Department of Pediatrics, The Evanston Hospital, Evanston IL, and Northwestern Medical School, Chicago IL
I have to admit that, despite growing up with 2 brothers, being in a fraternity during college for 4 years, 4 years in medical school, 3 years in residency in pediatrics, being in practice for the past 17 years and the father of 4 children (age range from 11-23 years of age), I have never heard of a popular child's game known by various names including "pudgy bunny" or "chubby bunny." Why bring the subject up? The reason is that a previously healthy 6th grade girl , who was in the midst of playing this game, developed acute, complete upper airway obstruction and, despite the best efforts of caretakers, was unable to be resuscitated (1).
A renowned Chicago Tribune columnist called the girl's father and talked with him. The column, entitled "Tragedy a signal that game only sounds harmless" was published in the newspaper on June 14, 1999 and was discussed on at least 2 TV channels that same day. (2) The father's purpose was "to get the word out about this potentially deadly 'game.'" The purpose of this communication is to do the same internationally.
Description Of The "Game" And Case Review
The game and its variations, which are played by children in many age groups, is played as follows: You stuff your mouth with as many marshmallows as humanly possible and then attempt to speak. If the child is able to say the words, "chubby bunny," then the child puts another marshmallow into his or her mouth; those who are not able to speak are out of the game. In addition, the rules are very specific and players are not allowed to chew and/or swallow; if they do, they are disqualified. The winner is the child who can say "chubby bunny" with the highest number of marshmallows in his or her mouth.
In this case, she was playing the game at a school's annual fair and started laughing after apparently stuffing one too many marshmallows into her mouth. Then she made a motion, could not speak and made her way to the drinking fountain. As she walked, her color began to change from dusky to cyanotic. Shortly thereafter, she collapsed. The paramedics arrived within 5 minutes and quickly suctioned her airway and successfully intubated her. On physical examination, she was cyanotic, unresponsive and apneic, therefore, positive pressure ventilation was initiated by the paramedic. An intravenous line was placed in a timely fashion by another of the paramedics. Her heart rate on the monitor revealed an idioventricular rhythm. Despite everyone's best efforts, she could not be resuscitated. After the endotracheal tube was placed, pink to red fluid literally bubbled out of the tube, so much that suctioning failed to ever completely clear the airway.
Contrary to the adult literature, which has documented that cardiac abnormalities are the most common cause of out of hospital arrest, in children, a respiratory event is by far the most common event and, if the patient becomes asystolic, it becomes unlikely that resuscitation will be successful. (3,4) After an extensive investigation, the school district office provided a press release with a cover letter. The Medical Examiner's Office determined that the cause of death to be choking.
The tremendous outflow of pulmonary edema fluid in this case probably resulted from the relief of acute upper airway obstruction. The following changes are postulated to occur during the obstruction: a) increases in pulmonary blood flow occur with subsequent changes in intravascular pressure in the pulmonary vascular bed resulting in increases in hydrostatic pressure, b) increased fluid shift into the alveoli, c) subsequent alveolar hypoxia. Once the obstruction is relieved, acute changes in vascular permeability in the pulmonary vascular bed result in florid pulmonary edema and the difficulty of successfully ventilating the patient. This phenomenon has been reported to occur in croup, epiglottitis or supraglottitis (3,4). In the pediatric literature, patients most frequently survive with vigorous supportive care including mechanical ventilation, positive end expiratory pressure, close attention to fluid balance and the potential use of diuretics (5). [Editors note: there are several possible explanations for this unusual phenomenon; a complete discussion of the pathophysiology will be forthcoming in a follow-up article.]
In conclusion, physicians need to be aware of the possibility of pulmonary edema with the relief of acute upper airway obstruction. Even more importantly, the evidence in this case and a review of the literature behooves us to "get the word out" that the "chubby bunny" game be eliminated at any age. Anything short of that would be unacceptable.
The information about the "Chubby Bunny" game including a videotape was provided by Dr. Gail Shorr, one of my pediatric colleagues. The family of this child has reviewed this article and has consented to its electronic publication.
- Press release with cover letter distributed by the Glenview Public School System detailing the events surrounding the death of "Casey Fish.". June 23, 1999
- Zorn E. "Tragedy a signal that game only sounds harmless" published on June 14th, 1999 in the Chicago Tribune.
- Pediatric Advanced Life Support Instructor's Manual. Quan L, Seidel J, Henderson D et al. eds. American Heart Association and American Academy of Pediatrics, 1995. (Chapter 4, p.4-1.)
- Travis K, Todres I, Shannon D. Pulmonary edema associated with croup and epiglottitis. Pediatrics 1977;59:695-698.
- Kendig's Disorders of the Respiratory Tract in Children. Chernick V, Kendig E, Jr. eds. Philadelphia: W.B. Saunders, 1990. p 348.
Accepted for publication August 24, 1999
Original publication, revised and reprinted with permission: Illinois Pediatrician 1999; 17(3): 4-5.