CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Identifying Child Abuse Fatalities During Infancy Vincent J. Palusci, MD, MS, FAAP,a Council on Child Abuse and Neglect, Amanda J. Kay, MD, MPH, FAAP,b Erich Batra, MD, FAAP,c Section on Child Death Review and Prevention, Rachel Y. Moon, MD, FAAP,d Task Force on Sudden Infant Death Syndrome, NATIONAL ASSOCIATION OF MEDICAL EXAMINERS, Tracey S. Corey, MD,e Thomas Andrew, MD,f Michael Graham, MDg

When a healthy infant dies suddenly and unexpectedly, it is critical to correctly abstract determine if the death was caused by child abuse or neglect. Sudden unexpected infant deaths should be comprehensively investigated, ancillary tests and forensic procedures should be used to more-accurately identify the aSchool of Medicine, New York University, New York, New York; bDepartment of Pediatrics, Christiana Care Health Systems, cause of death, and parents deserve to be approached in a nonaccusatory Wilmington, Delaware; cDepartments of Pediatrics and Family and manner during the investigation. Missing a child abuse death can place other Community Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania; dDepartment of Pediatrics, School of children at risk, and inappropriately approaching a sleep-related death as Medicine, University of Virginia, Charlottesville, Virginia; eAssociate maltreatment can result in inappropriate criminal and protective services Medical Examiner, Florida Districts 5 & 24 Medical Examiner’sOffice, f investigations. Communities can learn from these deaths by using Leesburg, Florida; Consultant, White Mountain Forensic Consulting Services, Concord, New Hampshire; and gDepartment of Pathology, multidisciplinary child death reviews. Pediatricians can support families School of Medicine, St Louis University, St Louis, Missouri during investigation, advocate for and support state policies that require Drs Palusci, Kay, Moon, Corey, Andrew, and Graham conceptualized autopsies and scene investigation, and advocate for establishing this clinical report and each wrote sections of the draft; and all authors reviewed and revised subsequent drafts and approved comprehensive and fully funded child death investigation and reviews at the the final manuscript as submitted. local and state levels. Additional funding is also needed for research to This document is copyrighted and is property of the American advance our ability to prevent these deaths. Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. INTRODUCTION Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external More than 60 years ago, the medical community began a search to reviewers. However, clinical reports from the American Academy of understand and prevent the sudden unexpected deaths of apparently Pediatrics may not reflect the views of the liaisons or the healthy infants. Sudden refers to the fact that death comes without organizations or government agencies that they represent. warning, and unexpected means that there is no preexisting condition The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking known that could have reasonably predicted it. In an effort to further into account individual circumstances, may be appropriate. study and categorize these deaths, the term sudden infant death syndrome 1,2 (SIDS) was coined. Almost simultaneously, medical professionals To cite: 3–6 Palusci VJ, AAP Council on Child Abuse and recognized the realities of child abuse. Since then, public and Neglect, Kay AJ, AAP Council on Child Abuse and Neglect, professional awareness of sudden unexpected infant death and fatal child AAP Section on Child Death Review and Prevention, AAP abuse have increased, and well-validated reports of homicide and child Task Force on Sudden Infant Death Syndrome, NATIONAL abuse have appeared in the medical literature and in the lay press.7–9 The ASSOCIATION OF MEDICAL EXAMINERS. Identifying Child US Commission on the Elimination of Child Abuse and Neglect Fatalities Abuse Fatalities During Infancy. Pediatrics. 2019;144(3): e20192076 has noted significant undercounting of child abuse fatalities and has called

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 144, number 3, September 2019:e20192076 FROM THE AMERICAN ACADEMY OF PEDIATRICS for improved identification and primary category of death in vital examination, and reliable clinical prevention of these deaths.10 statistics for children between 1 and history; Differentiating deaths from abuse 12 months of age, with a peak 3. Other causes and/or mechanisms from sudden infant deaths that are incidence between 1 and 4 months of of death, including meningitis, unintentional, however, can be age, and with 90% of these before the sepsis, aspiration, pneumonia, fi 11–13 21–23 adif cult diagnostic decision. age of 6 months. Rates in 2013 myocarditis, trauma, dehydration, Clinicians and pathologists need an were 2 to 3 times higher among non- fluid and electrolyte imbalance, appropriately high index of suspicion Hispanic African American and significant congenital defects, of abuse, and additional funding for American Indian or Alaskan Native inborn metabolic disorders, fi improved identi cation and research children when compared with