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

Value of stomach content in a case of fatal child homicide

In death investigations, the volume of gastric contents may be useful concerning the time of death estimation, or to clarify the circumstances of death. Here, the case of a 4-month-old male infant who was found dead in his mother's bed is presented. SIDS was assumed as the cause of death after initial police investigations. Later, autopsy results revealed that this case was a homicide due to extensive abusive head trauma. The infant had three skull fractures on the back of his head with subdural hemorrhage and cerebral oedema. The survival time after feeding him formula and corresponding the time of death was determined to evaluate the mother's initial claims that the infant was alive several hours after feeding. In this case, the volume of stomach contents of the last meal was known. From the volume of milky fluid found in the stomach at autopsy, it was possible to estimate the time of death within a narrow time frame of less than one hour after feeding. The mother's claims could be ruled out, and she later confessed to having killed the child soon after feeding him. Even methods with low precision for estimating time of death, like examining stomach contents, can be essential for solving practical cases. To our knowledge, this is one of the first published cases in which an infant's stomach content was used successfully in the reconstruction of a homicide.

Manner of death, causes of death and autopsies in infants, children and adolescents

Child mortality is an issue that is repeatedly discussed internationally and is subject to strong fluctuations depending on the country and region and the respective levels of development. Several studies on child mortality are available from e.g., the USA; however, data from institutes in Germany are still lacking.

The present study compared data on the manner and causes of deaths of infants, children and adolescents in Germany from 2002 to 2012 on different levels (the Institute of Legal Medicine and the Public Health Department, both in Cologne, as well as nationwide) with international data. Special attention is paid to autopsy figures and cases of sudden infant death syndrome (SIDS).

Throughout the observation period, child mortality decreased overall in all levels of data. Mortality rates were highest in the first year of life, with natural causes of death (premature birth, malformations, SIDS) dominating. With increasing age the number of non-natural deaths and thus, accident-related deaths, especially transportation accidents, increased.

Reasons for the reduced number of cases can be nationally effective prevention and awareness campaigns as well as constantly improving medical care. At a local level, targeted educational work leads to higher numbers of autopsies, particularly in cases of SIDS. In principle, the results of this study are generally comparable with other studies on child mortality, although the available data can only be used for detailed analyses to a limited extent

Infant urinary metabolomic profile in a fatal acute methadone intoxication

A case report suspicious for a Sudden Infant Death Syndrome is here described. Pathological findings were consistent with an acute respiratory failure while toxicological analysis revealed an elevated blood methadone concentration. Death was then ascribed to an acute methadone intoxication. In addition to the routinary approach, the urinary sample collected at autopsy was investigated with a ¹H NMR metabolomic approach and the identified metabolomic profile was challenged with the urinary metabolomic profiles previously obtained from 10 newborns who experienced perinatal asphyxia and 16 healthy control newborns. Intriguingly, the urinary profile of the methadone intoxicated infant was very similar to those belonging to the perinatal asphyxia newborns, especially to those belonging to the newborns characterised by the worst outcome. The results offer several hints on a shared metabolic derangement between different mechanisms of asphyxia/hypoxia. To the best of the authors’ knowledge, this is the first report of the use of a metabolomic approach in a pathological case, in which metabolomics offers useful additional information regarding the mechanism and the cause of death.

Multidisciplinary study of sudden unexpected infant death in Liguria (Italy): a nine-year report

INTRODUCTION

We conducted a retrospective analysis of cases of sudden unexpected infant death (SUID) referred to the SIDS-ALTE Center of the Liguria Region (Italy) from 2010 to 2018. In all cases, the death scene was inspected, and a multidisciplinary post-mortem evaluation was conducted. Our aim was to analyze the epidemiological data and etiological distribution.

EVIDENCE ACQUISITION

We examined 15 cases initially classified as sudden infant death.

EVIDENCE SYNTHESIS

In all cases, the death was initially unexplained. Seven cases involved males and eight involved females. Their mean age was 67.47 days; the youngest victim was 2 days old, while the oldest was 8.5 months (253 days). In 7 cases, the post-mortem analysis showed an infection of lung. In 4 cases, the prone position of the infant during sleep was identified as a risk factor. Only in one case the cause of death remains unexplained, and it was classified as sudden infant death syndrome II according to San Diego Classification.

