Heatstroke in well-wrapped infants

Fatal pediatric hyperthermia: A forensic review

This paper examines a pediatric hyperthermia homicide in which the decedent was placed into a room with only a diaper on and left unattended overnight. There were no furnishings in the room except for a 1500-W space heater and a stroller. The following morning, emergency personnel were summoned to the residence. A caretaker said the decedent playing normally 5 min before making the 911 call. The decedent's initial rectal temperature was 42.2°C. Law enforcement asked how long the child had to be exposed to a high temperature in order to induce fatal hyperthermia in an empty bedroom. The scene was reconstructed using the child's residence and the same heater. Environmental data were gathered over a 16-h period. The thermal parameters of the room and environment were analyzed using a lumped-element thermal model. These parameters were then fed into an adapted Gagge's two-node model of human thermal regulation, which provided a time-window of exposure necessary to elicit hyperthermia, which in this case, depending on certain variables, ranged from 45 min to 4 h.

Sudden twin infant death on the same day: a case report and review of the literature

Sudden infant death syndrome (SIDS) is a major contributor to infant mortality. The cause of death is unknown: suggested possibilities include cardiovascular disease, anaphylactic shock, and suffocation. The occurrence of simultaneous sudden infant death syndrome is uncommon, such cases being extremely rare in forensic pathologic practice. We report two 10-week-old male twins who appeared well at the time of their evening feeding, yet died while sleeping on their backs. Both infants had petechial hemorrhages on the visceral pleura, epicardial surface of the heart, and thymus gland. Microscopic examination revealed pulmonary edema, intra-alveolar hemorrhage, and minor lymphocytic infiltration, again in both infants. In this report, we discuss the risk factors for SIDS, which should be considered individually or in combination as possible causes of death.

Sudden Infant Death Syndrome

During the last decade, much attention has been paid to the risk factors of sudden infant death syndrome (SIDS). Many researchers have demonstrated that infant-care practices are linked to the risk of SIDS. Prone sleeping, bed sharing, maternal substance abuse, and cigarette smoking have been reported to be significant potentially modifiable risk factors for SIDS. Despite the reports that the incidence of SIDS has decreased by 38% in the United States, it remains the leading cause of death in the first year of life. Deaths resulting from child abuse or neglect inflicted or permitted by their caretakers being second only to SIDS in infant mortalities and some recommendations regarding the differentiation of SIDS and child abuse have generated speculation that some cases of infanticide were misdiagnosed as SIDS. To reach a proper conclusion as to the cause and manner of death of an infant who died suddenly and unexpectedly, investigation must be thorough and professional.

Transient bacteraemia: A possible cause of sudden life threatening events

The concept proposed is that transient bacteraemia occurring in otherwise healthy individuals can cause acute life threatening events due to bacterial toxaemia even though the bacteraemia is rapidly cleared (<20 min). This is most likely to occur in infancy at around two to three months of age when anti-toxin IgG reaches its nadir. Sudden unexpected death in infancy, acute life threatening events, haemorrhagic shock and encephalopathy, and the triad of retinal haemorrhage, encephalopathy and bilateral thin film subdural haematomata are conditions which could be caused by this mechanism. Investigations need to be directed to measuring bacterial toxins in blood, CSF and urine; anti-toxin IgG in blood; and bacterial specific nucleic acid sequences in blood, CSF and urine using polymerase chain reaction in order to confirm recent bacteraemia. Furthermore the upper respiratory tract bacterial flora should be mapped in cases and appropriately matched live healthy community controls. Sudden onset, profound life threatening physiological dysfunction occurring in later life could also be caused by a similar mechanism and should be investigated in a similar way; candidate conditions include epilepsy, migraine, stroke and cardiac arrhythmias.

Characteristics of hyperthermia and its complications in patients with Prader Willi syndrome

BACKGROUND

Thermoregulation problems, resulting in hypo- or hyperthermia, have been infrequently reported in children with Prader Willi syndrome (PWS), yet their clinical details remained unknown.

METHODS

The clinical characteristics of three infants with PWS are reported.

