This summer in Franklin, IN, Ronald Shanabarger admitted to suffocating his seven-month-old son with plastic wrap shortly after the cause of death had already been ruled Sudden Infant Death Syndrome (SIDS). In Philadelphia, a 70 year-old woman acknowledged killing, over time, eight of her children. Some physicians had believed they had died from SIDS.
The Forensic Panel Letter queried a group of specialists to separate myth from fact and experience, and proper procedure from presumption. What you'll learn will make you look twice at the case you may wrestle with prosecuting—or the case you one day defend.
Michael Baden, M.D., Forensic Pathology, New York, NY
Phipps Cohe, M.Ed., The SIDS Alliance, Baltimore, MD
Warren Guntherroth, M.D., Pediatric Cardiology, Seattle, WA
Bradley Thach, M.D., Pediatric Pulmonology, St. Louis, MO
Frederick Zugibe, M.D., Forensic Pathology, Rockland, NY
TFPL: How do you tell the difference between suffocation and SIDS?
PC: These are sensational cases we are talking about here; you can't cater to the exception instead of the norm.
WG: The parents just might be very, very unlucky. But a wise clinician would certainly start looking and thinking about it if there are any unusual elements of history or death scene investigation. It's not a bad idea to check with the local child protective services to see if the parents have a record with them. When parents have insured the child; especially, when they go to the pains to get it out of state.
FZ: SIDS is a diagnosis that can only be made after an autopsy that cannot find anything is completed. But some physicians are willing to have autopsies signed off as SIDS even though they are really limited autopsies.
MB: 85-95% of babies that look like SIDS turn out to be SIDS, but SIDS means undetermined. We always consider anything from natural causes, to poisoning, to trauma. The term SIDS rather than undetermined provides an explanation and solace to a grieving family. Pediatricians who feel it is their job to comfort the family tend to be less skeptical.
TFPL: Is SIDS genetically acquired?
MB: SIDS is not a genetic disease.
WG: I certainly know families where there were multiple homicides in the same family. But I don't know any families that had more than two kids die of SIDS.
FZ: In thirteen sets of twins studied, ten were certified as SIDS and 3 undetermined. All thirteen sets were later found to have died of intentional and non-intentional injuries.
WG: If you're looking at the second child in the family to die, you should be thinking about inherited diseases of metabolism as opposed to SIDS.
BT: In certain inherited diseases, there may not be a specific finding on post-mortem examination to show why the baby died. However, many of these deaths occur after one year of age, which is out of the range for SIDS.
MB: Even in metabolic or fungal conditions, the baby would get sick beforehand, and not likely to die suddenly.
TFPL: What are you likely to find on autopsy that is more suggestive of suffocation?
WG: There is no way to determine SIDS from intentional suffocation unless a perpetrator uses force.
BT: Even accidental suffocation, when the baby's head is wedged up against bedding, or can't otherwise move when it needs to in order to breathe, shows identical findings on post-mortem to SIDS.
FZ: But in SIDS you can never get pinpoint (petechial) hemorrhages on the eyes. You never get them above the neck.
MB: The plastic wrap method from the Indiana case is unusual. Suffocation by towels or bedding or pushing the baby's head against one's chest typically does not leave any evidence on autopsy alone. Even in the unusual instance of petechial hemorrhages, you still need more evidence to prove suffocation.
WG: Sometimes, in a full body autopsy of an infant, you'll find broken bones. That gives a clue that the child was abused in the past.
FZ: Bleeding in the brain or fractures of the (metaphyseal) bones are what you would see with shaken baby syndrome.
PC: Right now, more than half the states have specific laws mandating the autopsy of any infant who dies unexpectedly. It's a lot more difficult to have criminal cases fall through the cracks.
WG: When you invite the parents after autopsy results are back, bring them in to discuss what you have found to assure them that this was not their fault. At the same time, you try to help them through grief, you are gathering information on family history, social situations, and you are learning more about things you should pay further attention.
BT: Often, a more thorough investigation can be done after the commotion has died down 3-4 days, even up to 2 weeks later.
TFPL: Do you examine where the baby was found?
BT: Death scene investigation is a mandatory part of making a diagnosis of SIDS. You go to the home, it can be done immediately.
WG: In about 50% of the cases, the baby is picked up and rushed to the hospital to attempt resuscitation. That's why the death scene is not intact in more than half the cases. But it still helps.
FZ: There is a guide published by Bass in the New England Journal of Medicine (315: 100-105, 1986) entitled, Death Scene Investigation in Sudden Infant Death that gives excellent guidance about taking a doll to where the infant is found, and how to position it.
PC: Another set of guidelines for infant death investigation has been published in 1996 by the Center for Disease Control.
