Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  1  of  8  

Unusual Child Deaths

Andrew Baker, MD Hennepin County Medical Examiner

Minneapolis, MN

SIDS The decedent was a previously healthy, 5-week-old boy who was home alone with his mother when he was found unresponsive, prone, in his bassinet. Emergency medical personnel arrived and transported the child to the emergency room, where he was pronounced dead. A complete autopsy was performed, and no injuries or natural diseases were identified. Two years later, the previously healthy, 6-week-old daughter of this same mother died while she was in the sole care of her mother. References: Bergman AB. Wrong turns in sudden infant death syndrome research. Pediatrics 1999; 99: 119-120. Bohnert M, Grosse Perdekamp M, Pollak S. Three subsequent infanticides covered up as SIDS. Int J

Legal Med 2004; 119: 31-34. Corey TS, Schluckebier D. Physical findings in confessed homicidal suffocation of children: A case series.

Abstract presented at the American Academy of Forensic Sciences annual meeting, Chicago, 2003. Dix J. Homicide and the baby-sitter. Am J Forensic Med Pathol 1999, 19(4): 321-323. Firstman R, Talan J. The Death of Innocents: A True Story of Murder, Medicine, and High-Stakes

Science. New York, Bantam Books, 1997. Krugman RD. Unimaginable images: seeing is believing. Pediatrics 1997; 100(5): 890-891. Meadow R. Sudden infant death and suffocation [letter]. BMJ 1989; 299:455. Meadow R. Suffocation and sudden infant death syndrome [letter]. BMJ 1989; 299:179. Meadow R. Suffocation, recurrent apnea, and sudden infant death. J Pediatr 1990; 117: 351-357. Meadow R. Suffocation. BMJ 1989; 298:1572-1573. Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7-14. Rosen CL, Frost JD, Bricker T, Tarnow JD, Gillette PC, Dunlavy S. Two siblings with recurrent

cardiorespiratory arrest: Munchausen syndrome by proxy or child abuse? Pediatrics 1983; 71 (5): 715-720.

Southall DP, Plunkett MCB, Banks MW, Flakov AF, Samuels MP. Covert video recordings of life-threatening child abuse: lessons for child protection. Pediatrics 1997; 100(5): 735-760.

Southall DP, Samuels MP, Stebbens VA. Suffocation and sudden infant death syndrome [letter]. BMJ 1989; 299:178.

Southall DP, Stebbens VA, Rees SV, Lang MH, Warner JO, Shinebourne EA. Apnoeic episodes induced by smothering: two cases identified by covert video surveillance. BMJ 1987; 294: 1637-1641.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  2  of  8  

Submerged The decedent was a 6-month-old boy who lived at home with his parents and older siblings. He was at home alone with his father for the afternoon. When his mother came home from shopping, she found the child dead in a water-filled wash basin. References: Somers GR, Chiasson DA, Smith CR. Pediatric drowning. A 20-year review of autopsied cases: I.

Demographic features. Am J Forensic Med Pathol 2005; 26(4): 316-319. Somers GR, Chiasson DA, Smith CR. Pediatric drowning. A 20-year review of autopsied cases: II.

Pathologic features. Am J Forensic Med Pathol 2006; 27(1): 20-24. Somers GR, Chiasson DA, Smith CR. Pediatric drowning. A 20-year review of autopsied cases: III.

Bathtub drownings. Am J Forensic Med Pathol 2006; 27(2): 113-116. Kemp AM, Mott AM, Sibert JR. Accidents and child abuse in bathtub submersions. Arch Dis Child 1994;

70: 435-438. Greist KJ, Zumwalt, RE. Child abuse by drowning. Pediatrics 1989; 83: 41-46. Centers for Disease Control and Prevention. Drowning—United States, 2005-2009. Morbidity and

Mortality Weekly Report 61 (19): 344-347.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  3  of  8  

Squeezed The decedent was a 7-week-old male infant who became unconscious in his father’s care. He was transported to several hospitals and died after prolonged CPR. An autopsy determined that his death was from natural causes. Two years later, a newborn girl adopted into the same family presented to the hospital with a femur fracture. References: Baker AM, Craig BR, Lonergan GJ. Homicidal commotio cordis: the final blow in a battered infant. Child

Abuse and Neglect 2003; 27: 125-130. Barsness KA, Eun-Suk C, Bensard DD, Calkins CM, Partrick DA, Karrer FM, Strain JD. The positive

predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 2003; 54: 1107-1110.

Garcia VF, Gottschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma 1990; 30:695–700.

Kleinman PK, Marks SC, Nimkin K, Rayder SM, Kessler SC. Rib fractures in 31 abused infants: Postmortem radiologic-histopathologic study. Radiology 1996; 200: 807-810.

Kleinman PK, Marks SC, Spevak MR, Richmond JM. Fractures of the rib head in abused infants. Radiology 1992; 185: 119-123.

Kleinman PK, Schlesinger AE. Mechanical factors associated with posterior rib fractures: laboratory and case studies. Pediatr Radiol 1997; 27: 87–91.