RESULTS

Etiologies of high fever could not be identified in three children with PWS. One of these children was also admitted to the intensive care unit with extremely high body temperature in a life-threatening condition, similar to septic shock, without a plausible explanation.

CONCLUSION

Hyperthermia may be a part of the clinical spectrum in young infants with PWS and should be carefully monitored, since it may cause life-threatening complications.

Heat stroke in an incubator: an immunohistochemical study in a fatal case

The authors report the unique case of an 8-day-old infant succumbing to heat stroke caused by an abnormal increase of the environmental temperature in an incubator. At postmortem examination, second-degree burns were detected, and macroscopic and microscopic findings were typical for a heat-related death. An immunohistochemical study was performed. At the same time, a detailed examination of the incubator was conducted, revealing a malfunctioning of the temperature and relative humidity control system. We suggest that the diagnosis of heat stroke has to be confirmed on the basis of a detailed postmortem examination and a complete immunohistochemical investigation of heat shock proteins, molecules produced acutely in response to heat stress.

Heat stroke in familial dysautonomia

A 14-month-old female with familial dysautonomia was referred to the pediatric department with high fever (41.6 degrees C), watery diarrhea, and vomiting. A few hours later, signs of encephalopathy appeared. Laboratory tests revealed elevated levels of lactate dehydrogenase (3500 U/L), aspartate aminotransferase (640 U/L), alanine aminotransferase (320 U/L), and creatine kinase (28,420 U/L). The diagnosis was heat stroke. Impaired autonomic nervous system function may be another risk factor for the development of heat stroke in young children.

Environmental hyperthermic infant and early childhood death: circumstances, pathologic changes, and manner of death

Infant and early childhood death caused by environmental hyperthermia (fatal heat stroke) is a rare event, typically occurring in vehicles or beds. The aims of this study were to describe the demographics, circumstances, pathology, and manner of death in infants and young children who died of environmental hyperthermia and to compare these cases with those reported in the literature. Scene investigation, autopsy reports, and the microscopic slides of cases from three jurisdictions were reviewed. The subjects in 10 identified cases ranged in age from 53 days to 9 years. Eight were discovered in vehicles and 2 in beds. When the authors' cases were grouped with reported cases, the profile of those in vehicles differed from those in beds. The former were older, were exposed to rapidly reached higher temperatures, and often had more severe skin damage. The latter were mostly infants and were exposed to lower environmental temperatures. Hepatocellular necrosis and disseminated intravascular coagulation were reported in victims who survived at least 6 hours after the hyperthermic exposure. The consistent postmortem finding among nearly all victims was intrathoracic petechiae, suggesting terminal gasping in an attempt at autoresuscitation before death. The manner of death was either accident or homicide. Recommendations for the scene investigation are made.

Intestinal epithelial damage in sids babies and its similarity to that caused by bacterial toxins in the rabbit

Sections of the duodenum, jejunum, ileum, caecum and large intestine from 14 sudden infant death syndrome (SIDS) babies were examined by scanning (SEM) and transmission electron microscopy (TEM). The type and amount of damage was characterised and quantitated and compared with the presence of Clostridium perfringens, Clostridium difficile, Escherichia coli and Staphylococcus aureus in faecal samples from the babies and toxins from the bacteria in faecal samples and serum from the babies. The data were compared with the damage that these toxins cause to the rabbit intestinal epithelium (see the previous paper in this issue). Damage was present in most of the SIDS samples, varying from 0 to 96%, and most damage occurred when the faecal samples contained the above bacteria and their toxins. Damage varied from removal of microvilli, damage to villus tips, separation of and removal of epithelial cells from the lamina propria, and removal of enterocytes leaving goblet and tuft cells, to damage and breakdown of the lamina propria. The results support the hypothesis that the cause of death in a significant proportion of SIDS babies may result from the absorption of toxins from the intestinal tract initiating a toxic shock reaction.