non- asphyxia, drowning, burns, and into the causes and prevention of these Hispanic white children (172.4 and poisoning, have been sufficiently fatalities is needed. This report updates 177.6 vs 84.5 deaths per 100 000 live excluded as a cause of death; a previous statement14 on the basis of births, respectively).22 Increased risk 4. Comprehensive testing has new publications from the American for SIDS has been found in revealed no evidence of toxic Academy of Pediatrics (AAP) and other epidemiological studies with prone exposure to alcohol, drugs, or updated research to assist in the and side sleep positions, prenatal and other substances that may have identification and prevention of child postnatal tobacco and opioid contributed to death; and maltreatment fatality. exposure, sleeping on a soft surface, sharing a sleep surface with others, 5. Thorough review of the clinical overheating, late or no prenatal care, history and death- and incident- SUDDEN UNEXPLAINED INFANT DEATH young maternal age, preterm birth, scene investigation have revealed 24–30 no cause of death. The term SIDS was introduced in the low birth weight, and male sex. fi 1960s as the medical community Breastfeeding, paci er use, immunizations, and room sharing attempted to better identify and define CHILD MALTREATMENT FATALITY the sudden, unexpected, and unexplained without bed-sharing have been fi deaths of infants and young children.15,16 identi ed as protective factors. There Child abuse causes and contributes to Throughout the ensuing decades, there is no evidence that recurrent infant death in a number of ways. In was an increase in the depth and breadth episodes of cyanosis, apnea, or data from the US National Child of autopsy procedures and ancillary apparent life-threatening events Abuse and Neglect Data System, it “ ” testing and sophistication and detail of (sometimes called near-miss SIDS was noted in 2016 that of the death investigation, including scene and now called brief resolved estimated 1750 child maltreatment 11 investigation and caregiver interviews. unexplained events [BRUEs] ) deaths, almost half involved infants Knowledge has increased about less- increase the risk. younger than 1 year, a rate of 20.63 per 100 000 children in the obvious causes of death, such as inborn Despite extensive research, our population younger than 1 year.31 errors of metabolism, primary cardiac understanding of the causes of 17,18 Most maltreatment fatalities are dysrhythmias, and occult seizures. sudden unexpected infant death attributed to neglect, with or without Coinciding with improved investigative remains incomplete.15 There have additional physical abuse. Factors techniques, there has been a diagnostic been varying guidelines published to identified in families with increased shift away from using SIDS as a cause of facilitate research and administrative risk for child maltreatment fatality death, and in its place, many medical purposes with a growing consensus include poverty, previous or current examiners and coroners classify infant that these deaths can be described as involvement with child protective deaths occurring in an unsafe sleep unexplained only when: environment as having an “undetermined services, unrelated male caregivers, 1. A complete autopsy has been cause” or “accidental asphyxiation in an and previous unexplained death or performed, including examination of unsafe sleep environment” because they nonaccidental trauma of other the cranium and the cranial contents, 32–37 cannot attribute these deaths with infants. In recent literature, it is and the gross and microscopic certainty specifically to the sleep suggested that natural or accidental findings fail to demonstrate an environment. Because of this diagnostic deaths are more commonly reported anatomic cause of death; shift, sleep-related infant deaths are now than child abuse fatalities, with often grouped as “sudden unexpected 2. There is no evidence of acute or approximately 3700 sudden – fl infant deaths.”19 21 remote in icted trauma, unexpected infant deaths in 2015 in significant natural disease, or the United States.16 However, deaths In the United States over a number of significant and contributory reported as child maltreatment years through 2015, sudden unintentional trauma as judged by fatalities are believed to be unexpected infant death is the radiologic imaging, postmortem underestimates, with more than triple

