Sudden, unexplained infant death investigations.

Investigating sudden, unexplained infant death (SUID) in the United States serves as one of the many challenges facing law enforcement officers. Federal, state, and local investigators alike often receive little introduction to SUID and do not fully understand their role in a SUID investigation when required to handle one. A more complete understanding of this role can enable law enforcement officers to work effectively through a SUID investigation, providing a much greater chance of an accurate determination of what caused or contributed to a child's death.

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SUID AND SIDS 

SUID cases involve infant deaths that occur outside of a doctor's care without an immediate explanation of their cause. People should not confuse SUID with sudden infant death syndrome (SIDS), (1) which refers to the sudden death of a child under 1 year of age that remains unexplained even after a thorough case investigation (2)--scientists call it a "diagnosis of exclusion." SIDS is the most frequently determined cause of SUID. (3)

SUID investigators should consider that SIDS claims more infant lives in the United States than congenital anomalies, illnesses, injuries, and homicides combined. In fact, SIDS deaths outnumber abuse and neglect deaths in children under 1 year of age nearly 9 to 1. (4) Law enforcement officers that investigate infant deaths on Indian reservations must face an even more alarming concern: SIDS deaths among Native American babies occur at a rate of nearly 3 times the national average (6 per 1000) for that of Caucasian infants (2 per 1000)--in North and South Dakota, the rate is approximately 4 times that figure (8 per 1000). (5)

THE SUID INVESTIGATION

Agencies should treat the sudden, unexplained death of an infant like any other mysterious death. A meticulous investigation must begin immediately to determine if criminal behavior caused or contributed to the death of the child. Often, if investigators find no such evidence during the initial stages of a SUID case, health professionals (e.g., medical examiners, forensic pathologists, and coroners) in large metropolitan areas with ample investigative resources complete the investigation to determine the cause and manner of the infant's death. In more rural areas where these means may not exist, law enforcement officers commonly assist them in solving these cases. Regardless, without a complete investigation, the circumstances surrounding a baby's death will remain a mystery.

Approximately 15 percent of SUID investigations will identify a cause of death other than SIDS. (6) Murder serves as one example--in 2000, the homicide rate for children under the age of 1 year reached a 30-year high (9.1 murders per 100,000 infants), a number twice that reported in 1970 and nearly equivalent to the 2000 homicide rate for American teens between the ages of 15 and 19. (7) Many researchers consider this number low, not accurately depicting the number of infant murders in the United States.

Many law enforcement officers find the SUID investigation enigmatic; instead of looking for possible wrongdoing, they often must focus their efforts on establishing an overwhelming lack of evidence. In other words, an investigator engages in an "investigation of exclusion" by examining various areas outside the normal scope of a criminal case to rule out such possibilities as abuse, neglect, environmental factors, illness, accidental asphyxiation, or strangulation. To streamline this process and to ensure that they do not overlook critical evidence, officers should consider dividing a SUID investigation into four general categories: the death scene analysis, the autopsy, an examination of the infant's medical history, and a review of the family case history.

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The Death Scene

The death scene is the phase of a SUID investigation most affected by the passage of time. To work efficiently, investigators must know what to look for and how to document the findings. Officers should begin at the place where the infant's death was pronounced and quickly move to the location (if different) where the baby was found dead or unresponsive. If possible, investigators ought to occupy both places as soon as the death is reported and quickly identify the individuals who located the child because their observations can greatly assist the re-creation of the death scene.

At the scene, investigators should describe, in detail, the site where witnesses found the baby. For example, if the death occurred at home in the infant's bedroom, officers ought to include a description of the room, as well as their observations of the sleeping surface. Investigators must take great care in documenting these details (e.g., "The mattress is too small for the crib" or "Officers noticed a broken spring in the bedding"). They also should determine if anyone was sleeping with the child at the time of death and if this person was impaired by alcohol or other drugs. After examining the sleeping site, investigators then would record a variety of environmental factors, including inside temperature, outside temperature, type of heating present, type of air conditioning, any humidifier or vaporizer use, type of flooring, state of the home's cleanliness, number of people living in the residence, and any presence of animals.

