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Fraile-Martinez O, García-Montero C, Díez SC, Bravo C, Quintana-Coronado MDG, Lopez-Gonzalez L, Barrena-Blázquez S, García-Honduvilla N, De León-Luis JA, Rodriguez-Martín S, Saez MA, Alvarez-Mon M, Diaz-Pedrero R, Ortega MA. Sudden Infant Death Syndrome (SIDS): State of the Art and Future Directions. Int J Med Sci 2024; 21:848-861. [PMID: 38617004 PMCID: PMC11008475 DOI: 10.7150/ijms.89490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/10/2024] [Indexed: 04/16/2024] Open
Abstract
Sudden infant death syndrome (SIDS) is a type of death that occurs suddenly and without any apparent explanation, affecting infants between 28 days of life and up to a year. Recognition of this entity includes performing an autopsy to determine if there is another explanation for the event and performing both an external and internal examination of the different tissues to search for possible histopathological findings. Despite the relative success of awareness campaigns and the implementation of prevention measures, SIDS still represents one of the leading causes of death among infants worldwide. In addition, although the development of different techniques has made it possible to make significant progress in the characterization of the etiopathogenic mechanisms underlying SIDS, there are still many unknowns to be resolved in this regard and the integrative consideration of this syndrome represents an enormous challenge to face both from a point of view scientific and medical view as humanitarian. For all these reasons, this paper aims to summarize the most relevant current knowledge of SIDS, exploring from the base the characterization and recognition of this condition, its forensic findings, its risk factors, and the main prevention measures to be implemented. Likewise, an attempt will be made to analyze the causes and pathological mechanisms associated with SIDS, as well as potential approaches and future paths that must be followed to reduce the impact of this condition.
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Affiliation(s)
- Oscar Fraile-Martinez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Sofía Castellanos Díez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Coral Bravo
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - María de Guadalupe Quintana-Coronado
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Laura Lopez-Gonzalez
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
| | - Silvestra Barrena-Blázquez
- Department of General and Digestive Surgery, University Hospital Príncipe de Asturias, 28805 Madrid, Spain
- Department of Nursing and Physiotherapy, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Spain
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Juan A. De León-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Sonia Rodriguez-Martín
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Service of Pediatric, Hospital Universitario Principe de Asturias, 28801 Alcalá de Henares, Spain
| | - Miguel A Saez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Pathological Anatomy Service, Central University Hospital of Defence-UAH Madrid, 28801 Alcala de Henares, Spain
| | - Melchor Alvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Immune System Diseases-Rheumatology and Internal Medicine Service, University Hospital Príncipe de Asturias, CIBEREHD, 28806 Alcalá de Henares, Spain
| | - Raul Diaz-Pedrero
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
- Department of General and Digestive Surgery, University Hospital Príncipe de Asturias, 28805 Madrid, Spain
| | - Miguel A Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
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Erck Lambert AB, Shapiro-Mendoza CK, Parks SE, Cottengim C, Faulkner M, Hauck FR. Characteristics of Sudden Unexpected Infant Deaths on Shared and Nonshared Sleep Surfaces. Pediatrics 2024; 153:e2023061984. [PMID: 38374785 DOI: 10.1542/peds.2023-061984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVES Describe characteristics of sudden unexpected infant deaths (SUID) occurring on shared or nonshared sleep surfaces. METHODS We examined SUID among residents of 23 US jurisdictions who died during 2011 to 2020. We calculated frequencies and percentages of demographic, sleep environment, and other characteristics by sleep surface sharing status and reported differences of at least 5% between surface sharing and nonsharing infants. RESULTS Of 7595 SUID cases, 59.5% were sleep surface sharing when they died. Compared with nonsharing infants, sharing infants were more often aged 0 to 3 months, non-Hispanic Black, publicly insured, found supine, found in an adult bed or chair/couch, had a higher number of unsafe sleep factors present, were exposed to maternal cigarette smoking prenatally, were supervised by a parent at the time of death, or had a supervisor who was impaired by drugs or alcohol at the time of death. At least 76% of all SUID had multiple unsafe sleep factors present. Among surface-sharing SUID, most were sharing with adults only (68.2%), in an adult bed (75.9%), and with 1 other person (51.6%). Surface sharing was more common among multiples than singletons. CONCLUSIONS Among SUID, surface sharing and nonsharing infants varied by age at death, race and ethnicity, insurance type, presence of unsafe sleep factors, prenatal smoke exposure, and supervisor impairment. Most SUID, regardless of sleep location, had multiple unsafe sleep factors present, demonstrating the need for comprehensive safe sleep counseling for every family at every encounter.
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Affiliation(s)
- Alexa B Erck Lambert
- Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, Georgia
- DB Consulting Group, Inc., Silver Springs, Maryland
| | | | - Sharyn E Parks
- Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, Georgia
| | - Carri Cottengim
- Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, Georgia
| | - Meghan Faulkner
- Michigan Public Health Institute, Center for National Prevention Initiatives, Okemos, Michigan
| | - Fern R Hauck
- Unversity of Virginia, Department of Family Medicine, Charlottesville, Virginia
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Thyden NH, Slaughter-Acey J, Widome R, Warren JR, Osypuk TL. Structural Bias in the Completeness of Death Investigations for Sudden Unexpected Infant Deaths (SUIDs). J Public Health Manag Pract 2024; 30:285-294. [PMID: 38151718 PMCID: PMC11068335 DOI: 10.1097/phh.0000000000001849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
OBJECTIVE To assess sudden unexpected infant death (SUID) investigations for structural inequities by race/ethnicity and geography. METHODS The SUID Case Registry compiles data on death investigations. We analyzed cases from 2015 to 2018 (N = 3847) to examine likelihood of an incomplete death investigation, defined as missing autopsy, missing scene investigation, or missing detailed information about where and how the body was found. We also analyzed which specific components of death investigations led to the greatest number of incomplete investigations. RESULTS Twenty-four percent of SUIDs had incomplete death investigations. Death scenes in rural places had 1.51 times the odds of incomplete death investigations (95% confidence interval [CI], 1.19-1.92) compared with urban areas. Scene investigations led by law enforcement were more likely to result in incomplete death investigations (odds ratio [OR] = 1.49; 95% CI, 1.18-1.88) than those led by medical examiners. American Indian/Alaska Native SUIDs were more likely than other racial groups to have an incomplete investigation (OR = 1.49; 95% CI, 0.92-2.42), more likely to occur in rural places ( P = .055), and more likely to be investigated by law enforcement ( P < .001). If doll reenactments had been performed, 358 additional cases would have had complete investigations, and if SUID investigation forms had been performed, 243 additional cases would have had complete investigations. American Indian/Alaska Native SUIDs were also more likely to be missing specific components of death investigations. CONCLUSION To produce equitable public health surveillance data used in prevention efforts, it is crucial to improve SUID investigations, especially in rural areas and among American Indian/Alaska Native babies.
