Search

Objective: Develop guidelines for child death review teams that will improve the consistency in classifying child maltreatment (CM) and distinguish between classification of exposure to hazards and neglect for sleep-related sudden unexpected infant deaths (SUID)., Methods: Sleep-related SUID (n = 25 797) were identified from the National Fatality Review-Case Reporting System between 2004 and 2018. Key variables considered when classifying CM among sleep-related SUID were identified. Logistic regression was used to assess the strength of associations and identify factors that distinguished between exposure to hazards and neglect. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Guidelines were developed based on these findings., Results: Among the 13 034 sleep-related SUID with CM identified, hazards in the infant sleep environment were strongly associated with classification of both exposure to hazards and neglect, as were supervisor impairment and child welfare substantiation of the death. Comparing neglect to exposure to hazards, there was no association with sleep environment hazards with ORs ranging from 0.8 to 1.3 (95% CI 0.4-3.0), but sleep-related SUID were approximately twice as likely to be classified as neglect when the supervisor was impaired (OR 2.3, 95% CI 2.0-2.7) or child welfare action was taken (OR 1.8, 95% CI 1.5-2.0). The guidelines recommend classification of exposure to hazards for sleep environment hazards with elevation to neglect if the supervisor was impaired or child welfare substantiated the death., Conclusions: Among sleep-related SUID, classification of exposure to hazards is based on presence of sleep environment hazards, whereas neglect is based on supervisor impairment and child welfare action., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Despite being widely used, few studies have assessed the utility of the San Diego definition of sudden infant death syndrome (SIDS). The purpose of this study was to evaluate pathologists' application of the San Diego definition in all cases of sudden unexpected death in infancy (SUDI) that occurred in Queensland, Australia, between 2010 and 2014. Key coronial documents of 228 cases of SUDI were reviewed independently by three reviewers and classified according to the San Diego definition. Clear guidance regarding the evidentiary threshold for classification and interpretation of the San Diego definition was provided. All reviewers classified cases identically in 202 cases (88.6%). Consensus was achieved on the classification of the remaining 26 deaths following case discussion. After review, 79 cases were classified as SIDS, a one third reduction compared with the original classification, mainly due to a high probability of accidental asphyxia. The number of cases classified as undetermined (USID) almost doubled (75/228, 32.9%), and there was more than a fivefold increase in cases classified as asphyxia (43/228, 18.9%). Natural conditions decreased by approximately one third (21/228, 9.2%). This study demonstrates that with clear guidelines for interpretation, the San Diego definition can be applied reliably, with discrepancies resolved through a process of peer review.

This report details the proceedings and conclusions from the 3rd International Congress on Unexplained Deaths in Infants and Children, held November 26-27, 2018 at the Radcliffe Institute at Harvard University. The Congress was motivated by the increasing rejection of the diagnosis Sudden Infant Death Syndrome (SIDS) in the medical examiner community, leading to falsely depressed reported SIDS rates and undermining the validity and reliability of the diagnosis, which remains a leading cause of infant and child mortality. We describe the diagnostic shift away from SIDS and the practical issues contributing to it. The Congress was attended by major figures and opinion leaders in this area from countries significantly engaged in this problem. Four categories (International Classification of Diseases (ICD)-11 categories of MH11, MH12, MH14, PB00-PB0Z) were recommended for classification, and explicit definitions and guidance were provided for death certifiers. SIDS was reframed as unexplained sudden death in infancy or SIDS/MH11 to emphasize that either term signifies the lack of explanation following a rigorous investigation. A distinct category for children over the age of 1 was recommended (MH12). Definitions and exclusions were provided for the alternative categories of accidental asphyxia and undetermined. As recommended, unexplained sudden death in infancy or SIDS on a death certificate will code a unique, trackable entity, accurately reflecting the inability to determine a definitive explanation, while satisfying surveillance needs and reliable identification for research efforts. The conclusions will be submitted to the World Health Organization for inclusion in the upcoming ICD-11.

