Caring for infants and helping their families are among the great joys in pediatric practice. However, the sudden, unexpected death of an infant presents a difficult and stressful situation for everyone. Several agencies and investigators will become involved, potentially compounding grief and stress.
Pediatricians play a critical role in addressing the needs of parents and surviving siblings after an infant’s death, but they often lack the training and skills to respond effectively. When there are concerns of child abuse or neglect, this process becomes even more complex and difficult.
The AAP and the National Association of Medical Examiners offer help in the updated joint clinical report Identifying Child Abuse Fatalities During Infancythat expands on prior guidance. The report from the AAP Council on Child Abuse and Neglect, Section on Child Death Review and Prevention and the Task Force on Sudden Infant Death Syndrome is available at https://doi.org/10.1542/peds.2019-2076 and will be published in the September issue of Pediatrics.
After reviewing the history of our understanding of sudden infant death syndrome (SIDS), the report stresses the importance of determining whether an infant death was caused by child abuse or neglect. Missing a child abuse death can place other children at risk, and approaching a sleep-related death as maltreatment can result in inappropriate criminal and protective services investigations.
Guidance on investigations, response
Estimates of the incidence of infanticide among cases previously designated as SIDS range from 1% to 10%. The report outlines elements of the history and examination that can assist in making a correct determination. It recommends a thorough assessment, since there may be few findings when parents try to suffocate their infants.
To help pediatricians explain the investigation process to families, the report offers information on the postmortem examination, testing, imaging and other forensic procedures that are used.
The management of sudden, unexpected infant death also includes understanding how families can react and addressing their needs. Grief and long-term effects are significant, especially for remaining children in the home. Parents deserve to be approached in a nonaccusatory manner during the investigation, and the ethical and professional response to every child death must be compassionate, empathic and supportive.
Depending on the medical examiner or coroner system in a community, pediatricians may be called to facilitate communication with investigators and provide medical evaluation of surviving siblings and referrals for community services.
Teams need pediatricians, support
All states have child death review teams that evaluate child fatalities to improve case identification, services and prevention strategies. The report recommends that teams include pediatricians and work to improve community services to address the immediate and long-term effects of infant death.
Pediatricians should continue to support the Safe to Sleep campaign, child death review and other strategies to reduce the risk of infant sleep-related and maltreatment deaths.
Pediatricians also can work with their AAP chapters to advocate for and support state policies that require autopsies for sudden, unexpected infant deaths and that establish comprehensive and fully funded child death investigation and review systems at the local and state levels.
Dr. Palusci, a lead author of the clinical report, is a member of the AAP Section on Child Death Review and Prevention Executive Committee.