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Affiliation(s)
- Naomi Harada Thyden
- University of Minnesota, Minnesota Population Center, Minneapolis, Minnesota (Drs Thyden, Warren, and Osypuk); Division of Epidemiology & Community Health (Drs Thyden, Widome, and Osypuk) and Department of Sociology (Dr Warren), University of Minnesota, Minneapolis, Minnesota; University of Illinois Chicago, Community Health Sciences, Chicago, Illinois (Dr Thyden); and University of North Carolina at Chapel Hill, Gillings School of Public Health, Department of Epidemiology, Chapel Hill, North Carolina (Dr Slaughter-Acey)
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Aquila I, Sacco MA, Gorniak J, Rouse M, Gualtieri S, Cordasco F, Tarallo AP, Raffaele R, Ricci P. Unexplained and Unexpected Pediatric Deaths: Forensic Review and New Perspectives. Diagnostics (Basel) 2023; 13:3111. [PMID: 37835854 PMCID: PMC10572571 DOI: 10.3390/diagnostics13193111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Unexplained and unexpected pediatric deaths are a major challenge in global healthcare. The role of the forensic pathologist is crucial in determining the cause and manner of death in these cases, although to date, there are many limitations in post-mortem diagnosis. The role of the autopsy and related forensic investigations become a fundamental tool to investigate and give an explanation for an unacceptable event, considering the young age of the victims. From this point of view, even today, it is necessary that this phenomenon is correctly recorded through standardized systems and universally accepted methods. Furthermore, it is essential that scientific research on this topic is increased through the implementation of universally accepted operating protocols recognizing real risk factors in order to prevent such events. The purpose of the study is to offer a review of the state of the art about unexplained pediatric death and, above all, to propose an international reporting platform, extending proper investigations not only to judicial cases but also to all the other cases of unexpected pediatric death.
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Affiliation(s)
- Isabella Aquila
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
| | - Matteo Antonio Sacco
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
| | - Jan Gorniak
- Clark County Office of Coroner Medical Examiner, 1704 Pinto Lane, Las Vegas, NV 89106, USA; (J.G.); (M.R.)
| | - Melanie Rouse
- Clark County Office of Coroner Medical Examiner, 1704 Pinto Lane, Las Vegas, NV 89106, USA; (J.G.); (M.R.)
| | - Saverio Gualtieri
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
| | - Fabrizio Cordasco
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
| | - Alessandro Pasquale Tarallo
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
| | - Roberto Raffaele
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
| | - Pietrantonio Ricci
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Viale Europa, Loc. Germaneto, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (F.C.); (A.P.T.); (R.R.); (P.R.)
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Parks SE, DeSisto CL, Kortsmit K, Bombard JM, Shapiro-Mendoza CK. Risk Factors for Suffocation and Unexplained Causes of Infant Deaths. Pediatrics 2023; 151:e2022057771. [PMID: 36464994 PMCID: PMC9942004 DOI: 10.1542/peds.2022-057771] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome). METHODS We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios. RESULTS We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8-51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9-4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7-12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1-2.4) among nonsupine positioned infants. COCLUSIONS We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.
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Macdonald M, Thompson D, Perry R, Brooks R. Comparing asphyxia and unexplained causes of death: a retrospective cohort analysis of sleep-related infant death cases from a state child fatality review programme. BMJ Open 2022; 12:e059745. [PMID: 36104144 PMCID: PMC9476159 DOI: 10.1136/bmjopen-2021-059745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To examine the characteristics and circumstances of infants who died while sleeping or in a sleep environment and compare deaths classified as either unintentional asphyxia or an unexplained cause. DESIGN A retrospective cohort study. SETTING Data were extracted from the National Fatality Review Case Reporting System and Florida Vital Statistics databases. PARTICIPANTS Data on 778 sleep-related infant deaths occurring from 2014 to 2018 in Florida were analysed. PRIMARY OUTCOME MEASURE Cause of death classification as unintentional asphyxia or unexplained. RESULTS Overall, 36% (n=276) of sleep-related infant deaths in this study sample were classified as resulting from an unexplained cause compared with unintentional asphyxia. Most infants were reported to be in an adult bed (60%; n=464) and sharing a sleep surface with a person or animal (60%; n=468); less than half (44%; n=343) were reportedly placed to sleep on their back. After controlling for the influence of other independent variables, female sex (adjusted risk ratio: 1.36; 95% CI 1.06 to 1.74) and fully obstructed airway condition (adjusted risk ratio: 0.30; 95% CI 0.18 to 0.50) were associated with an unexplained cause of death. CONCLUSIONS The results of this analysis indicate that sleep environment hazards remain prevalent among infants who die suddenly and unexpectedly, regardless of the cause of death determination. While significant differences were observed for some factors, in many others the distributions of both demographic and incident characteristics were similar between unexplained deaths and those resulting from asphyxia. The results of this study support growing evidence that unsafe sleep environments contribute to all forms of sudden unexpected infant death, underscoring the need for standardising cause of death determination practices and promoting consistent, high-quality forensic investigations to accurately explain, monitor and prevent these deaths.