The classification of the cause of unexpected infant deaths by both pathologists and researchers may be quite inconsistent. For example, if an infant is found lying face down on soft bedding the death may still be certified as 'sudden infant death syndrome (SIDS)', 'accidental suffocation', 'undetermined', 'unclassified sudden infant death (USID)', or 'sudden unexpected death in infancy (SUDI)'. As the San Diego definition of SIDS does not appear to be rigorously or consistently applied, clarifying 'mechanical asphyxia not determined with certainty' may help to more clearly separate SIDS from USID. Including a classification algorithm with the definition may also help to better define unsafe sleep factors and suffocation. This commentary reviews the current situation with regard to classifying these deaths and concludes that the absence of diagnostic pathological markers with conflicting classification systems has led to idiosyncratic certification practices., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background: Sharp declines in sudden unexpected infant death (SUID) in the 1990s and a diagnostic shift from sudden infant death syndrome (SIDS) to unknown cause and accidental suffocation and strangulation in bed (ASSB) in 1999-2001 have been documented. We examined trends in SUID and SIDS, unknown cause, and ASSB from 1990 to 2015 and compared state-specific SUID rates to identify significant trends that may be used to inform SUID prevention efforts., Methods: We used data from US mortality files to evaluate national and state-specific SUID rates (deaths per 100 000 live births) for 1990-2015. SUID included infants with an underlying cause of death, SIDS, unknown cause, or ASSB. To examine overall US rates for SUID and SUID subtypes, we calculated the percent change by fitting Poisson regression models. We report state differences in SUID and compared state-specific rates from 2000-2002 to 2013-2015 by calculating the percent change., Results: SUID rates declined from 154.6 per 100 000 live births in 1990 to 92.4 in 2015, declining 44.6% from 1990 to 1998 and 7% from 1999 to 2015. From 1999 to 2015, SIDS rates decreased 35.8%, ASSB rates increased 183.8%, and there was no significant change in unknown cause rates. SUID trends among states varied widely from 41.5 to 184.3 in 2000-2002 and from 33.2 to 202.2 in 2013-2015., Conclusions: Reductions in SUID rates since 1999 have been minimal, and wide variations in state-specific rates remain. States with significant declines in SUID rates might have SUID risk-reduction programs that could serve as models for other states., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

The purpose of this study was to examine the neuronal expression of apoptotic markers in the rostral medulla of a newly characterized dataset of sudden unexpected death in infancy (SUDI), and to determine the impact of diagnostic groupings on these findings and whether they pertain to the intrinsic apoptotic pathway. Immunohistochemical staining was quantified to determine the percentage of neurons positive for active caspase-9 (specific to the intrinsic apoptotic pathway), active caspase-3 (common to the intrinsic and extrinsic apoptotic pathways) and Terminal deoxynucleotidyl transferase mediated dUTP nick-end labelling (TUNEL) (labels DNA fragmentation) in nine nuclei of the rostral medulla. Expression was compared between groups of SUDI infants where the cause of death was initially classified by a forensic pathologist or subsequently after reclassification by an expert panel using the San Diego Criteria. 68 SUDI infants were studied and originally classified as explained SUDI (n = 12), Sudden Infant Death Syndrome (SIDS) (n = 27) and undetermined (n = 29). Reclassification resulted in a decrease in the number of explained SUDI cases to 7 and a decrease in the number of undetermined cases to 4, with a corresponding increase in the number of SIDS cases to 57 (8 SIDS I; 49 SIDS II). The expression of apoptotic markers was similar in explained SUDI and SIDS I infants. However, TUNEL expression was greater in the cuneate (p < 0.001), vestibular (p = 0.01) and hypoglossal (p < 0.001) nuclei and active caspase-3 expression was lower in the arcuate nucleus (p = 0.037) in SIDS II compared to explained Sudden Unexpected Death in Infancy (eSUDI) infants. Compared to SIDS I infants, SIDS II infants had greater TUNEL expression in the dorsal motor nucleus of the vagus (p < 0.01) and greater active caspase-9 expression in the medial and spinal vestibular nuclei (p = <0.01). Changes in apoptotic expression predominated in SIDS II infants. We postulate that these are due to a combination of contributing risk factors including the presence of an upper respiratory tract infection and bed-sharing/co-sleeping. The absence of changes in active caspase-9 expression compared to eSUDI indicates that the intrinsic apoptotic pathway is not upregulated in SIDS.

Sudden unexpected infant death (SUID) is the leading cause for post-neonatal mortality in industrialized nations. Case-control studies have identified risk factors for SUID that have shaped research into studies of causation. Most current hypotheses for the mechanisms for SUID contribute to the "SUID sequence"-hypoxia and/or hypercarbia in sleep to which a vulnerable infant fails to respond adequately and that results in death. Reducing vulnerability in infants and promoting safe sleep for infants is important for prevention and requires knowledge of the prevalence of risk factors within the target population and a culturally sensitive approach. [Pediatr Ann. 2017;46(8):e278-e283.]., (Copyright 2017, SLACK Incorporated.)

Question: For many years, the term apparent life-threatening event (ALTE) was associated with sudden infant death syndrome, and parents who described an acute event in their infants were sent to the hospital for admission. I understand that for infants new terminology is recommended. What is the current approach to a near-death experience of an infant?, Answer: A recent clinical practice guideline revised the name and definition of an ALTE to a brief resolved unexplained event (BRUE). The diagnosis of BRUE in infants younger than 1 year of age is made when infants experience 1 of the following BRUE symptoms: a brief episode (ie, less than 1 minute and usually less than 20 to 30 seconds) that is entirely resolved (infant is at baseline), which remains unexplained after the history and physical examination are completed, and includes an event characterized by cyanosis or pallor; absent, decreased, or irregular breathing; hypertonia or hypotonia; or altered responsiveness. Low-risk infants should not be admitted to the hospital and overtesting is discouraged., (Copyright© the College of Family Physicians of Canada.)

