Nasal and intrapulmonary haemorrhage in sudden infant death syndrome

Negative pressure pulmonary edema and hemorrhage after near fatal suffocation in an infant: a case report

BACKGROUND

Pulmonary hemorrhage is rare but potentially life-threatening in children. Many causes are usually described, as cardiogenic, infective or immune. Pulmonary hemorrhage related to negative pressure pulmonary edema (NPPE) is uncommon in the pediatric population and there is limited literature about it. This is one of the few case reports regarding NPPE in infants presenting with pulmonary hemorrhage.

CASE PRESENTATION

We describe the story of a 6-weeks-old boy who presented epistaxis and hemoptysis associated with symptoms related to NPPE after near fatal suffocation. Radiological findings were consistent with alveolar hemorrhage. Supportive therapy was performed, with clinical recovery within a few days and radiological normalization within one month.

CONCLUSION

NPPE associated with pulmonary hemorrhage is a dramatic condition but usually has a quick recovery with just supportive therapy. The aim of our report is to increase the awareness and emphasizes the importance of including this entity in the differential diagnosis of pulmonary hemorrhage in children with a suspicious anamnestic history of upper airway obstruction.

Infant death from accidental suffocation and strangulation in bed in England and Wales: rare or unrecognised events?

BACKGROUND

Mandatory joint police and healthcare investigations of sudden unexpected death in infancy (SUDI) have been in place since 2008 in England. These include death scene examination with cause of death determined at multiprofessional case conference. Detailed evidence on sleep arrangements is available for most cases potentially leading to more being identified as due to accidental suffocation. SUDI remaining unexplained following investigation are classified as SIDS (sudden infant death syndrome) or unspecified deaths.Our objective was to determine whether detailed SUDI investigation has led to an increase in deaths classified as accidental suffocation or strangulation in bed (ASSB)?

METHODS

We obtained official mortality data for England and Wales for infants dying aged 0-364 days for International Statistical Classification of Diseases and Related Health Problems, 10th revision codes R95 (SIDS), R96, R98, R99 (unspecified causes of mortality) and W75 (ASSB) for the years 2000-2019.We calculated the mortality rate for ASSB, SIDS and unspecified causes based on total live births each year.

RESULTS

Unexplained SUDI decreased from 353 in 2000 to 175 in 2019, with the mortality rate falling from 0.58 to 0.29 per 1000 live births. The total postneonatal mortality rate fell during this time from 1.9 to 0.9 per 1000 live births suggesting this is a genuine fall. SIDS accounted for 70% of unexplained SUDI in 2000 falling to 49% in 2020 with a corresponding increase in R99 unspecified deaths.Few deaths were recorded as ASSB (W75), ranging between 4 in 2010 and 24 in 2001. The rate for ASSB ranged from 0.6 to 4.0 per 100000 live births.

CONCLUSIONS

There is a shift away from SIDS (R95) towards unspecified causes of death (R96, R98, R99). Improved investigation of deaths has not led to increased numbers of death identified as due to ASSB. There needs to be clear guidelines on accurate classification of deaths from ASSB to facilitate learning from deaths and inform prevention efforts.

Classification of sleep-related sudden unexpected death in infancy: A national survey

AIM

To identify how British Child Death Overview Panels (CDOPs) and paediatric pathologists classify cause of death for sleep-related Sudden Unexpected Death in Infancy (SUDI). To determine compliance with national requirements for SUDI investigation.

METHODS

Electronic survey of CDOPs and pathologists using three vignettes of SUDI cases illustrating: accidental asphyxia, typical Sudden Infant Death Syndrome (SIDS) and SIDS with co-sleeping.

