November 26, 2019

Toy hazard warnings: Do they work?

Data study from Wayne State answers whether federal regulations on toys prevent childhood choking deaths


A  Wayne State University School of Medicine physician-researcher is the first to confirm that federal regulations on toys enacted 50 years ago to battle childhood deaths by choking have worked, helping decrease these preventable deaths to one-quarter of previous rates. 

The project’s principal investigator, Assistant Professor of Otolaryngology – Head and Neck Surgery John Cramer, M.D., treated a child during his residency training who suffered from tracheal obstruction due to an aspirated toy. The moment, he said, has stuck with him ever since.

John Cramer MD
John Cramer, M.D., led the study published in the Journal of the American Medical Association.

“We wanted to explore the impact of policy changes on the incidence of mortality from aspirated objects,” Dr. Cramer said. “We were also surprised that there were no other studies examining this question. Many of these deaths happen before patients arrive at the hospital, so I think there may be some lack of awareness about the mortality rate among physicians.”

“Object-Related Aspiration Deaths in Children and Adolescents in the United States, 1968 to 2017,” is published in the Journal of the American Medical Association’s latest issue.

A team led by Dr. Cramer reported 20,629 object-related choking deaths in children and teens (to age 17) from 1968 to 2017 based on data from the National Vital Statistics System. The deaths declined from 1.02 per 100,000 children (719 deaths) in 1968 to 0.25 per 100,000 children (184 deaths) in 2017.

The Child Protection and Toy Safety Act was enacted in 1969. Ten years later, products designed for young children were prohibited from containing small parts that could fit into a test cylinder approximating the size of the upper digestive tract of children younger than 3 years old. In 1994, products designed for older children containing small parts were required to display a warning label as well. And in 2010, the American Academy of Pediatrics proposed warning labels to vending machines and internet sites that sell toys.

“I think policy changes over the last 50 years have saved lives, although we can't say from our data which policy changes specifically led to the decrease in mortality,” Dr. Cramer said. “Some of the regulations from the last 50 years have forced people to do the right thing. When you buy toys or cribs now, products are designed so that they can’t be choked on. If you’re a parent and you go buy a crib, you don’t have to think about buying a crib without small parts. It’s already regulated.”

Although a number of laws, regulations and guidelines were adopted during that time, researchers cannot determine their effect on the decline in deaths or if other factors were involved. They recommended additional prevention strategies to reduce the exposure of children to objects already restricted with warning labels.

“It is important to remember that 184 children died in the most recent year from aspiration of objects. Unfortunately, the present dataset does not allow us to examine the specific reasons for deaths. I think our study emphasizes the need for ongoing monitoring of this issue,” he said.

Dr. Cramer was assisted in the study by Taha Meraj, M.D., a fourth-year resident in the Otolaryngology – Head and Neck Surgery program at WSU. Dr. Meraj assisted with statistical analysis and writing of the manuscript. Dr. Cramer also collaborated with his former training colleague Jennifer Lavin, M.D., M.S., a pediatric otolaryngologist at Children’s Hospital of Chicago; and Emily Boss, M.D., M.P.H., a mentor in patient safety and quality improvement and pediatric otolaryngologist at Johns Hopkins University School of Medicine. Both assisted with data analysis and writing.