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Affiliation(s)
- Megan Macdonald
- Division of Children's Medical Services, Florida Department of Health, Tallahassee, Florida, USA
| | - Daniel Thompson
- Independent Statistical Consultant, Tallahassee, Florida, USA
| | - Robin Perry
- Social Work, Florida Agricultural and Mechanical University, Tallahassee, Florida, USA
| | - Robert Brooks
- Division of Children's Medical Services, Florida Department of Health, Tallahassee, Florida, USA
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Polavarapu M, Klonoff-Cohen H, Joshi D, Kumar P, An R, Rosenblatt K. Development of a Risk Score to Predict Sudden Infant Death Syndrome. Int J Environ Res Public Health 2022; 19:ijerph191610270. [PMID: 36011906 PMCID: PMC9407916 DOI: 10.3390/ijerph191610270] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 06/12/2023]
Abstract
Sudden Infant Death Syndrome (SIDS) is the third leading cause of death among infants younger than one year of age. Effective SIDS prediction models have yet to be developed. Hence, we developed a risk score for SIDS, testing contemporary factors including infant exposure to passive smoke, circumcision, and sleep position along with known risk factors based on 291 SIDS and 242 healthy control infants. The data were retrieved from death certificates, parent interviews, and medical records collected between 1989−1992, prior to the Back to Sleep Campaign. Multivariable logistic regression models were performed to develop a risk score model. Our finalized risk score model included: (i) breastfeeding duration (OR = 13.85, p < 0.001); (ii) family history of SIDS (OR = 4.31, p < 0.001); (iii) low birth weight (OR = 2.74, p = 0.003); (iv) exposure to passive smoking (OR = 2.64, p < 0.001); (v) maternal anemia during pregnancy (OR = 2.07, p = 0.03); and (vi) maternal age <25 years (OR = 1.77, p = 0.01). The area under the curve for the overall model was 0.79, and the sensitivity and specificity were 79% and 63%, respectively. Once this risk score is further validated it could ultimately help physicians identify the high risk infants and counsel parents about modifiable risk factors that are most predictive of SIDS.
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Affiliation(s)
- Mounika Polavarapu
- School of Population Health, The University of Toledo, HH 1010, Mail Stop 119, 2801 W. Bancroft St., Toledo, OH 43606, USA
| | - Hillary Klonoff-Cohen
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Divya Joshi
- Department of Pediatrics, Johns Hopkins All Children’s Hospital, St. Petersburg, FL 33701, USA
| | - Praveen Kumar
- Department of Pediatrics, Children’s Hospital of Illinois, Peoria, IL 61603, USA
| | - Ruopeng An
- Brown School, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Karin Rosenblatt
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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Moon RY, Carlin RF, Hand I. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics 2022; 150:188305. [PMID: 35921639 DOI: 10.1542/peds.2022-057991] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.
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Affiliation(s)
- Rachel Y Moon
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Rebecca F Carlin
- Division of Pediatric Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York City, New York
| | - Ivan Hand
- Department of Pediatrics, SUNY-Downstate College of Medicine, NYC Health + Hospitals, Kings County, Brooklyn, New York
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Hamayasu H, Miyao M, Kawai C, Osamura T, Yamamoto A, Minami H, Abiru H, Tamaki K, Kotani H. A proof-of-concept study to construct Bayesian network decision models for supporting the categorization of sudden unexpected infant death. Sci Rep 2022; 12:9773. [PMID: 35697924 DOI: 10.1038/s41598-022-14044-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/31/2022] [Indexed: 02/06/2023] Open
Abstract
Sudden infant death syndrome (SIDS) remains a leading cause of infant death in high-income countries. Supporting models for categorization of sudden unexpected infant death into SIDS/non-SIDS could reduce mortality. Therefore, we aimed to develop such a tool utilizing forensic data, but the reduced number of SIDS cases renders this task inherently difficult. To overcome this, we constructed Bayesian network models according to diagnoses performed by expert pathologists and created conditional probability tables in a proof-of-concept study. In the diagnostic support model, the data of 64 sudden unexpected infant death cases was employed as the training dataset, and 16 known-risk factors, including age at death and co-sleeping, were added. In the validation study, which included 8 new cases, the models reproduced experts’ diagnoses in 4 or 5 of the 6 SIDS cases. Next, to confirm the effectiveness of this approach for onset prediction, the data from 41 SIDS cases was employed. The model predicted that the risk of SIDS in 0- to 2-month-old infants exposed to passive smoking and co-sleeping is eightfold higher than that in the general infant population, which is comparable with previously published findings. The Bayesian approach could be a promising tool for constructing SIDS prevention models.
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Fitzgerald DA, Jeffery H, Arbuckle S, du Toit-Prinsloo L, O'Sullivan T, Waters K. Sudden Unexpected Death in Infancy [SUDI]: What the clinician, pathologist, coroner and researchers want to know. Paediatr Respir Rev 2022; 41:14-20. [PMID: 34998675 DOI: 10.1016/j.prrv.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 11/24/2022]
Abstract
The loss of an apparently healthy infant is confronting for any family, puzzling for a clinician and challenging for the pathologist charged with the task of demonstrating a cause for death. The term "cot death" evolved to "sudden infant death syndrome" [SIDS] and now "sudden unexpected death in infancy [SUDI]" as the epidemiology and pathology of infant death changed. Community interventions were successful in changing sleep practices for young babies. The current research focus is on understanding genetic predispositions to unexpected death in early childhood. Whilst much has been achieved in reducing the infant mortality rate from SUDI by between 50%, and 80% in some countries, over the last 30 years, there remain challenges for improving rates of accurate diagnosis and reaching out to more vulnerable families with clearly modifiable risk factors for SUDI. These challenges directly involve the clinician through taking a systematic and detailed history and better standardised death scene evaluations with specifically accredited assessors. Better knowledge regarding circumstances of SUDI cases will help Coroners and researchers provide answers for grieving families now, and in the future contribute to further reductions in the rate of SUDI in communities across the world.
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Abstract
After a sudden infant death, parents and caregivers need accurate and open communication about why their infant died. Communicating tragic news about a child's death to families and caregivers is difficult. Shared and consistent terminology is essential for pediatricians, other physicians, and nonphysician clinicians to improve communication with families and among themselves. When families do not have complete information about why their child died, pediatricians will not be able to support them through the process and make appropriate referrals for pediatric specialty and mental health care. Families can only speculate about the cause and may blame themselves or others for the infant's death. The terminology used to describe infant deaths that occur suddenly and unexpectedly includes an assortment of terms that vary across and among pediatrician, other physician, or nonphysician clinician disciplines. Having consistent terminology is critical to improve the understanding of the etiology, pathophysiology, and epidemiology of these deaths and communicate with families. A lack of consistent terminology also makes it difficult to reliably monitor trends in mortality and hampers the ability to develop effective interventions. This report describes the history of sudden infant death terminology and summarizes the debate over the terminology and the resulting diagnostic shift of these deaths. This information is to assist pediatricians, other physicians, and nonphysician clinicians in caring for families during this difficult time. The importance of consistent terminology is outlined, followed by a summary of progress toward consensus. Recommendations for pediatricians, other physicians, and nonphysician clinicians are proposed.
