (petechiae and purpura, which is essentially bleeds of different sizes) due to ruptured capillaries (that’s the smallest type of blood vessel) in this case after releasing a tourniquet-like force on the children’s legs (tourniquets are basically something that stops the blood, ones “ties off” the circulation essentially, potentially lifesaving in cases of catastrophic bleeds in arms or legs). None of the three children were sick nor had labwork that could completely explain a Rumpel Leed sign/phenomenon. All lesions on all of the three children resolved (without any kind of treatment) over the following weeks. The importance of this article is due to the other reasons that someone can develop Rumple Leed sign/phenomenon which are quite severe illneses, therefore a child with Rumpel Leed sign/phenomenon will be directed and recommended to a quite high level of acute medical care to rule out certain conditions and/or illnesses by labwork and observations.
2017 Gaw, Chounthirath & Smith did a large study on “Nursery Product-related Injuries…” that received treatment in U.S. emergency departments, they collected data for a number of products (including slings and carriers) from NEISS going back to 1991 all the way up to 2011. The goal was to determine the epidemiology (the reason and background) to the injuries. First I would like to show these diagrams, they are of total injuries (so not just slings or carriers) but they do show on some quite alarming trends (to me).
Looking at the full line (“Baby Carriers”) there is an interesting, but not surprising, drop in injuries between 2010 and 2011, possibly related to the tragedies with the bag-slings. But what I also find quite alarming is that the level of injuries related to baby carriers looks to have been either the highest or the second highest since 1998.
Looking at this diagram it’s quite obvious that head trauma (concussions and/or closed head injury) did rise quite substantially during this time. Concussions and CHI was however not the most common type of injury, soft tissue injuries represented 38% (in total) in comparison with 26,3% for Concussions/CHI. The frequency of concussions/CHI were highest among the 0-6 months age group with 34,7% and there after declined steadily. The body region most frequently injured was the head up until 12 months of age, thereafter instead the face was the most common. 58,7% of all total injuries occurred during the first 12 months of life.
The most common cause for injury was a fall (80% of total), children under 6 months of age however were more likely to get injured by a “… breathing-related mechanism…” (if you’re into statistics RR, 4.41 [95% CI, 3.48–5.60]), the adult or caregiver falling (RR, 5.98 [95% CI, 5.16–6.92), or the product in question failing (RR, 3.02 [95% CI, 2.33–3.91]) in comparison to the older children.
Baby carriers was the most common product related to injury with 19,5% in total (age wise), but as high as 54% or children 0-6 months. And the following doesn’t really leave much room for waving the data off (IMHO): “Baby carriers were 5.52 times (95% CI, 4.61–6.60; 7.9% vs 1.4%) more likely to be related to a caregiver fall compared with other product groups, and they accounted for more than one-half (57.3%) of caregiver-related falls… Product failure accounted for 0.9% of injuries, and almost one-half were associated with baby carriers (29.9%) or strollers/carriages (19.3%).”
Looking at the severity of injuries in regard of need for hospital admission as well as lethal incidents: “Baby carriers (25.8%), cribs/mattresses (19.5%), and baby walkers/jumpers/exercisers (18.7%) were most commonly associated with injuries requiring hospital admission. The breathing-related and nonfatal submersion mechanisms of injury combined were 6.56 (95% CI, 5.03–8.55; 24.9% vs 3.8%) times more likely to lead to hospitalization than the other mechanisms… Of the 0.2% of injuries that resulted in death, 80.2% were among patients <1 year old, 86.9% were associated with the breathing-related mechanism, and 73.4% were associated with cribs/mattresses. Baby carriers were associated with an additional 10.1% of deaths.”.
“Despite the significant decline in both the number and rate of nursery product–related injuries from 1991 through 2003, primarily attributable to the decline in baby walker/jumper/exerciser-related injuries, both the number and rate of injuries increased significantly from 2003 through 2011. Part of this increase was driven by an increase in the number and rate of concussions/CHIs, which is likely attributable to multiple factors, including heightened awareness about concussions during recent years among parents, child caregivers, and health professionals.”
This study comes with similar limitations (as always with data from NEISS, and here also the cases that did made it to the ER) but due to the sample size and time span the dataset is strengthened. Also I would like to address the fact that the term “baby carrier” also seemed to contain “baby carrier seats” so all the data referred to as being related to a baby carrier might not be in relation to babywearing/carrying.
These are the articles I can identify in the medical databases I have access to. The furthest date is 1990 and the most recent is in 2013, however not in the same country. But then we have other sources, as other kinds of databases, media, magazines and so on. So there is more, unfortunately…
2010 a carrier referred to as a “bag sling” were submitted to a recall due to the death of four infants in the US. According to the lawyers who were involved in the process there had been concerned raised over this “bag sling” previously to these incidents (Feldman & Shepherd, n.d.). The case settled in 2013. After these incidents there were a number of “alerts” issued on carriers and slings in Australia, Canada and the U.S.
2014 in Australia the CARRS-Q (Centre for Accident Research & Road Safety – Queensland) did a large survey on slings, injury and safety. The survey being prompted by three previous deaths by suffocation (since 2010) of infants being linked to slings. The survey asked almost 800 parents in Australia and 95% said that they were planning to or were already using a sling, the majority considered it safe for use from birth, most answered that they bought their sling online and that 50% turned to the internet for guidance on how to use it. They also found that 1 in 20 of the children carried in slings had either gotten injured or were nearly injured, of these 5% most were reported as the baby falling, the parent falling or the baby getting injured in conjunction to being positioned in or removed from the sling. This survey in turn prompted the development of an educational resource for parents on sling safety that can be found here.
