CHILD FATALITIES
Child fatality may be the result of repeated abuse, a single act, or a failure to act. As an
investigator, you collect the information and evidence that can identify a cause of death in a
child.
Natural Deaths (See “Causes of Natural Death in Children”)
Death can occur as a result of genetic and/or metabolic causes, complications from being born
prematurely, or complications of cerebral palsy or Down syndrome. Natural deaths can be
divided into causes related to the different systems of the body such as the central nervous
system, cardiovascular system, respiratory system, and gastrointestinal system. Natural death
can also be infectious disease related.
In all cases, it is important to obtain all medical information on the child and family, including
the birth records. Ask if trauma occurred during the birth of the child and if the mother abused
drugs and/or alcohol during the pregnancy.
Accidental Deaths (See “ Causes of Accidental Death in Children”)
Obtain any pertinent medical information and information about the scene. Thoroughly
document the scene with photographs and document the witness(es) and/or family
statements.
When plausible, use a doll to reconstruct how the child was discovered.
Smothering
Smothering is a form of suffocation where the nose and mouth are compressed and/or blocked,
preventing breathing. Smothering can occur when someone places a hand or object over the
child’s mouth and nose, places tape or other adhesive material over the face, or by
compressing the nose and mouth by other means. Smothering is most often intentional;
however, it can be accidental or unintentional.
Suffocation can accidentally occur when a blanket or other bedding material obstructs the
airways, when a bag is accidentally placed over the head by a child, or when someone
accidentally covers the child while sleeping.
Scene examination is crucial in suspected cases of smothering since there are usually few, if
any, autopsy findings.
Search for bloody fluid on items around or near the body and take multiple photographs of the
scene. Make sure to take statements as to what occurred and take anything that may be useful
as evidence in the investigation.
In the case of a struggle, there may be tears and contusions of the oral cavity (including the
lips), abrasions on the head and face (especially around the nose), blood from the nose, and
there may be fractures of the nose. When there is no struggle, the scene examination,
investigation, and statements become even more important as evidence.
Shaken (Baby) Impact Syndrome
In 1972, the term “shaken baby syndrome” was used for a diagnosis in which the children had
been violently shaken. Some believe that shaking alone will not cause the injuries to the brain
and adjacent tissues, whereas others still believe that shaking alone can cause trauma-induced
hypoxic-ischemic injury to the brain as a result of apnea, hypotension, bradycardia, or seizures
possibly due to strain at the junction of the brain with the neck or other regions of the brain or
spinal cord.
As a result of this controversy, the term shaken baby impact (shaken-impact) syndrome
encompasses both mechanisms of injury for this syndrome.
With shaken-impact syndrome there is forceful shaking, making the head jerk back and forth
followed by some type of impact against a surface such as a wall, floor, a piece of furniture, or
even a bed.
The typical case involves an infant less than six months old. External injuries are seen in about
25% to 50% of the cases and most commonly there are “fingertip” contusions on the arms and
chest.
Findings or markers associated with shaken baby syndrome are:
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Subdural hematoma (bleeding in the area between the dura mater and the arachnoid
mater of the brain)
Subarachnoid hemorrhage (bleeding into the area between the arachnoid mater and the
pia mater surrounding the brain)
Cerebral edema (the accumulation of fluid and swelling of the brain)
Retinal hemorrhages and associated hemorrhages of optic nerves (the bleeding of the
blood vessels in the retina and the optic nerves)
Usually there are no skull fractures, bruises, or cuts on the scalp. In cases involving impact,
there is often bleeding below the scalp associated with skull fracture.
Whether the shaking alone or the impact with the shaking causes these injuries is still unclear.
Some witness accounts and confessions that only shaking took place. As a result, some
pathologists record the cause of death as due to craniocerebral injuries (injuries to the skull and
the brain) or abusive head trauma.
Sudden Infant Death Syndrome
In 1989, the Second International Conference on Causes of Sudden Death in Infants defined
Sudden Infant Death Syndrome (SIDS) as:
…the sudden death of an infant under one year of age which remains unexplained after a
thorough case investigation, including performance of a complete autopsy, examination of
the death scene, and review of the clinical history.
Though the cause of SIDS is not definitely known, we do know it is not genetic or hereditary.
However, there are risk factors that increase the occurrence of SIDS. Children who die of SIDS
are usually between two and four months of age (95% of cases are less than 6 months of age)
and have a low birth weight, a shorter gestation period, and neonatal problems at delivery.
Children who are born to a mother who had multiple births in a short period of time, is of a
young maternal age, and/or who smoked during and/or after pregnancy are at a greater risk for
SIDS.
External finding of a SIDS child may include a normal appearing infant with good nutritional
status and clenched hands, but nothing is suggestive of SIDS. Froth or foam may be coming
from the nares; however, it is usually minimal and occasionally may be blood-tinged.