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Affiliation(s)
| | - Vincent J. Palusci
- Department of Pediatrics, Grossman School of Medicine, New York University, New York, New York
| | - Benjamin Hoffman
- Department of Pediatrics, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Erich Batra
- Departments of Pediatrics and Family and Community Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Marc Yester
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tracey S. Corey
- Florida Districts 5 & 24 Medical Examiner’s Office, Leesburg, Florida
| | - Mary Ann Sens
- Department of Pathology, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, North Dakota
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12
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Sessa F, Esposito M, Messina G, Di Mizio G, Di Nunno N, Salerno M. Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance. Healthcare (Basel) 2021; 9:870. [PMID: 34356248 PMCID: PMC8307931 DOI: 10.3390/healthcare9070870] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/27/2022] Open
Abstract
The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.
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Affiliation(s)
- Francesco Sessa
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Massimiliano Esposito
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95121 Catania, Italy; (M.E.); (M.S.)
| | - Giovanni Messina
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Giulio Di Mizio
- Forensic Medicine, Department of Law, Economy and Sociology, Campus “S. Venuta”, Magna Graecia University, 88100 Catanzaro, Italy;
| | - Nunzio Di Nunno
- Department of History, Society and Studies on Humanity, University of Salento, 73100 Lecce, Italy;
| | - Monica Salerno
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95121 Catania, Italy; (M.E.); (M.S.)
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13
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Claudet I, de Visme S, Duthoit G, Barnet L, Marchand-Tonel C, Chever M, Daussac E, Bréhin C, Levieux K. Prevalence of positive toxicology analysis from the French national registry for sudden unexpected infant death (Tox-MIN). Clin Toxicol (Phila) 2021; 60:38-45. [PMID: 34080518 DOI: 10.1080/15563650.2021.1933005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sudden unexpected infant death (SUID) remains the leading cause of postnatal mortality in many countries. French and international guidelines recommend a thorough examination with toxicology studies. OBJECTIVES The main objective was to determine the prevalence of toxic detection and positive analyses. The secondary objectives were to describe the different toxics and compare children with positive (Tox+) and negative results (Tox-) with other SUID risk factors. DESIGN AND METHODS We used the data registered from May 2015 to December 2018 by the French national SUID registry (OMIN). It collects data for all SUID cases admitted to any of the 35 participating French SUID referral centers. RESULTS Of the 624 SUID cases registered in the OMIN, a post-mortem toxicological analysis was performed in 398 infants. Thirty-six patients (9%) were positives for expected (Etox+ (n = 19 [53%], e.g., resuscitation drugs, regular treatments) and unexpected (UTox+) (n = 17 [47%]) toxics. The unexpected toxics were opioids (n = 8), cannabis (n = 4), cocaine (n = 3), cotinine (n = 2), carbon monoxide (n = 2), caffeine (n = 2), alcohol (n = 1) and GHB (n = 1). UTox + infants had a different seasonal distribution (p = .03), a higher incidence of inappropriate sleeping position and bedding at the time of death (respectively OR 3.8, p = .037 - OR 5.4, p = .026); inadequate body hygiene (OR 10.6, p = .0005), a younger maternal age (p = .045) and a higher rate of maternal drug abuse (OR 21.9, p = .0008). CONCLUSION The high rate of positive results warrants routine toxicology testing. The imputability of identified molecules is complicated by the presence of other known risk factors for SUID.
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Affiliation(s)
- Isabelle Claudet
- The Pediatric Emergency Department, Children's Hospital, Toulouse University Hospital (CHU), France.,UMR 1295, Inserm, Paul Sabatier University, UPS, Toulouse, France
| | | | - Gilles Duthoit
- The Pediatric Mobile Care Unit (SMUR), Children's hospital, Toulouse CHU, France
| | - Lucile Barnet
- The Pediatric Mobile Care Unit (SMUR), Children's hospital, Toulouse CHU, France
| | - Claire Marchand-Tonel
- Director of the Health Division, IFRASS, Toulouse, France.,The LISST laboratory, Jean-Jaurès University, UT2J, Toulouse II, France
| | - Martin Chever
- The Pediatric Emergency Department, Children's Hospital, Toulouse University Hospital (CHU), France
| | - Elisabeth Daussac
- The Pediatric Mobile Care Unit (SMUR), Children's hospital, Toulouse CHU, France
| | - Camille Bréhin
- The Pediatric Emergency Department, Children's Hospital, Toulouse University Hospital (CHU), France.,UMR 1416, Inserm, IRSD, Toulouse, France
| | - Karine Levieux
- The Pediatric Emergency Unit, Children's Hospital, Nantes CHU, France
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14
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Abstract
BACKGROUND Sudden unexpected infant death (SUID) represents a broad group of explained and unexplained infant deaths (<1 year old). Explaining why SUID occurs is critical to understanding etiology and prevention. Death certificate data cannot differentiate explained from unexplained SUID cases nor describe the surrounding circumstances. We report SUID rates by explained and unexplained categories and describe demographics and history of recent injury or illness using the Centers for Disease Control and Prevention SUID Case Registry. METHODS The registry is a population-based surveillance system built on Child Death Review programs. Data are derived from multiple sources, including death certificates, scene investigations, and autopsy reports. Cases included SUIDs reported by states or jurisdictions participating in the registry during 2011-2017. Cases were classified into explained and unexplained categories by using the registry's classification system. Frequencies, percentages, and mortality rates per 100 000 live births were calculated. RESULTS Of the 4929 SUID cases, 82% were categorized as unexplained. Among all cases, 73% had complete case information. Most SUIDs (72%) occurred in an unsafe sleep environment. The SUID mortality rate was 97.3 per 100 000 live births. Among explained and possible suffocation deaths, ∼75% resulted from airway obstruction attributed to soft bedding. CONCLUSIONS Unsafe sleep factors were common in explained and unexplained SUID cases, but deaths could only be classified as explained suffocation for ∼20% of cases. Further analysis of unexplained deaths, including continued improvements to death scene investigation and documentation, may generate hypotheses for physiologic and genetic research, advance our understanding of gaps in SUID investigation, and enhance our understanding of infants at highest risk.
