Death and serious-injury reviewers flag growth-faltering and non-fatal strangulation trends, urge multidisciplinary response

The Child Death and Serious Injury Review Panel (CDSIRP) presented its annual findings and case-review activity to the Health and Human Services Committee, raising concerns about two recurring themes: growth faltering diagnoses in infants and a cluster of non-fatal strangulation incidents.

"We flagged nine cases for potential level two review around growth faltering," Erica Simson, chair of the panel and family services director at a domestic-violence coalition, told the committee. The panel asked for more in-depth investigation into whether the rise reflects medical practice variation, bias in reporting or real changes in incidence.

Panelists also identified five cases requiring further thematic review for non-fatal strangulation, including situations where pediatric non-fatal strangulation occurred alongside adult non-fatal strangulation in the same incident. Simson noted that strangulation is a statutory aggravated assault in Maine when the intentional impeding of breathing is established and said the panel would follow criminal-case constraints when reviewing some incidents.

A separate data concern: the panel reported a steep increase in ingestion reports for the review period, but said much of that rise came from intentional adolescent substance use (ages roughly 14'17) rather than the accidental ingestions the panel traditionally reviews for young children. After consulting with OCFS, the panel said it will use a new OCFS definition of "serious ingestion" (medical intervention or likely serious injury) to filter cases beginning Jan. 1, 2026.

Panel recommendations and themes: CDSIRP summarized four cross-cutting priorities it repeatedly raised in its review work:

- Strengthen multidisciplinary responses and provide tailored tools for mandated reporters so observations are recorded objectively; - Assess and mitigate bias in reporting and investigative responses; - Use pediatric child-abuse specialists and imaging resources (skeletal surveys, specialist consults) when injuries raise abuse/neglect questions; and - Address social determinants (food insecurity, housing instability, access to firearms) that increase vulnerability upstream.

The panel said some longstanding prevention efforts are showing measurable progress. For example, sudden unexpected infant death and unsafe-sleep deaths have declined, and the panel cited hospital newborn outreach and public education as contributing factors.

Context and next steps: CDSIRP said it conducted quarterly and level-one reviews, completed a 15-year historical recommendations assessment, and expects to issue a consolidated annual report with fewer new recommendations and more follow-up on past items. The panel also noted the practical difficulty of including people with lived experience in fatality review meetings and is developing guidance on safe, appropriate family engagement.

The committee asked the panel to make its past-recommendations list available in a consolidated form; the panel said it will prepare and share that compilation. Panel chairs and OCFS staff also stressed the need for clear public messaging to avoid misrepresenting panel statistics.

Quotes from the hearing: "We're seeing a resurgence of people making that [growth-faltering] diagnosis in medical settings," Simson said. On ingestions, the panel warned: "Do not be alarmed by the raw count'much of it reflects intentional adolescent use rather than accidental exposure."