Downloaded from www.aappublications.org/news by guest on October 3, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS the number officially reported being infant’s death. Missing a child abuse also be explained by a heritable disorder estimated to occur.10,31 death can place other children at risk, that is undefined and/or unrecognized and inappropriately labeling a sleep- at the time of investigation, 2 separate Closed head injury is considered the related death as a homicide can result in leading cause of fatal abuse, with a peak and unrelated natural disease processes, an inappropriate criminal investigation incidence at 1 to 2 months of age, a time or an unrecognized environmental and possible prosecution. Comprehensive ’ period that overlaps with sudden hazard.Whenaninfants sudden medical evaluation, scene investigation, unexpected infant deaths.38 Several unexpected death has been thoroughly and autopsy are critical to improving findings, such as subdural hematoma, evaluated and alternate genetic, identification and reporting of the cause fl retinal hemorrhages, optic nerve sheath environmental, accidental, or in icted of an infant’s death.45 hemorrhages, rib fractures, and classic causes have been carefully excluded, metaphyseal lesions, have most Most sudden unexpected infant deaths parents can be informed that the risk in frequently been identified.39 occur at home. Parents are shocked, subsequent children is not likely Characteristics may include the absence bewildered, and distressed. Parents who increased. Parents can be given a clearly of a history of trauma as well as the are innocent of blame in their infant’s stated, honest, and forthright conclusion, absence of external evidence of impact death often feel responsible, even if that conclusion lacks the solidity to the head, skull fractures, subdural nonetheless, and imagine ways in which of a specificdiagnosis,suchas hemorrhage, or hypoxic-ischemic they might have contributed to or pneumonia or congenital heart changes. Some additional causes of child prevented the tragedy, and they often disease.55 Good communication with abuse fatalities have been found to be feel remorse, guilt, and fear of parents should include an adequate intentional asphyxia; abdominal, consequences.45 Grief and long-term explanation that “undetermined” simply thoracic, and other trauma; and effects of such stress are significant, means “unable to be determined” or “we poisoning.30 especially for remaining children in the do not know.” The term undetermined home.46–50 The appropriate ethical It may be difficult to differentiate does not necessarily imply that a death medical professional response to every among a natural infant death, an is suspicious and should not diminish child death must be compassionate, unintentional or accidental infant parental access to appropriate grief empathic, supportive, and death, and an intentional or neglectful counseling. It can be explained to nonaccusatory.51 Inadvertent comments infant death when findings of parents that the investigation might and accusatory questioning by medical maltreatment are absent. Parents have enable them and their physician to personnel and investigators are likely to been observed trying to suffocate and understand why their infant died and – cause additional stress. It is important harm their infants,7,40 42 and estimates how other children in the family, for those in contact with parents during of the incidence of infanticide among including children born later, might be this time to remain nonaccusatory and cases designated as sudden infant affected. to allow them to begin the process of death have ranged from 1% to 10%.43 grieving while a thorough death Certain circumstances in the medical Depending on local protocols and investigation is conducted. Concerns history can indicate increased risk for statutes, and if permitted by the about unsafe sleep and bed-sharing as intentional suffocation,44 including: medical examiner, the family may be ’ possible contributors to a child sdeath given a supervised opportunity to see • recurrent cyanosis, apnea, or should be shared with parents as and hold the infant and collect BRUEs occurring only while in the appropriate at some time during the materials once death has been care of the same person; investigation. The National Institute of pronounced.56 It is suggested that an • age at death older than 6 months; Justice and National Institute of unrelated professional remain with Standards and Technology have • previous unexpected or the family throughout this period to identified key principles and resources unexplained deaths of 1 or more serve as a witness should issues to assist medical examiners and families siblings; regarding postmortem artifacts arise. during investigation.51 • simultaneous or nearly Professionals need to have the many simultaneous death of twins; and The likelihood of a repetition of sudden immediate issues that require • previous death of an infant under the unexpected infant death within a sibship attention addressed, including 52–54 care of the same unrelated person. in the medical literature is unclear. baptism, grief counseling, funeral Although repetitive sudden unexpected arrangements, religious support, infant deaths occurring within the same resolution of breastfeeding, and the INITIAL MANAGEMENT OF SUDDEN family should compel investigators to reactions of surviving siblings. All UNEXPECTED INFANT DEATH consider the possibility of serial parents can be provided with It is critical to identify whether child homicide,8 it is important to remember information about sudden unexpected abuse or neglect has contributed to an that infant deaths within a sibship can infant death and how to contact the

