Sudden, Unexpected Infant Death: Information for the Emergency Medical Technician

• Introduction
• The EMT: Playing a Vital Role
• Grief Responses: Parents/Caregivers
• Grief Responses: EMT’s
• Causes of Sudden and Unexpected Infant Death
• Additional Resources

Introduction

As an emergency medical technician (EMT), you are often the first person on the scene following the discovery of a lifeless infant. Responding to these calls is especially difficult and emotionally wrenching—even for the most experienced and well-trained EMT.

Dealing with a sudden infant death presents both professional and personal challenges for the first responder. While working to hopefully revive the infant, the EMT may also be faced with consoling the parent or other caregiver, as well as assessing and recording information about the death scene. Moreover, infants—especially seemingly healthy infants—are not supposed to die. It is not surprising that local officials and the community pay much more attention to the death of a baby than incidents involving adult fatalities.

This fact sheet provides an overview of the EMT’s role in responding to a sudden infant death. We also discuss potential grief responses, causes of sudden infant death, and the differences between sudden infant death syndrome (SIDS) and child abuse.

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The EMT: Playing a Vital Role

The EMT has three major roles in responding to a sudden, unexpected infant death:

• Providing immediate emergency medical care to the baby
• Observing, assessing, and documenting the scene
• Offering support and consolation to parents/caregivers.

Caring for the Infant
Depending on local jurisdiction and agency, you may be required to carry out infant resuscitation based on physical assessment. Some jurisdictions require resuscitation and transport to the hospital, even when signs of death are obvious. You, and all members of the emergency medical services (EMS) response team, should be familiar with local medical examiner (ME) or coroner policies and follow these protocols when responding to a call involving an unexpected infant death.

Once you have determined the infant’s status, calmly explain to the parent/caregiver what is happening and what will happen next.

• Take control of the scene.
• Stay focused.
• Try to be as factual as possible.
• Record actions and the behavior of anyone at the scene (what the person is doing, not how he/she seems).
• Don’t prejudge.
• Be aware that there may be a language barrier.
• Respect the differences in how various racial/ethnic groups react to and deal with a sudden, unexpected infant death.
• Offer your condolences to the grieving parent/caregiver.

Supporting the Parent/Caregiver
Ideally, the first responder team should have enough help on the scene to explain to parents what is going on and to comfort them. Express condolences to the parents/caregivers and be sure to let them know that it is routine to investigate all sudden deaths. You may need to seek help from other family members or neighbors in translating what is happening for non-English speaking parents or caregivers.

Your skill and sensitivity will set the tone for the family’s and caregiver’s interactions with other officials and professionals who will subsequently become involved. But don’t try to control parent/caregiver reactions during this tragic and trying time. Ask if there is someone, for example, other family member, neighbor, or member of the clergy who the parent or caregiver would like you to contact.

Some locales require the baby to be transported to the hospital. The parent or caregiver may want to accompany the baby to the hospital. Depending on your agency and local procedures, the parent may be allowed to travel in the ambulance with the infant and the EMTs. If this is not the practice in your community or agency, see if a friend or relative can take the parent or caregiver to the hospital.

Sudden Infant Death Syndrome is the sudden death of an infant under 1 year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history (Willinger et al., 1991).

Observing, Assessing, and Documenting the Scene
The ME/coroner likely will not be at the death scene. Therefore, the ME will rely on documentation from the EMS team and law enforcement to help determine cause of death. Although law enforcement officials may conduct the formal investigation, the first responder team’s information about the scene is often invaluable.

You should expect that you will need to prepare a report for the ME on what you saw and heard at the scene of the baby’s death. Keep in mind that this report is a legal document. Parents, other family members, and the child death review team also may review your report. Therefore, your report should be objective, accurate, and complete and should follow local protocol.