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Affiliation(s)
- Sharyn E Parks
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia;
| | | | - Fern R Hauck
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia; and
| | - Carri R Cottengim
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meghan Faulkner
- Center for National Prevention Initiatives, Michigan Public Health Institute, Okemos, Michigan
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15
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Bishop-Freeman SC, Young KA, Aurelius MB, Hudson JS. Pediatric opioid fatalities: What can we learn for prevention? J Forensic Sci 2021; 66:1410-1419. [PMID: 33893645 DOI: 10.1111/1556-4029.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 11/27/2022]
Abstract
The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12 years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24 months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.
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Affiliation(s)
- Sandra C Bishop-Freeman
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kerry A Young
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA
| | - Michelle B Aurelius
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jason S Hudson
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA
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16
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Crandall LG, Lee JH, Friedman D, Lear K, Maloney K, Pinckard JK, Lin P, Andrew T, Roman K, Landi K, Jarrell H, Williamson AK, Downs JCU, Pinneri K, William C, Maleszewski JJ, Reichard RR, Devinsky O. Evaluation of Concordance Between Original Death Certifications and an Expert Panel Process in the Determination of Sudden Unexplained Death in Childhood. JAMA Netw Open 2020; 3:e2023262. [PMID: 33125496 PMCID: PMC7599447 DOI: 10.1001/jamanetworkopen.2020.23262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The true incidence of sudden unexplained death in childhood (SUDC), already the fifth leading category of death among toddlers by current US Centers for Disease Control and Prevention estimates, is potentially veiled by the varied certification processes by medicolegal investigative offices across the United States. OBJECTIVE To evaluate the frequency of SUDC incidence, understand its epidemiology, and assess the consistency of death certification among medical examiner and coroner offices in the US death investigation system. DESIGN, SETTING, AND PARTICIPANTS In this case series, 2 of 13 forensic pathologists (FPs) conducted masked reviews of 100 cases enrolled in the SUDC Registry and Research Collaborative (SUDCRRC). Children who died aged 11 months to 18 years from 36 US states, Canada, and the United Kingdom had been posthumously enrolled in the SUDCRRC by family members from 2014 to 2017. Comprehensive data from medicolegal investigative offices, clinical offices, and family members were reviewed. Data analysis was conducted from December 2014 to June 2020. MAIN OUTCOMES AND MEASURES Certified cause of death (COD) characterized as explained (accidental or natural) or unexplained, as determined by SUDCRRC masked review process. RESULTS In this study of 100 cases of SUDC (mean [SD] age, 32.1 [31.8] months; 58 [58.0%] boys; 82 [82.0%] White children; 92 [92.0%] from the United States), the original pathologist certified 43 cases (43.0%) as explained COD and 57 (57.0%) as unexplained COD. The SUDCRRC review process led to the following certifications: 16 (16.0%) were explained, 7 (7.0%) were undetermined because of insufficient data, and 77 (77.0%) were unexplained. Experts disagreed with the original COD in 40 cases (40.0%). These data suggest that SUDC incidence is higher than the current Centers for Disease Control and Prevention estimate (ie, 392 deaths in 2018). CONCLUSIONS AND RELEVANCE To our knowledge, this is the first comprehensive masked forensic pathology review process of sudden unexpected pediatric deaths, and it suggests that SUDC may often go unrecognized in US death investigations. Some unexpected pediatric deaths may be erroneously attributed to a natural or accidental COD, negatively affecting surveillance, research, public health funding, and medical care of surviving family members. To further address the challenges of accurate and consistent death certification in SUDC, future studies are warranted.
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Affiliation(s)
| | - Joyce H. Lee
- NYU Grossman School of Medicine, New York, New York
| | | | - Kelly Lear
- Arapahoe County Coroner’s Office, Centennial, Colorado
| | - Katherine Maloney
- Erie County Medical Examiner's Office, Buffalo, New York
- University at Buffalo School of Medicine, Buffalo, New York
| | | | | | - Thomas Andrew
- White Mountain Forensic Consulting Services, Concord, New Hampshire
| | | | | | | | | | | | - Kathy Pinneri
- Montgomery County Forensic Services Department, Conroe, Texas
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17
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Vladescu JC, Day-Watkins J, Schnell LK, Carrow JN. Safe to sleep: Community-based caregiver training. J Appl Behav Anal 2020; 53:1922-1934. [PMID: 32989789 DOI: 10.1002/jaba.777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 11/07/2022]
Abstract
Annually, thousands of infant deaths are classified as sudden unexpected infant deaths (SUIDs). In an effort to reduce the risk of SUIDs, the American Academy of Pediatrics has made a number of recommendations to educate caregivers, childcare providers, and healthcare professionals on safe infant sleep practices. The purpose of the current study was to extend the literature on safe infant sleep practices by teaching caregivers to arrange safe infant sleep environments using a mannequin and common infant items. We partnered with community-based agencies to evaluate the effectiveness of behavioral skills training delivered in a single training session as part of the ongoing pre- or postnatal care these agencies provided. Following training, all participants demonstrated a substantial change in responding and returned favorable social validity ratings. We discuss these outcomes in light of previous studies, limitations, and future directions.
