In cases of child deaths, the differentiation between natural and unnatural death is essential. However, in some cases this differentiation is rather difficult as children tend to injure themselves and are often involved in accidents. Therefore, with every atypical injury to a child, abuse or neglect must be considered and a forensic specialist should be consulted if there is any doubt. This article will provide an overview of findings, risk factors and prevention of sudden infant death as well as typical signs of child abuse.

sick-little-girl-in-bed

Image: “Sickies.” by Monica H. License: CC BY 2.0


Definitions

Sudden infant death syndrome (SIDS) is defined as an unexpected or inexplicable death of an infant while they are asleep without any obvious cause. The prerequisite is that despite an autopsy, no other cause could be determined, meaning it is a diagnosis of exclusion.

Brief resolved unexplained event (BRUE), previously referred to as “Apparent life-threatening event (ALTE)” is defined as a sudden, brief (less than one minute), and now resolved episode in an infant that includes at least one of the following features:

  • Cyanosis or pallor
  • Absent, decreased, or irregular breathing
  • Marked change in tone (hyper- or hypotonia)
  • Altered level of responsiveness

Epidemiology

In the United States, SIDS is the most common cause of death in infants after the first month of life.

Public Domain, https://en.wikipedia.org/w/index.php?curid=11768958

The incidence of SIDS has declined dramatically in the United States due to “Back to Sleep” campaign that encouraged non-prone sleeping. From 1988 to 2001, the SIDS rate has decreased from 1.4 to 0.56 per 1000 live births in the US. The same decline in SIDS incidence is observed in other nations that have encouraged non-prone sleeping.

The SIDS incidence also varies significantly within different racial and ethnic groups in the US. It is highest in American Indians and non-Hispanic black, while it is lowest in the Asian and Pacific Islanders.

By Benutzer41 – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=28699160

Sudden Infant Death Risk Factors

Multiple risk factors for SIDS have been identified. In the majority of affected children, at least one of the following risk factors would be present:

Maternal factors

  • Young mothers
  • Single mothers
  • Maternal smoking or drug abuse
  • Low socioeconomic status

Infant and environmental factors

  • Prone position while sleeping
  • Overheating babies who sweat excessively
  • Covered head
  • Bed sharing (sleeping in the parents’ bed)
  • Brief resolved unexplained event
  • Premature birth before the 33rd week or low birth weight.
  • Sleeping on a soft surface
  • Sibling of SIDS victim

Measures to Prevent SIDS

The most important preventive measure is the avoidance of risk factorsas many of the aforementioned risk factors are modifiable.

  • Baby should sleep in a supine position on a firm mattress in a sleeping bag on a separate bed but in the same room as of the parents.
  • Mothers should avoid smoking, alcohol, and illicit drugs during and after pregnancy.
  • The temperature in the baby’s room should be between 61 and 64º Fahrenheit (16-18°C).
  • There should not be any stuffed animals, blankets, comfort blankets or similar items that can cover the child’s face in the baby’s bed.
  • Breastfeeding until the sixth month of life also drastically reduces the risk of sudden infant death syndrome.
Note: Supine position, smoke-free, correct bedding!

Hypotheses Explaining SIDS

Multiple theories have been proposed to explain SIDS. The most probable one is multifactorial genesis in particularly vulnerable babies, in which internal and external factors work together.

In a majority of the cases, there is an initial hypoxia followed by progressive bradycardia and gasping for air. After several minutes, there are prolonged periods of apnea without adequate arousal reaction, causing the child to suffocate.

Common Postmortem and Autopsy Findings

Typically, the deceased child is in good condition and well fed. There are no external injuries or petechiae. Lips and nail beds are cyanotic. As the baby is usually found in prone position, livor mortis can be found on the front of the body. If the baby was lying face down, there is typically no livor mortis on the face. Moist bed sheets hint toward sweating. Foamy, bubbly secretion can be found in the airways and it is possible that vomit can be found in the mouth area.

In addition to that, the right side of the heart is often filled with blood and there may be associated pulmonary edema. In most cases, the deceased baby’s bladder is empty and signs of an acute infection can be found in the upper airways.

Differential Diagnosis

Since SIDS is a diagnosis of exclusion, all the natural and unnatural causes of death have to be considered in the differential diagnosis.

Natural deaths in babies can occur as a result of infections, metabolic disorders, malformations such as bronchopulmonary dysplasia, Reye syndrome as well as hyperthermia of internal etiology. These causes of death must be distinguished from unnatural deaths such as asphyxia, trauma caused by shaking, intoxication, neglect, and hyperthermia of external origin.