Increased facial temperature as an early warning in Sudden Infant Death Syndrome

The promotion of supine sleeping position in young infants has resulted in significant declines in the incidence of Sudden Infant Death Syndrome although little is understood in terms of mechanisms. We hypothesize that supine sleeping position promotes appropriate thermal regulation via the face and head which is the major source of infant heat loss. By facilitating temperature regulation, the supine position ensures that the centre for thermoregulation in the hypothalamus does not become dysfunctional due to local temperature fluctuations. Because these hypothalamic, thermoregulatory neurones are synaptically linked to those regulating respiration in the medulla, adequate temperature control by the infant maintains normal respiration. In contrast, an increase in face and head temperature over and above core temperature would suggest thermoregulatory stress and an increased likelihood of respiratory apnoea.

Simultaneous sudden infant death syndrome: a proposed definition and worldwide review of cases

Epidemiologic studies of sudden infant death syndrome (SIDS), the leading cause of death of infants during the postperinatal period (7-365 days), have mainly focused on the deaths of single infants. Simultaneous sudden infant death syndrome (SSIDS), the death of a pair of twins occurring at the same time, has received limited attention within the medical community. To the authors' knowledge, this article is the first to describe the 41 SSIDS cases cited in the world literature from 1900 to 1998 by the location of death, a summary of the circumstances surrounding the deaths, and evaluation of these cases in terms of a proposed definition of SSIDS. This evaluation critiques whether the 41 pairs of SSIDS cases adhere to a newly proposed definition of SSIDS. Twin infant deaths must meet all three criteria to be considered SSIDS. The study found that only 12 pairs of twins met all three criteria (29.2%), nine pairs met two criteria (21.9%), alternative cause of death was offered in five pairs of twins (12.1%) and in the remaining 15 pairs (36.6%), only limited information was available; therefore, no conclusions could be reached.

CLINICAL REVIEW ARTICLE: Is changing the sleep environment enough? Current recommendations for SIDS

Sudden infant death syndrome (SIDS or cot death) was the major cause of post-neonatal infant death in many countries in the late 1970s and 1980s. There is now very strong evidence that public intervention campaigns targeting the prone sleeping position, which had been identified by epidemiological studies as a major risk factor, were followed by substantial falls in the rate of SIDS. In the present review we discuss the evidence on which current recommendations for the prevention of SIDS are based. The prone sleeping position is now clearly causally associated with SIDS. Further reductions in SIDS may be produced by recommending the back sleeping position as opposed to the side position. Maternal smoking in pregnancy and bed sharing by infants of mothers who smoke are also strongly associated with SIDS, but have been harder to influence. Paternal smoking has also been implicated, although the magnitude of the reported risk is small. Finally, breastfeeding, pacifier use and having the infant sharing the parents bedroom, but not the bed, may also reduce risk. Continued reductions in SIDS mortality will require innovative public health education to target these major risk factors, while building on the "back to sleep" approach.

Hemorrhagic shock and encephalopathy syndrome: neurologic features

Hemorrhagic shock and encephalopathy syndrome (HSES) is a severe disease that affects previously healthy infants of less than 1 year of age and is associated with significant mortality and neurologic morbidity. It is characterized by sudden onset of shock, convulsions and coma, bleeding due to severe coagulopathy, fever, diarrhea, metabolic acidosis, and hepatorenal dysfunction. Central nervous system involvement with recurrent seizures and brain edema is the most common cause of high mortality and neurological morbidity. In this report, we describe four patients of HSES and review the initial and follow-up neurological features, electroencephalography findings, and the results of neuroradiological examinations of this catastrophic illness.

Influence of core temperature on autoresuscitation during repeated exposure to hypoxia in normal rat pups

Failure to autoresuscitate by hypoxic gasping during prolonged sleep apnea has been suggested to play a role in sudden infant death. Furthermore, thermal stress brought about by a contribution of infection, overwrapping, or excessive environmental heating has been shown to be associated with an increased risk of sudden infant death, particularly in prone sleeping infants. The present experiments were carried out on newborn rat pups to investigate the influence of "forced" changes in core temperature on their time to last gasp during a single hypoxic exposure and on their ability to autoresuscitate during repeated exposure to hypoxia. On day 5 or 6 postpartum the pups were placed in a temperature-controlled chamber regulated to 33, 35, 37, 39, or 41 degrees C and exposed to a single period of hypoxia (97% N(2)-3% CO(2)) and their time to last gasp was determined, or they were exposed repeatedly to hypoxia and their ability to autoresuscitate from primary apnea was determined. Increases in core temperature brought about by changes in ambient temperature from 33 to 41 degrees C decreased the time to last gasp after a single hypoxic exposure and decreased the number of successful autoresuscitations after repeated hypoxic exposures. Thus our data support the hypothesis that forced changes in core temperature brought about by changes in ambient temperature influence protective responses in newborns that may prevent death during hypoxia, as may occur during single or repeated episodes of prolonged sleep apnea.

