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;