Collecting Information
At the scene, as you ask questions about the circumstance of the death and the baby’s health history, you should obtain key information, including current medication (take samples to the hospital), and circumstances at the time of death. Open-ended, precise questions are most effective, for example:

• Can you tell me what happened?
• Where was the baby?
• Who found the infant?
• What did you do when you found the baby?
• Has the infant been moved?
• What time was the infant last seen alive?
• How did the infant seem that day?
• Had the infant recently been sick?

Answers to questions such as these will help you prepare your formal report, as part of the death scene investigation. The ME will refer to this information in determining the cause of death.

Documenting Findings
Recording your observations may be very difficult if you are attending the baby while supporting parents and caregivers. Also, depending on your agency and community, the death scene documentation protocol may be lengthy.

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Grief Responses: Parents/Caregivers

In responding to a call involving a sudden infant death, you will likely encounter parents/caregivers who have intense and traumatic reactions to the infant’s death. It is important to respect these reactions and feelings.

First, be aware that not everyone reacts to shock, trauma, and fear in the same way. When confronted with such a sudden and traumatic loss, some parents and caregivers will become angry, even hysterical. Some parents or caregivers may blame themselves. Others may withdraw, with no visible response. Others may deny that the infant is dead.

It is important that you remain calm and patient. Parents or caregivers may repeat the same question or questions. Try to explain in terms that the parent or caregiver can understand.

Some parents or caregivers ask that the EMS team try to resuscitate the baby. Other parents or caregivers ask that resuscitation be terminated. Some parents want to be alone with the infant.

Recognize that the parents and family, as well as other caregivers, may have cultural beliefs, values, and practices related to death. The baby’s family may have various rituals that they will want to observe, and that are part of their religious and cultural background.

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Grief Response: EMTs

There is no doubt that a sudden and unexpected infant death is especially tragic. Although experienced in dealing with death resulting from illness, accidents, or even homicide, you may be surprised at the depth of your feelings regarding an infant’s death.

Even “veteran” EMTs report reacting emotionally to an infant death. It is not unusual to feel symptoms of grief and guilt similar to those of the parents/caregivers. Some first responders express regret and frustration at being unable to revive the baby. Other common reactions include anger, blame, identification with the parent/caregiver, self-doubt, sadness, and depression.

It may help to discuss the circumstances surrounding the death in a critical incident stress debriefing or support group. These debriefing sessions usually are conducted within 24 to 72 hours after the death. Many EMS agencies have found that debriefing sessions help confirm that the EMT did everything that he or she could have done.

Grief responses are normal and usually resolve in time. Don’t walk away or try to “bury” your feelings. They will catch up with you eventually.

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Causes of Sudden and Unexpected Infant Death

SIDS is the most common cause of sudden, unexpected death among infants between 1 month and 1 year of age. Ninety percent of SIDS deaths occur under 6 months of age, with most SIDS deaths happening in babies between 2 and 4 months of age.
Sudden, unexpected death may also be due to injury, congenital birth defects, infection, or metabolic disorders. The ME/coroner will determine the cause of death based on information taken from the death scene investigation, autopsy, and clinical history.
SIDS is often confused with child abuse. The following table lists important characteristics that can help the first responder distinguish between SIDS and child abuse/neglect.

SIDS Physical Appearance	Child Abuse/Neglect Physical Appearance
No external signs of injury “ Natural” appearance of a deceased baby	Distinguishable and visible signs of injury
Lividity—-settling of blood, frothy drainage from the nose/mouth	Broken bone(s)
Small marks (e.g., diaper rash) look more severe	Bruises
Cooling/rigor mortis (takes place quickly in infants, about 3 hours)	Burns
Purple mottled markings on head and facial area, may appear as bruises	Cuts
	Head Trauma (e.g., black eye)
	Scars
	Welts
	Wounds
Appears to be a well-developed baby	May be obviously malnourished
	Other siblings may show patterns of injuries commonly seen in child abuse and neglect
May initially suspect SIDS when all of the above are present PLUS parents say that the infant was well and healthy when put to sleep (last time seen alive).	May initially suspect child abuse/neglect when all of the above appear accurate and parents’ story does not account for all injuries on the infant.