RESULTS

Thirty-eight (41%) of 92 CDOPs returned questionnaires, and 32 were complete. Thirteen (14%) of 90 pathologists returned complete questionnaires. Thirty-one (97%) CDOPs and 7 (53%) pathologists agreed with the cause of death in the accidental asphyxia case; 24 (75%) CDOPs and 9 (69%) pathologists in the typical SIDS case; and 11 (34%) CDOPs and 1 (8%) pathologist in the co-sleeping SIDS case. Pathologists used the terms SUDI or unascertained as the cause of death for the accidental asphyxia case (46%) and the co-sleeping SIDS case (77%). These terms were used by CDOPs for the typical SIDS case (25%) and the co-sleeping SIDS case (41%). Seventeen (46%) CDOPs reported compliance with guidelines for investigation in more than 75% of cases.

CONCLUSION

There is wide variation in classification of deaths, with only limited agreement between CDOPs and pathologists. The terms SIDS and accidental asphyxia are underused, even in typical cases.

Recurrent sudden unexpected death in infancy: a case series of sibling deaths

OBJECTIVES

To determine the rate of sudden unexpected death in infancy (SUDI) for infants born after a previous SUDI in the same family, and to establish the causes of death and the frequency of child protection concerns in families with recurrent SUDI.

DESIGN

Observational study using clinical case records.

SETTING

The UK's Care of Next Infant (CONI) programme, which provides additional care to families who have experienced SUDI with their subsequent children.

PATIENTS

Infants registered on CONI between January 2000 and December 2015.

MAIN OUTCOME MEASURES

Cause of death, presence of modifiable risk factors for SUDI and child protection concerns.

RESULTS

There were 6608 live-born infants registered in CONI with 29 deaths. 26 families had 2 deaths, and 3 families had 3 deaths. The SUDI rate for infants born after one SUDI is 3.93 (95% CI 2.7 to 5.8) per 1000 live births. Cause of death was unexplained for 19 first and 15 CONI deaths. Accidental asphyxia accounted for 2 first and 6 CONI deaths; medical causes for 3 first and 4 CONI deaths; and homicide for 2 first and 4 CONI deaths. 10 families had child protection concerns.

CONCLUSIONS

The SUDI rate for siblings is 10 times higher than the current UK SUDI rate. Homicide presenting as recurrent SUDI is very rare. Many parents continued to smoke and exposed infants to hazardous co-sleeping situations, with these directly leading to or contributing to the death of six siblings. SUDI parents need support to improve parenting skills and reduce risk to subsequent infants.

Parent-child bed-sharing: The good, the bad, and the burden of evidence

The practice of parent and child sharing a sleeping surface, or 'bed-sharing', is one of the most controversial topics in parenting research. The lay literature has popularized and polarized this debate, offering on one hand claims of dangers, and on the other, of benefits - both physical and psychological - associated with bed-sharing. To address the scientific evidence behind such claims, we systematically reviewed 659 published papers (peer-reviewed, editorial pieces, and commentaries) on the topic of parent-child bed-sharing. Our review offers a narrative walkthrough of the many subdomains of bed-sharing research, including its many correlates (e.g., socioeconomic and cultural factors) and purported risks or outcomes (e.g., sudden infant death syndrome, sleep problems). We found general design limitations and a lack of convincing evidence in the literature, which preclude making strong generalizations. A heat-map based on 98 eligible studies aids the reader to visualize world-wide prevalence in bed-sharing and highlights the need for further research in societies where bed-sharing is the norm. We urge for multiple subfields - anthropology, psychology/psychiatry, and pediatrics - to come together with the aim of understanding infant sleep and how nightly proximity to the parents influences children's social, emotional, and physical development.

A Systematic Review of the Probability of Asphyxia in Children Aged <2 Years with Unexplained Epistaxis

OBJECTIVE

To determine the proportion of children aged <2 years who have been asphyxiated presenting with epistaxis in the absence of trauma or medical explanation and to identify the characteristics of the clinical presentation indicative of asphyxiation.