We have reached a conundrum in assigning cause of death for sudden unexpected infant deaths. We summarize the discordant perspectives and approaches and how they have occurred, and recommend a pathway toward improved consistency. This lack of consistency affects pediatricians and other health care professionals, scientific investigators, medical examiners and coroners, law enforcement agencies, families, and support or advocacy groups. We recommend that an interdisciplinary international committee be organized to review current approaches for assigning cause of death, and to identify a consensus strategy for improving consistency. This effort will need to encompass intrinsic risk factors or infant vulnerability in addition to known environmental risk factors including unsafe sleep settings, and must be sufficiently flexible to accommodate a progressively expanding knowledge base.

Sudden unexpected infant deaths (SUID) accounted for 1 in 3 postneonatal deaths in 2010. Sudden infant death syndrome and accidental sleep-related suffocation are among the most frequently reported types of SUID. The causes of these SUID usually are not obvious before a medico-legal investigation and may remain unexplained even after investigation. Lack of consistent investigation practices and an autopsy marker make it difficult to distinguish sudden infant death syndrome from other SUID. Standardized categories might assist in differentiating SUID subtypes and allow for more accurate monitoring of the magnitude of SUID, as well as an enhanced ability to characterize the highest risk groups. To capture information about the extent to which cases are thoroughly investigated and how factors like unsafe sleep may contribute to deaths, CDC created a multistate SUID Case Registry in 2009. As part of the registry, the Centers for Disease Control and Prevention developed a classification system that recognizes the uncertainty about how suffocation or asphyxiation may contribute to death and that accounts for unknown and incomplete information about the death scene and autopsy. This report describes the classification system, including its definitions and decision-making algorithm, and applies the system to 436 US SUID cases that occurred in 2011 and were reported to the registry. These categories, although not replacing official cause-of-death determinations, allow local and state programs to track SUID subtypes, creating a valuable tool to identify gaps in investigation and inform SUID reduction strategies., (Copyright © 2014 by the American Academy of Pediatrics.)

The use of different definitions of sudden infant death syndrome (SIDS) may make comparison of data among studies difficult. Fifty randomly selected papers dealing with SIDS that were published between 2010 and 2011 in peer-reviewed journals were reviewed to determine whether one of three internationally accepted definitions of SIDS had been either written in the text or referenced. A significant improvement in the use of definitions has occurred since 2005, with the percentage of papers either quoting or referencing a standard definition increasing by 26%, from 42 to 68%. The 1989 NICHD definition remained the most commonly used definition (35.1%) followed by the 2004 San Diego definition (26.3%). Although the percentage of papers where either no definition was provided or where an idiosyncratic or mis-cited definition was used fell 26%, from 58 to 32%, nearly one in three papers published on SIDS in peer-reviewed journals that were included in this study still did not cite a standard definition., (Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

A study was undertaken reclassifying cases of sudden infant death syndrome (SIDS) taken from two geographically separate locations utilizing the San Diego definition with subclassifications. One hundred twenty-eight infant cases were examined from files at Forensic Science South Australia in Adelaide, SA, Australia over a 7.5-year period from July 1999 to January 2007. Thirty-one cases (24%) had initially been diagnosed as SIDS and 30 (23%) as undetermined while 67 (52%) had an explainable cause of death. After reclassification, the number of SIDS cases had increased to 49 of the 128 cases, now representing 38% of the cases; category IB SIDS constituted 10 (20%) and II SIDS 39 (80%) of the SIDS cases. No cases were classified as IA SIDS. Two hundred eighteen infant cases were identified from the files of the Department of Forensic Medicine, Aarhus University, Denmark over a 16-year period from 1992 to 2007. Eighty-two (38%) were originally diagnosed as SIDS, 128 (59%) with identifiable causes of death, and 8 (4%) as unexplained. After review, 77 (35%) cases were reclassified as SIDS, a decrease of 6%. Twenty (26%) infants were classified as category IB SIDS and 57 (74%) as II SIDS. None of the cases met the criteria for IA SIDS. Problems arose in assessing cases with failure to thrive, fever, and possible asphyxia. Modifications to the San Diego subclassifications might improve the consistency of categorizing these cases.

Current classification schemes for sudden unexpected infant death (SUID) may not be optimal for capturing scene events that potentially predispose to asphyxia. (1) To compare causes of death in a group of SUID cases assigned by multiple reviewers using our recently published classification scheme for SUID that is based on asphyxial risk at the death scene, and (2) To compare these newly assigned causes of death to that originally assigned by the medical examiners of record who performed the autopsies. Five reviewers independently assigned causes of death for 117 cases of SUID, including 83 originally diagnosed as sudden infant death syndrome (SIDS), accessioned into the San Diego SIDS/SUDC Research Project from the San Diego County Medical Examiner's Office. The diagnostic categories are: A: SIDS; B: Unexplained-Potentially Asphyxia; C: Unexplained-Other Potential Causes of Death; D: Unclassified-Other; E: Unclassified; and F: Known Cause of Death. The reviewers collectively opined that conditions at the death scene contributed to or caused death in 32-50% of all of the 117 cases as well as in 40-59% of the 83 originally diagnosed SIDS cases. Another cause of death was considered plausible in 2-12% of the SIDS cases. Application of this new classification system resulted in 55-69% decrease in SIDS diagnoses. Asphyxia as a potential contributor to, or as the specific cause of death, appears to exist in a large percentage of cases designated as SIDS using other classification schemes. When certifiers use a classification system that focuses upon potential asphyxia in determining the cause of death the incidence of SIDS dramatically declines.

