investigation of child a team based approach -...

1

Investigation of Child Fatalities: A Team Based

Approach

Antoinette L. Laskey, MD, MPH, MBA

Professor of Pediatrics

Objectives

• Recognize leading causes of preventable deaths inchildren

• Describe a multidisciplinary approach to childfatality (or near‐fatality) investigations

Causes of Death in Infants (28 days to 11 months)1. SIDS

2. Congenital anomalies

3. Unintentional injuries

4. Diseases of the circulatory system

5. Gastritis

6. Homicide

2

Most Common Causes of Preventable Death in InfantsManner of Death: Accident

• Asphyxiation

• Fire

• Traffic

• Exposure (overheating)

• Drowning

Most Common Causes of Preventable Death in InfantsManner of Death: Homicide

• Abusive head trauma

• Physical abuse (smothering, beating, strangling)

• Drowning/poisoning

• Neglect resulting in death

Most Common Causes of Preventable Death in InfantsManner of Death: Underdetermined

• SUID

• SIDS

3

Terminology

• SUIDI: Sudden Unexpected Infant DeathInvestigation

• SUID: Sudden Unexpected Infant Death

• SIDS: Sudden Infant Death Syndrome

• SUID ≠ SIDS

• Co‐sleeping: sharing a room with a baby

• Bed‐sharing: sharing a sleep surface with a baby

*

Unsafe Sleep Deaths

Can be due to • Wedging

• Overlay

• Smothering

• Rebreathing/overheating

Determining the Cause and Manner• SIDS/SUID is a diagnosis that cannot be mademedically without key scene information

• This means DOCTORS cannot determine if this is the cause of death in the hospital or at autopsy without having other data!

4

SUIDI Team Players

Death Investigators• Law enforcement• Deputy coroners• Child Protection workers

• Pathologist

Witnesses and family• Placer• Last Known Alive• Finder

The Top 25

• National panel of forensic pathologists developed the Top 25

• Includes information that has to be collected by non‐medical investigators

• Includes information that has to be collected as soon as possible to the precipitating events

Death Scenes

• If an infant dies at the scene, the investigators areinvolved immediately and know what to do

If an infant makes it to the hospital, the death scene • May be in multiple locations

• May not be properly investigated due to delays inactivation of the system

5

Fatal Physical Abuse


Leading cause: Abusive head trauma

Second leading cause: Abusive abdominal trauma

May also be due to

• Poisoning

• Smothering/strangulation

• Weapons

• Burns

• Severe physical assault

• Drowning


• General scene information• Location of rooms and furniture

• Upkeep and condition of premises

• Any medications or potential poisons

• Presence of food (and access to food)

• Evidence related to event• Clothing

• Water (examples: tub, sink, water on floor)

6

Abusive Head Trauma

• Leading cause of inflicted trauma death <4 years

• Studies in international populations show shaking is more common than medically recognized

• >80% of head trauma deaths <2y are due to abuse

Victims

• Children less than 2 years of age• Highest risk between 6 weeks and 4 months

• Older children can be shaken hard enough to causeinjury

Risk Factors for Infants

• Normal infants cry for 2‐3 hours per day

• Research has shown 20‐30% of infants exceed this,sometimes substantially

7

Triggers

• “I didn’t want to choke him, but I wanted him tostop crying. I picked him up and I shook him; I threw him on the bed and he bounced…”

• “He was crying; it drove me crazy, I shook him…maybe 10 times and threw him on the sofa.”

Triggers

• “I had fits of anger. She would cry; sometimes, when she did that, I’d shake her…I got worked upand twisted her arm; I was slapping her hard for more than 2 months.”

• “I shook her so she’d be quiet, it lasted maybe 5 minutes; I was exasperated; I shook her up anddown…I was shaking her hard; I was crying just likeshe was and I was worked up.”

Intracranial Injury

• Shaken Baby Syndrome (SBS)

• Abusive Head Trauma (AHT)• Inflicted Traumatic Brain Injury (iTBI)

• Shaken Impact Syndrome (SIS)

• Whiplash Shaken Baby Syndrome• Non‐Accidental Head Trauma (NAT)