STUDY DESIGN

An all-language systematic review was conducted by searching 10 databases from 1900 to 2015 and gray literature to identify high-quality studies that included children with epistaxis aged <2 years (alive or dead) with explicit confirmation of intentional or unintentional asphyxiation (upper airway obstruction). Studies of traumatic or pathological epistaxis were excluded. For each comparative study, the proportion of children presenting with epistaxis that were asphyxiated is reported with 95% CI.

RESULTS

Of 2706 studies identified, 100 underwent full review, resulting in 6 included studies representing 30 children with asphyxiation-related epistaxis and 74 children with non-asphyxiation-related epistaxis. The proportion of children presenting with epistaxis that had been asphyxiated, reported by 3 studies, was between 7% and 24%. Features associated with asphyxiation in live children included malaise, altered skin color, respiratory difficulty, and chest radiograph abnormalities. There were no explicit associated features described among those children who were dead on arrival.

CONCLUSION

There is an association between epistaxis and asphyxiation in young children; however, epistaxis does not constitute a diagnosis of asphyxia in itself. In any infant presenting with unexplained epistaxis, a thorough investigation of etiology is always warranted, which must include active exploration of asphyxia as a possible explanation.

Could intra-alveolar hemosiderin deposition in adults be used as a marker for previous asphyxial episodes in cases of autoerotic death?

Intra-alveolar hemorrhage and hemosiderin have been cited as possible markers of recent and remote asphyxial events. Little study has been undertaken of the potential significance of intra-alveolar hemosiderin in adults as a potential marker of previous sublethal asphyxial episodes. Ten cases of lethal sexual asphyxia (an entity known to be associated with repetitive sublethal asphyxial episodes) and 20 randomly selected, age- and sex-matched controls had sections of lung stained for hemosiderin. Subsequently, intra-alveolar, iron-containing macrophages were counted. All cases were men (ages 15-50 years; mean 31.8). No significant increase in hemosiderin was found in victims of sexual asphyxia, indicating that asphyxial episodes in sublethal sexual asphyxial activities may not be sufficiently intense or prolonged to cause intra-alveolar hemorrhage or that intra-alveolar hemorrhage in adults is a relatively nonspecific finding. These results do not support intra-alveolar hemosiderin deposition as a marker for previous sublethal asphyxial events in autoerotic asphyxia.

Do resuscitation-related injuries kill infants and children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the "CPR defense," that is, they attribute the cause of injuries found at autopsy to their "untrained" resuscitative efforts. A 10-year (1994-2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (N(atraumatic) = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

SIDS: past, present and future

Despite the large reduction in SIDS mortality, which occurred in the early 1990s following the 'Back to Sleep' campaigns, SIDS remains the leading cause of death in the postneonatal age group. This paper describes the position in the 1980s, the contribution of the New Zealand Cot Death Study, what should be recommended and the current research priorities.

CONCLUSION

SIDS is preventable. Application of what we currently know could eliminate SIDS. The challenge is to find ways of implementing our knowledge.

The frequency and significance of alveolar haemosiderin-laden macrophages in sudden infant death

Alveolar haemosiderin-laden macrophages (HLMs) in histological sections of the lung represent evidence of previous pulmonary haemorrhage and in infants may be associated with features of non-accidental injury (NAI). The aim of this study is to establish the frequency of alveolar HLMs detected at post-mortem in a large series of sudden unexpected infant deaths, and to determine their clinical significance with particular regard to a possible association with NAI. A search was performed of a database of 1516 anonymised paediatric autopsies to identify all infants (<1 year of age) that died suddenly and unexpectedly in whom HLMs were demonstrated on routine histological examination of lung sections using special iron (Perls') stains. Clinical details and other post-mortem findings were then reviewed. During the study period (1996-2005 inclusive), there were 601 sudden unexpected infant deaths. Of the 536 autopsies in whom histological data regarding HLMs were recorded and slides were available for review, 29 (5%) demonstrated alveolar HLMs in lung sections. In 9 (31%) infants there were additional features of NAI; in 11 (38%) infants, there were features in the clinical history and/or on pathological examination of natural disease sufficient to potentially explain the presence of HLMs, and 9 (31%) represented otherwise unexplained infant deaths with no significant clinical history or other abnormalities. HLMs were present in 9 of the 27 (33%) total infant deaths with other features indicative of NAI, compared to only 9 of the 242 (4%) unexplained infant deaths without any other features of NAI or other contributory pathology (difference 29.6%, 95% CI 14.6-48.6%, p<0.0001; positive likelihood ratio 9.0, 95% CI 3.9-19.8). This association remained even if cases with rib fractures were excluded. Alveolar HLMs may be identified in a significant minority of sudden infant deaths following routine histological examination of the lungs with special stains for iron pigment. In most, there will be features in the clinical history or findings at post-mortem to indicate underlying natural disease which may account for their presence. However, in the absence of such features, alveolar HLMs, whilst not diagnostic, are associated with a significantly increased risk for the detection of other features of NAI; the presence of otherwise unexplained alveolar HLMs at autopsy should therefore prompt a careful exclusion of inflicted injury.