Heat strokes: aetiopathogenesis, neurological characteristics, treatment and outcome

Heat stroke is a thermal insult to the cerebral thermoregulatory system controlling heat production and heat dissipation. The thermal insult may be environmental as in 'classic heat stroke' or endogenous as in 'exertional heat stroke' in joggers or runners. The insult will lead to a steady rise in body core temperature to 40 degrees C or more, exhaustion of sweating with hot dry skin and central nervous system disturbances ranging from confusion to deep coma. Multisystem insult will follow leading to a fatal outcome, if not diagnosed and treated promptly. Rapid evaporative cooling and support of vital organs are the essential factors in the management of this condition. If treated early, no sequelae results, however, pancerebellar syndrome and spastic or flaccid paraparesis have been described in a few cases. Limited sun exposure, proper use of sunscreens, adequate fluid and electrolyte replacement and acclimatization are the key factors for prevention. Despite appropriate prevention and prompt treatment, heat stroke is unlikely to be totally prevented, but the mortality has improved dramatically to less than 10%.

Hemorrhagic shock and encephalopathy syndrome. An unusual cause of sudden death in children

Hemorrhagic shock and encephalopathy syndrome (HSES) is a sudden-onset symptom complex occurring in previously healthy infants and children. It was first described in 1983 in the United Kingdom in 10 infants. Subsequently, > 140 cases have been reported worldwide, although no cases have been previously reported in the forensic literature. Typically the child presents with fever, shock, encephalopathy with coma and seizures, evidence of hemorrhage, and diarrhea. Laboratory investigation reveals falling hemoglobin and platelet counts, renal impairment, evidence of disseminated intravascular coagulation, metabolic acidosis, and raised serum transaminases. Microbiological cultures are uniformly negative. The condition has a high mortality and morbidity. The etiology is unknown and may be multifactorial. However, hyperpyrexia appears to play a central role in pathogenesis. The diagnosis of HSES in the deceased child is one of exclusion and requires a careful antemortem history as well as a thorough autopsy with toxicological and microbiological investigations. A case of HSES is reported and the literature reviewed.

Overheating alone can trigger malignant hyperthermia in piglets

Seven out of eight piglets which were susceptible to malignant hyperthermia (MHS) died when subjected to a heat challenge which was well tolerated by controls. The piglets which succumbed developed the classical clinical and biochemical changes of malignant hyperthermia before they died. These results show that overheating alone can trigger malignant hyperthermia in susceptible animals. Because the biochemical basis of malignant hyperthermia is similar in both humans and pigs, these observations suggest that overheating can also trigger malignant hyperthermia in humans. The susceptibility to overheating in malignant hyperthermia susceptible humans and animals probably explains why the myopathy which predisposes to this condition has also been reported to predispose to heat-stroke and the sudden infant death syndrome. In view of this, particular care to prevent overheating should be taken in infants of parents who are susceptible to malignant hyperthermia.

Pathophysiology of overheating in a piglet model: findings compared with sudden infant death syndrome

OBJECTIVE

To examine the nature of hyperthermia-induced pathophysiological changes in an animal model including effects on lung compliance.

METHODOLOGY

Piglets were randomly assigned to heated or non-heated groups. Heated animals were warmed to 4 degrees C above normal body temperature while sedated and breathing spontaneously. Cardiorespiratory variables were recorded serially and haematological assessments and blood cultures taken at 0 and 6 h. After 6 h the animals were killed and a limited postmortem was performed. Control animals had all procedures without heating.

