Toddler Fatalities: The Terrible Twos

Abstract

The majority of childhood deaths investigated by medical examiners and coroners are under the age of one, and medical examiners and coroners are well-versed in the challenges involved in investigating these fatalities. As infants mature to toddlers, there is a paradigm shift with a decrease in both the number of fatalities and the number of undetermined causes of death. A subset of these, however, remain undetermined, causing frustration for both the parents and medical examiner/coroner. In an effort to facilitate a differential diagnosis in these cases, death certificate data from the New York City Office of Chief Medical Examiner for deaths from one to four years of age over a five year period was examined. Of the 230 deaths investigated by the New York City Office of Chief Medical Examiner, the manner was natural in 39%, accident in 32%, homicide in 19%, therapeutic complication in 5%, and undetermined in 5%. Diligent scene investigation and a thorough histologic examination are key components to the investigation. While the lack of a cause of death in a portion of these undetermined deaths is due to limits in current postmortem techniques, a differential diagnosis for these deaths should include channelopathies, seizure disorders, and accidental injuries involving asphyxial mechanisms and inadvertent drug/toxin ingestion.