Sudden oronasal bleeding in a young child

Sudden severe upper-airway obstruction occurring in a hospital setting can sometimes precipitate an episode of acute haemorrhagic pulmonary oedema. A review of 197 published case reports shows that the presenting feature is almost always the sudden appearance of blood stained fluid coming up through the larynx or out through the mouth and nose of an adult or child in obvious respiratory distress. Such overt features are seen in 10-15% of cases of sudden severe, but sub-lethal, upper-airway obstruction. Signs normally appear within minutes once the obstruction is relieved but are occasionally only recognized after 1-4 h. All signs and symptoms usually resolve within 12-24 h. Other causes of acute pulmonary haemorrhage are rare in young children.

CONCLUSION

If what looks like blood is seen in, or coming from, the mouth or nose of a previously healthy young child who has suddenly become distressed and started to struggle for breath, that child has most probably suffered an episode of acute pulmonary oedema, and the commonest precipitating cause is sudden upper-airway obstruction.

Unclassified sudden infant death associated with pulmonary intra-alveolar hemosiderosis and hemorrhage

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.

Consenso para o manejo e seguimento de pacientes com episódios de possível ameaça a vida (ALTE) e abordagem do diagnóstico diferencial de ALTE com primeira crise convulsiva

OBJETIVO: Este estudo teve como objetivo a elaboração de guia para manejo e seguimento de crianças com episódios de possível ameaça a vida (ALTE) com enfoque especial ao diagnóstico diferencial deste evento com primeiro episódio de crise convulsiva. MÉTODOS: Através de revisão da literatura foi elaborado um consenso, entre os membros do comitê de Síndrome da Morte Súbita do Lactente (SMSL) da Associação Latinoamericana de Pediatria (ALAPE), para orientação quanto ao manejo e investigação etiológica de pacientes com ALTE. RESULTADOS: A proposta de sistematização da investigação destes pacientes inicia definindo a gravidade do evento e estabelecendo a necessidade de internação ou seguimento ambulatorial. A pesquisa da etiologia deve ser realizada gradualmente sendo dividida em exames iniciais e exames específicos, que são aprofundados de acordo com as características clínicas do caso em questão. O manejo após alta hospitalar e a indicação de monitorização domiciliar devem ser individualizados e avaliados caso a caso. O ALTE pode ser a primeira manifestação de uma crise epiléptica ,entretanto, este diagnóstico algumas vezes é tardio, quando não é disponível EEG ictal. O EEG interictal, nestes casos, geralmente é normal e o refluxo gastroesofágico, distúrbio muito prevalente na infância, pode confundir o diagnóstico da manifestação epiléptica. CONCLUSÃO: O ALTE não deve ser considerado um diagnóstico etiológico, mas conjunto de sinais percebidos pelo observador que deve ser amplamente investigado. Apesar de pouco freqüente, a apnéia pode ser a única manifestação ictal de uma crise parcial. Esta possibilidade deve ser lembrada e excluída no diagnóstico diferencial da etiologia de ALTE. As orientações sugeridas neste artigo assim como o fluxograma de investigação apresentado podem auxiliar no manejo e seguimento dos pacientes com ALTE assim como resultar em redução do tempo e custo de internação destes pacientes.