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18
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Osawa M, Ueno Y, Ikeda N, Ikematsu K, Yamamoto T, Irie W, Kozawa S, Kotani H, Hamayasu H, Murase T, Shingu K, Sugimoto M, Nagao R, Kakimoto Y. Circumstances and factors of sleep-related sudden infancy deaths in Japan. PLoS One 2020; 15:e0233253. [PMID: 32822352 PMCID: PMC7444554 DOI: 10.1371/journal.pone.0233253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/06/2020] [Indexed: 01/15/2023] Open
Abstract
Background Sudden unexpected death in infancy (SUDI) comprises both natural and unnatural causes of death. However, few epidemiological surveys have investigated SUDI in Japan. Objective This retrospective study was conducted to investigate the latest trends of circumstances and risk factors of SUDI cases in which collapse occurred during sleep. Methods Forensic pathology sections from eight universities participated in the selection of subjects from 2013 to 2018. Data obtained from the checklist form were analyzed based on information at postmortem. Results There were 259 SUDI cases consisting of 145 male infants and 114 female infants with a mean birth weight of 2888 ± 553 and 2750 ± 370 g, respectively. Deaths most frequently occurred among infants at 1 month of age (18%). According to population data as the control, the odds ratio (95% confidence interval) of mother’s age ≤19 years was 11.1 (6.9–17.7) compared with ages 30–39. The odds ratio for the fourth- and later born infants was 5.2 (3.4–7.9) compared with the frequency of first-born infants. The most frequent time of day for discovery was between 7 and 8 o’clock, and the time difference from the last seen alive was a mean of 4.1 h. Co-sleeping was recorded for 61%, and the prone position was found for 40% of cases at discovery. Mother’s smoking habit exhibited an odds ratio of 4.5 (2.9–5.8). Conclusion This study confirmed the trends that have been observed for sudden infant death syndrome; particularly, very high odds ratios were evident for teenage mothers and later birth order in comparison with those in other developed countries. Neglect was suspected in some cases of the prolonged time to discovery of unreactive infants. To our knowledge, this is the first report of an extensive survey of SUDI during sleep in Japan.
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Affiliation(s)
- Motoki Osawa
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- * E-mail:
| | - Yasuhiro Ueno
- Department of Legal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Noriaki Ikeda
- Department of Forensic Pathology and Sciences, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Kazuya Ikematsu
- Department of Forensic Pathology and Science, Graduate School of Biomedical Sciences Nagasaki University, Nagasaki, Japan
| | - Takuma Yamamoto
- Department of Legal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Wataru Irie
- Department of Legal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shuji Kozawa
- Department of Forensic Medicine and Sciences, Mie University School of Medicine, Tsu, Mie, Japan
| | - Hirokazu Kotani
- Department of Forensic Medicine and Molecular Pathology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideki Hamayasu
- Department of Forensic Medicine and Molecular Pathology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takehiko Murase
- Department of Forensic Pathology and Science, Graduate School of Biomedical Sciences Nagasaki University, Nagasaki, Japan
| | - Keita Shingu
- Department of Forensic Pathology and Science, Graduate School of Biomedical Sciences Nagasaki University, Nagasaki, Japan
| | - Marie Sugimoto
- Department of Legal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Ryoko Nagao
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Yu Kakimoto
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Cottengim C, Parks S, Rhoda D, Andrew T, Nolte KB, Fudenberg J, Sens MA, Brustrom J, Payn B, Shapiro-Mendoza CK. Protocols, practices, and needs for investigating sudden unexpected infant deaths. Forensic Sci Med Pathol 2019; 16:91-98. [PMID: 31741206 DOI: 10.1007/s12024-019-00196-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 12/01/2022]
Abstract
Understanding case identification practices, protocols, and training needs of medical examiners and coroners (MEC) may inform efforts to improve cause-of-death certification. We surveyed a U.S.-representative sample of MECs and described investigation practices and protocols used in certifying sudden unexpected infant deaths (SUID). We also identified MEC training and resource needs. Of the 377 respondents, use of the SUID Investigation Reporting Form or an equivalent was 89% for large, 87% for medium, and 52% for small jurisdictions. Routine completion of infant medical history, witness interviews, autopsy, photos or videos, and family social history for infant death investigations was ≥80%, but routine scene re-creation with a doll was 30% in small, 64% in medium, and 59% in large offices. Seventy percent of MECs reported infant death investigation training needs. Increased training and use of standardized practices may improve SUID cause-of-death certification, allowing us to better understand SUID.
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Affiliation(s)
- Carri Cottengim
- Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, N.E. MS S107-2, Chamblee, GA, 30341, USA.
| | - Sharyn Parks
- Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, N.E. MS S107-2, Chamblee, GA, 30341, USA
| | - Dale Rhoda
- Biostat Global Consulting, Worthington, OH, formerly at Battelle, Columbus, OH, USA
| | - Tom Andrew
- Office of Chief Medical Examiner, Concord, NH, USA
| | - Kurt B Nolte
- Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - John Fudenberg
- Clark County Office of the Coroner/Medical Examiner, Las Vegas, NV, USA
| | - Mary Ann Sens
- Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | | | - Betsy Payn
- University of Washington, Seattle, WA, USA
| | - Carrie K Shapiro-Mendoza
- Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, N.E. MS S107-2, Chamblee, GA, 30341, USA
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20
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Bennett T, Martin LJ, Heathfield LJ. Global trends in the extent of death scene investigation performed for sudden and unexpected death of infant (SUDI) cases: A systematic review. Forensic Sci Int 2019; 301:435-444. [PMID: 31229847 DOI: 10.1016/j.forsciint.2019.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/25/2019] [Accepted: 06/09/2019] [Indexed: 11/28/2022]
Abstract
Sudden unexpected death of infants (SUDI) is the rapid and unexpected death of an infant aged less than 1year old. These deaths are referred for a medico-legal investigation to establish cause of death. National and regional protocols for the investigation of SUDI cases have been established in some countries and these typically include a death scene investigation component. However, there is a paucity of literature detailing the nature and extent of death scene investigation protocols. A systematic review was conducted to review the scope of death scene investigation of SUDI cases worldwide. Relevant articles (n=74) were identified by searching four literature databases, three discipline-specific journals, as well as each article's reference list, until saturation was reached. Of the 16 countries represented by the included articles, seven made specific reference to the standardised protocol used, which included photography, interviews and/or scene re-enactments. The remaining 54 studies appeared to include a subset of these analyses during death scene investigation, which varied between countries, and between SUDI admissions. This may be attributed to the differing socio-economic standings of countries, and the resources available. Only four studies were from developing countries, three of which originated from South Africa. Overall, where a standardised death scene investigation was performed, it added value to the post-mortem investigation; as such, death scene investigation should be encouraged in SUDI investigation. To this end, protocols should be established nationally, and contain core analyses, which could be expanded depending on the needs and resources of the country.
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Affiliation(s)
- Tracy Bennett
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa.
| | - Lorna J Martin
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa.
| | - Laura J Heathfield
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, South Africa.