We compared written text on infant death certificates for deaths coded as sudden infant death syndrome (R95), unknown cause (R99), and accidental suffocation (W75). Using US mortality files supplemented with the death certifiers' written text for all infant deaths with International Classification of Diseases (ICD)-10 assigned codes R95, R99, and W75, we formed cause-of-death subcategories from common themes identified from the written text. Among all infant deaths in 2003-2004, the underlying cause of death was listed as R99 for 2128 deaths, R95 for 4408 deaths, and W75 for 931 deaths. Among the postneonatal deaths, the differences in subcategories varied between assigned ICD-10 codes: for R99-coded deaths, 45.8% were categorized as "Unknown" and 48.6% as "Pending"; for R95-coded deaths, 67.7% were categorized as "sudden infant death syndrome (SIDS)"; and for W75-coded deaths, 76.4% were categorized as "Suffocation." Examination of the written text on the death certificates demonstrates variability in the assigned ICD-10 codes which could have an important effect on the estimates of SIDS cases in the United States., (2011 American Academy of Forensic Sciences. Published 2011. This article is a U.S. Government work and is in the public domain in the U.S.A.)

Objective: To illustrate the benefits and utility of the child death review (CDR) reporting system when examining risk factors associated with infant death occurring within two subgroups of sudden unexpected infant deaths (SUID)-unintentional suffocation and sudden infant death syndrome (SIDS)-in a large urban county in Wisconsin., Design: Retrospective CDR data were analysed, 2007-2008, for Milwaukee County, Wisconsin. PATIENTS OR SUBJECTS: Unintentional suffocation and SIDS infant deaths under 1 year of age in Milwaukee County, Wisconsin, 2007-2008, with a CDR record indicating a death in a sleep environment. Main outcome measure Study examined demographic characteristics, bed-sharing, incident sleep location, position of child when put to sleep, position of child when found, child's usual sleep place, crib in home, and other objects found in sleep environment., Results: Unintentional suffocation (n=11) and SIDS (n=40) classified deaths with CDR data made up 18% (51/283) of all infant deaths in Milwaukee County from 2007 to 2008. The majority of infants who died of unintentional suffocation (n=9, 81.8%) or SIDS (n=26, 65.0%) were black and under the age of 3 months. Bed-sharing was involved in most of the unintentional suffocation deaths (n=10, 90.9%) and the SIDS deaths (n=28, 70.0%). All unintentional suffocation deaths (n=11, 100%) and the majority of SIDS deaths (n=31, 77.5%) took place in a non-crib sleeping environment., Conclusions: The study demonstrates how CDR provides enhanced documentation of risk factors to help steer prevention efforts regarding SUID deaths in a community and reaffirms infants in an unsafe sleep environment have an increased risk of death.

Background: Incidence of sudden unexpected death in infancy (SUDI) and sudden infant death syndrome (SIDS) differs among studies and non-autopsied cases are difficult to assess., Objectives: To investigate causes of sudden death in infancy in a nationwide setting. Validate the use of the ICD-10 code for SIDS (R95) in the Danish Cause of Death registry., Design: A retrospective analysis of all infant deaths (< 1 year of age) in Denmark in 2000-2006. All death certificates and autopsy reports were read., Results: We identified 192 SUDI cases (10% of total deaths, 0.42 per 1000 births) with autopsy performed in 87% of cases. In total, 49% of autopsied SUDI cases were defined as SIDS (5% of all deaths, 0.22 per 1000 births); Cardiac cause of death was denoted in 24% of cases. The Danish Cause of Death Registry misclassified 30% of SIDS cases., Conclusions: A large proportion of infant deaths are SUDI, and the majority of these are caused by cardiac disease or SIDS. Autopsy is not always performed and valuable information is subsequently lost. Cause of Death registry data is not accurate in describing SIDS.