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 144, number 3, September 2019 3 medical examiner’s or coroner’soffice and/or pediatric neuropathologist) can with inflicted injuries.66 It is also and local support groups.57–59 also be invaluable. Doll reenactment important to review medical history for has become an increasingly valuable any previous medical encounters that investigative tool, as well.61 included imaging that could show INVESTIGATION evidence of previous injuries or normal If standard and case-appropriate fi variants. Thorough documentation of all It continues to be dif cult to toxicology tests are not performed, distinguish fatal child abuse by autopsy sites of suspected skeletal injury may 60,61 infant deaths attributable to accidental require additional procedures, including, alone. Intheabsenceofacomplete 63 or deliberate poisoning will be missed. but not limited to, specimen resection, investigation of the circumstances of In 1 review of autopsies in the early death and case review, child high-detail specimen radiography, CT, 1990s, it was found that 17 (40%) of 43 and histologic analysis to assess aging. maltreatment is missed, familial and infants who died before 2 days of age genetic diseases go unrecognized, without an obvious cause of death at public health threats are overlooked, autopsy had toxicological evidence of PATHOLOGY inadequate medical care goes cocaine exposure.64 In a separate review undetected, product safety issues of 600 infant deaths, evidence of cocaine For infants who die suddenly and fi remain unidenti ed, and progress in exposure in 16 infants (2.7%) younger unexpectedly, the AAP and the National understanding the causes and than 8 months who died suddenly and Association of Medical Examiners have mechanisms of unexpected infant death 65 endorsed universal performance of 10,18,51,52,61,62 unexpectedly was revealed. Lethal is delayed. Athorough concentrations of opioids, cocaine, and autopsies by forensic pathologists investigation can remove the shroud of many other drugs are not well experienced in the evaluation of infant fi suspicion while maintaining good established in infancy, and blood and death and quali ed in forensic communication with families. liver concentrations must always be pathology by the American Board of Pathology. The forensic pathologist A comprehensive scene investigation is interpreted in the context of the complete investigation. performing the autopsy should have oneessentiallegofacompleteand access to specialists and reference 61 thorough infant death investigation. laboratories for consultation and fi Personnel on rst-response teams ancillary testing. Medical specialist fi POSTMORTEM IMAGING should have speci ctrainingtomake consultants may include but are not observations at the scene, including Radiographic skeletal surveys and limited to neuropathologists, position of the infant; marks on the computed tomography (CT) imaging ophthalmologic pathologists, pediatric body; pattern and distribution of livor performed before autopsy may reveal neurologists, cardiac specialists, mortis; rigor mortis; location of the evidence of traumatic skeletal injury or geneticists, pediatric pathologists, infant when found, including type of skeletal abnormalities indicative of pediatric radiologists, and child abuse bed, crib, or other sleep environment a naturally occurring illness. The pediatricians. Reference laboratories and any defects in it; amount and presence of both old and new traumatic may include but are not limited to fi position of clothing and bedding; room injuries as well as fractures speci cfor postmortem toxicology laboratories, fl temperature; type of ventilation and abuse may suggest in icted injuries and clinical pathology laboratories, and heating; and reaction of the caregivers. may lend focus to the postmortem laboratories screening for inborn errors Medics and emergency department examination, investigation of the of metabolism. Historically, postmortem personnel should be trained to circumstances of death, and police findings in cases of fatal child abuse fi distinguish normal ndings from investigation. Ideally, such imaging have included evidence of intracranial trauma attributable to abuse. Death should only be performed at the injuries, retinal hemorrhages, investigators should be trained and direction of the medical examiner or abdominal trauma (eg, liver laceration, skilled in the recognition of potentially coroner, and it is helpful for medical hollow viscous perforation, or important environmental features, such examiners and coroners to create intramural hematoma), fractures, as cigarette or other smoke, the protocols for this to occur. The skeletal bruises, burns, or drowning.67–69 presence of drugs or alcohol, sources of survey and/or CT scans should be carbon monoxide in the sleep room of performed according to American Testing for inborn errors of metabolism the deceased infant, or a wet bathtub or College of Radiology guidelines as is considered by many to be a routine infant bathing area. Appropriate recommended for living infants in ancillary test in the evaluation of an consultations by medical examiners whom abuse is suspected and reviewed unexplained infant death. When these and coroners with available medical by a radiologist experienced in deaths have occurred more than once specialists (eg, general pediatrician, identifying the sometimes subtle within a sibship, a thorough evaluation child abuse pediatrician, pediatric radiologic changes seen with abuse as to exclude or confirm an inborn error pathologist, pediatric radiologist, well as findings that may be confused of metabolism is essential.70 Analysis of