Child Abuse and Neglect

Definition and Background

Child abuse may be defined in broader terms as any injury (physical, emotional, sexual, or intellectual) inflicted upon a child by a parent or caretaker.

If child abuse is strongly suspected, this represents a justifiable mandatory reporting and a physician must breach patient-doctor confidentiality in the best interest of the child. A physician cannot be held legally responsible for reporting child abuse even if the suspicion cannot be proven, but a physician can be held legally responsible if he or she does not report suspected child abuse.

It is estimated that about 0.7 to 1.25 million children are abused or neglected annually in the United States, with around 18% of the cases involving physical abuse. Child abuse is also closely related to domestic violence and these overlap in between 30 to 60% of the cases. Mothers of abused children are also affected by violence in around half of the cases.

Types of Child Abuse

As children are often defenseless, there are many different methods of abuse. These include beating with or without tools, kicking, pulling hair, throwing or tossing, shaking, choking, thermal force such as burning, scalding, submerging in cold water, locking away, darkness, tying up, standing for hours, taking on painful positions, forcing to eat feces or vomit, hunger or thirst as well as sexual abuse.

tongue-with-a-pedicled-base

Image: “Lesion located on the tongue with a pedicled base” (5-year-old, sexually abused boy) by Openi. License: CC BY 2.0

Clinical Findings in Cases of Child Abuse

General findings in cases of child abuse are a compromised general condition (also referred to as psychosocial short stature), a great number of frequently occurring injuries, as well as the atypical location of the injuries along with untreated injuries. Frequently, there is a discrepancy between the findings and the statements made by the child or the guardian. In many cases, pediatricians or the treating clinics are changed and examination records are missing.

Note: Falls from a height of between three and five foot (100-150 cm), i.e., from the changing table, typically do not result in life-threatening injuries in babies and infants.

Typical localization of abrasions and hematoma:

Typical for falls Typical for abuse
Palms Back
Knee and shins Buttocks
Elbows Forearms
Nose, forehead, back of the head Eyes, lips, ears

Typical findings in thermal injuries:

 Accidental  Third-party cause
Irregular injury pattern  Uniform depth
Irregular margins Sharply demarcated, stocking or glove pattern burns due to immersion burns
Splash pattern  Missing trailing-off pattern

Shaken baby syndrome
Trauma caused by shaking, or shaken baby syndrome, is one of the most common causes of death in child abuse cases. In the USA, it is one of the causes of permanent mental disability. It is common in small children, less than three years of age. The caregivers violently shake the baby in frustration especially when the baby cries inconsolably.

Typically, shaken baby syndrome consists of the triad of subdural hematoma, retinal bleeding, and diffuse severe brain swelling. The external injuries are typically absent. As far as differential diagnosis is concerned, other causes to be considered can be ruled out by simultaneous fractures of long hollow bones and histological findings of diffuse axonal damage.

Subdural-hematoma-MRT

Image: “Subdural hematoma on MRI” by Hellerhoff. License: CC BY-SA 3.0

Other common findings are finger marks on the baby’s shoulders, arms and thorax. When presenting at the clinic, symptoms are lethargy, vomiting and cramps caused by the increasing pressure in the brain. The diagnosis is made via babygram (an X-ray of the entire body of the infant), skull CT and ophthalmic examination.

retinal-hemorrhage

Image: “Retinal hemorrhage” by Openi. License: CC BY 2.5

Battered child syndrome

Battered child syndrome is the term for X-ray findings in children who are battered. Classical findings are periosteal reactions such as collar formation on the long hollow bones, epiphyseal detachments and simultaneous rib fractures (in part with callus formation).

Multiple-Rib-Fractures

Image: “Fractures of ribs in an infant” by National Institute of Health. License: Public domain

Behavior patterns in abused children

  • Anxiety, jumpiness
  • Compliance, even apathy
  • Depression and tension
  • Seeking help and clinging behavior, overly friendly toward strangers
  • Provoking behavior
  • Observing behavior, alertness

Munchhausen Syndrome by Proxy

Munchhausen by proxy syndrome, or factitious disorder, constitutes exaggerating, fabricating or causing symptoms in third parties, mostly children, in order to force medical attention. This artificial disorder usually affects one parent, whereby the mother is affected in significantly more cases.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) uses the term “factitious disorder imposed on another”. This term includes fabricated or induced illness in an adult, children or pet, and is not specific to the children.

