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The risk of harm from children and neonates entangled in lines | Signals

Reference number
Issue date14 February 2011

This Signal concerns the risk of harm to children and neonates from entanglement in lines or tubes. A sample incident reads:

“Baby fed by naso - gastric tube (continuous feed by pump from 18.00-23.00) Baby asleep in cot, rolled, tube wrapped round his neck twice. Mum found baby, blue around the lips. Tube unwrapped and baby recovered immediately.” 

Children and neonates who are unwell often require IV lines or tubing relating to the supply of oxygen or enteral feeding. These children may be cared for in a healthcare setting or at home. The NPSA has received an enquiry relating to the incidence of entanglement during overnight feeding of children with feeding tubes. 

The National Reporting and Learning System (NRLS) database was searched for incidents reported from 1 November 2003 to 6 July 2010 to identify all paediatric and neonatal incidents relating to any line or tube that had caused entanglement.  The search identified 44 incidents, 29 reported as resulting in no harm, 12 in low harm and three in moderate harm.  Most commonly, the line or tube had become tangled around the child’s neck, although other body parts were affected. The type of lines cited as causing entanglement were:

• nasogastric tubes;
• oxygen tubing;
• gastrostomy tubes;
• intravenous lines;
• central Intra venous catheters;
• monitor leads.

The use of nasogastric or gastrostomy tubes for overnight feeding may be necessary to achieve optimal nutritional balance. However, reports reveal that some entanglement issues with overnight feeding occurred when a child moved about during the night in a cot or bed either in hospital or at home.

There are currently no national guidelines for overnight feeding of children. Some organisations have developed local risk assessments for overnight enteral feeding in the community.  These are undertaken by the multidisciplinary team and inform parents and staff of possible hazards, including entanglement.

Staff should be vigilant to the potential for entanglement in other types of line or lead, either through deliberate self harm, as seen in some reports, or accidental harm as a result of child movement.

We would like to hear from you – please contact us with information about your initiatives to reduce risks in any of these areas. 

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.