Pulmonary intra-alveolar hemorrhage in SIDS and suffocation

The differentiation of SIDS from accidental or inflicted suffocation may be impossible in some cases. Severe pulmonary intra-alveolar hemorrhage has been suggested as a potential marker for such differentiation. Our aims are to: (1) Compare pulmonary hemorrhage in SIDS and a control group comprised of infants whose deaths were attributed to accidental or inflicted suffocation. (2) Review individual cases with the most severe pulmonary hemorrhage regardless of the cause of death, and (3) Assess the effect of age, bedsharing, cardiopulmonary resuscitation, and postmortem interval, with regard to the severity of pulmonary hemorrhage in SIDS cases. We conducted a retrospective study of all postneonatal cases accessioned by the Office of the Medical Examiner in San Diego County, California who died of SIDS or suffocation between 1999 and 2004. A total of 444 cases of sudden infant death caused by SIDS (405), accidental suffocation (36), and inflicted suffocation (3) from the San Diego SIDS/SUDC Research Project database were compared using a semiquantitative measure of pulmonary intra-alveolar hemorrhage [absent (0) to severe (4)]. Grades 3 or 4 pulmonary hemorrhage occurred in 33% of deaths attributed to suffocation, but in only 11% of the SIDS cases, however, all grades of pulmonary hemorrhage occurred in both groups. Therefore, our results indicate that the severity of pulmonary hemorrhage cannot be used in isolation to determine the cause or manner of sudden infant death. Among SIDS cases, those with a higher pulmonary hemorrhage grade (3 or 4) were more likely to bedshare, and with more than one co-sleeper, than those with a lower pulmonary hemorrhage grade (0 or 1). We conclude that each case must be evaluated on its own merits after thorough review of the medical history, circumstances of death, and postmortem findings.

A comparison of pulmonary intra-alveolar hemorrhage in cases of sudden infant death due to SIDS in a safe sleep environment or to suffocation

The differentiation of SIDS from accidental or inflicted suffocation may be impossible without corroborating findings from the death scene or autopsy or in the absence of a confession from a perpetrator. Pulmonary intra-alveolar hemorrhage (PH) has been proposed as a potential clue to suffocation, but none of the previous studies on this topic have limited SIDS cases to those who were in a safe sleep environment, in which all were found supine and alone on a firm surface with their heads uncovered. Our aims are to: (1) compare PH in SIDS cases found in a safe sleep environment to a control group comprised of infants whose deaths were attributed to accidental or inflicted suffocation and (2) assess the effect of age, CPR, and postmortem interval (PMI), with regard to the severity of PH in this subset of safe-sleeping SIDS cases. We conducted a retrospective study of all postneonatal cases accessioned by the Office of the Medical Examiner in San Diego County, California who died of SIDS or suffocation between 1999 and 2004. A total of 74 cases of sudden infant death caused by SIDS (34 cases as defined above, comprising 8% of the total SIDS cases), accidental suffocation (37), and inflicted suffocation (3) from the San Diego SIDS/SUDC Research Project database were compared using a semiquantitative measure of pulmonary intra-alveolar hemorrhage. The most severe (grade 3 or 4) PH occurred in 35% of deaths attributed to suffocation, but in only 9% of the SIDS cases. Age, duration of CPR attempts and PMI had no effect on the severity of PH in SIDS. Our results indicate that the severity of PH cannot be used independently to differentiate SIDS from suffocation deaths. Each case must be evaluated on its own merits after thorough review of the medical history, circumstances of death, and postmortem findings.

