Infant Acute Life-Threatening Event—Dysphagic Choking Versus Nonaccidental Injury

A 4-month-old male infant presented to the emergency room with a history of choking while bottle feeding at home, and was found by emergency medical services (EMS) to be apneic and pulseless. He subsequently developed disseminated intravascular coagulopathy and died. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subdural hemorrhages (SDHs), subarachnoid hemorrhage (SAH), and retinal hemorrhages (RHs), along with findings of hypoxic-ischemic encephalopathy (HIE). The caretaker account appeared to be inconsistent with the clinical and imaging features, and a diagnosis of nonaccidental injury with “shaken baby syndrome” was made. The autopsy revealed diffuse anoxic central nervous system (CNS) changes with marked edema, SAH, and SDH, but no evidence of “CNS trauma.” Although NAI could not be ruled out, the autopsy findings provided further evidence that the child’s injury could result from a dysphagic choking type of acute life threatening event (ALTE) as consistently described by the caretaker.