Child abuse by suffocation: A cause of apparent life-threatening events

Despite decades of attention, child maltreatment is a pervasive problem that remains under-recognized (1,2), leaving younger children and infants at great risk of lethal child maltreatment (3). Recurrent intentional suffocation of a child by a caregiver – termed suffocatory abuse – is a particularly deadly form of maltreatment. The present article summarizes the importance of considering suffocatory abuse as a differential diagnostic possibility, especially in infants with apparent life-threatening events (ALTEs) or apparent sudden infant death syndrome (SIDS). Suffocatory abuse occurs when a parent or caregiver intentionally suffocates a child with their hand or an object such as a cloth, pillow or plastic wrap. Suffocatory abuse is highly lethal: approximately 33% of children will die at the hands of their abusers (4,5). Infants who have been suffocated usually present with vague, nonspecific, apparently life-threatening symptoms, such as limpness, pallor, cyanosis or apnea. As a result of the nonspecific nature of the signs and symptoms, a high index of suspicion is required to detect suffocatory abuse. Although it is likely under-reported, intentional suffocation is a rare phenomenon, and what is known about the condition is derived mostly from small case series (5–9). As a result, accurate victim or abuser demographics are difficult to define. Because recurrent intentional suffocation targets mostly infants and leaves no physical marks, it often baffles physicians who, after numerous investigations, remain unable to identify the cause of the child's symptoms. When a diagnosis is made, it is often erroneous; children who die may be diagnosed with SIDS, whereas surviving children may be given diagnoses such as ‘near-miss SIDS’ or ALTE. It is recognized that suffocatory abuse is rarely documented as a consideration in the differential diagnosis of ALTEs (5,7). Similarly, some deaths attributed to SIDS are actually due to intentional suffocation (7). Because there is no proven association between ALTEs and SIDS, the continued use of the terms ‘near-miss SIDS’ or ‘aborted SIDS’ should be avoided, as it reflects a misunderstanding of the etiology and epidemiology of SIDS and ALTEs. SIDS is a diagnosis of exclusion that can only be made postmortem. It is used to encompass previously healthy infants who die unexpectedly, usually in their sleep, without an identifiable cause (see Appendix) (10). ‘Near miss SIDS’ or ‘aborted SIDS’ are older terms that should not be used and have been replaced by the term ‘apparent life-threatening event’. By definition, an ALTE is an observed episode that is frightening to the caregiver, characterized by some combination of apnea, colour change and alteration in muscle tone, sometimes accompanied by choking or gagging. When such an event occurs, caregivers fear the child is dead or is about to die (11). Many conditions may give rise to ALTEs. These include isolated choking events, gastroesophageal reflux, seizures, infection, accidental smothering or inflicted injuries, to name only a few. Although some infants suffocate accidentally in soft bedding or when a sleeping or impaired parent rolls over them while cosleeping, such situations are completely different from cases of recurrent intentional suffocation. In accidental smotherings, the diagnosis is typically readily obvious in the clinical history, whereas in suffocatory abuse, usually no history is provided to explain the child's life-threatening symptoms. Most parents who repeatedly intentionally suffocate their infants do not necessarily intend to kill them. Suffocation may represent an unhealthy response to an infant's crying. Alternatively, recurrent suffocation may occur as part of Munchausen Syndrome by Proxy. In such cases, a caregiver uses suffocation as a way to manipulate a health professional and to assume the sick role by proxy (6,7). Infants suffocated as part of Munchausen Syndrome by Proxy may suffer at the hands of their abuser for several months before the correct diagnosis becomes apparent (4). Studies performed to clarify risk factors for suffocatory abuse have found that the risk of a child being the victim of suffocatory abuse increases dramatically as the child ages and as the number of unexplained episodes rises (Table 1). Clues that suffocatory abuse may be the cause of recurrent apparent life-threatening events (ALTEs) High number or recurrent, poorly explained ALTEs/apneas Infant older than six months of age Events always witnessed by the same caregiver Family history of sudden infant death syndrome/ALTEs Presence of facial bleeding after an ALTE Events that decrease or cease with admission to hospital or in which in-hospital onset are never witnessed by an unbiased observer High number or recurrent, poorly explained ALTEs/apneas Infant older than six months of age Events always witnessed by the same caregiver Family history of sudden infant death syndrome/ALTEs Presence of facial bleeding after an ALTE Events that decrease or cease with admission to hospital or in which in-hospital onset are never witnessed by an unbiased observer Clues that suffocatory abuse may be the cause of recurrent apparent life-threatening events (ALTEs) High number or recurrent, poorly explained ALTEs/apneas Infant older than six months of age Events always witnessed by the same caregiver Family history of sudden infant death syndrome/ALTEs Presence of facial bleeding after an ALTE Events that decrease or cease with admission to hospital or in which in-hospital onset are never witnessed by an unbiased observer High number or recurrent, poorly explained ALTEs/apneas Infant older than six months of age Events always witnessed by the same caregiver Family history of sudden infant death syndrome/ALTEs Presence of facial bleeding after an ALTE Events that decrease or cease with admission to hospital or in which in-hospital onset are never witnessed by an unbiased observer Abuse by suffocation is not usually an isolated event. Children who survive suffocatory abuse often present to the hospital repeatedly for unexplained near-death events (4,5,7–9). In such cases, the initial diagnosis may be that of an ALTE. Often, although numerous medical investigations are performed in an effort to uncover an underlying pathological process, no pathology is found (4). In cases where physicians have information that leads them to suspect the possibility of child abuse as the cause of an ALTE, the safety of the patient and of other children in the home is of primary concern. Physicians should ask care-givers about other siblings or access to other children, paying attention to the current whereabouts and relationship of such children to the suspected abuser. After determining that a child is at potential risk, physicians have a legal duty to report their concerns without delay