Fatal Hyponatremic Encephalopathy as a Result of Child Abuse From Forced Exercise.

We report a case of fatal hyponatremic encephalopathy in a child who was forced to exercise as a form of punishment. A 9-year-old girl with attention-deficit/hyperactivity disorder was forced to run repeated 50-ft sprints to the point of exhaustion by her grandmother as punishment for taking candy from a classmate. After more than 3 hours of forced running, the child collapsed, began to vomit, and had repeated clonic seizures. Upon presentation to the emergency department, she was nonresponsive with a Glasgow Coma Scale score of 11 and had noncardiogenic pulmonary edema with serum sodium of 117 mEq/L. She was treated with antiepilectic medications and transferred to a university children's hospital where she later died. On postmortem examination, she was found to have massive cerebral edema with transtentorial herniation and pulmonary edema. Her clinical presentation closely resembled exercise-associated hyponatremic encephalopathy seen in adult endurance athletes. This appears to be the first report of fatal exercise-associated hyponatremia in a child.

Prolonged Abusive Chest Compressions in an Infant: An Occult Form of Child Abuse: Review of Hemodynamics.

This is the case of a 4-month-old male infant whose mother sought medical care because of poor feeding and low-grade temperature. The infant had no external evidence of abuse, but chest radiographs showed multiple bilateral rib fractures. There were no retinal hemorrhages. Investigation revealed that the father had repeatedly squeezed the child to unconsciousness. The cardiopulmonary effects of this form of abuse are restriction of respiration and reduced cardiac output. This is an unusual case of occult child abuse.

Guidelines for postmortem protocol for ocular investigation of sudden unexplained infant death and suspected physical child abuse.

Postmortem examination is a cornerstone in identifying the cause of unexplained sudden death in children. Even in cases of suspected or known abuse, an autopsy may help characterize the nature of the abuse, which is particularly important in the forensic autopsy of children in the first 3 to 4 years of life when inflicted neurotrauma is most common. Forensic examinations are vital in cases that might otherwise be diagnosed as sudden infant death syndrome. The ocular autopsy in particular may demonstrate findings that were not appreciated on antemortem clinical examination. This protocol for postmortem examination of the eyes and orbits was developed to promote more consistent documentation of findings, improved clinical and forensic decision making, and more replicable and coherent research outcomes.