Downloaded from www.aappublications.org/news by guest on October 3, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS blood and bile may facilitate diagnosis death review teams have been could include, but would not be of a fatal inborn error of metabolism. established to review child fatalities, limited to, careful history-taking by Blood tests for evaluation of many and improved case identification and emergency responders and medical metabolic disorders are now available evidence for prevention strategies in personnel at the time of death with at low cost, and many states include many jurisdictions are offered in such transmission of this information to – testing for a number of metabolic reviews.76 78 The focus of such teams the medical examiner or coroner; diseases on their newborn metabolic varies, ranging from infant or child prompt investigation with doll screening panel. However, a negative deaths with accidental or homicidal reenactment of the scene at which newborn screen result does not manner to all childhood deaths from the infant was found lifeless or eliminate an inborn error of all causes. Many child fatality review unresponsive; careful interviews metabolism as the cause of death, so teams routinely review sudden of household members by additional postmortem testing may be unexpected infant deaths. Ideally, knowledgeable, culturally sensitive considered.Ifaninbornerrorof a multidisciplinary child death review professionals, such as police, death metabolism is suspected by autopsy team should include child welfare or investigators, prosecutors, and child findings (eg, hepatic steatosis) or child protective services, law protective services professionals history (eg, previous unexpected enforcement, public health, the who have the legal authority and deathsinchildhoodinthefamily),the medical examiner or coroner, mandate to conduct such forensic pathologist may elect to retain a pediatrician with expertise in child investigations; complete autopsy additional tissues such as brain, liver, maltreatment, a forensic pathologist, performed by a forensic pathologist kidney, heart, muscle, adrenal gland, a representative of the emergency within 24 hours of death, including and/or pancreas for further analysis. In medical services system, a pediatric examination of all major body any case in which the medical examiner pathologist, public health and school cavities, including cranial contents is unable to demonstrate an adequate officials, a local prosecutor, and other and microscopic examination of reason for death, a blood sample can be agencies pertinent to the case.79 The major organs; photographs; retained for potential future analysis. proceedings of these committees radiographic examination, including should be confidential and protected More recently, it has been suggested skeletal survey; toxicological and by appropriate state or local laws. that genetic mutations associated metabolic screening; collection of Sharing data among agencies should with cardiac rhythm disturbances, medical history through interviews be allowed to ensure that information such as prolonged QT syndrome, of caregivers and key medical in community systems can be used to catecholaminergic ventricular providers; and review of previous identify areas of prevention and to paroxysmal tachycardia, and others, medical charts. correctly attribute the cause of death. are responsible for up to 10% of • There should be consultations as In addition, surviving and subsequent cases of sudden unexpected infant needed with available local or siblings may need to be protected, death.71,72 In addition, associations in-state medical specialists (eg, and services need to be provided for with sleep suggest that sleep is pediatrician, child abuse family members to address the a significant risk factor for sudden pediatrician, pediatric pathologist, immediate and long-term effects of unexpected death in epilepsy and that pediatric radiologist, pediatric the death. A growing number of the prone position might be an neurologist) by medical examiners pediatricians and medical examiners important contributory factor.73,74 and coroners and consideration of and coroners in several jurisdictions Identification of a possible index case intentional asphyxia, especially in are currently receiving support from thus warrants referral of the family cases of unexpected infant death in the Centers for Disease Control and for comprehensive genetic counseling siblings and with a history of Prevention for a sudden unexpected and additional testing. However, the recurrent cyanosis, apnea, or BRUEs infant death case reporting system to cost of routine genetic testing may be witnessed only by a single caregiver. review cases using standard data beyond the capacity of some medical • collection forms and procedures.80,81 Pediatricians, other health care examiner’s or coroner’soffices, but it professionals, and investigators may be possible to obtain payment should maintain an unbiased, ’ RECOMMENDATIONS for genetic testing via the family s nonaccusatory approach to parents health insurance carrier. The following recommendations are during investigation and provide made to improve the identification of services or referral to address grief MULTIDISCIPLINARY CASE REVIEW child abuse fatalities during infancy: and stresses for surviving family Multidisciplinary case reviews of • A thorough assessment of each members. child fatalities have been unexpected infant fatality should • Because an investigation may recommended.75 In all states, child be completed. Such evaluation require an extended period of time,

