Pediatric Strangulation: What You Need to Know
Written by Christine Foote-Lucero, Diana Faugno, and Kathy Bell   

Courtesy of the Academy of Forensic Nursing


This article appeared in the May-June 2021 issue of Evidence Technology Magazine.
You can view that full issue here.

NONFATAL STRANGULATION OF CHILDREN is often under-estimated, under-reported, and under-researched. This article will review pediatric head and neck anatomy that impacts risks related to strangulation; how child victims of strangulation commonly present; common exam findings; and any recommendations for the clinical evaluation of children.

Strangulation is defined as external pressure applied to the neck that compresses the internal blood vessels and/or airway (Faugno et al 2013). Significant trauma can occur as a result of this lack of blood flow to the brain or damage to the vessels or structures of the neck and airway. Most often, there are no outward, external signs.

Choking is different than strangulation. Choking is the blocking of a respiratory passage, such as with a grape or hotdog, preventing oxygen getting to the lungs. With complete occlusion, the person cannot speak, talk, or breathe. Persons that are choking will often clutch their throat or point to their throat and display panic.

Children may be strangled when caregivers lose control, as part of physical and/or sexual assault, or as a way of demonstrating ultimate power and control over the child (Training Institute on Strangulation Prevention 2019). Mechanism for pediatric strangulation can be different than the typical and common mechanism of manual strangulation that we see in adults. While it may be manual (including chokehold), it is also easier to lift children off the ground with their clothing, thus creating a ligature strangulation, which increases pressure and compression on neck.

Any child can be strangled, but nonverbal (less than three years old) and developmentally delayed children can certainly present challenges for law enforcement and health-care professionals as it may be more difficult to obtain an accurate history.

Any child can be strangled, but nonverbal (less than three years old) and developmentally delayed children can certainly present challenges for law enforcement and health-care professionals as it may be more difficult to obtain an accurate history. In addition, cognitive and developmental differences may make it difficult for a child to effectively describe the strangulation event. Children are most frequently strangled by the people they love and trust, and these perpetrators are more commonly female. As a result, children might be hesitant to disclose details of their assault if they feel they might cause trouble for a caregiver or loved one, especially when being questioned by law enforcement or health-care professionals (Baldwin-Johnson & Wiese 2015).

Pediatric patients have distinct differences in their anatomical structures when compared to adults. A child’s airway is smaller and therefore easier to occlude than an adult. Even relatively minor changes, such as neck flexion or mild swelling can completely occlude a child’s airway (Adewale 2009). Children also have a larger tongue size proportionately, and a narrower epiglottis that is softer and more horizontal until about the age of four to five years old (Adewale 2009). In addition, the muscle and ligament development in the neck is significantly less than that of adults and infants, and toddlers have a proportionally larger head and occiput relative to body size (Jain et al. 2001). Pediatric patients also have smaller nasal apertures, which can become easily obstructed by secretions, edema, or blood.

While there is no literature that discusses the implications of these anatomical differences during a strangulation assault, in general, the medical provider can infer that the pediatric airway is simply more susceptible to compromise. While research with children is limited, children can be presumed at greater risk of life-threatening injuries if strangled due to the variation in anatomy and physiology compared to adults. Pressures required to occlude blood and/or air passages are also likely less than in adults.

Typical symptoms reported by children include voice changes, sore throat or neck pain, difficulty breathing, and problems swallowing.

Typical symptoms reported by children include voice changes, sore throat or neck pain, difficulty breathing, and problems swallowing. Older children may report urinary and/or fecal incontinence. Children may report dizziness, chest pain, or a loss or near-loss of consciousness (Training Institute on Strangulation Prevention 2019). Be alert that a child may describe their symptoms in ways that are very different from an adult but are developmentally appropriate, such as “I talked like a duck,” “I saw sparkles in my eyes,” or “I fell asleep.” Some children may be able to articulate that they thought they were going to die.

Typical signs that may be assessed by a health-care provider evaluating the child can include petechiae of neck, face, or conjunctivae; bruising of neck, potentially patterned, from fingers or thumbs, ligatures, or clothing; defensive scratch marks on neck; abrasion patterns from jewelry or clothing on the neck; or other findings such as vision changes, oral injuries, or respiratory distress (Training Institute on Strangulation Prevention 2019).

“Strangled children and adolescents are at risk for serious and life-threatening injuries,” said Dr. Bill Smock, police surgeon for Louisville Police Department in a personal communication. “Based upon the medical literature, although rare, this group of patients is at risk for vertebral and carotid artery dissections, thrombosis of the carotid and vertebral arteries, stroke, and anoxic brain injuries. Fractures of the hyoid bone and the laryngeal cartilages occurs less frequently than in adults due to the flexibility of the structures. Vertebral artery dissections are more common in children than carotid artery injuries. Children, like adults, with undiagnosed vascular injuries are at risk for stoke days or weeks post incident. Documented symptoms of an impending or developing stroke from a vascular injury include: neck pain, headache, vomiting, facial paralysis, aphasia, ataxia, nystagmus, hemiparesis, syncope and vertigo.”

There is no conclusive evidence to support routine imaging in pediatrics at this time. However, “based upon a review of the radiological literature, the gadolinium enhanced MRI/MRA is the most sensitive procedure for the detection of vascular injuries in the carotid and vertebral arteries,” continued Smock. “Radiographic studies without the ability to visualize the arterial lumen, i.e. non-contrast CT and Doppler ultrasound, have a high false-negative rate and can miss intra-vascular injuries, especially in the proximal internal carotid and vertebral arteries. The recommendations that are being considered are MRI/MRA with gadolinium and CT with angiography (CTA).”

