Children Can Be Trapped in or Fall from Cribs
Hazard [Health Devices Jul-Aug 1989;18(7-8):287-8]
A member hospital reported that a 14-month-old child was found
trapped between the raised head section and head rails of a canopy-style crib. The child was cyanotic
but recovered without medical intervention. Another incident in which a child crawled through
the opening of similar crib was reported through the U.S. Food and Drug Administration
(FDA) Device Experience Network in 1983. The child was caught before he fell to the floor.
Although this report was related to certain brands of
cribs with gatch springs, other manufacturers' models may also be involved. Cribs whose
head or knee sections can be raised are likely to create a hazard because the openings
between the mattress springs and head and foot rails become larger as the end sections are
In the incident reported to ECRI, the head section of the mattress was raised
30°, and the opening (about 4 inches) was not wide enough for the child to fall completely through. A nurse passing by the
room noticed that the child was not in his crib, investigated, and found him suspended by
his head with his chin caught on the edge of the mattress. Apparently, the child's body
slid through the opening in the corner of the crib, and his head lodged between the
mattress and head rails.
The supplier of the incident crib models
developed modifications for its cribs with gatch springs, consisting of a
bedspring extender that automatically extends beyond the head section as the
mattress is raised and a safety plate that will be installed below the
mattress frame at the foot of the crib. These modifications should eliminate the opening at the
head section of the crib and provide enough support for a child who has crawled
through the foot section to stand. The supplier also recommends that mattresses of adequate size be
used in the cribs.
- With the mattress both flat and raised, examine the spaces between the
mattress springs and head, foot, and side rails of all cribs in service. If the opening
exceeds 4 inches, follow the recommendations below. Also
examine the spacing between crib railings of all cribs in service. If a crib has railing
spaces that exceed 2-3/8 inches, remove it from service. (The
Consumer Product Safety Commission (CPSC) regulation "Requirements for Full-Size Baby
Cribs" [Title 16, Part 1508] recommends that spaces between crib railings not exceed
- Inspect your crib mattresses to determine whether they are of adequate size.
The CPSC regulation for full-sized cribs in home use can be used as a guideline; it recommends
that mattress dimensions be no less than ¾ in (2 cm)
of the crib dimensions.
- Follow these interim steps for any manufacturer's
crib that presents the risk of entrapment or falling; these steps
allow positioning of patients who need to be inclined because of respiratory
or digestive difficulties or allow older children to sit up while eating,
reading, or talking with visitors:
- Position the mattress flat, and, if
possible, remove the crank. Because the crank on some cribs cannot
be easily removed, label the crib above the crank with a warning
that the mattress should not be adjusted.
- When the child's head or knees must be
raised, keep the mattress flat and use wedge-shaped patient
positioners in the crib. Such positioning devices should fit the
width of the crib.
- Do not use ordinary pillows to position the
child—the child may suffocate.
- If you have experienced a similar incident in which a child has become
trapped or has fallen, or if the spacing between the mattress springs and head, foot, or
side rails in any other manufacturers' cribs in your hospital exceeds 4² , follow the above recommendations and contact
Beds, Pediatric [10-362]
Cause of Device-Related Incident
Device factor: Design/labeling error
Mechanism of Injury or Death