• Blunt force trauma to the head

8

Physical Vulnerabilities

• Big heads relative to body size• Child’s head is 10‐15% of total body weight

• Adult’s head is 2‐3% of total body weight

• Weak neck muscles

• Larger relative space between the brain and theinside of the skull

• Less developed brains than adults

Shaking and Impact

• There often is an impact• Baby can be thrown down

• Baby can be slammed into a stationary object

• We may not be able to tell there was an impact externally

• There is impact within the skull

Retinal Hemorrhages

• Not found in all cases

• 85% of fatalities

• Doesn’t predict severity

9

Retinal Hemorrhages

• Not all retinal hemorrhages are the same• Single layer are non‐specific

• Posterior pole are non‐specific

• Retinoschisis is specific for abuse

• Multi‐layer to the periphery are specific

Rib Fractures

• Most often posterior

• Acute may not be seen on initial x‐ray

• 10‐14 days for callus formation

• Squeezing mechanism

• Rarely bruising associated

Metaphyseal Fractures

• Only in patients <15m

• Difficult to see if images not collimated on the joint

• Due to forceful separation of the metaphysis from the shaft

10

Other Injuries

• May be no external injuries seen

Key Point

If a child presents with • Vomiting

• Lethargy

• New onset seizure

• Irritability

You must conduct a complete• History

• Physical exam

Trauma History

Ask

• Length of fall

• Landing surface

• Position baby landed

• Response of baby after trauma

• Response of caregiver after trauma

• Symptoms noted by any witness

11

Exam

Examine all of the skin • Document bruises, petechiae

Examine the mouth

• Document the labial and lingular frenula• Torn frenula are rare in non‐mobile infants

Key Point

You should consider

• Head CT or MRI

• Skeletal survey

• Blood counts

• Liver function

• Coagulations studies

• Dilated fundoscopic exam

Imaging

• Skeletal survey should be done according to theACR Guidelines (Google: ACR Skeletal Survey)

• Repeat the skeletal survey in 2 weeks to look for healing rib fractures (may leave off repeat skull, pelvis and spine films)

12

Key Point

• Abusive head trauma that is missed due to subtle initial presentation may result in further injury or death if returned to the caregiver who caused theinjury

Outcomes

• Approximately 1/3 of patients will die

• 1/3 have serious, life long morbidity

• 1/3 that look “normal” at discharge almost always have some level of behavioral, developmental or learning impairment manifest as they get older

Cases

• 6mo found not breathing in crib by boyfriend ofmom

• Claims fed normally then put down, checked on her 15 minutes later and found not breathing

• At hospital, found to have massive skull fracture, devastating brain injury, bruising and swelling over back of head

13

Cases

• 4m infant, reportedly laid on couch while mom’s boyfriend fixed her bottle in kitchen

• Returned to find baby being “shaken” like a toy by puppy

• Grabbed baby from puppy’s jaws and drove tohospital

• Baby had bleeding on the brain (subduralhemorrhage) and in the eyes

Second only to AHT

• 2nd leading cause of child abuse fatalities

• 40% fatality rate

Victims

Tend to be older than abusive head trauma victims

Triggers are slightly different• Discipline issues

• Toilet training issues

14

Types of Injuries

Most common injuries:• Transected or perforated duodenum

• Fractured or contused pancreas• Traumatic pancreatitis

• Liver contusion or fracture• Disseminated intravascular coagulation (DIC)

• Traumatic hepatitis

• Splenic rupture

Types of Injuries

Types of Injuries

15

Mechanism of Injury

• Kicks to the abdomen

• Punches to the abdomen

• “Jack‐knifing”—being thrown against an object andbending in half

• Body slams

Difficulty in Identifying Injury

If non‐offending caregiver isn’t present for the event, they may not be able to recognize the serious internal injury

• Symptoms are non‐specific• Vomiting

• Crying

• Abdominal pain

• Anorexia

Difficulty in Timing the Injury

Symptoms may slowly progress• Peritonitis

• Bleeding

• Infection

Symptoms may rapidly progress• Bleeding

• Shock

16

Key Point

• When considering the possibility of abdominaltrauma, consider concurrent injuries

• Skeletal survey, even in slightly older children (up to 36 months)

• Head injuries, especially in infants

• Cutaneous injuries: document all bruises

Key Point

Lab studies • Liver function tests: AST or ALT >80 indicate the possibility of a forensically relevant injury, even if it is not a clinically relevant injury

• Blood counts: consider risk of anemia and hypovolemiaas well as infection

Confusing Cases

Older children can have serious internal injuries from traumas like

• Seat belts

• Bicycle handlebars

• Being run over by a car

17

Confusing Cases

The key to understanding these cases is the history• History from the victim or witnesses if possible

• History from caregivers about symptoms

Poisoning

Poisoning

Increasing number of deaths nationally due to poisoning in children

Leading drugs• Methadone

• Fentanyl patches

• Methamphetamine

• Illicit drugs (all kinds)

