Rebecca Moles, MD Amy Goldberg, MD Yale Child Abuse Program Aubin Child Protection Center

Yale School of Medicine Warren Alpert Medical School

New Haven, CT of Brown University

Providence, RI

No Financial Conflicts of Interest

Not Medical Examiners

Review SBS/AHT as a cause of infant death at home

Explain mechanisms of inflicted abdominal trauma

Define SIDS and SUID and their significance in the investigation of child deaths

Infants and children die from inflicted injuries

No external injuries ≠ trauma didn’t kill them

All medical providers need history to guide workup (alive or dead)

Collaborative information sharing is crucial

Maintain a high level of suspicion balanced with empathy and tact in the face of family tragedy

SIDS All infant/child deaths

without obvious cause

Medical Basics

◦Abusive Head Trauma

◦ Inflicted Abdominal Trauma

◦SIDS/SUID

These dead infants may all look the same initially

Baby Joey 3 month old infant home with mother’s boyfriend, mom working

BF calls 911 with “eyes rolled back”

911 instructs in CPR over phone

EMT/police to scene

Infant lifeless but was resuscitated

Intubated, lifeflight to ED

Subdural bleeding Many rib fractures Brain swelling Dies 2 days later

How can medical providers distinguish between accidental injuries and abusive injuries?

History ◦ Plausibility ◦ Developmental Ability ◦ Possible Mechanisms

Corroborating reports and statements. ◦ Witnesses ◦ EMS ◦ Law Enforcement ◦ Medical

Radiographic Studies ◦ Head CT/Brain MRI

◦ Skeletal survey

◦ Abdominal CT

Laboratory studies

Ophthalmologic exam

Violent rotational forces applied to the brain, frequently described as shaking. The shaking is sometimes followed by an impact.

May or may not result in external signs of injury

Normal

Retinal hemorrhages

Infants have no ability to protect themselves

Infants have large heads and weak necks

They cannot tell anyone if they are being harmed

Crying can cause adults to become angry with infants,

Compared 29 confession cases with 83 non-confession cases

Analysis of written statements ◦ Number of violent acts ◦ Delay between shaking and symptoms ◦ Child’s behavior after the violence ◦ Mechanism of the violence ◦ Head impact

“When I can’t calm my son I take him

under the arms and, holding him firmly,

I move him forward and back; I shook

him several times without realizing my

own strength. His head snapped back

and forth from time to time. After I shake

him like that, he’s tired and goes to

sleep. . . .” “He was crying; it drove me crazy, I

shook him . . . maybe 10 times, and threw

him on the sofa.”

“I shook her so she’d be quiet, it lasted

maybe 5 minutes; I was exasperated; I

shook her up and down, in front of me,

without holding her against me; I was

shaking her hard; I was crying just like

she was, and I was worked up.”

“I didn’t want to choke him, but I wanted

him to stop crying. I picked him up and I

shook him; I threw him on the bed and he

bounced on the sheet.”

Medical Basics ◦ Abusive Head Trauma

◦ Inflicted Abdominal Trauma

◦ SIDS/SUID

These dead infants all look same initially

Baby Zoe 3 month old infant

Mom brings child to ED

Baby turned blue and not right

Mom says father dropped baby 2 days ago

Had been fussy and teething

Abdomen distended

Very low blood pressure

Coded

Died in ED

Widely variable estimates of the % of physical

abuse cases (.5%-20%) 3%

40-50% fatal- the most lethal form of child abuse

Underrecognition

Organs- Liver, intestines, pancreas

Combination of mechanism- compression, vascular damage, shearing

Signs and Symptoms ◦ PAIN

◦ Vomiting

◦ Various degrees of shock

◦ +/- Abdominal Bruising-(<20%)

Silent Historian/No trauma reported ◦ Symptoms Only ◦ Sudden onset of unresponsiveness

Mild Trauma ◦ Fall ◦ Play ◦ Other children

Silent Child ◦ Too sick/young/scared ◦ “Distracting injury” ◦ Lack of abdominal bruising