to the appropriate child welfare authority. When an infant is suspected of having been intentionally suffocated, admission to the hospital is useful because it ensures the immediate safety of the child, while allowing the medical team to assess the true nature of the child's symptoms. Keeping in mind that many ALTEs do not have an obvious pathological cause (12,13), once medical causes of an ALTE have been reasonably ruled out and if suspicions of intentional suffocation exist, the physician should consider an assessment by a child protection team in a tertiary care centre. The assessment of suspected suffocatory abuse is complex and may involve covert video surveillance of the child in an effort to clarify the events around the time of the child's unexplained symptoms. When a child arrives dead, or dies during treatment, and a suspicion of intentional suffocation or other form of maltreatment exists, it is not the responsibility of the attending physician to investigate the underlying cause of death. A report should immediately be made to the local coroner or medical examiner (depending on the jurisdiction). Reporting the case to the local child welfare agency should also be done to ensure the safety of any other child the physician may not know about. The term SIDS should not be misconstrued to be synonymous with sudden unexpected death, the latter of which is a generic term that encompasses children who die unexpectedly, but from a variety of known causes (14). Past literature from multiple jurisdictions has shown that despite efforts to restrict the use of the term SIDS, up to 10% of deaths attributed to SIDS are subsequently determined to be unnatural and mostly attributable to homicide (5,15–17). For this reason, some have advocated abandoning the term SIDS in favour of labelling the manner and/or cause of death for what they really are: undetermined (5). Because of implications in both the health and legal systems (9), and because the term SIDS is often inappropriately used (5,10), the diagnostic criteria for SIDS have evolved since the term was introduced in the late 1960s. To make the diagnosis, a very specific list of criteria must be met (10). These include a review of the circumstances of death and of the child and family's medical history, a scene investigation, and a complete autopsy and toxicology screen. Only when all of these fail to reveal a cause of death can SIDS be diagnosed. Suffocation rarely leaves any physical signs, making it impossible to differentiate from SIDS on clinical grounds alone (7). Because the diagnosis of SIDS requires an autopsy and an extensive death investigation, no physician other than a medical examiner or coroner should make a diagnosis of SIDS. To reduce the likelihood that a death from intentional suffocation (a homicide) is erroneously labelled as SIDS (a natural cause of death), all Canadian jurisdictions have laws mandating the report of any unexpected child death to a medical examiner or coroner for investigation. In addition to being able to order autopsies, medical examiners or coroners' offices have dedicated death investigators who collect information by attending death scenes and by talking to witnesses, police and/or child welfare authorities. In addition, many jurisdictions have multidisciplinary child death review teams. As a result, the coroner or medical examiner has access to much more information than individual physicians, and is therefore in a better position to rule on a final manner and cause of death. Although the presence of blood in the nose and mouth of an infant may suggest smothering (5,7,8), very few signs are specific to suffocation. Investigations such as postmortem skeletal surveys, toxicology screens and careful attention to neurological and ophthalmological examination at autopsy are critical in determining whether a death is due to child abuse. Positive findings, however, would likely be due to mechanisms of injury other than suffocation alone. For these reasons, a death investigation is crucial in unexpected infant deaths. Certain historical and demographic features may raise the coroner or medical examiner's index of suspicion for suffocatory abuse. Victims of suffocatory abuse demonstrate a high death rate in prior infant siblings, usually either unexplained or ascribed to SIDS (4,5). Studies comparing victims of recurrent suffocation with bona fide victims of SIDS have documented significant differences in clinical presentations between the two groups. Whereas the majority of children who die of SIDS tend to be previously healthy infants younger than six months of age, victims of suffocation are usually older than six months of age at the time of death, have a history of previous apneas or unexplained disorder, and have a family history of unexpected infant deaths (4,18). Although they may sometimes die during a daytime nap, infants that have died of SIDS are usually found dead in their cribs in the morning, having last been seen well 8 h to 10 h earlier. In contrast, children who are intentionally suffocated are often found moribund during the day or evening, with a history of having last been seen well shortly before death (5). Many practitioners will sign death certificates for their patients. Although this is an acceptable practice in cases of expected deaths, physicians who do not have additional training to act as coroners or medical examiners would be prudent to refrain from signing a certificate for any manner of death other than ‘natural'. The key to protecting children from suffocatory abuse is to include it in the initial differential diagnosis when infants present with ALTEs. Failure to do so may engender long delays between the onset of symptoms and an accurate diagnosis, rendering the child susceptible to fatal abuse. When evaluating an infant with recurrent ALTEs, it is wise to consider suffocatory abuse in the differential diagnosis. Consulting an unbiased colleague or a tertiary centre child protection team may be helpful. When an infant dies unexpectedly and without explanation, it is important to consider the possibility of child abuse and to defer diagnosing a cause of death, especially SIDS, to the medical examiner or coroner. When abuse is suspected as a cause for symptoms, one must consider whether there are other children (in the family or in other settings) who may be in need of protection; a call to the local child welfare authority is never wrong when doubt exists. It may save a life. The author thanks Dr Amy Ornstein for her review and feedback. The unexpected death of an infant younger than one year of age, with onset of the fatal episode apparently occurring during sleep, which remains unexplained after a thorough investigation, including the performance of a complete autopsy and a review of the circumstances of death and of the clinical history.

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