According to Rosenberg, four diagnostic criteria must be met to confirm the diagnosis:

  1. The child’s illnesses are simulated, caused or maintained by a reference person.
  2. The child is repeatedly presented to physicians and subjected to medical diagnostics and treatment.
  3. The true cause of the child’s symptoms is not given when presenting the child.
  4. The child’s symptoms and medical conditions vanish once he/she has been separated from the individual causing them.

Among the simulated symptoms are usually illnesses that are difficult to verify, such as epileptic seizures. Children are also intentionally poisoned or almost suffocated and subsequently presented to the emergency room in order to be praised as the savior.

It is typical that the affected individuals have medical knowledge or even work in the medical field. Therefore, they do not draw attention due to implausible statements, but rather after frequently presenting the child or, in cases where the perpetrator is a nurse, the children getting sick frequently or even dying during their shift. The cause of this disorder is attention seeking.

Child Murder

False statements in cases of child murder frequently constitute falls, accidents or alleged stillbirth. While the first two can be identified via the aforementioned information concerning child abuse, the differentiation between stillbirth and postnatal murder is often difficult, as only a little force is needed.

Signs that a newborn was alive:

  • Positive lung float test according to Schreyer (caution: the lung float test is falsely positive with decay, meaning that the liver float test is usually positive as well, with frozen lungs and after reanimation attempts; it is falsely negative in births in liquids)
  • Positive float test of segments of the gastrointestinal tract
  • Navel demarcation

Signs that a baby is newborn:

  • Vernix caseosa in skin folds in the groin area and the arm pits
  • Dried blood in hair and on the skin
  • Possible birth trauma (cephalohematoma)

Popular Exam Questions Regarding Sudden Infant Death Syndrome and Child Abuse

The answers are below the references.

1. Which of the following is not a risk factor for sudden infant death syndrome?

  1. Passive smoking
  2. Male gender
  3. Sleeping in parents’ bed
  4. Sleeping without a blanket
  5. Premature birth before the 33rd week

2. A six-year-old boy is presented to the emergency room by his mother. She states that her son and his little sister had spent the day with their father and that she noticed a circular red mark with some bleeding in the neck area when giving the children a bath. When questioned, the boy reacts scared and tells his mother and the pediatrician that his two-year-old sister had thrown a block at him. Which of the following applies to this case?

  1. The mother suffers from Munchhausen by proxy syndrome.
  2. The boy most likely suffers from a personality disorder and has inflicted the injury himself.
  3. There is the urgent suspicion that the father is guilty of child abuse.
  4. The boy’s statement is plausible in light of the injury pattern.
  5. The fact that the boy is scared in his mother’s presence is an indicator that she is the one who injured him.

3. What is not a typical finding of shaken baby syndrome?

  1. Retinal bleeding
  2. Subdural hematoma
  3. Cerebral edema
  4. Finger marks in the head and facial area
  5. Diffuse axonal damage

References

S1-Leitlinie Plötzlicher Kindstod der Deutschen Gesellschaft für Schlafforschung und Schlafmedizin (DGSM). In: AWMF online (Stand: 31.01.2012 , gültig bis 31.01.2017)

Deeg, K.-H., Reisig, A.: „Dopplersonografisches Screening der Blutströmung in der Arteria basilaris während Kopfrotation reduziert das Risiko für den plötzlichen Kindstod. “ Ultraschall Med 31, 2010

Kinney, H. C. et al.: Serotonergic brainstem abnormalities in Northern Plains Indians with the sudden infant death syndrome. In: J Neuropathol Exp Journ, 2003

Paterson, D. S. et al.: Multiple serotonergic brainstem abnormalities in sudden infant death syndrome. In: JAMA, 2006

Bohnel, H. et al.:Is there a link between infant botulism and sudden infant death? Bacteriological results obtained in central Germany. Eur J Pediatr. 2001

Helfer, M. E., Kempe, R. S., Krugman, R. D.: Das mißhandelte Kind. Körperliche und psychische Gewalt; Sexueller Mißbrauch; Gedeihstörungen; Münchhausen-by-proxy-Syndrom; Vernachlässigung, 2002 – Suhrkamp

Herrmann, B., Dettmeyer, R., Banaschak, S., Thyen, U.: Kindesmisshandlung, 2. Auflage (2010) – Springer Verlag

Deegener, G., Körner W. (Hrsg.): Kindesmisshandlung und Vernachlässigung (2005) – Hogrefe

Dettmeyer, R. B., Schütz, H. F., Verhoff, M. A.: Rechtsmedizin, 2. Auflage (2014) – Springer Verlag

Correct answers: 1D, 2C, 3D

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