Abuse- peak age 2-3 year olds ◦ Increased mobility… exploring

◦ Normal negativism

◦ Toilet training

Accidental- peak age 4-10 years old ◦ MVC

◦ Bicycle

◦ Fallsintrusive, focal application

With severe presentation (dead or almost dead) and a minor/no history ◦ Abuse must be considered

Even when no external signs of injury

Take home examples

Medical Basics ◦ Abusive Head Trauma

◦ Inflicted Abdominal Trauma

◦ SIDS/SUID

These dead infants may all look the same initially

Baby Aidan 4 1/2 month old infant home with parents

Grandma calls 911

Infant found in crib dead 5 hours after last feeding

No bruising

Parents distraught

Standard infant crib

7 yo sibling interviewed and no concerns

Autopsy unrevealing

Sudden Infant Death Syndrome

Description, not diagnosis

General public ◦ “baby died of some mystery illness while sleeping:

those poor parents”

Another thought ◦ “Is it really SIDS?”

CR

IB D

EA

TH

SIDS Family Studies

Research,

baby monitors

Suffocation

Back to Sleep

SUID

Medical Advances

Daw

n o

f T

ime

Child Abuse

1970’s

1990’s

Safe Sleep

1950’s

Current

Diagnosis of Exclusion ◦ Child < 1year

◦ Unexplained death

Case investigation

Autopsy

Death scene investigation

Clinical history

Hymel, KP and CoCAN. Distinguishing Sudden Infant Death Syndrome

from Child Abuse Fatalities. PEDIATRICS Vol 118, Number 1, July 2006,

421-427

“Most common cause of infant death between 1-6 mos”

90% cases occur under 6 months

Peak 2-4 months old

No autopsy finding is specific

+/- pink frothy mouth/nose secretions

Hymel 2006

Maternal smoking

Late or no prenatal care

Young mother/parent

Low SES

Unemployed parents

Prone/side sleep

Overheating

Co-Sleeping/Co-bedding

Cause ◦ Misclassification?

Prevention?

“Back to Sleep”

Familial/genetic issue?

No specific autopsy finding Lack of other findings Complete autopsy ◦ No skeletal bone trauma ◦ Neck ◦ Other medical causes excluded

Infection, cardiac issues, metabolic issues, others

◦ Need all info from caregivers and investigators

SIDS should never be diagnosed in the field SIDS should never be diagnosed in an

Emergency Department Diagnosis of exclusion, needs complete scene

investigation, autopsy “Near SIDS” cases should be assessed like

inflicted injury SUID

http://www.cdc.gov/SIDS/SUID.htm

Baby Jasmine 4 month old infant home with dad

Mom calls 911 after dad calls mom

Dad fell asleep holding baby

Baby not breathing

No bruising Parents distraught Standard infant crib

full of toys House shambles Dad smells of

alcohol Many

medications/pills in home

Autopsy nonspecific

Petechiae in thoracic cavity

Scene investigation and interviews crucial

Infants have a 40X increased risk of death if sleeping in adult bed

Other children, next pregnancy?

Baby should sleep in crib alone ◦ No live things

No parents

No siblings

No pets

◦ No inert things No pillows

No quilts

No comforters

No sheepskins

No stuffed animals

◦ Pacifiers

Only mom and baby in bed

No soft bedding/pillows

Not “excessively” tired

No alcohol or medications

Not on a couch or waterbed

Medical Basics ◦ Abusive Head Trauma

◦ Inflicted Abdominal Trauma

◦ SIDS/SUID

These dead infants all look same initially

Baby Joey

Baby Zoe

Baby Aidan

Baby Jasmine

Abusive Head Trauma

Abdominal Trauma

SIDS

Overlaying

Infants and children die from inflicted injuries

No external injuries ≠ trauma didn’t kill them

All medical providers need history to guide workup (alive or dead)

Collaborative information sharing is crucial for dead child and siblings

First responders often have CRUCIAL information