Meadow, Southall, and the General Medical Council of the United kingdom

In this article we address the recent actions of the General Medical Council in the United Kingdom affecting 2 pediatricians who are major contributors to pediatric knowledge about the intentional suffocation of infants. The General Medical Council struck one of them from the register of licensed medical practitioners, but the decision was appealed successfully. The council restricted the practice of the other pediatrician. After a review of the transcripts of the hearings, we conclude that the opinions given by both doctors were responsible, and the transcripts suggest that the conduct of the hearings was unfair. Licensing boards may have difficulty in competently regulating doctors' expert testimony, at least in cases involving child maltreatment.

Pulmonary intra-alveolar siderophages in SIDS and suffocation: a San Diego SIDS/SUDC Research Project report

Pulmonary intra-alveolar siderophages (PS) have been suggested as a marker of previous attempts at imposed suffocation in infants dying suddenly and unexpectedly. The aims of this study were to (1) compare PS counts between cases of sudden infant death syndrome (SIDS) and a control group comprised of infants whose deaths were attributed to accidental or inflicted suffocation, (2) compare clinical variables in SIDS and control suffocation cases, and (3) review individual cases irrespective of the cause and manner of death with an average PS count greater than 200 per 20 high-power fields (hpf) per lung lobe. Retrospective assessment of siderophages in available iron-stained lung sections was undertaken in 91 SIDS cases and 29 cases of death due to suffocation (27 accidents and 2 homicides) from the San Diego SIDS and Sudden Unexplained Death in Childhood (SUDC) Research Project (SDSSRP) database. Neither the means of the log-transformed PS counts nor the medians of the raw PS counts were significantly different between the SIDS and control suffocation groups. The distributions of the PS data were different, however-the range was wider in the SIDS group. Only 6% of each group had a history of prior apparent life-threatening events. Approximately three fourths of the families from both groups had no prior referral to Child Protective Services. The number of PS varies widely in cases of sudden infant death caused by SIDS and accidental or inflicted suffocation and cannot be used as an independent variable to ascertain past attempts at suffocation.

Acute idiopathic pulmonary haemorrhage in infancy: case report and review of the literature

This report presents the case of a 4-month-old male infant with recurrent bouts of haemoptysis for which no cause could be detected after extensive investigation. Literature reports of this condition from other geographic locations around the world are reviewed, together with epidemiologic studies attempting to provide a link with certain environmental exposures, toxic and infectious. A diagnostic entity of acute idiopathic pulmonary haemorrhage in infancy has recently been proposed. To my knowledge, this is the first case reported from New Zealand. Although the incidence of such reported cases appears to be rare, they constitute an interesting public health problem, particularly because some of the risk factors appear to overlap with risk factors for sudden infant death. They can therefore trigger an investigation into the home and outdoor environments, and may provide valuable insights into a possible underlying genetic factor and potentially harmful exposures in the modern urban or rural settings.

Unnatural causes of sudden unexpected deaths initially thought to be sudden infant death syndrome

The aim of this clinicopathological study was to determine the frequency of infant deaths due to unnatural causes among cases of sudden and unexpected infant death. Nine institutes of legal medicine in Germany that took part in the German study on Sudden Infant Death Syndrome (GeSID), representing 35% of the German territory, investigated in a 3-year period (from 1998 to 2001) 339 cases of infant death that were not expected to be due to unnatural causes from the first external examination. All cases were investigated by complete, standardised, post-mortem examination including death scene investigation, autopsy, histology, toxicology and neuropathology. The frequency of unnatural deaths was 5.0% (n=17). The causes of death were head injury (n=7), suffocation (n=5), poisoning (n=2), neglect (n=2) and septicaemia due to aspiration of a foreign body (n=1). Two deaths were unsuspected accidents and 12 were due to infanticide. In 3 cases, it was not possible to differentiate between accidental death and infanticide. A complete postmortem examination including an analysis of the clinical history, death scene investigation, autopsy, histology, toxicology, and neuropathology is mandatory to differentiate sudden and unexpected deaths due to natural causes (e.g. SIDS) and cases of unnatural death.