CONCLUSIONS

In the forensic approach to cases of SUID, it is always important to conduct a thorough multidisciplinary investigation. In order to avoid procedural errors that might compromise the post-mortem investigation, it is necessary to consider the medical and social history of both mother and child, in addition to the circumstances of the death. Moreover, a complete pediatric post-mortem examination and multidisciplinary discussion are required in order to identify potentially important causative or contributory factors.

Cases of asphyxia in children and adolescents: a retrospective analysis of fatal accidents, suicides, and homicides from 1998 to 2017 in Hamburg, Germany

PURPOSE

Injury-related asphyxia is one of the most common causes of death in children in Germany. However, only a few systematic studies have analyzed the causes and circumstances of asphyxia in children and adolescents.

METHODS

All cases of asphyxia in children and adolescents (0-21 years of age) among the Hamburg Legal Medical Department's autopsy cases from 1998 to 2017 were retrospectively analyzed with special focus on how often external findings were completely absent.

RESULTS

Among 249 cases of fatal asphyxia, 68% were accidents, 14% were suicides, and 13% were homicides. Most of the cases involved boys. Adolescents and young adults aged 15-21 years represented the main age group. Drowning was the leading mechanism of asphyxia. Younger age was associated with less frequent detection of external signs of asphyxia in the postmortem external examination. Petechial hemorrhages were the most common visible external indication of asphyxia. No external findings indicative of asphyxia were present in 14% of the cases.

CONCLUSION

Asphyxia in children and adolescents often involves accidents. However, postmortem external examination alone is insufficient to identify asphyxia and the manner of death.

Medico-legal investigation in an explicable case of congenital central hypoventilation syndrome due to a rare variant of the PHOX2B gene

The heterozygous PHOX2B gene mutation is related to congenital central hypoventilation syndrome (CCHS). It is characterized by defective autonomous nervous system development leading to inadequate breathing response to hypoxia and hypercapnia, leading to hypoventilation especially during non-REM sleep, but also during waking in the more severe cases. Herein we report a case of sudden death in a 28-day-old child. The mother reported the infant was found lying on her own bed in the prone position. The infant was wearing a romper and lying in her crib without any blanket or other objects. At autopsy no significant pathological findings were detected. Histologically, sparse aspirated milk residues were present in some lung fields. Toxicological and microbiological examinations were within the norm. The initial postmortem investigation ruled out any readily identifiable cause of death. However, genetic analysis revealed a rare heterozygous 21bp in-frame deletion of the polyalanine coding sequences of the PHOX2B gene. In-frame contractions of the poly-Ala tract of the PHOX2B gene have already been reported in patients with symptoms suggestive of sporadic hypoventilation, apparent life-threatening events or neonatal respiratory distress.

[Retinal bleeding and venous stasis in a 10-month-old infant after a fall?]

This report describes the case of a 10-month-old infant, who was delivered to our hospital by the emergency physician intubated and in an unclear unconscious state. The father reported that the child had fallen from the couch to the ground. The consulted ophthalmologist reported venous stasis in both eyes including intraretinal and preretinal bleeding in all four quadrants, a diffuse vitreous hemorrhage in the right eye and temporal retinal wrinkling in both eyes. Based on these particular clinical findings a shaken baby syndrome was suspected. This report demonstrates the importance of recognizing and correctly interpreting the typical ophthalmological signs of physical child abuse in order to detect and prevent further mistreatment of children; moreover, the increasing importance of photographic documentation and histological work-up of the findings for forensic reasons are emphasized.

