The game consists of two main variants. One can be a solo operation, using a necktie, belt or other type of binding to put pressure on the carotid artery in the neck. The other method involves a partner, who can apply pressure to the neck or chest until the subject passes out, cutting off blood flow to the brain.
Physician awareness of the problem remains too low, according to a paper published Monday in the January issue of Pediatrics. "The choking game may not be as prevalent as other [risky behaviors] like drugs, but the issue is, it can result in death," said Bass, one of the paper's authors.
Documentation is iffy - many deaths from the choking game can be mislabeled as suicide - but reports seem to be on the rise. In February 2008, the Centers for Disease Control and Prevention surveyed news stories from 1995 to 2007 and found 82 deaths that were likely the result of the choking game.
A 2007 paper on youth in Williams County, Ohio, reported that 11% of adolescents said they had played the choking game. That number did not include teens who thought better of admitting to it, nor those who knew someone who had tried it even if they hadn't themselves.
A survey of students published earlier this year in the journal Injury Prevention - performed in the wake of a student death at a Texas school - found that 68% of respondents had heard of the game and 45% knew someone who had "played."
The Internet has also raised the choking game's profile. A study published July in Clinical Pediatrics documented 65 YouTube videos of the game, which had collectively been viewed 173,550 times.
Bass' report in Pediatrics suggests doctors are not keeping up with the trend. Of 163 Ohio physicians who responded to Bass' survey, only 111 (68.1%) said they had heard of the game - mostly through popular media sources, not from professional education. Of those who knew about the game, only 7.6% reported having a patient who they suspected may have been engaging in the activity.
Children may not realize how dangerous the game is: The Injury Prevention paper found that 40% of students surveyed said they perceived no risk from it. That's why doctors should be aware, able to recognize its symptoms and educate patients, Bass said.
She said she now looks for tell-tale signs - unexplainable headaches, red marks dismissed as hickeys, bloodshot eyes, signs of depression.
The best way to deal with patients, she said, is to be straight with them. "I'll just come out and say, 'Have you ever heard of the choking game, and have you ever played it?' " Their reaction usually reveals all - then it's time for hard facts. "I just do a bit of education and say, 'Frankly, kids have died doing this,' " Bass said.
Paying attention to this issue among myriad others could be seen as a tall order, said Bass' coauthor Dr. Julie McClave, a pediatric resident at Rainbow Babies. Pediatricians are always fighting time and have to prioritize their talking points with patients: Safe sex, drinking while driving and drug use tend to take up the few minutes doctors have to educate older children about risk-taking behaviors.
Bass and McClave said they hope their paper will encourage more wide-scale study - and will prompt organizations such as the American Academy of Pediatrics to include information on symptoms, as well as tips for talking with patients, in its educational materials.