The Centers for Disease Control and Prevention funded seven states, including Kentucky, to clarify statewide death certification practices in sudden, unexpected infant death and compare state performances with national expectations. Accurate assignment of the cause and manner of death in cases of sudden, unexpected infant death is critical for accurate vital statistics data to direct limited resources to appropriate targets, and to implement optimal and safe risk reduction strategies. The primary objectives are to (1) Compare SUID death certifications recommended by the KY medical examiners with the stated cause of death text field on the hard copy death electronic death certificates and (2) Compare KY and national SUID rates. Causes of death for SUID cases recommended by the medical examiners and those appearing on the hard copy and electronic death certificates in KY were collected retrospectively for 2004 and 2005. Medical examiner recommendations were based upon a classification scheme devised by them in 2003. Coroners hard copy death certificates and the cause of death rates in KY were compared to those occurring nationally. Eleven percent of infants dying suddenly and unexpectedly did not undergo autopsy during the study interval. The KY 2003 classification scheme for SIDS is at variance with the NICHD and San Diego SIDS definitions. Significant differences in causes of death recommended by medical examiners and those appearing on the hard copy and electronic death certificates were identified. SIDS rates increased in KY in contrast to decreasing rates nationally. Nationwide adoption of a widely used SIDS definition, such as that proposed in San Diego in 2004 as well as legislation by states to ensure autopsy in all cases of sudden unexpected infant death are recommended. Medical examiners' recommendations for cause of death should appear on death certificates. Multidisciplinary pediatric death review teams prospectively evaluating cases before death certification is recommended. Research into other jurisdictions death certification process is encouraged.

Aims: Presently, pathologists in the UK use diverse terminologies for the classification of sudden unexpected infant deaths, including 'unascertained,' 'sudden unexpected death in infancy' (SUDI) and 'sudden infant death syndrome' (SIDS). This study uses the Delphi method to investigate the views of paediatric pathologists on their use of these terms in order to determine areas of consensus., Methods: There were three Delphi rounds overall; in the final one, participants were asked to score each statement using a modified Likert scale (0-9). The scores were analysed using non-parametric statistics, and statements in which the median score was or=7 (approximately 70% agreement) were considered to have reached 'consensus agreement.', Results: Twenty-five of the 36 UK paediatric pathologists who were approached in the initial round contributed to all three rounds. There was consensus that 'SIDS' be used for unexplained sudden unexpected infant deaths that occurred during sleep. 'Infancy' was defined as up to 1 year of age, but there was no consensus regarding the lower age limit of SIDS. There was agreement that 'SUDI' be used for unexplained sudden infant deaths with a history of preceding illness, deaths with minor histological abnormalities of uncertain significance and co-sleeping-associated deaths. Most paediatric pathologists used 'unascertained' for findings suspicious of a non-natural cause of death. There was consensus that co-sleeping-associated deaths should be classified as 'unascertained' if parents had consumed alcohol or used drugs in the preceding 24 h., Conclusions: The areas of consensus relating to terminology around SUDI and SIDS should guide future use by pathologists. However, there remains a significant lack of agreement, suggesting that acceptable alternative terms be identified for infant deaths which remain unexplained following autopsy in whom there are no suspicious features; the authors propose that 'unexplained SUDI,' followed by a comment, may represent the most factually correct compromise.

The sudden infant death syndrome (SIDS) is the sudden dead of every infant or small child (usually within the first year of life). It is an unexpected event, according to the anamnesis of the subject, and the necroscopic examination of the event does not allow to demonstrate with success the proper cause of death. The careful forensic medical appraisal of the death scene and the clinician and anamnestic data, together with the anatomoistopatologic findings, are essential elements to make a correct diagnosis and discriminate between natural and violent causes of death, even if with remarkable interpretative difficulties. Only in rare cases (with variable statistical data), in spite of the scrupulous application of the surveying protocol, it is not possible to define the exact cause of the death. In these cases, generally characterized by an unspecific anossic anatomopathologic picture, the accepted diagnosis of death is exactly that of SIDS, reasoning by elimination. The study of the phenomenon must be based on a multidisciplinary approach, in which the legal surgeon's cooperation with other specialists, such as the anatomopathologist and the pediatrician, plays an important role.

Objective: To examine cause-of-death terminology written on death certificates for sudden infant death syndrome (SIDS) and to determine the adequacy of this text data in more fully describing circumstances potentially contributing to SIDS deaths., Study Design: With 2003 and 2004 US mortality files, we analyzed all deaths that were assigned the underlying cause-of-death code for SIDS (R95). With the terminology written on the death certificates, we grouped cases into SIDS-related cause-of-death subcategories and then assessed the percentage of cases in each subcategory with contributory or possibly causal factors described on the certificate., Results: Of the 4408 SIDS-coded deaths, we subcategorized 67.2% as "SIDS" and 11.0% as "sudden unexplained (or unexpected) infant death." The terms "probable SIDS" (2.8%) and "consistent with SIDS" (4.6%) were found less frequently. Of those death certificates that described additional factors, "bedsharing or unsafe sleep environment" was mentioned approximately 80% of the time. Most records (79.4%) did not mention any additional factors., Conclusion: Our death certificate analysis of the cause-of-death terminology provided a unique opportunity to more accurately characterize SIDS-coded deaths. However, the death certificate was still limited in its ability to more fully describe the circumstances leading to SIDS death, indicating the need for a more comprehensive source of SIDS data, such as a case registry.