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21
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Erck Lambert AB, Parks SE, Cottengim C, Faulkner M, Hauck FR, Shapiro-Mendoza CK. Sleep-Related Infant Suffocation Deaths Attributable to Soft Bedding, Overlay, and Wedging. Pediatrics 2019; 143:peds.2018-3408. [PMID: 31010907 PMCID: PMC6637427 DOI: 10.1542/peds.2018-3408] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Unintentional suffocation is the leading cause of injury death among infants <1 year old in the United States, with 82% being attributable to accidental suffocation and strangulation in bed. Understanding the circumstances surrounding these deaths may inform prevention strategies. METHODS We analyzed data from the population-based Sudden Unexpected Infant Death Case Registry from 2011 to 2014. Cases categorized as explained suffocation with unsafe sleep factors (suffocation), per the Centers for Disease Control and Prevention's Sudden Unexpected Infant Death Case Registry classification system, were included and assigned a mechanism of obstruction, including soft bedding, overlay, or wedging. We calculated frequencies and percentages of suffocation deaths by mechanism and selected demographic and sleep-environment characteristics. RESULTS Fourteen percent of sudden unexpected infant death cases were classified as suffocation; these cases were most frequently attributed to soft bedding (69%), followed by overlay (19%) and wedging (12%). Median age at death in months varied by mechanism: 3 for soft bedding, 2 for overlay, and 6 for wedging. Soft-bedding deaths occurred most often in an adult bed (49%), in a prone position (82%), and with a blanket (or blankets) obstructing the airway (34%). Overlay deaths occurred most often in an adult bed (71%), and infants were overlaid by the mother (47%). Wedging deaths occurred most often when the infant became entrapped between a mattress and a wall (48%). CONCLUSIONS Safe sleep environments can reduce infant suffocation deaths. Increased knowledge about the characteristics of suffocation deaths can help inform prevention strategies by targeting highest-risk groups.
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Affiliation(s)
| | - Sharyn E. Parks
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carri Cottengim
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meghan Faulkner
- Center for National Prevention Initiatives, Michigan Public Health Institute, Okemos, Michigan
| | - Fern R. Hauck
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia
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22
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Affiliation(s)
- Lindsay S. Womack
- Epidemic Intelligence Service, Atlanta, Georgia,Division of Vital Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland,Public Health Service, Rockville, Maryland
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Abstract
OBJECTIVES To discuss the role of investigations after death in children as part of a supplement on "Death and Dying in the PICU." DATA SOURCES Literature review, personal experience, and expert opinion. DATA SELECTION Not applicable. DATA EXTRACTION Moderated by three experts on investigations after death in children. DATA SYNTHESIS Not relevant. CONCLUSIONS A multidisciplinary cliniciopathologic conference is important after the death of a child in order to help bring closure to the family and to attempt to address any concerns they may have about the care. It is also an important part of the quality of care process for a tertiary care institution and provides an unique opportunity for ongoing medical education. The model of a multidisciplinary cliniciopathologic conference used by the Ontario Coroner's Office to investigate sudden and unexpected deaths in children under 5 years old, which has been functioning for over 30 years, is described. Reports from this Pediatric Death Review Committee have been influential in improving the care of children in the province of Ontario.
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24
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Abstract
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.
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Affiliation(s)
| | - Sharyn E. Parks
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Rueda M, Wagner JL, Phillips TC, Topol SE, Muse ED, Lucas JR, Wagner GN, Topol EJ, Torkamani A. Molecular Autopsy for Sudden Death in the Young: Is Data Aggregation the Key? Front Cardiovasc Med 2017; 4:72. [PMID: 29181379 PMCID: PMC5694161 DOI: 10.3389/fcvm.2017.00072] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 10/27/2017] [Indexed: 12/18/2022] Open
Abstract
The Scripps molecular autopsy study seeks to incorporate genetic testing into the postmortem examination of cases of sudden death in the young (<45 years old). Here, we describe the results from the first 2 years of the study, which consisted of whole exome sequencing (WES) of a cohort of 50 cases predominantly from San Diego County. Apart from the individual description of cases, we analyzed the data at the cohort-level, which brought new perspectives on the genetic causes of sudden death. We investigated the advantages and disadvantages of using WES compared to a gene panel for cardiac disease (usually the first genetic test used by medical examiners). In an attempt to connect complex clinical phenotypes with genotypes, we classified samples by their genetic fingerprint. Finally, we studied the benefits of analyzing the mitochondrial DNA genome. In this regard, we found that half of the cases clinically diagnosed as sudden infant death syndrome had an increased ratio of heteroplasmic variants, and that the variants were also present in the mothers. We believe that community-based data aggregation and sharing will eventually lead to an improved classification of variants. Allele frequencies for the all cases can be accessed via our genomics browser at https://genomics.scripps.edu/browser.
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Affiliation(s)
- Manuel Rueda
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States
| | - Jennifer L Wagner
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States
| | - Tierney C Phillips
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States
| | - Sarah E Topol
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States
| | - Evan D Muse
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States.,Division of Cardiology, Scripps Clinic, La Jolla, CA, United States
| | - Jonathan R Lucas
- Medical Examiner Department, San Diego County, San Diego, CA, United States
| | - Glenn N Wagner
- Medical Examiner Department, San Diego County, San Diego, CA, United States
| | - Eric J Topol
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States.,Division of Cardiology, Scripps Clinic, La Jolla, CA, United States
| | - Ali Torkamani
- The Scripps Translational Science Institute, Scripps Health, The Scripps Research Institute, La Jolla, CA, United States
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26
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Abstract
This review article describes the role of the medicolegal death investigator and medical examiner or coroner (MEC) in the investigations of a sudden unexpected infant death (SUID) beginning with an introduction into the case types that should be investigated and how infant deaths fit into that legal framework. The article also provides an overview of the history of the Centers for Disease Control and Prevention SUID investigation guidelines and process. The article concludes with a description of how the MEC correlates the scene investigation with autopsy findings, as well as the role of the MEC in cause of death determinations. There is also a brief discussion on how infant mortality data are captured and subsequently used to decrease infant mortality. [Pediatr Ann. 2017;46(8):e297-e302.].