• Over the counter cough and cold medications

18

Poisoning

• Cases frequently look like “SIDS” at autopsy, only discovered to be poisoning after tox screen comes back

• Better to assume possibility of poisoning from theoutset

Scene Considerations

• Evidence of illegal drug use or production

• Evidence of large quantities of prescription drugs

• Evidence of methadone

• Medications left out as if being currently used

Case

• 3mo infant found unresponsive face up in crib

• Sleep environment dangerous—pillows, blankets, stuffed animals

• None of these apparently near child on discoverythough

• Mom reports baby woke normally at 3AM, fedwithout difficulty and then went back to sleep

• Mom work at 11AM and realized baby hadn’t woken up around 8AM as usual

19

Case

• On entering the room, mom reports she “knewsomething was wrong” and ran to bedside

• Baby was cold to the touch and not breathing

• EMS finds infant in crib as mom described, fixedlividity posteriorly

• Documents “probable SIDS” and transports tohospital

• ED documents no injuries on exam, non‐viable infant

Case

• ED discharge diagnosis (and initial report to LE)“probably SIDS”

• Autopsy next day reveals no external or internal injuries, no clear evidence of suffocation

• Preliminary autopsy report is “undetermined/undetermined”

• Toxicology is sent

Case

• 4 weeks later, official toxicology report is received:• Oxycodone

• Methadone

• Scene investigation…• Mom has subsequently moved, unable to be located

20

Drug Endangered Children

• Remember—if you find drugs or paraphernalia inthe child’s home—they are drug endangered

• Parents who use are unable to effectively and safely parent

• Increased risk for children of all ages for physicalabuse, sexual abuse and neglect

• Increased risk of accidental ingestion

• Increased risk of being intentionally given drugs


• Children generally should not be drug tested unless they are exhibiting symptoms

• A negative drug test (including hair) does not meanthe child was not endangered or exposed


• Children DO need a medical evaluation by a primary care physician, preferably who knows them

• They need to be screened for growth, development, immunizations, unmet healthcare needs AND develop a continuity relationship

21

Drowning

Drowning

• 10 people die each day from drowning• 2 of these will be <14y old

• 2nd leading cause of death for children

1‐14y old

• For every child who drowns, 4 receive care for near‐drowning events

• Increasing number of autistic victims

• Survivors can have substantial neurological injuries

Drowning

Inside• Buckets

• Tubs

• Toilets

• Sinks

Outside• Pools/hot tubs

• Decorative fish ponds

• Natural bodies of water

22

Scene Investigation

Evidence of submersion• Wet clothes

• Wet surfaces

• Water where the submersion reportedly took place

Evidence of barriers • Locks on doors, fences

• Dog doors

• Barriers and ladders

Scene Investigation and Interview

• Evidence of supervision• Quality of supervision: Eyes on? Ears on? Arm’s length?

• Distractors

• Impairments

• Hand offs

Drowning

• It may not be possible to sort out an intentionalfrom an unintentional

• A tragic “accident” may have been preventable with appropriate supervision

• Consider: Was it neglect?

• Are other children at risk due to inadequate supervision+/‐ hazards in the environment

23

Summary

• Infants and children don’t die from the same things as adults

• Scene investigation and interviews must be broadfrom the beginning to not miss important clues

• Detailed histories of time courses and allsurrounding events are crucial

Summary

• Medical information can be confusing—finding someone who can be an interpreter is helpful

• Find out who is your closest child abuse pediatrician ormedical resource

• Talk with the medical examiner

• Talk to the child’s primary care physician

The Team Approach

Identifying fatal (or near fatal) child abuse is dependent on a multidisciplinary approach

• Medical professionals have critically necessaryinformation that investigators need

• Often, the diagnosis cannot be made with only medical information

24

The Team Approach

Medical providers should share • The history they have from the caregivers

• The medical information in terms that a non‐medical professional can understand

• Whether the injuries are consistent with the statedhistory

• Suspected timing based on the medical information• Remember: this answer may be “We don’t know”

The Team Approach

Investigators can provide the medical team• Scene information

• Scene photos

• Witness statements

• Caregiver statements

The Team Approach

When a child dies, more than one medical provider may be able to help the investigators

• First responders• Radiologists

• Surgeons

• Primary care physicians

• Forensic pathologists

25

The Team Approach

• Working together as a team helps a child tell their story

Summary

• Prevention is always the goal• We can’t turn back the clock on a death that has alreadyoccurred

• We may be able to prevent a future death—in thisfamily or another one in the community