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 144, number 3, September 2019 5 pediatricians can advocate and review systems at the local SECTION ON CHILD DEATH REVIEW AND for proper death certification and state levels. Pediatricians PREVENTION, 2018–2020 and prompt communication to can also advocate for additional Erich Batra, MD, FAAP, Chairperson parents and the use of consistent funding for research into the Carol Berkowitz, MD, FAAP diagnostic categories on death causes, identification, and Amanda Kay, MD, MPH, FAAP certificates as soon as possible after prevention of sudden unexpected Howard Needelman, MD, FAAP Timothy Corden, MD, MPH, FAAP review; work with families to obtain infant fatality. information from the medical examiner and offer to meet with STAFF LEAD AUTHORS families to review findings; reinforce Florence Rivera, MPH Safe to Sleep guidelines for other Vincent J. Palusci, MD, MS, FAAP children; and refer families to Amanda J. Kay, MD, MPH, FAAP TASK FORCE ON SUDDEN INFANT DEATH Erich Batra, MD, FAAP social services agencies as needed SYNDROME, 2016–2018 Rachel Y. Moon, MD, FAAP and for further assessment if Tracey S. Corey, MD Rachel Y. Moon, MD, FAAP, Chairperson potential inheritable conditions are Thomas Andrew, MD Robert Darnall, MD, FAAP identified. Michael Graham, MD Lori Feldman-Winter, MD, MPH, FAAP • There should be review of collected Michael Goodstein, MD, FAAP Fern R. Hauck, MD, MS, FAAP data and prevention strategies by COUNCIL ON CHILD ABUSE AND NEGLECT child death review teams with EXECUTIVE COMMITTEE, 2018–2020 CONSULTANTS participation of the medical Andrew P. Sirotnak, MD, FAAP, Chairperson examiner or coroner. Child death Emalee G. Flaherty, MD, FAAP, Immediate Carrie Shapiro-Mendoza, PhD – Centers for review teams at both the state Past Chairperson Disease Control and Prevention – and local levels should include CAPT Amy R. Gavril, MD, MSCI, FAAP Marion Koso-Thomas, MD Eunice Kennedy Amanda Bird Hoffert Gilmartin, MD, FAAP Shriver National Institute of Child Health and pediatricians who serve as expert Suzanne B. Haney, MD, FAAP, Chairperson- Human Development members in reviewing case files of Elect the medical examiner and other Sheila M. Idzerda, MD, FAAP STAFF agencies, particularly for deaths of Antoinette “Toni” Laskey, MD, MPH, children who were their patients; MBA, FAAP James Couto, MA Lori A. Legano, MD, FAAP information should be shared with Stephen A. Messner, MD, FAAP providers caring for the family to Bethany Anne Mohr, MD, FAAP NATIONAL ASSOCIATION OF MEDICAL the extent allowable by law. Rebecca L. Moles, MD, FAAP EXAMINERS Shalon Marie Nienow, MD, FAAP • Pediatricians should continue to Tracey S. Corey, MD Vincent J. Palusci, MD, MS, FAAP support the Safe to Sleep campaign Thomas Andrew, MD and the adoption of safe sleep Michael Graham, MD LIAISONS practices, child death review, and other strategies focusing on ways to Beverly Fortson, PhD – Centers for Disease reduce the risk of infant sleep- Control and Prevention ABBREVIATIONS Brooks Keeshin, MD, FAAP – American related and maltreatment deaths. Academy of Child and Adolescent Psychiatry AAP: American Academy of • Pediatricians can work with their Elaine Stedt, MSW, ACSW – Administration Pediatrics state AAP chapters to advocate for for Children, Youth and Families, Office on BRUE: brief resolved and support state policies that Child Abuse and Neglect unexplained event Anish Raj, MD – Section on Pediatric Trainees require autopsies for sudden CT: computed tomography unexpected infant deaths and that SIDS: sudden infant death establish comprehensive and fully STAFF syndrome funded child death investigation Tammy Piazza Hurley

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: https://doi.org/10.1542/peds.2019-2076 Address correspondence to Vincent J. Palusci, MD, MS, FAAP. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics

Downloaded from www.aappublications.org/news by guest on October 3, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on October 3, 2021 Identifying Child Abuse Fatalities During Infancy Vincent J. Palusci, Council on Child Abuse and Neglect, Amanda J. Kay, Erich Batra, Section on Child Death Review and Prevention, Rachel Y. Moon, Task Force on Sudden Infant Death Syndrome, NATIONAL ASSOCIATION OF MEDICAL EXAMINERS, Tracey S. Corey, Thomas Andrew and Michael Graham Pediatrics originally published online August 26, 2019;

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