The collection and thorough documentation of physical evidence at the death scene can prove essential in accurately establishing an infant's cause of death. Items considered important to a SUID investigation include the baby's clothes and diaper, bedding, formula, time and contents of the last bottle, over-the-counter or prescribed drugs or medications, and other appropriate items, such as folk remedies or unpasteurized honey (if ingested within 30 days of the time of death). In addition, investigators should collect any toys located nearby and document their relative position to the child.

Officers also must meticulously document the baby's general appearance. This serves as a critical portion of the death scene investigation and provides invaluable information to the health professional--in this regard, investigators can communicate more effectively when familiar with basic medical concepts and terms related to infant death. When documenting the general appearance of the child, officers should note the body, face, head, and neck positions; rigor mortis; postmortem lividity (creating a drawing and depicting the pattern); birthmarks; body temperature; physical development; evidence of trauma; state of hydration; and any fluids (e.g., vomitus, blood, mucus, or other secretions) or obstructions present in or around the baby's mouth or nostrils. Additionally, they ought to document all attempts to resuscitate the child, along with any physical signs of attempted resuscitation (e.g., endotracheal tube, chest ecchymosis, (8) EKG monitor pads, or intravenous lines).

The Autopsy

The forensic autopsy of the infant serves as a critical step in a SUID investigation. Without a thorough autopsy by a competent, experienced health professional, the cause and manner of the baby's death will remain in question. The law enforcement officer plays a critical, though limited, part in this phase of the investigation. While carrying out their role in this process, investigators ought to remain sensitive to the needs of the child's family and effectively explain the importance of a forensic autopsy.

First, the officer obtains parental consent, a coroner's directive, or a court order authorizing the autopsy. Next, the investigator must coordinate the transportation of the infant (while maintaining a proper chain of custody). The officer also should make efforts, early in the investigation, to obtain the baby's medical records, as well as documentation of the mother's prenatal care. Copies of these records ought to accompany the infant to the autopsy. Finally, the investigator should remain available, either in person or by telephone, to provide input and observations to the health professional at the time of the autopsy.

The Infant's Medical History

Investigators can gather much of the information about the child's medical history from records, as well as interviews with parents, guardians, or caretakers--of course, if the infant's death resulted from abuse, neglect, or homicide, these individuals may be suspects. Important information to gather during this phase of the investigation includes if the baby had an illness within 48 hours of the time of death, received any medications (prescribed or over the counter), or exhibited any recent changes in behavior or sleeping habits. Officers also should determine if the infant had exposure to tobacco smoke or illicit drugs at any time.

As the investigation into the child's medical history continues, the investigator must determine if the infant experienced previous traumatic injuries, had illnesses not documented in medical records, or contracted illnesses or medical complications during the first week of life. If the baby required resuscitation at any time since birth, it should be documented in detail. In addition, officers ought to determine if the child ever required oxygen, an apnea monitor, pacemaker, or antibiotic or anticonvulsant medications.

To complete the medical history, the investigator must examine the date and circumstances of the infant's last doctor's visit; determine if the child ever received emergency room attention and, if so, under what circumstances; and ascertain if the baby ever required a hospital stay or surgery. The officer also should document, in detail, the infant's immunizations and when they were administered. Finally, the investigator ought to develop information about the child's feeding history (e.g., Did the infant have any food intolerances?) and establish the baby's exposure to illness through contact with adults or animals.

The Family's Case History

A review of the infant's family case history may prove the most time-consuming part of a SUID investigation. The investigator begins by interviewing immediate family members to determine if they have experienced any suspicious childhood accidents, a history of infant or childhood death, SIDS, congenital anomalies, infections, pneumonia, premature birth, life-threatening trauma, HIV, hepatitis, or sickle-cell anemia. If so, the officer ought to conduct a logical and thorough investigation to gather as much information as possible about each particular instance. If necessary, the investigator should widen this phase of investigation to include extended family members. After the interviews of family members, the officer must contact an appropriate agency, such as social services or child protection services, and inquire about any family contacts and the nature of these contacts.

The investigator also needs to examine and document the mother's prenatal history and medical care. Information ought to include any health problems (e.g., anemia, diabetes, high blood pressure, infections, physical trauma, or sexually transmitted diseases) or use of alcohol, controlled substances, or tobacco during pregnancy. In addition, the officer should determine if the mother had any previous pregnancies, previous live births, previous abortions or miscarriages, or a history of fertility treatment.

