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A state committee in Missouri focused on child abuse and neglect spent about a year analyzing child deaths resulting from abuse or neglect.

The Child Fatality Review Panel Subcommittee on Child Abuse and Neglect Fatalities recently released its findings — Eliminating Child Abuse and Neglect Fatalities in Missouri, which looked at data from 2015.

Published in late April, the report looked at 58 infant deaths from across the state and attributed about 32 percent of the deaths to unsafe sleep environments.

Sleep-related deaths remain a leading cause of death for Missouri infants, the report determined. It's 2019 predecessor looked at data from 2014 and came to the same conclusion.

Safe sleep has been a priority in preventing children's deaths.

Missouri has championed safer sleeping environments for children for years.

The state's Safe Cribs for Missouri program provides free portable cribs and safe sleep education for mothers who qualify — low-income families that have no other resources for obtaining a crib. Clients must be eligible for the Women, Infants and Children program or have an income at or below 185 percent of the federal poverty level.

Jill Prater, a registered nurse and family planning coordinator for the Cole County Health Department, said the county has been successful in getting cribs into the hands of mothers who need them.

Over the past two years, it has distributed 23 cribs to clients, Prater said.

"Once the state of Missouri approves a client for a crib, the crib is shipped to the Cole County Health Department. And then, the client is called to come pick up the crib and attend an educational session regarding safe sleep for their baby," Prater said.

The continuing number of preventable deaths from unsafe sleep environments is troubling, Jennifer Tidball, acting director of the Missouri Department of Social Services, said in a news release.

The 2021 executive report may be found at

The study was intended to "identify effective prevention and intervention processes to decrease preventable child deaths through systematic evaluation of individual child deaths and the personal, familial, and community conditions, policies, and behaviors that contribute to preventable deaths," the report states.

Its goal is to advocate for actions to prevent child deaths and to keep children healthy, safe and protected.

In 2012, then-President Barack Obama signed the Protect Our Kids Act, which established a commission to eliminate child abuse- and neglect-related deaths. The commission recommended: steps regarding use of federally funded child welfare services; best practices for prevention of abuse and neglect fatalities; federal, state and local data collection systems and their improvement; mitigation of risk factors; and prioritization of prevention services for families.

The commission also recommended each state review the previous five years of child abuse- and neglect-related deaths, which led to creation of the subcommittee.

Missouri statute has required each county to create a child fatality review panel since 2014. County prosecuting attorneys are tasked with organization of the panels, which investigate the deaths of children younger than 18. Panels include the prosecuting attorney or circuit attorney, coroner or medical examiner, law enforcement personnel, member of the children's division, public health care specialist, representative from juvenile court and emergency medical provider. Other participants may be included.

The subcommittee intended to improve accuracy of identification and classification of abuse- and neglect-related fatalities; identify risk factors; assess system factors and how they functioned at times surrounding deaths; and develop prevention strategies, according to the report.

It acknowledged "neglect" is a broad spectrum, so it took a wide-ranging look at the issue to focus on children and their environments, and avoided casting blame.

That resulted in public awareness campaigns, child protective services including more education during home visits and distribution of free devices that make homes safer and more secure.

"For most families, there is not one thing that leads to a child dying due to abuse and neglect; rather, there is a combination of risk factors that together create the perfect storm and an environment that is dangerous for a child," the report states. "Families face a variety of social issues, including parental substance abuse, mental health problems, intimate partner violence, extreme poverty, multi-generational abuse, and neglect."

The involved families regularly have multiple touches with different agencies that have opportunities to intervene. But, interventions are also often made difficult by lack of family cooperation, frequent moves and inconsistent inter-agency communication.

The child deaths "illustrate the need for a multi-pronged approach to prevention," but also illustrate some of the challenges, according to the report.

The report provided seven recommendations:

Create a culture of safe sleep.

Increase the functionality of county and state child fatality review panels.

Improve mandated reporters' ability to recognize and respond to the suspected child maltreatment.

Increase and improve collaboration in cases with suspected child maltreatment.

Educate citizens on how to prevent or address scenarios that increase child death risk.

Improve provision of resources to high-risk and/or high-needs families.

Improve systemic response to child deaths.

A safe sleep environment should allow for a small child to be placed alone, on their back, on a firm sleep surface (such as a crib, pack 'n' play or mattress) free from bumpers, loose bedding, clothing and toys.

While there are clear recommendations about what constitutes a safe sleep environment, the report says, some families receive mixed messages from social media, popular culture and other family members.

Also, in many cases where the death occurred in an unsafe sleep environment, the parent was not the caregiver. So, the report states, there needs to be an emphasis on reaching a broad audience with safe sleep education.

Chaos within homes led to several of the children's fatalities. Risk factors observed through the study included caregiver substance use, maternal mental health disorder, non-relative male caregivers in the home, intimate partner violence and a lack of safe child care options. Environmental risk factors, such as poverty, lack of resources and generational violence also contributed to a number of the deaths, the report said.

"To prevent child maltreatment-related deaths, it is critical to have a state where those who interact with children and their caregivers have knowledge and adopt responsibility of their well-being and safety," the report finds.

A great deal of child fatalities are going to be sleep-related, said Locke Thompson, Cole County prosecuting attorney. He added his office comes in as part of the investigation into a death.

"We make sure we're not missing some criminal liability," Thompson said. "When we do end up with a criminal case, we work with the state technical support team."

Also known as the State Technical Assistance Team, the organization is intended to assist agencies in protection of Missouri children.

"We work with them on our most high-profile child-death cases," he added.

Douglas Beal, a Columbia pediatrician and neonatologist, is part of the STAT team, Thompson said. When Cole County receives an abuse or neglect case that becomes criminal, Beal is able to step in and take investigations a little farther than medical examiners.

For instance, if a baby dies and is found to have methamphetamine in its system, Beal can determine whether the drug entered the baby's body through breast milk or through ingestion, Thompson said.

Some mandatory reporters aren't doing well enough, the report said.

Those who interact with the children and caregivers must report concerns about suspected abuse and neglect to the appropriate authorities, the report said.

In 2015, of the 58 reviewed cases, 19 had previous reports of concerns about abuse, the report said.

Mandated reporters must better recognize signs of child maltreatment, the report found. Of the 39 cases with fatalities that were not sleep-related, six showed reports of injuries or weight loss that were either seen or discussed with a mandated reporter prior to a fatality.

In half of these cases, there was contact with a mandated reporter (and injuries identified) less than one month prior to death, the report showed.

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