Although the rate of the sudden infant death syndrome (SIDS) has decreased over the last two decades, medical examiners and coroners are increasingly unwilling to use the SIDS diagnosis, particularly when there is an unsafe sleeping environment that might pose a risk for asphyxia. In order to reliably classify the infant deaths studied in a research setting in the mixed ancestory population in Cape Town, South Africa, we tested a classification system devised by us that incorporates the uncertainty of asphyxial risks at an infant death scene. We classified sudden infant deaths as: A) SIDS (where only a trivial potential for an overt asphyxial event existed); B) Unclassified-Possibly Asphyxial-Related (when any potential for an asphyxial death existed); C) Unclassified-Non-Asphyxial-Related (e.g., hyperthermia); D) Unclassified-No autopsy and/or death scene investigation; and E) Known Cause of Death. Ten infant deaths were classified according to the proposed schema as: SIDS, n = 2; Unclassified-Possibly Asphyxial-Related, n = 4; and Known Cause, n = 4. A conventional schema categorized the deaths as 6 cases, SIDS, and 4 cases, Known Cause, indicating that 4/6 (67%) of deaths previously classified as SIDS are considered related importantly to asphyxia and warrant their own subgroup. This new classification schema applies a simpler, more qualitative approach to asphyxial risk in infant deaths. It also allows us to test hypotheses about the role of asphyxia in sudden infant deaths, such as in brainstem defects in a range of asphyxial challenges.

This study evaluates the hypothesis that a decline in sudden infant death syndrome in Minnesota is associated with increases in other categories of sudden unexpected infant death. Matched birth and death certificates, autopsy reports, and home visit questionnaires were reviewed for 722 sudden unexpected infant deaths that occurred from January 1, 1996 through December 31, 2002. Descriptive data and cause of death were recorded. Cause of death was compared for 2 periods: early (1996-1998) and late (2000-2002). The age of the infant at death, sex, race, and infant death rates were similar between the 2 periods ( P = .637). Sudden infant death syndrome declined by 50.1% (P < .001). Overlay deaths increased 235.5% (P < .01). Asphyxia related deaths increased 259.6% (P < .001). Injury-related deaths increased 840.0% (P < .001). A decline in sudden infant death syndrome in Minnesota was associated with increased deaths in categories that are asphyxial in nature and are potentially preventable.

The significance of severe pulmonary intra-alveolar hemosiderosis in sudden infant death is controversial in forensic pathology. We report a previously healthy 9-month-old female infant who died suddenly and unexpectedly after being placed and then found prone in her crib. Her gestation and delivery were uncomplicated, and she had no history of anemia, hemoptysis, chest trauma, or chronic lung disease. Autopsy revealed diffuse severe pulmonary congestion and severe multifocal intra-alvedar hemorrhage. Metabolic and toxicological screening, microbiologic cultures, and vitreous chemistry were noncontributory. A diagnosis of SIDS had been made by the medical examiner. Subsequent semiquantitative assessment of the severity of pulmonary intra-alveolar hemosiderosis prompted consideration of other disorders, including a heretofore undescribed lethal infantile variant of idiopathic pulmonary hemosiderosis, but none could be confirmed. Therefore, we assigned a study diagnosis of unclassified sudden infant death. We recommend that a diagnosis of SIDS not be made in cases with unexplained large numbers of intra-alveolar PS. We also recommend that quantitative assessment of lung sections stained for iron be undertaken in cases with numerous intra-alveolar macrophages in order to accumulate data that might allow diagnostic correlations with the circumstances of death and autopsy findings.

Given that there are a number of contradictions in the SIDS literature and that the definition of SIDS that was relied upon to authenticate cases in reports is not always specified, an audit of publications was undertaken. Fifty papers dealing with SIDS that were published in 2005 were reviewed. The majority (58%) of reports had either not specified a definition of SIDS, or had used non-standard or idiosyncratic definitions. Of the papers that had documented a definition: 30% used the 1989 NICHD definition, 10% used the 2004 San Diego definition, and 2% used the 1969 Seattle definition. Failure to use standard published definitions of SIDS and/or to clearly specify the definition that has been followed may severely hamper the evaluation of SIDS research.

Objective: Sudden Infant Death Syndrome (SIDS) is defined as a diagnosis of exclusion, after an evaluation of the medical history, complete postmortem examination, and scene investigation. The diagnosis of SIDS in many sudden and unexplained infant deaths has not been consistently applied nationally or, prior to July 2003, in the state of Kentucky. In order to better standardize practices in formulating the diagnosis of SIDS in cases of sudden and unexpected infant deaths, all of the Kentucky medical examiners formed a working group to collectively standardize the classification of this enigmatic type of infant death., Methods: We conducted a retrospective review (2000-2004) of infants < 1 year who underwent complete historical review, circumstantial investigation, postmortem examination, and toxicological analysis performed at the Medical Examiners' Offices in Kentucky encompassing all deaths certified as Sudden Infant Death Syndrome, positional asphyxia, overlay, and undetermined cause and manner of death., Results: A total of 417 cases were deemed sudden unexplained infant deaths after postmortem examination at the Medical Examiners' Offices in Kentucky between 2000 and 2004. A total of 237 (56.8%) infants had been bedsharing with at least one other person when found. Prior to the SIDS classification policy change in July 2003, a significantly greater number of sudden unexpected infant death cases were deemed undetermined in both cause and manner in contrast to a smaller number classified as SIDS. After the policy change, the number of deaths classified as SIDS greatly surpassed the number classified as undetermined., Conclusions: The increase in the number of deaths consistent with SIDS and a reciprocal decline in cases reported as undetermined cause and manner of death in Kentucky is due to the uniformity and standardization of terminology, rather than an actual increase in the number of infant deaths. The Kentucky policy in July 2003 has been invaluable in ensuring uniform criteria in the diagnosis of SIDS and other categories of sudden unexpected death in infants < 1 year.