Rate of deaths due to child abuse and neglect in children 0-3 years of age in Germany

In recent years, increasing attention has been paid to the issue of (fatal) child abuse and neglect, largely due to the media attention garnered by some headline-grabbing cases. If media statements are to be believed, such cases may be an increasing phenomenon. With these published accounts in mind, publicly available statistics should be analysed with respect to the question of whether reliable statements can be formulated based on these figures. It is hypothesised that certain data, e.g., the Innocenti report published by UNICEF in 2003, may be based on unreliable data sources. For this reason, the generation of such data, and the reliability of the data itself, should also be discussed. Our focus was on publicly available German mortality and police crime statistics (Polizeiliche Kriminalstatistik). These data were classified with respect to child age, data origin, and cause of death (murder, culpable homicide, etc.). In our opinion, the available data could not be considered in formulating reliable scientific statements about fatal child abuse and neglect, given the lack of detail and the flawed nature of the basic data. Increasing the number of autopsies of children 0-3 years of age should be considered as a means to ensure the capture of valid, practical, and reliable data. This could bring about some enlightenment and assist in the development of preemptive strategies to decrease the incidence of (fatal) child abuse and neglect.

Caput succedaneum and facial petechiae--birth-associated injuries in healthy newborns under forensic aspects

In cases of suspected neonaticide, the results of a forensic autopsy might be important for conviction or acquittal. But autopsy findings in dead newborns are often unspecific and can rarely provide corroborative evidence of inflicted injury, as they are known to occur during normal birth as well. In our study, we examined 59 vaginally delivered, healthy newborns within the first 30 min after birth to know more about the prevalence and possible correlations of a caput succedaneum and facial petechiae. Caput succedaneum occurred in 33.9%, facial petechiae in 20.3%. As for the occurrence of caput succedaneum, statistically significant differences could be shown for the duration of delivery and the mother's parity. These correlations could not be shown for the occurrence of facial petechiae. Within the scope of our study, we could demonstrate that neither caput succedaneum nor facial petechiae are rare findings in healthy newborns. In the forensic investigation of suspected neonaticide, their potential significance can only be ascertained together with further investigations of the circumstances of death and a thorough forensic pathological autopsy.

Retinal hemorrhage in abusive head trauma

Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.

Petechial bleedings in sudden infant death

The autopsy reports of 484 cases of deceased infants (201 females, 283 males) were analysed retrospectively for the existence of external and internal petechial bleedings (PET). The cases were divided into five groups on the basis of the cause of death (sudden infant death syndrome, sepsis, airway infections, asphyxia and trauma). Internal PET (pleural, pericardial, epicardial, thymic and peritoneal) were observed in each group with a lower prevalence in cases of trauma. The highest prevalence of external (cutaneous and conjunctival) PET was detected in cases of asphyxia (38% and 31%, respectively). However, even if with low prevalence, such bleedings were detected in every group. Factors like sex, age, cardiopulmonary resuscitation and its duration did not influence the presence of PET. The detection of external PET at autopsy is a suspicious finding that suggests asphyxia. Because of the possible natural origin of these bleedings, the medicolegal investigation has to be as complete as possible and has to include histology as mandatory.

A Unifying Theory for SIDS

The Sudden Infant Death Syndrome (SIDS) has four distinctive characteristics that must be explained by any theory proposed for it. (1) A characteristic male fraction of approximately 0.61 for all postneonatal SIDS in the US; (2) a distinctive lognormal-type age distribution arising from zero at birth, mode at about 2 months, median at about 3 months, and an exponential decrease with age going towards zero beyond one year; (3) a marked decrease in SIDS rate from the discovery that changing the recommended infant sleep position from prone to supine reduced the rate of SIDS, but it did not change the form of the age or gender distributions cited above; (4) a seasonal variation, maximal in winter and minimal in summer, that implies subsets of SIDS displaying evidence of seasonal low-grade respiratory infection and nonseasonal neurological prematurity. A quadruple-risk model is presented that fits these conditions but requires confirmatory testing by finding a dominant X-linked allele protective against cerebral anoxia that is missing in SIDS.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

BACKGROUND

Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality.

METHODS

Selective literature review including an overview over national and international recommendations.

RESULTS

Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations.

CONCLUSIONS

The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

Recognising and responding to child maltreatment

Professionals in child health, primary care, mental health, schools, social services, and law-enforcement services all contribute to the recognition of and response to child maltreatment. In all sectors, children suspected of being maltreated are under-reported to child-protection agencies. Lack of awareness of the signs of child maltreatment and processes for reporting to child-protection agencies, and a perception that reporting might do more harm than good, are among the reasons for not reporting. Strategies to improve recognition, mainly used in paediatric practice, include training, use of questionnaires for asking children and parents about maltreatment, and evidence-based guidelines for who should be assessed by child-protection specialists. Internationally, studies suggest that policies emphasising substantiation of maltreatment without concomitant attention to welfare needs lead to less service provision for maltreated children than do those in systems for which child maltreatment is part of a broad child and family welfare response.