Upon “a review of the pediatric medical literature, the gadolinium-enhanced MRI/MRA is the most sensitive imaging study available. The CT with angiography (CTA) should also be considered if an MRI/MRA is not available within a reasonable amount to time,” concluded Smock.

The child’s physician will determine the need for imaging and must consider the benefits and risks of various options. Physicians may also consider a skeletal survey for children under five years of age.

A medical forensic examination with a specially trained forensic nurse should also be included. A complete and thorough evaluation should occur that includes a history for diagnosis and treatment; a full head-to-toe examination; a thorough head, eyes, ears, nose, and throat (HEENT) examination with assessment of cranial nerves, which will also determine if there are visual or auditory changes; a detailed intraoral assessment; photography and documentation of all injury findings; evaluation of the cardinal gazes; and a full set of vital signs to include pediatric Glascow Coma Score (GCS).

The forensic nurse should also check for ataxia, limb weakness, or other peripheral neurological signs such as restlessness, confusion, or irritability. The forensic nurse may determine there is evidentiary value in specimen collections, which many include swabs of the neck, fingernails, and a reference (buccal).

Discharge instructions should include thorough parent/guardian teaching, including a low threshold to return for medical care, which includes, but is not limited to, neck swelling, coughing up blood, weakness/tingling, lethargy, new or worsening headache, drooling, voice changes, and/or seizures. If the patient is not admitted, a follow-up visit should be scheduled for 24 hours after discharge. Ice packs for neck pain and popsicles for throat pain may also be including in the discharge teaching.

Case Study
Brian is a six-year-old boy who reports to school on Tuesday. The teacher notes bruises on the child’s face. She asks him what happened. The boy responds that his dad makes him talk like a duck when he is not good and that his neck is hurting. The teacher recognizes the concerns and suspicions for strangulation and knows that teachers are mandatory reporters. Child protective services and law enforcement are notified.

The child is brought to the child advocacy center for a forensic interview and a medical/forensic examination. Swabs are collected and photographs obtained.

Parents are ultimately charged with child abuse and the child is placed with grandparents. Parents are currently serving jail time. At last report, the child appears to be happy and well-adjusted with his grandparents.

In summary, strangulation does occur in pediatrics. While signs and symptoms are similar to adults that have been strangled, the reported symptoms from the child may not be as clearly described due to the cognitive and developmental differences in pediatric populations.

“Children and adolescents who are strangled, either accidentally or intentionally, are at risk for internal injuries including intra-vascular damage,” stated Smock. “Damage to structures in the neck, including arterial dissections, can occur even without visible external injuries. Arterial dissections are associated with significant morbidity and mortality. The undiagnosed carotid or vertebral artery dissection can result in embolic strokes, vessel thrombosis, brain damage and death.”

Image 1. Linear red marks on the left face and neck from manual strangulation by history.

Image 2. Negative inverted picture of Image 1. This is always shown side-by-side with the original RAW file.

Strangulation may be a component of a larger abuse picture. One must consider that in 2020, Covid-19 had an impact on individuals seeking treatment. This means that children experiencing strangulation and abuse might not be identified due to the isolation caused by homeschooling, as well as fear of virus exposure if brought to a hospital. Staff and program education is key in recognizing this potentially lethal form of abuse for children.

Figures 3 & 4. Three-year-old who is following directions for the non-fatal strangulation photodocumentation protocol with no injury or hemorrhages noted in the eyes/sclera.

About the Authors

Christine Foote-Lucero MSN, RN, CEN, SANE-A, SANE-P has been a licensed Registered Nurse in Colorado for 18 years, with a focus on critical care. She received a Bachelors of Science in Nursing at Creighton University in 2002 and a Masters of Science in Forensic Nursing in 2019. For the past decade, she has worked as a Forensic Nurse Examiner (FNE). She currently manages the FNE team at the University of Colorado Hospital (UCH) in Aurora, CO where she developed a robust FNE orientation program as well as education and training for on-going FNE performance-based competencies, clinical skills exemplars, and high-fidelity simulations. She has also created a Strangulation Pathway at UCH that serves as a clinical practice guideline for Emergency Providers.

Diana Faugno MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN, DF-AFN is a forensic nurse consultant in Dallas, Georgia and the founding president of the Academy of Forensic Nursing.

Kathy Bell MS, RN, DF-AFN joined the Tulsa Police Department in 1994. She provides the day-to-day operations management of the forensic nurse examiner programs. Bell is a forensic nurse, performing examinations for victims of sexual assault, domestic violence, elder abuse, and drug-endangered children. She is designated Distinguished Fellow and Founding Board member of the Academy of Forensic Nursing.


Adewale, L. 2009. Anatomy and assessment of the pediatric airway. Pediatric Anesthesia. 19 Suppl 1:1-8. doi: 10.1111/j.1460-9592.2009.03012.x

Baldwin-Johnson, C., and T. Wiese. 2015. “Strangulation in Children.” Responding to Strangulation in Alaska: Guidelines for Law Enforcement, Healthcare Providers, Advocates and Prosecutors. San Diego: Training Institute on Strangulation Prevention.

Faugno, D., D. Warzak, G. Strack, M. A. Brooks, and C. Gwinn. 2013. Strangulation forensic examination: Best practice for health care providers. Advanced Emergency Nursing. 35(4):314-327.

Jain, V., M. Ray, S. Singhi. 2001. Strangulation injury: A form of child abuse. Indian Journal of Pediatrics. 68(6):571-572.

Training Institute on Strangulation Prevention. 2019. Pediatric Strangulation. Retrieved from:

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