Sudden infant death syndrome, sudden unexpected infant death, and apparent life-threatening events

Unexplained and Unexpected Pediatric Deaths: Forensic Review and New Perspectives

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.

Verbal Autopsies for Out-of-Hospital Infant Deaths in Zambia

OBJECTIVES

In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called "brought in dead" infants.

METHODS

We analyzed free-text narratives from verbal autopsies, in which families narrate the final series of events leading to each infant's death. Using the 3-delays model framework and working iteratively to achieve consensus, we coded each narrative using NVivo software to identify, characterize, and quantify the contribution of delays and other factors to the fatal outcome.

RESULTS

Verbal autopsies were collected from 230 families of brought in dead infants younger than 6 months of age. As many as 82.8% of infants had 1 or more delays in care. The most-common delay was in the family's decision to seek care (54.8%), even as severe symptoms were frequently described. Similarly, 27.8% of infants died en route to a health care facility. Delays in receiving adequate care, including infants dying while waiting in line at a clinic or during referral from a clinic to a hospital, occurred in 24.7% of infants. A third of infants had been previously evaluated by a clinician in the days before their death.

CONCLUSIONS

Delays in care were the rule rather than the exception in this population of Zambian infants. Accessing care requires families to navigate significant logistic barriers, and balance complex forces in deciding to seek care. Strategies to avoid such delays could save many infants lives.

The effects of bed sharing on sleep: From partners to pets

BACKGROUND

Bed sharing is common practice across the global population. However, the vast majority of research on bed sharing has focused solely on mother-infant bed sharing.

METHODS

Here, we provide a holistic review of research on bed sharing. Articles investigating the relationship between bed sharing and sleep were identified in 4 dyad categories: (1) parent and child, (2) couples, (3) siblings, and (4) pet owners and pets. Of interest was whether sleep-promoting factors such as psychological comfort were generalizable across bed-sharing dyads; alternatively, sleep-demoting factors such as movement or heat may be commonalities.

RESULTS

We found that, across dyad types, in general, subjective reports of sleep quality were better when bed sharing despite generally worse objective measures of sleep.

CONCLUSIONS

Understanding bed sharing is important to treating sleep disturbances, given the prevalence of shared beds. This scoping review points to critical gaps in our understanding of bed sharing that motivate future research.

The problem of determination of cause of laboratory animal's death: a critical review of definitions of "fatal" and "incidental" lesions

The determination of the cause of a laboratory animal's death in gerontological experiments has become extraordinarily urgent in connection with the appearance of ideas on the programmed death of organisms. Unfortunately, the past approach to diagnosis of fatal and incidental changes based only on data of autopsy and histopathology (according to the human pathology model) is not correct for laboratory rodents. Nevertheless, the exact determination of death causes is principally possible in the future under conditions of adequate experimental design (including a large set of clinical, physiological, biochemical, and morphological examinations). However, it seems that even in this case causes of some experimental animal's death will remain unclear.

[Apparent life-threatening events and sudden unexpected death in infancy: Two different entities]

Most infant apparent life-threatening events (ALTEs) are minor with spontaneously favorable prognosis. Frequent etiologies are gastroesophageal reflux, obstructive apneas, respiratory infections, and breath-holding spells. Some rare but potentially serious causes must be discussed. Diagnosis is usually guided by careful questioning of the parents and repeated clinical examinations. A few complementary examinations are systematically needed and their performance is increased if they are oriented by clinical aspects. Hospitalization is usual for monitoring, further etiological investigation, and management of parental anxiety. ALTE and sudden unexpected death in infancy (SUDI) etiologies are often different. SUDI is called sudden unexplained death in infancy if it remains unexplained after investigation including autopsy. The annual incidence in France fell sharply after prevention campaigns in the 1990s, and now is about 400 SUDI, including 250 unexplained SUDI. The main guidelines of prevention are back sleeping, cessation of smoking during and after pregnancy, securing the bed and bedding, prevention of hyperthermia, and avoidance of dangerous factors of bed sharing. In the future, infants with particular vulnerabilities may be identified. The Haute Autorité de santé (French National Authority for Health) has published guidelines to support SUDI, standardize procedures, and improve our understanding of the causes of death.

Metabolic disease in 10 patients with sudden unexpected death in infancy or acute life-threatening events

In order to determine the associations between sudden unexpected death in infancy (SUDI) or acute life-threatening events (ALTE) and inborn errors of metabolism, particularly organic acidemia and fatty acid oxidation disorders, we evaluated clinical features in patients with SUDI or ALTE. The subjects were infants between the ages of 7 days and 3 years who developed SUDI or ALTE between January 2004 and December 2013. They were then diagnosed as having inborn errors of metabolism on gas chromatography-mass spectrometry (GC/MS) and/or tandem mass spectrometry (MS/MS). The age distribution, onset forms, and clinical findings were evaluated during the acute phase. Inborn errors of metabolism were detected in three of 196 patients with SUDI, and in seven of 167 patients with ALTE. Of these 10 patients, nine had a history of poor feeding and somnolence during the neonatal period, and symptoms of infection such as cough, fever or vomiting during infancy. Routine laboratory tests during an acute phase indicated hyperammonemia, liver dysfunction, increased blood creatine kinase, acidosis, positive ketone bodies in urine or blood, or hypoglycemia. When SUDI or ALTE are encountered in the emergency unit, it is essential that a detailed medical history is taken, particularly with regard to the neonatal period, and that specific abnormalities are investigated on routine laboratory tests. Moreover, samples such as urine, serum, and filter paper blood specimens should be collected for GC/MS and/or MS/MS of organic acids and acylcarnitines, to identify inborn metabolic disorders.

Sudden cardiac death in the young: the bogeyman

Sudden cardiac death in the young is a relatively uncommon but marked event usually related to congenital diseases or anomalies. Despite the prevalence of each condition being variable, most common causes include primary myocardial diseases and arrhythmic disorder, frequently with inheritance pattern. Sudden cardiac death is usually preceded by symptoms, thus making personal and family history fundamental for its prevention. Nevertheless, in more than 50% of cases, sudden cardiac death is the first manifestation of the disease. In this review, we describe the different causes of sudden cardiac death, their incidence, and currently used preventive strategies.

[Genetics of sudden unexplained death]

Sudden unexplained death is defined by death without a conclusive diagnosis after autopsy and it is responsible for a large percentage of sudden deaths. The progressive interaction between genetics and forensics in post-mortem studies has identified inheritable alterations responsible for pathologies associated with arrhythmic sudden death. The genetic diagnosis of the deceased enables the undertaking of preventive measures in family members, many of them asymptomatic but at risk. The implications of this multidisciplinary translational medical approach are complex, requiring the dedication of a specialized team.