Kleinman PK. Bony thoracic trauma. In Kleinman PK editor: Diagnostic Imaging of Child Abuse, 2nd ed, St. Louis, 1998, Mosby, pp. 110-148.

Zumwalt RE, Fanizza-Orphanol AM. Dating of healing rib fractures in fatal child abuse. Advances in Pathology, Vol 3 (1990); 193-206.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  4  of  8  

Sedated The decedent was a 12-week-old male infant who was at a caretaker’s residence. He was found unresponsive after 15 minutes in reclining bouncer. He was cool, cyanotic, and asystolic in the emergency room, where he was pronounced dead. The autopsy and postmortem radiographs were negative for any natural diseases or injuries. Toxicological testing yielded a diphenhydramine level of 1.1 mg/dL. All adults with access to the child denied ever giving him any medication. The daycare provider refused a search of her home. References: Baker AM, Johnson DG, Levisky JA, Hearn WL, Moore KA, Levine B, Nelson SJ. Fatal diphenhydramine

intoxication in infants. J Forensic Sci. 2003; 48(2): 425-8. Aaron FE. A case of acute diphenhydramine hydrochloride poisoning. Br Med J 1953; 2:24. Davis JH, Hunt HH. Accidental Benadryl poisoning: report of a fatal case. J Pediat 1949; 34:358-361. Filloux F. Toxic encephalopathy caused by topically applied diphenhydramine. J Pediatr 1986; 108: 1018-

1020. Goetz CM, Lopez G, Dean BS, Krenzelok EP. Accidental childhood death from diphenhydramine

overdosage. Am J Emerg Med 1990; 8: 321-322. Hausmann E, Wewer H, Wellhoner HH, Weller JP. Lethal intoxication with diphenhydramine: report of a

case with analytical follow-up. Arch Toxicol 1983; 53: 33-39. Hestand HE, Teske DW. Diphenhydramine hydrochloride intoxication. J Pediatr 1977; 90(6): 1017-1018. Huston RL, Cypcar D, Cheng GS, Foulds DM. Toxicity from topical administration of diphenhydramine in

children. Clin Pediatr (Phila) 1990; 29: 542-545. Köppel C, Ibe K, Tenczer J. Clinical symptomatology of diphenhydramine overdose: an evaluation of 136

cases in 1982 to 1985. Clin Toxicol 1987; 25: 53-57. Reyes-Jacang A, Wenzl JE. Antihistamine toxicity in children. Clin Pediatr 1969; 8:297-299. Schunk JE, Svendsen D. Diphenhydramine toxicity from combined oral and topical use. Am J Dis Child

1988; 142: 1020-1021. Simons KJ, Watson WT, Martin TJ, Chen XY, Simons FE. Diphenhydramine: pharmacokinetics and

pharmacodynamics in elderly adults, young adults, and children. J Clin Pharmacol 1990; 30: 665-671. Wyngaarden JB, Seevers MH. The toxic effects of antihistaminic drugs. J Am Med Assoc 1951; 145(5):

277-282.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  5  of  8  

Swallowed The decedent was a 4-year-old boy with microcephaly and developmental delay who presented to the ER with gastrointestinal symptoms that were managed conservatively. Two days later he presented to the ER with vomiting and was treated with an antiemetic and sent home. On day four of his illness he returned to the ER with worsening symptoms, clinically dehydrated with intractable vomiting. He was admitted to the hospital with abdominal pain and a fever to 39.1 C. Within a few hours he became agitated and combative, and suddenly arrested. A presumptive diagnosis of aqueductal stenosis was made by CT scan. The child met criteria for brain death, and died after medical support was withdrawn.                                                                              References: Shannon MW et al. Lead exposure in children: prevention, detection, and management. Pediatrics 2005;

116 (4): 1036-1046. CDC. Fatal pediatric poisoning from leaded paint—Wisconsin, 1990. MMWR 1990; 40:193–195. CDC. Fatal pediatric lead poisoning — New Hampshire, 2000. MMWR 2001; 50: 457-459.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  6  of  8  

Squished The decedent was a 7-year-old girl who was a client at a day treatment facility. Her psychiatric history included oppositional defiant disorder. She was regularly placed in control holds to deal with her behavior. On the day of her death, she was in a control hold that lasted for more than an hour. When she was found to be unresponsive she was emergently transported to the hospital, where she died. A complete autopsy was remarkable only for minor injuries.

Classification of Asphyxia

Suffocation: deprivation of oxygen in the environment or blockage of the external or internal air passages • Environmental • Smothering • Choking

• Mechanical • Positional

Strangulation: Pressure on the neck • Hanging • Ligature

• Manual • ‘Choke holds’

Chemical: Prevention of transport or utilization of oxygen at the cellular level • Carbon monoxide • Hydrogen cyanide • Hydrogen sulfide

References: Boos SC. Constrictive asphyxia: a recognizable form of fatal child abuse. Child Abuse and Neglect 2000;

24(11): 1503-1507. Byard RW, Hanson KA, James RA. Fatal unintentional traumatic asphyxia in childhood. J Paediatr Child