Finally, the investigator ought to document the infant's gestational age (considering 40 weeks as "full term") and weight at birth, method of delivery (vaginal birth or cesarean section), and if the baby was part of a dual or multiple birth. To ensure completeness, the officer should determine the age and health of the other children in the infant's family and describe the family's demographics (e.g., employment, education, income, ages of parents, and citizenship).

After examining and documenting the family history, the SUID investigator must contact the health professional involved with the case and provide the information gathered during the investigation. A discussion of these findings then determines the need for additional work by the officer. Regardless, the investigator must remain available to provide input as necessary during the autopsy/investigation to help determine cause and manner of death.

CONCLUSION

Law enforcement officers can play a crucial role in SUID investigations. The information gathered during an extensive analysis of the death scene, examination of the infant's medical history, and review of the family case history can greatly supplement the autopsy results and enable the medical professional to properly interpret postmortem findings.

Sudden, unexplained infant deaths can prove challenging to both the law enforcement and medical communities. The team effort between the investigator and the health professional in ensuring a thorough, complete investigation is essential in establishing the true cause and manner of an infant's death.

Online Resources

* SIDS Alliance

http://www.sidsalliance.org

* Interagency Panel on Sudden Infant Death Syndrome

"Guidelines for Death Scene Investigation of Sudden, Unexplained Infant Deaths"

http://www.cdc.gov/mmwr/preview/mmwrhtml/00042657.htm

* Office of Juvenile Justice and Delinquency Prevention 

"Recognizing When a Child's Injury or Illness Is Caused by Abuse"

http://www.ncjrs.org/html/ojjdp/portable_guides/abuse_02/key.html#sids

* Canadian Association of Chiefs of Police 

"Code of Police Practice--A Guide for First-Line Officers"

http://www.rcmp-learning.org/copp/encopp/d_infant.htm

Endnotes

(1) For further information, see Linda Esposito, Larry Minda, and Claire Forman, "Sudden Infant Death Syndrome: Police Can Make a Difference," FBI Law Enforcement Bulletin, September 1998, 1-5.

(2) A thorough case investigation includes a complete autopsy, an examination of the death scene, and a review of the infant's clinical history. See Jodi Shaefer, Kathleen Fernbach, and Mary McClain, "SIDS Is Not Homicide But ..."; retrieved on September 17, 2003, from http://www.asipl.org/sid_not_homicide.html. Without such an analysis, an infant death cannot be attributed to SIDS; it must remain in the "undetermined" or "unexplained" category.

(3) Interagency Panel on Sudden Infant Death Syndrome, "Guidelines for Death Scene Investigation of Sudden, Unexplained Infant Deaths"; retrieved on September 17, 2003, from http://www.cdc.gov/mmwr/preview/mmwrhtml/00042657.htm.

(4) Arizona SIDS Advisory Council, Facts About Sudden Infant Death Syndrome (SIDS) for Police Officers and Pre-Hospital Personnel, Infant Death Support Series (April 29, 1994).

(5) Department of Health and Human Services, MiCinca Kin Towani Ewaktonji Kte Sni, Results of the Aberdeen Area Infant Mortality Study (June 6, 1998).

(6) Supra note 3.

(7) Laura Sessions Stepp, "Infants Now Murdered As Often As Teens," The Washington Post, December 10, 2002, sec. A, p. 3.

(8) Evidence of ruptured blood vessels.

(9) A model protocol is available at http://www.fbi.gov/hq/cid/indian/about.htm.

RELATED ARTICLE: Considerations During a SUID Investigation

1. Remain sensitive to the family, but stay focused. Although painful for the family, a detailed investigation may shed light on the true cause of death.

2. Time is critical. Crucial evidence will become lost or destroyed if the investigation does not begin immediately.

3. Trust your investigative instincts. Remain alert to the possibility of rollover death (also referred to as overlying death), accidental suffocation, strangulation, positional asphyxiation, child abuse, child neglect, or homicide. Investigators should use their experience, training, and judgment to develop additional leads in any stage of the SUID investigation.

4. Use a SUID investigative protocol. (9) This written checklist, or guide, ensures that investigators do not overlook critical evidence during the "investigative window" of a SUID investigation.