Patent Ductus Arteriosus as a Natural Cause of Pulmonary Hemorrhage in Infants

Patent ductus arteriosus (PDA) is a recognized risk factor for massive pulmonary hemorrhage (MPH) in the newborn and is generally seen in association with other MPH risk factors such as prematurity. We report 6 cases of sudden and unexpected death of infants older than 4 days with MPH and PDA at autopsy. The cases were reviewed for other factors that could contribute to MPH to ascertain whether PDA is directly linked to MPH. Histology samples were examined for distribution of hemorrhage in the lungs and iron stained for hemosiderin evaluation. All of the cases had clinical histories and scene examinations which raised the differential diagnosis of mechanical asphyxia in the form of so-called overlayings. The diagnostic dilemma of attributing the MPH to the PDA as the sole cause, dual cause, or incidental finding is discussed. These cases illustrate the medicolegal dilemma faced by the pathologist, as well as the need for further research into the potential association of PDA with MPH.

Three subsequent infanticides covered up as SIDS

Within a period of 9 years a young woman lost 3 daughters during infancy and each time death was attributed to the sudden infant death syndrome. The children had different fathers and died at the ages of 11 weeks, 7 weeks and 2 weeks, respectively. A fourth daughter survived and lives separated from the mother together with her father and is healthy. At autopsy the last of the three deceased infants did not reveal any pre-existing pathological organ findings, except for acute pulmonary emphysema and extensive intra-alveolar bleeding. As a consequence the strong suspicion of mechanical suffocation arose. Subsequent police investigations produced incriminating clues that the first two children had also been suffocated. On confrontation with the autopsy findings and investigation results, the woman confessed that she herself had killed the first two infants by pressing a cushion on their faces. In the case of the third death the baby had been smothered by the child's father who in agreement with the mother put a plastic film on mouth and nostrils.

Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003

Infants with an apparent life-threatening event (ALTE) should not be treated nor monitored without a detailed medical evaluation, as different medical causes may be responsible for the initial clinical presentation. Standard and specific evaluation procedures are listed to help identify a cause for the ALTE. The most frequent problems associated with an ALTE are digestive (about 50%), neurological (30%), respiratory (20%), cardiovascular (5%), metabolic and endocrine (under 5%), or diverse other problems, including child abuse. Up to 50% of ALTEs remain unexplained. The finding of medical or surgical anomalies leads to specific treatments. Surveillance programmes with the use of home monitoring devices may be undertaken, preferably with cardiorespiratory monitors, and when possible, with event monitors, although no currently available home monitoring device is free of false alarms or offers complete protection. Long-term follow-up programmes of infants with an apparent life-threatening event contribute to adapt medical attitudes to the child's needs and to confirm the medical diagnosis.

CONCLUSION

a systematic diagnostic evaluation, together with a comprehensive treatment programme, increases survival and quality of life for most affected infants.

Sudden infant death syndrome: overview and update

The past decade and a half has seen marked changes in the epidemiology of sudden infant death syndrome (SIDS). The avoidance of certain risk factors such as sleeping prone and cigarette smoke exposure has resulted in the death rate falling dramatically. Careful evaluation of environmental factors and endogenous characteristics has led to a greater understanding of the complexities of the syndrome. The development and implementation of death scene and autopsy protocols has led to standardization in approaches to unexpected infant deaths with increasing diagnoses of accidental asphyxia. Despite these advances, there is still confusion surrounding the diagnosis, with deaths being attributed to SIDS in many communities and countries where death scene investigations and autopsies have not been conducted. The following review provides a brief overview of the historical background, epidemiology, pathology, and pathogenesis of SIDS. Contentious issues concerning the diagnosis and current problems are discussed. Despite calls to abandon the designation, SIDS remains a viable term for infants who die in their sleep with no evidence of accident, inflicted injury, or organic disease after a full investigation has been conducted according to standard guidelines.