Current recommendations on infants' sleeping position are being followed-initial results of a population-based sentinel study on risk factors for SIDS, 1996-2006, in Hamburg, Germany

Sudden infant death syndrome (SIDS) is a target for public health care in Germany. The aim of this study was to monitor data on risk-related behavior in the population of Hamburg, Germany, in order to respond to changes quickly and to estimate the effectiveness of prevention activities. Data have been gathered using the sentinel system with repeated surveys (1996, 1998, 2001, and 2006) in pediatric practices, thus allowing an estimate of the prevalence of risk factors in an urban population, both transversally and vertically. From 1996 to 2007, the SIDS rate in Hamburg fell from 0.9/1,000 live births to 0.1. The prevalence of infants sleeping prone declined from 8.1% in 1996 to 3.5% in 2006. In this small subgroup, up to 81.7% (2006) of the caretakers were well aware of the risk of sleeping prone. The prevalence of infants sleeping on their sides fell from 55.3% in 1998 to 10.6% in 2006. The sentinel setting is suitable for gathering risk-related data on SIDS. Despite the fact that, so far, no nationwide back-to-sleep campaign has been instituted in Germany, local campaigns have proved successful in reducing prone sleeping for infants. Moreover, the substantial reduction of side sleeping within a short time span going along with a reduced SIDS rate is an indicator of the effectiveness of prevention activities on a local basis.

[The problem of differentiating between sudden infant death syndrome, fatal Munchausen's syndrome by proxy, and infanticide]

INTRODUCTION

Sudden infant death syndrome (SIDS) is the most common type of post-neonatal death in infants under 1 year of age. It is defined as the sudden death of an infant that is unexpected on the basis of the child's history and unexplained by a thorough post-mortem examination. The incidence of SIDS in Germany has fallen from 1.7 per 1000 live births in 1990 to 0.62 in 2000. In the U.K. the incidence was 0.56 in 1998. According to the literature, 5 to 11 percent of deaths recorded as SIDS may be disguised homicides. These homicides can be caused by a Munchausen's syndrome by proxy (MSBP). Munchausen's syndrome by proxy is defined as an extreme form of abuse wherein the caregivers produce symptoms of illness in a child by means of internal or by external manipulation. Using case reports, this paper examines some difficulties in differentiating between SIDS, MSBP, and homicide.

CASE REPORT

In a family with three children, the youngest daughter died suddenly of suffocation at the age of 17 months. Before her death, the child had been admitted 11 times to different hospitals for various reasons. The mother reported that her daughter was admitted for epileptic seizures, suffocation attacks, and diarrhoea. No noticeable organic signs or symptoms were found during the child's stays in a hospital. The girl was discharged each time without symptoms and without a clear-cut diagnosis. Toxicological analysis of the blood revealed the presence of caffeine. Clinically, an accidental death appeared to be unlikely.

CONCLUSIONS

When assessing cases of SIDS, a MSBP, or homicide, practitioners should be on the lookout for recurrent symptoms of illness, repeated hospitalisation and/or consultation of physicians, multiple diagnostic procedures without establishment of a clear-cut diagnosis, a certain resistance to therapy, illness or unnatural death of siblings, and repeated signs of poisoning or suffocation. Differentiation between SIDS, MSBP, and homicide should be extensive and done with great care since the legal consequences differ vastly according to the facts of the matter.