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27
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Ostfeld BM, Schwartz-Soicher O, Reichman NE, Teitler JO, Hegyi T. Prematurity and Sudden Unexpected Infant Deaths in the United States. Pediatrics 2017; 140:peds.2016-3334. [PMID: 28759397 DOI: 10.1542/peds.2016-3334] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Prematurity, a strong risk factor for sudden unexpected infant death (SUID), was addressed in recommendations by the American Academy of Pediatrics in 2011 for safe sleep education in NICUs. We documented associations between gestational age (GA) and SUID subsequent to these guidelines. METHODS Using the 2012-2013 US linked infant birth and death certificate period files, we documented rates per live births of sudden infant death syndrome, ill-defined and unspecified causes, accidental suffocation and strangulation in bed, and overall SUID by GA in postneonatal, out-of-hospital, and autopsied cases; compared survivors and cases; and estimated logistic regression models of associations between GA and SUID. RESULTS SUID cases were more likely than survivors to be <37 weeks' GA (22.61% vs 10.79%; P < .0001). SUID rates were 2.68, 1.94, 1.46, 1.16, 0.73, and 0.51 per 1000 live births for 24 to 27, 28 to 31, 32 to 33, 34 to 36, 37 to 38, and 39 to 42 weeks' GA, respectively. Logistic regression models additionally indicated declines in the risk for SUID as GA increased. Prenatal smoking, inadequate prenatal care, and demographics associated with poverty were strongly associated with SUID. CONCLUSIONS Despite the 2011 American Academy of Pediatrics recommendations for increased safe sleep education in the NICUs, SUID rates were inversely associated with GA in 2012 to 2013, suggesting that risk of SUID associated with prematurity has multiple etiologies requiring continued investigation, including biological vulnerabilities and the efficacy of NICU education programs, and that strategies to reduce SUID should be multifaceted.
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Affiliation(s)
- Barbara M Ostfeld
- Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey;
| | - Ofira Schwartz-Soicher
- Data and Statistical Services, Princeton University Library, Princeton University, Princeton, New Jersey
| | - Nancy E Reichman
- Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.,Institute of Health Evaluation, Management and Policy, University of Toronto, Toronto, Ontario, Canada; and
| | | | - Thomas Hegyi
- Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
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29
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Pinneri K, Matshes EW. Recommendations for the Autopsy of an Infant who has Died Suddenly and Unexpectedly. Acad Forensic Pathol 2017; 7:171-181. [PMID: 31239972 DOI: 10.23907/2017.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/27/2017] [Accepted: 04/22/2017] [Indexed: 11/12/2022]
Abstract
As the result of improved death scene investigations and the performance of more thorough and thoughtful pediatric forensic autopsies, there has been a widespread increase in the recognition of asphyxial mechanisms of death as well as lethal natural diseases that might have otherwise been erroneously labeled as sudden infant death syndrome (SIDS) or sudden unexpected infant death (SUID). Although it is fair to state that "more thorough autopsies provide more thorough medical evidence" from which to draw upon when determining cause and manner of death, there is no standard, accepted baseline from which forensic pathologists operate. Although anatomic pathologists are quite accustomed to practicing within well-defined boundaries for specimen (and thus diagnostic) adequacy, forensic pathologists are frequently hesitant to embrace or adopt such concepts. This has made it difficult to evaluate standards of practice in forensic pathology. Recommendations have been developed and published by the National Association of Medical Examiners for the postmortem assessment of suspected infant head trauma. However, significant variation exists in the way autopsies are performed on infants without trauma, such as the common scenario of an infant who has died suddenly and unexpectedly of asphyxial or apparent natural means. A wide variety of autopsy techniques and ancillary studies are available to forensic pathologists, but as survey data indicates, are not consistently used throughout the United States. This paper will discuss the different components of the pediatric autopsy and make recommendations for the best use of available tests and consultation services.
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30
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Burns KM, Bienemann L, Camperlengo L, Cottengim C, Covington TM, Dykstra H, Faulkner M, Kobau R, Erck Lambert AB, MacLeod H, Parks SE, Rosenberg E, Russell MW, Shapiro-Mendoza CK, Shaw E, Tian N, Whittemore V, Kaltman JR. The Sudden Death in the Young Case Registry: Collaborating to Understand and Reduce Mortality. Pediatrics 2017; 139:e20162757. [PMID: 28228502 PMCID: PMC5330401 DOI: 10.1542/peds.2016-2757] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 12/13/2022] Open
Abstract
Knowledge gaps persist about the incidence of and risk factors for sudden death in the young (SDY). The SDY Case Registry is a collaborative effort between the National Institutes of Health, the Centers for Disease Control and Prevention, and the Michigan Public Health Institute. Its goals are to: (1) describe the incidence of SDY in the United States by using population-based surveillance; (2) compile data from SDY cases to create a resource of information and DNA samples for research; (3) encourage standardized approaches to investigation, autopsy, and categorization of SDY cases; (4) develop partnerships between local, state, and federal stakeholders toward a common goal of understanding and preventing SDY; and (5) support families who have lost loved ones to SDY by providing resources on bereavement and medical evaluation of surviving family members. Built on existing Child Death Review programs and as an expansion of the Sudden Unexpected Infant Death Case Registry, the SDY Case Registry achieves its goals by identifying SDY cases, providing guidance to medical examiners/coroners in conducting comprehensive autopsies, evaluating cases through child death review and an advanced review by clinical specialists, and classifying cases according to a standardized algorithm. The SDY Case Registry also includes a process to obtain informed consent from next-of-kin to save DNA for research, banking, and, in some cases, diagnostic genetic testing. The SDY Case Registry will provide valuable incidence data and will enhance understanding of the characteristics of SDY cases to inform the development of targeted prevention efforts.
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Affiliation(s)
- Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute and
| | - Lauren Bienemann
- Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Carri Cottengim
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Theresa M Covington
- National Center for Fatality Review and Prevention, Michigan Public Health Institute, Okemos, Michigan; and
| | - Heather Dykstra
- National Center for Fatality Review and Prevention, Michigan Public Health Institute, Okemos, Michigan; and
| | - Meghan Faulkner
- National Center for Fatality Review and Prevention, Michigan Public Health Institute, Okemos, Michigan; and
| | - Rosemarie Kobau
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Heather MacLeod
- National Center for Fatality Review and Prevention, Michigan Public Health Institute, Okemos, Michigan; and
| | - Sharyn E Parks
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ellen Rosenberg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute and
| | - Mark W Russell
- Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Esther Shaw
- National Center for Fatality Review and Prevention, Michigan Public Health Institute, Okemos, Michigan; and
| | - Niu Tian
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Vicky Whittemore
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute and
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