Does Postmortem Imaging Provide Additional Findings After Unexpected Deaths in Infants and Children?

Abstract

ObjectivesThe yield of postmortem imaging (PMI) after sudden unexpected deaths in children has not been well studied. Findings consistent with physical abuse detected on PMI may alert the physician to this diagnosis before the autopsy results. Our objectives are to describe the PMI performed and their diagnostic yield after unexpected deaths in children and to adherence to the American Academy of Pediatrics guidelines regarding performance of skeletal survey and autopsy in infants at our institution.MethodsWe performed a retrospective study of unexpected deaths in children 2 years or younger between 2008 and 2018. Children with known traumatic deaths and those transferred after a cardiopulmonary arrest at an outside institution were excluded. We collected patient demographics, physical examination findings, and type of PMI performed along with their results.ResultsWe analyzed 150 deaths with majority (128; 85.3%) being infants. No PMI was performed in 20 children (13.3%). An autopsy was not performed in 22 children (14.6%). A skeletal survey and an autopsy were performed only in 72.6% (93/128) infants. PMI provided additional findings in 51 infants (34%) and 13 children (59.1%) aged 13 to 24 months. PMI identified abuse in 11 children with a negative physical examination result, 3 of whom had a negative autopsy.ConclusionsThe American Academy of Pediatrics recommendations of performance of a skeletal survey and an autopsy were not adhered to after all infant deaths. PMI is useful in identification of additional findings in children 2 years or younger, especially those concerning for physical abuse in infants with a negative physical examination.

Yield of Postmortem Skeletal Surveys in Infants Presenting to Emergency Care With Sudden and Unexpected Death

“…Our results suggest lower yields of PM-SS in this population than those identified in a recent 2020 study by Yurkovich and colleagues. 5 Yurkovich and colleagues describe children aged younger than 2 years with unexpected cardiac arrests who died in the ED or intensive care. When stratifying by age, nearly 20% of infants undergoing PM-SS had a traumatic finding identified.…”

“…In studies evaluating postmortem imaging use, this modality is not universally obtained after unexpected infant deaths. 4,5 When reporting PM-SS findings, previous published research has largely compared the yield of PM-SS to the yield of skeletal surveys in live children, or assessed yield of PM-SS in heterogeneous populations. [6][7][8] For example, McGraw and colleagues 8 evaluated the yield of 106 consecutive PM-SS performed in children aged younger than 2 years, identifying 7 children (6.6%) with fractures in the setting of child abuse.…”

“…However, only three quarters of infants had a PM-SS. 5 Thus, selection bias in qualifying for PM-SS may have impacted the yield. In addition, subjects in this study either died in the emergency department (ED) or at a later time after admission, distinguishing this population from those with SUID.…”

“…Previous research has largely focused on adherence to PM-SS performance guidelines and the sensitivity and specificity of PM-SS as a modality, but less is known about the yield (ie, percentage positivity for fracture) of PM-SS in specific pediatric populations. In studies evaluating postmortem imaging use, this modality is not universally obtained after unexpected infant deaths 4,5 …”

“…Traumatic findings were ultimately identified in nearly 1 in 5 skeletal surveys performed in this age group. However, only three quarters of infants had a PM-SS 5 . Thus, selection bias in qualifying for PM-SS may have impacted the yield.…”