Sudden infant death syndrome (SIDS) still accounts for considerable numbers of unexpected infant deaths in many countries. While numerous theories have been advanced to explain these events, it is increasingly clear that this group of infant deaths results from the complex interaction of a variety of heritable and idiosyncratic endogenous factors interacting with exogenous factors. This has been elegantly summarised in the "three hit" or "triple risk" model. Contradictions and lack of consistencies in the literature have arisen from diverse autopsy approaches, variable applications of diagnostic criteria and inconsistent use of definitions. An approach to sudden infant death is outlined with discussion of appropriate tissue sampling, ancillary investigations and the use of controls in research projects. Standardisation of infant death investigations with the application of uniform definitions and protocols will ensure optimal investigation of individual cases and enable international comparisons of trends.

The new definition of the term sudden infant death syndrome (SIDS) and the criteria introduced in San Diego for the subclassification of cases have been used to re-classify the first 100 consecutive cases of sudden and unexpected infant deaths that were registered with the German SIDS study (GeSID). Although there are 30 different variables that have to be considered in the general and stratified sections of the San Diego definition, it is practical, in particular, as an international standard to perform scientific studies. The comparison of the San Diego definition and the classification used for GeSID shows similarities in the methods but differences in the criteria used. Nevertheless, the numbers of cases classified as SIDS and borderline SIDS are similar (San Diego n=69, GeSID n=74). The SIDS IA criteria of the San Diego definition were not fulfilled by any case because metabolic screening and vitreous chemistry were not included in the GeSID investigation scheme. An important advantage of the San Diego definition is the introduction of the category of unclassified sudden infant death, which includes cases for which no autopsy was performed. This demonstrates that such cases cannot be classified as SIDS. In conclusion, we recommend the universal acceptance and use of the San Diego SIDS definition.

The recent US decline in sudden infant death syndrome (SIDS) rates may be explained by a shift in how these deaths are classified or reported. To examine this hypothesis, the authors compared cause-specific mortality rates for SIDS, other sudden, unexpected infant deaths, and cause unknown/unspecified, and they evaluated trends in the age and month of death for these causes using 1989-2001 US linked birth/death certificate data. Reported deaths in state and national data were compared to assess underreporting or overreporting. SIDS rates declined significantly from 1989-1991 to 1995-1998, while deaths reported as cause unknown/unspecified and other sudden, unexpected infant deaths, such as accidental suffocation and strangulation in bed (ASSB), remained stable. From 1999-2001, the decline in SIDS rates was offset by increasing rates of cause unknown/unspecified and ASSB. Changes in the cause-specific age at death and month of death distributions suggest that cases once reported as SIDS are now being reported as ASSB and cause unknown/unspecified. Most of the decline in SIDS rates since 1999 is likely due to increased reporting of cause unknown/unspecified and ASSB. Standardizing data collection at death scenes and improving the reporting of cause of death on death certificates should improve national vital records data and enhance prevention efforts.

There is increasing concern with using SIDS as a diagnosis, especially where the postmortem examination reveals additional findings that may be contributory to the death exclusion. This report shows how varying the criteria for a diagnosis of SIDS significantly alters the SIDS rate in Ireland.

Background: Sudden infant death syndrome (SIDS) makes up the largest component of sudden unexpected infant death in the United States. Since the first recommendations for supine placement of infants to prevent SIDS in 1992, SIDS postneonatal mortality rates declined 55% between 1992 and 2001., Objective: The objective of this analysis was to examine changes in postneonatal mortality rates from 1992 to 2001 to determine if the decline in SIDS was due in part to a shift in certification of deaths from SIDS to other causes of sudden unexpected infant death. In addition, the analysis reviews the change in mortality rates attributed to the broad category of sudden unexpected infant death in the United States since 1950., Methods: US mortality data were used. The International Classification of Diseases (ICD) chapters "Symptoms, Signs, and Ill-Defined Conditions" and "External Causes of Injury" were considered to contain all causes of sudden unexpected infant death. The following specific ICD (ninth and tenth revisions) underlying-cause-of-death categories were examined: "SIDS," "other unknown and unspecified causes," "suffocation in bed," "suffocation-other," "aspiration," "homicide," and "injury by undetermined intent." The average annual percentage change in rates was determined by Poisson regression. An analysis was performed that adjusted mortality rates for changes in classification between ICD revisions., Results: The all-cause postneonatal mortality rate declined 27% and the postneonatal SIDS rate declined 55% between 1992 and 2001. However, for the period from 1999 to 2001 there was no significant change in the overall postneonatal mortality rate, whereas the postneonatal SIDS rate declined by 17.4%. Concurrent increases in postneonatal mortality rates for unknown and unspecified causes and suffocation account for 90% of the decrease in the SIDS rate between 1999 and 2001., Conclusions: The failure of the overall postneonatal mortality rate to decline in the face of a declining SIDS rate in 1999-2001 raises the question of whether the falling SIDS rate is a result of changes in certifier practices such that deaths that in previous years might have been certified as SIDS are now certified to other non-SIDS causes. The observation that the increase in the rates of non-SIDS causes of sudden unexpected infant death could account for >90% of the drop in the SIDS rates suggests that a change in classification may be occurring.