Health 2003; 39(1): 31-32. Corey TS, Collins KA. Pediatric forensic pathology. In: Stocker JT, Dehner LP. Pediatric Pathology (2nd

ed). Philadelphia, Lippincott Williams & Wilkins, 2001. Corliss RF. Compressional asphyxia due to prone restraint hold in a child. Abstract presented at the

American Academy of Forensic Sciences annual meeting, San Antonio, 2007. DiMaio VJ, DiMaio D. Forensic Pathology (2nd ed). Boca Raton, CRC Press, 2001. DiMaio VJM, Dana SE. Handbook of Forensic Pathology. Austin, Landes Bioscience, 1998. Knight B. Forensic Pathology. London, Edward Arnold, 1991. Kohr RM. Inflicted compressional asphyxia of a child. J Forensic Sci 2003; 48(5): 1148-1150. Sarihan H, Abes M, Akyazici R, Cay A, Imamoglu M, Tasdelen I, Imamoglu I. Traumatic asphyxia in

children. J Cardiovasc Surg 1997; 38: 93-95.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  7  of  8  

Seizure The decedent was a 10-year-old boy who was running with his school’s run club one afternoon. He suddenly collapsed, and a school nurse began CPR. The boy was emergently transported to the hospital, where he died after 90 minutes of ongoing CPR. Approximately 6 weeks before he died, he had a “seizure” without loss of consciousness during a soccer game. A complete neurological workup that included an MRI of his brain was negative. There was no family history of seizures, syncope, or sudden death. References: Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation. 2007 Mar

13;115(10):1296-305. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with

origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol, 2000; 35(6): 1493 - 1501.

Davis JA, Cecchin F, Jones TK, Portman MA. Major coronary artery anomalies in a pediatric population: incidence and clinical importance. J Am Coll Cardiol 2001;37:593–7

Friedman AH, Fogel MA, Stephens P Jr, Hellinger JC, Nykanen DG, Tweddell J, Feltes TF, Rome JJ. Identification, imaging, functional assessment and management of congenital coronary arterial abnormalities in children. Cardiol Young. 2007 Sep;17 Suppl 2:56-67.

Gharib AM, Ho VB, Rosing DR, Herzka DA, Stuber M, Arai AE, Pettigrew RI. Coronary Artery Anomalies and Variants: Technical Feasibility of Assessment with Coronary MR Angiography at 3 T. Radiology, 2008; 247(1): 220 - 227.

Kumpf M, Sieverding L, Gass M, Kaulitz R, Ziemer G, and Hofbeck M. Anomalous origin of left coronary artery in young athletes with syncope. BMJ, 2006; 332(7550): 1139 - 1141.

Michigan  Association  of  Medical  Examiners  2012  Fall  CME  Conference                                                                                              November  9-­‐11,  2012  Unusual  Child  Deaths                                            Andrew  M.  Baker,  MD   Page  8  of  8  

Slammed The decedent was a teenage boy who was “slam dancing” in a “mosh pit” party on New Year’s Eve. While dancing, he collapsed against a wall and fell to the ground. Despite resuscitative efforts, he could not be revived and was pronounced dead in the Emergency Room. A complete autopsy with toxicological testing failed to find a cause of death. References: Boglioli, L. R., Taff, M. L., & Harleman, G. (1998). Child homicide caused by commotio cordis. Pediatric

Cardiology, 19, 436–438. Denton, J. S., & Kalelkar,M. B. (2000). Homicidal commotio cordis in two children. J For Sci, 45, 734–5.. Frazer, M., & Mirchandani, H. (1984). Commotio cordis, revisited. Am J Forensic Med Pathol, 5, 249–251. Link, M. S., Maron, B. J., VanderBrink, B. A., Takeuchi, M., Pandian, N. G.,Wang, P. J.,&Estes, N. A., III.

(2001). Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. Journal of the American College of Cardiology, 37, 649–654.

Link, M. S.,Wang, P. J., Maron, B. J., & Estes, N. A., III. (1999). What is commotio cordis? Cardiology in Review, 7, 265–269.

Link, M. S., Wang, P. J., Pandian, N. G., Bharati, S., Udelson, J. E., Lee, M., Vecchiotti, M. A., VanderBrink, B. A., Mirra, G., Maron, B. J., & Estes, N. A. M., III. (1998). An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). NEJM, 338, 1805–1811.

Maron, B. J., Link, M. S., Wang, P. J., & Estes, N. A., III. (1999). Clinical profile of commotio cordis: An under appreciated cause of sudden death in the young during sports and other activities. Journal of Cardiovascular Electrophysiology, 10, 114–120.

Maron, B. J., Poliac, L. C., Kaplan, J. A., & Mueller, F. O. (1995). Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. NEJM, 333, 337–342.

Maron, B. J., Strasburger, J. F., Kugler, J. D., Bell, B. M., Brodkey, F. D., & Poliac, L. C. (1997). Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes. American Journal of Cardiology, 79, 840–841.

Perron, A. D., Brady,W. J., & Erling, B. F. (2001). Commotio cordis: An underappreciated cause of sudden cardiac death in young patients: Assessment and management in the ED. American Journal of Emergency Medicine, 19, 406–409.