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Additional Resources

Sudden Infant Death Syndrome: A Manual for First Responders and Emergency Room Personnel (1997)
Illinois Department of Public Health
Springfield, IL
Phone: (217) 557-2931

Training Guide for Training of Emergency Personnel (2001)
California SIDS Program
Gold River, CA
Phone: (800) 369-7437 or (916) 851-7437

Responding to Sudden Deaths in Infants and Young Children: Interactive Training Guide for Death Investigators, Law Enforcement and Emergency Medical Personnel (2003)
Northwest Infant Survival & SIDS Alliance
Seattle, WA
Phone: (206) 548-9290

Skills Update for First Responders, Emergency Medical Technicians, Paramedics, and Emergency Department Personnel
Georgia Division of Public Health
Sudden Infant Death Syndrome/Other Infant Death Information and Counseling Center
Atlanta, GA
Phone: (404) 657-6700

Sudden Infant Death Syndrome: Study Outline for EMT’s and Paramedics
SIDS of Pennsylvania
Pittsburgh, PA
Phone: (800) 721-7437

References

American Academy of Pediatrics, Committee on Child Abuse and Neglect. “Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities,” Pediatrics February 2001; 107(2): 437­441.

Georgia Emergency Medical Services for Children, Pediatric Life Support March 2003; www.ems-c.org/downloads/pdf/1031gapls.pdf.

Mathews TJ, Menacker F, MacDorman MF. “Infant Mortality Statistics from the 2001 Period Linked Birth/Infant Death Data Set.” National Vital Statistics Reports; (52)2. Hyattsville, (MD): National Center for Health Statistics. September 15, 2003.

National Clearinghouse on Child Abuse and Neglect Information Child Maltreatment 2001: Summary of Key Findings. nccanch.acf.hhs.gov.

Willinger M, James LS, and Catz, C. “Defining the Sudden Infant Death Syndrome (SIDS): Deliberations of an Expert Panel Convened by the National Institute of Child Health and Human Development,” Pediatric Pathology 1991; 11: 677­84.

Additional References

American Academy of Pediatrics, Committee on Child Abuse and Neglect. “Addendum: Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities,” Pediatrics September 2001; 108(3): 812.

Association of SIDS and Infant Mortality Programs. The Unexpected Death of an Infant or Child: Standards for Services to Families. Minneapolis (MN): Association of SIDS and Infant Mortality Programs, 2001.

Carolan PL. “Sudden Infant Death Syndrome.” Pediatrics: An On-line Medical Reference. 1st Edition. St. Petersburg, FL. Emedicine Online Textbooks. Ed. Steven Altschuler et al., 2001. Emedicine.com, Inc. www.emedicine.com/PED/topic2171.htm.

Centers for Disease Control and Prevention. “Guidelines for Death Scene Investigation of Sudden, Unexplained Infant Deaths: Recommendations of the Interagency Panel on Sudden Infant Death Syndrome.” Morbidity and Mortality Weekly Report 1996; 45 (No. RR-10).

Centers for Disease Control and Prevention. “Variation in Homicide Risk During Infancy—United States, 1989­1998.” Morbidity and Mortality Weekly Report 2002; 51(09), 187­9.

This publication was produced by the
National SIDS/Infant Death Resource Center (NSIDRC)
8280 Greensboro Drive
Suite 300
McLean, VA 22102
Phone: (866) 866-7437, (703) 821-8955
E-mail: sids@circlesolutions.com
www.sidscenter.org

The NSIDRC is funded under contract to Circle Solutions, Inc., with the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration, U.S. Department of Health and Human Services. This publication is not copyrighted; it may be reproduced in whole or in part without permission. However, in accordance with accepted publishing standards, it is requested that proper credit be given to the source(s). The views in this publication do not necessarily reflect the views of the sponsoring agency.

Health Resources and Services Administration
Maternal and Child Health Bureau
SIDS/Infant Death Program
(301) 443-2115
www.hrsa.gov

Rev. 2004

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