The Role of Environmental Factors in the Causation of Sudden Death in Infants: Two Cases of Sudden Unexpected Death in Two Unrelated Infants Who Were Cared for by the Same Babysitter

We report two cases of sudden unexpected death in two unrelated African American female infants, 2 months and 4 months old. Both infants were attended to by the same babysitter in the same apartment and died 39 days apart in the same bed and in the same bedroom. The autopsy of the first infant revealed sudden unexplained death in an infant. Toxicologic analysis for carbon monoxide (CO) was not performed because it was not suspected. When the second infant died, investigation into the ambient air quality within the apartment revealed high levels of CO emanating from a poorly ventilated and defective hot water heater, which was located across a hallway from the bedroom where the two babies died. CO saturation levels in the postmortem blood samples of the two babies were elevated and were similar (13% and 14%). Nicotine and cotinine were not detected in the blood sample of the two infants. Cherry-red livor mortis was absent. Acute CO intoxication was determined to be the underlying cause of these two unexpected deaths. These two cases underscore the need to integrate ambient air analysis and postmortem CO analysis as routine components of the comprehensive death investigation of infants who die suddenly and unexpectedly.

Surveillance of injury-related deaths: medicolegal autopsy rates and trends in Finland

Medicolegal autopsies are a vital tool for obtaining reliable injury mortality data. In Finland, medicolegal autopsies have increased from 13.6% of all deaths in 1970 to 23.8% in 2004. In fact, medicolegal autopsies are performed in 87.2% of all unintentional injury deaths, 98.3% of homicides and 99.5% of suicides. Finland has exceedingly high medicolegal autopsy rates compared with other countries. Autopsy rates should be appropriately considered when performing international comparisons of injury-related deaths.

Nicotine and cotinine in infants dying from sudden infant death syndrome

The aim of this component of the German Study on Sudden Infant Death was to determine (1) nicotine concentrations in hair (NCH), as a marker of long standing exposure to tobacco, (2) cotinine concentrations in pericardial fluid (CCP) and (3) cotinine concentrations in liquor cerebrospinalis (CCL), the latter measures being markers of recent exposure to tobacco in the last few hours of life. The results obtained were compared with data on parental smoking revealed from interviews. In 100 cases of sudden infant death syndrome, material was taken at autopsy to determine NCH. In 41 cases, NCH and CCP, and in 70 cases, NCH and CCL were determined. Infants of mothers who stated having smoked during pregnancy had higher NCH than infants of non-smoking mothers (p = 0.008). Furthermore, there was a weak but statistically significant relationship between NCH's and the daily cigarette consumption of the mother during pregnancy (n = 64, r = 0.24, p = 0.05). In 43% of infants, nicotine could be detected in their hair, although the mothers had said at the interview that they did not smoke during pregnancy. On the other hand, in 33% of infants whose mother stated they had smoked during pregnancy nicotine was not detectable in the infant's hair. CCP's were strongly correlated with CCL's (r = 0.62, p = 0.0027). For this reason, both parameters were treated as equivalent for the detection of tobacco smoke exposure in the last hours before death. The influence of breast-feeding was evaluated by comparison of the nicotine concentrations in breast fed and non-breast-fed infants from smokers and non-smokers. Fivefold higher nicotine concentrations were determined in non-breast-fed infants of parents who smoked as compared to all other groups. It can be concluded that nicotine intake by passive smoking is much more important than by breast-feeding. We conclude that both interview data and biochemical measures should be sought to understand the true exposure to tobacco smoke.

Risk factors, diagnosis and prevention of sudden unexpected infant death

The diagnosis of the cause of sudden unexpected infant death (SUID) is often difficult work for forensic pathologists. Its misdiagnosis or misclassification is the cause of crucial epidemiological and medicolegal problems. During the sudden infant death syndrome (SIDS) epidemic, many reports described the risk factors of SIDS as well as mechanical suffocation during sleep. Meadow's report has invited worldwide debate over whether the cause of SUID is attributable to SIDS or suffocation. On the basis of this background, the problems concerning causal diagnosis and risk factors, particularly the accidental suffocation of infants during sleep, and the specific pattern of suffocation, was reviewed from the forensic pathological viewpoint. The following tasks remain to be done for the future: (1) to avoid preventable SUIDs, the most effective measure worldwide is to identify high-risk factors for all SUIDs, including SIDS, accidental suffocation and undetermined causes, and then transmit this information to the public. (2) SIDS should be uniformly defined and diagnosed as strictly as possible to gain its reliability in the public health community and in a legal framework.

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.

Sudden infant death syndrome (SIDS)--standardised investigations and classification: recommendations

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

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.

The San Diego definition of SIDS: practical application and comparison with the GeSID classification

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