Objective: Sudden infant death syndrome (SIDS) remains a challenge for health professionals despite decreasing rates in recent years. The figures for different areas and time periods are hardly comparable, because of differences in postmortem investigations and classification criteria. In 1992, the European Society for the Study and Prevention of Infant Deaths (ESPID) proposed a classification for any sudden and unexpected death in infancy. This proposal has been used in our study since 1993 to better classify sudden infant death (SID) cases., Method: 56 consecutive SID cases observed between 1993 and 2002 in Styria, the south-eastern province of Austria, were analysed by a multidisciplinary team of health professionals. The study group consisted of pediatricians, forensic pathologists, pathologists, psychologists, nurses, members of the parents' association and health authorities. SID cases were analysed with regard to potential risk factors during pregnancy and early life, the circumstances of death (death scene) and post-mortem findings. From the latter, every SID was classified as either 1) classic SIDS, 2) borderline SIDS, 3) non-autopsied SID or 4) explained death., Results: Of the 56 SID cases, 22 were assigned to category 1, 19 to category 2, four to category 3, and in 11 cases death could be explained by major post-mortem findings. For 17/22 cases in category 1 and 11/19 cases in category 2, the death scene investigation showed the typical risk profile of manner of bedding and/or environmental conditions. In three cases, child abuse or infanticide was considered possible but could not be proven despite careful autopsy. In recent years, SIDS incidence in Styria has decreased to approximately 0.18/1,000 live-born infants, and the few deaths still occurring mainly present with the typical risk profile., Conclusion: An extensive analysis of SID events is a prerequisite for reliable and comparable SIDS statistics. Our data show that in several SID cases careful post-mortem examinations led to an explanation of death. In other cases, minor alterations may have contributed to the lethal event. These findings should therefore be considered in the classification of SIDs. The ESPID classification of 1992 appears to be very useful for this purpose and its use may therefore be recommended.

Unlabelled: Sudden infant death syndrome (SIDS) is known to occur more frequently at night. In two studies it has now been shown that a prone sleep position is more strongly associated with SIDS occurring during the day, whereas night-time deaths are more strongly associated with maternal smoking and illness., Conclusion: This variation, although unexplained, does suggest at least two SIDS subtypes: one related to sleep position and possibly a thermal mechanism, and one related to an uncontrolled inflammatory response to infection predominantly occurring at night. In addition, there are probably other mechanisms that do not show a circadian variation.

More than 25 years have elapsed since continuous cardiorespiratory monitoring at home was suggested to decrease the risk of sudden infant death syndrome (SIDS). In the ensuing interval, multiple studies have been unable to establish the alleged efficacy of its use. In this statement, the most recent research information concerning extreme limits for a prolonged course of apnea of prematurity is reviewed. Recommendations regarding the appropriate use of home cardiorespiratory monitoring after hospital discharge emphasize limiting use to specific clinical indications for a predetermined period, using only monitors equipped with an event recorder, and counseling parents that monitor use does not prevent sudden, unexpected death in all circumstances. The continued implementation of proven SIDS prevention measures is encouraged.

Sudden infant death syndrome (SIDS) is a term that was first proposed in 1969 for a distinctive subgroup of unexpected infant deaths that occur during the postneonatal period with relatively consistent clinical, epidemiological, and pathological features. This term played an important role by focusing attention on a major category of postneonatal infant death, providing support to grieving families, and diminishing the guilt and blame characteristic of these deaths. Unfortunately, the application of this term has become increasingly controversial. Some have applied it too liberally, and others not at all. According to the definition proposed in 1969, despite slight changes suggested in 1989, SIDS remains a diagnosis of exclusion. Although this syndrome has several distinctive features, including age distribution and apparent occurrence during sleep, there has been reluctance to include these features in the definition. The problems created by the lack of an adequate definition are discussed. A 2-tiered approach is suggested, with a more general definition intended primarily for case management and death administration, and a more restrictive one intended primarily for research purposes, which distinguishes those deaths closely fitting the classic SIDS profile from those with one or more less typical features.