And then in 2019 there was another lethal incident in Australia. The mother had wrapped her son up and went on a walk to the postnatal-check up, where she upon arrival found the baby to be unresponsive and not breathing. Kidspot (2019) says that the baby was 3 weeks old and had been delivered by forceps at term.
Additional data from NEISS and the CPSC (so this is from the US) can be found at BCIA (Baby Carrier Industry Alliance). BCIA have gathered the reports from NEISS regarding baby carriers and slings from 2010 to 2015.
| NEISS, 2010 – Nov 2015. |
11 deaths 10 reports of compromised breathing 8 injuries 31 “faulty products/buckle breakage/improper construction leading to near fall incident” 47 compliance/consumer complaints/reports |
The same data from the same source but from 2017 to 2019, that I retained via Facebook prior to sitting in on the conference call regarding these incidents, can be summarised as following:
| NEISS, Feb 2017 – Aug 2019. |
2 deaths 5 child injuries 13 child falling out/buckle/latching/structural failure 6 caregiver fell while wearing child in sling 4 caregiver pain/injury 8 reports of sale of non-compliant products |
By now I guess you’re wondering WHY ON EARTH does someone write about this?! The short answer is because I can and that I, in ways, feel obligated to. I love babywearing and carrying but I cannot unsee these numbers and I cannot enough distress the fact that we STILL need to address this problem within the babywearing/carrying community. If I can help just a tiny bit by bringing this very very very hard discussion up… I’m going to do it!
To further address the severity, I can only identify one of the lethal incidents as possibly happening before the year of 2000, leaving 46 lethal incidents happening from 2003 until 2019, and that number being flagged to possibly be underestimated. All babywearing/carrying needs to be safe, this is far far far beyond too many tragedies for incidents that could have been avoided!
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References
Batra, E. K., Midgett, J. D., & Moon, R. Y. (2015). Hazards Associated with Sitting and Carrying Devices for Children Two Years and Younger. The Journal of Pediatrics, 167(1), 183–187. https://doi-org.sll.idm.oclc.org/10.1016/j.jpeds.2015.03.044
BCIA – Baby Carrier Industry Alliance. (2015). NEISS Data: CPSC-Compiled Incident Reports. Retrieved 20-02-06 from https://babycarrierindustryalliance.org/neiss-data-cpsc-compiled-incident-reports/
Bergounioux, J., Madre, C., Crucis-Armengaud, A., Briand-Huchet, E., Michard-Lenoir, A. P., Patural, H., … Rambaud, C. (2015). Sudden deaths in adult-worn baby carriers: 19 cases. EUROPEAN JOURNAL OF PEDIATRICS, 174(12), 1665–1670. https://doi-org.sll.idm.oclc.org/10.1007/s00431-015-2593-6
Cote, A., Bairam, A., Deschenes, M., & Hatzakis, G. (2008). Sudden infant deaths in sitting devices. ARCHIVES OF DISEASE IN CHILDHOOD, 93(5), 384–389. https://doi-org.sll.idm.oclc.org/10.1136/adc.2007.119180
Feldman &
Shepherd…https://feldmanshepherd.com/results/8-million-settlement-for-death-of-infant-in-baby-sling/ and https://feldmanshepherd.com/news/infant-sling-death-lawsuit-ends-in-8-mil-settlement/
Frisbee, S. J., & Hennes, H. (2000). Adult-worn child carriers: a potential
risk for injury. Injury Prevention:
Journal Of The International Society For Child And Adolescent Injury
Prevention, 6(1), 56–58. Retrieved from https://search-ebscohost-com.sll.idm.oclc.org/login.aspx?direct=true&db=cmedm&AN=10728544&lang=sv&site=eds-live&scope=site
Gaw, C. E., Chounthirath, T., & Smith, G. A. (2017). Nursery Product-Related Injuries Treated in United States Emergency Departments. PEDIATRICS, 139(4). https://doi-org.sll.idm.oclc.org/10.1542/peds.2016-2503
Kidspot. (2019). Baby sling carrier linked to three-week-old’s death. Retrieved 20-02-06 from https://www.kidspot.com.au/parenting/real-life/in-the-news/baby-sling-carrier-linked-to-threeweekolds-death/news-story/d7f320066be2b1e6301e1767eafdfec9
Madre, C., Rambaud, C., Avran, D., Michot, C., Sachs, P., & Dauger, S. (2014). Infant deaths in slings. European Journal of Pediatrics, 173(12), 1659–1661. https://doi-org.sll.idm.oclc.org/10.1007/s00431-013-2238-6
Maqueda Castellote, E., Gili Bigatà, T., Sánchez Pérez, S., & Escofet Soteras, C. (2012). [Infant suffocation associated with the incorrect use of a baby sling]. Anales De Pediatria (Barcelona, Spain: 2003), 77(6), 416–417. https://doi-org.sll.idm.oclc.org/10.1016/j.anpedi.2012.06.015
Nguyen, T. A., Garcia, D., Wang, A. S., Friedlander, S. F., & Krakowski, A. C. (2016). Rumpel-Leede Phenomenon Associated With Tourniquet-like Forces of Baby Carriers in Otherwise Healthy Infants: Baby Carrier Purpura. JAMA DERMATOLOGY, 152(6), 728–730. Retrieved from https://search-ebscohost-com.sll.idm.oclc.org/login.aspx?direct=true&db=edswsc&AN=000379588600034&lang=sv&site=eds-live&scope=site
QUT – CARRS-Q. (2014). Parents urged to be safer with baby slings: New study. Retrieved 20-02-05 from https://www.qut.edu.au/health/about/news?news-id=70398