Information that you should obtain from the caregiver at the scene or from evaluation at the
scene should include:
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Conditions of the sleeping area (e.g. clutter, toys, blankets)
Whether the child was sleeping alone, in a crib, on a bed, or in a bassinet
Whether the child was breast-fed. If so, collect a sample of the breast milk for toxicology
testing.
Whether items were defective items, such as a defective crib, swing, or playpen. Report
defective items to Consumer Product Safety Commission.
You should thoroughly examine the scene, record the room temperature and body
temperature, and look for bright red blood on the infant. Confirm who placed the child in the
position or how the child got into the position and how/when the child was found. Ask if CPR
was performed and have the individual who performed CPR demonstrate how it was done on a
doll. Ask about any co- sleeping and whether the person sleeping with the child had been
drinking alcohol and/or using drugs/medications.
It is important to obtain:
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Birth and prenatal records
Information about medications/prescriptions
The child’s growth and development pattern
Medical records (e.g. visits to the pediatrician and/or emergency room)
Take the bedding and sleep surface as evidence. Make sure to record unsafe sleeping
conditions, as autopsy alone will not rule out types of asphyxial death.
Beatings
Beatings, or deaths due to blunt force trauma in children, include injury to the chest, abdomen,
and/or head. Beatings are usually related to a child not doing what the caretaker has told them
to do or failing to meet expectations related to bedtime and using the restroom.
The most common injury in children is soft tissue injuries. Trauma to the skin is often the first
indication of abuse. However, you should always keep in mind that some contusions can only
be seen internally at autopsy. Children can die of loss of blood in the soft tissues from a beating
or beatings.
Be suspicious of contusions in children who are less than nine months old, injuries other than
contusions, such as abrasions or scratches, if the injuries are in unusual locations for a child of
that age, or when there are multiple contusions on multiple areas of the body, such as 15 or
more contusions.
Contusions suggestive of abuse/beating are seen along the chest, lower back, buttocks,
genitals, inner thighs, upper arms, and face, especially the cheeks, earlobes, and lips.
Contusions that are symmetrical or patterned are rarely accidental, and the bruises of a beating
are often different ages (colors), suggestive of prior abuse. Contusions may result from
gripping, pinching, slapping, and biting.
Look for patterned contusions on the arms or legs where the child has been gripped tightly with
fingertips or contusions consistent with the child being hit with a belt or coat hanger.
Head injuries are the most frequent cause of traumatic death
in pediatric cases as children can have serious and fatal brain injuries from accidents and
inflicted head trauma.
Abdominal injuries are the second most common cause of death in child abuse cases.
Injuries to organs in children are not common, and, when they occur without any trauma, like a
motor vehicle accident, intentional trauma should be suspected. Intestines can be
perforated, the pancreas can be injured, and there may be laceration with hemorrhage of the
liver. Death from blunt abdominal trauma may not occur soon after the injury, but rather from
complications from peritonitis (inflammation of the lining of the abdomen).
The most common internal injury in the thoracic (chest) area in children is pulmonary
contusion.
Fractures commonly seen in child abuse are metaphyseal fractures (fractures in the lower
limbs), rib fractures, scapular fractures, vertebral fractures, multiple fractures of different ages,
complex skull fractures, and fractures of digits in a child who is not able to walk yet.
Fractures involving the shaft of a long bone (femur, tibia, fibula, radius, and ulna) are the most
common fractures of abuse. Rib fractures, skull fractures, and metaphyseal fractures are more
commonly seen in a child less than one year old, whereas fractures of long bones are more
commonly seen in a child older than one year.
Questions to ask concerning a child who has fractures include:
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Does the account of the injury seem possible or plausible?
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Was medical care sought promptly?
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Are there any old fractures and if so, how did the fractures occur?
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Are the fractures of various ages?
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Does the child visit the hospital or doctors office regularly for treatment?
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Does the child have some predisposing condition to enable ease of fracturing?
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Does the injury fall under abuse?
Also look for burns on the body, which may be consistent with cigarette burns.
Ask the caregiver the following questions:
• Has the child had any recent or old falls? If so, ask when the fall(s) happened and how the
fall(s) occurred.
• How was the child doing after the injury occurred?
• Did others besides the caregiver see the incident or were children around when it occurred?
• Was CPR performed? If so, has the caretaker been trained?
• Was EMS called to the scene? If so, what actions were taken.
Ask the caregiver for the explanation for the injuries and then ask yourself if the
story/explanation is consistent with the findings.
Scene examination is crucial and should be thoroughly documented with photographs.
Make sure to take anything that may be useful as evidence in the investigation or that may
have been used for the beating.
Consider all information that is obtained, such as:
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Crime scene
Body of decedent
Statements
History (medical and Child Protective Services [CPS])
Determine if the information and statements given is consistent with what is seen on the child
and observed at the scene. Secure any object(s) that may have been used in the incident.
Process objects as evidence, performing necessary testing and bringing the object to the
autopsy for comparison purposes with findings noted during the postmortem examination.