RESULTS

Heated piglets developed tachycardia, hypotension and a metabolic acidosis in addition to tachypnoea, hypocapnic alkalosis and a neutrophil leucocytosis. Rectal temperature after death fell at the same rate in both groups. Lung histology revealed an excess of lung haemorrhage and alveolar oedema in the heated group. No significant group differences in dynamic lung compliance were demonstrated.

CONCLUSIONS

The pathological changes that occur during hyperthermia are non-specific but not incompatible with those found in sudden infant death syndrome. There was no confirmation of the thesis that hyperthermia causes death by altering lung compliance.

Syndromes with renal failure and shock

Renal failure occurs commonly in children with shock, coagulopathy and multi-organ failure. Successful management of these patients requires not only management of the renal failure, but recognition and treatment of the underlying process. In addition to common and well-recognised causes of renal failure and shock, such as Gram-negative sepsis, there are a number of syndromes which are either less well recognised or confined to specific geographic locations. This article reviews the clinical and epidemiological features of the syndromes with shock and renal failure, focusing on the more recently recognised syndromes such as staphylococcal and streptococcal toxic shock syndrome, haemorrhagic shock and encephalopathy syndrome and viral haemorrhagic fevers.

The reaction of an early latency boy to the sudden death of his baby brother

Surprisingly little has been written on the impact of the death of a baby on an older sibling. This paper describes how a narcissistically vulnerable latency boy grappled, in the course of his psychotherapy, with the painful loss of his baby brother. Emotional and cognitive aspects of his early confrontation with the reality of death are considered. The patient's six theories about the cot death are described. Attention is drawn to the value of the sibling relationship and to the narcissistic needs which this relationship fulfilled. The termination phase is discussed in the light of the dynamics of sudden loss. The safe therapeutic context provided the space in which this young, rather muddled latency boy could grieve and mourn this traumatic loss.

Haemorrhagic shock encephalopathy syndrome in the British Isles

The aetiopathogenesis of haemorrhagic shock encephalopathy syndrome (HSES) remains unclear and after concern that a novel environmental agent was the cause, the British Paediatric Association and the Public Health Laboratory Service Communicable Disease Surveillance Centre in 1983 initiated surveillance of this condition in the British Isles. After 1986 cases were ascertained via the British Paediatric Surveillance Unit 'active' reporting scheme; this report presents the findings for 1985-8. Sixty five patients were reported, of whom 52 satisfied the criteria for inclusion. Of those whose outcome was known, 24 (46%) died, 18 had severe neurological damage, and six survived apparently intact. Epidemiological features of note were: the median age of 15 weeks (range 3-140); statistically significant clustering of admission times suggesting a peak onset period at night; lack of geographic clusters, of secular trends and, except for a slight excess in winter months, of seasonality. Clinical and pathological features followed a highly consistent pattern, suggesting that HSES is an individual clinical entity distinguishable from conditions with similar presentations, such as septicaemia and Reye's syndrome. There was no microbiological or epidemiological evidence to support the emergence of a novel environmental agent. Many of the features of HSES were, however, the same as those described in heat stroke and we suggest that the two conditions are the same even though there is usually no history of overt overheating.

Bacterial toxins: a possible cause of cot death

AIM

To test the hypothesis that sudden infant death syndrome (SIDS) may be caused by toxins of commonly occurring bacteria in infants lacking developed immunity.

METHODS

Nasopharyngeal microbial isolates from 22 pairs of SIDS cases and healthy infants matched for age (by month), sex, and sampling time (by month) were compared for lethal toxigenicity. Crude toxin preparations were made from isolates cultured on dialysis membrane overlaid on agar, and these preparations were then tested for lethality by intravenous injection into 11 day old chick embryos.

RESULTS

Fifteen (68%) of the SIDS cases were each found to have at least one lethally toxigenic organism in their nasopharyngeal flora; only eight (36%) of the flora of normal infants included a lethally toxigenic species.

CONCLUSION

Infants who have died of SIDS have a significantly higher (p less than 0.05) probability than matched healthy infants of having a lethally toxigenic bacterial species in their nasopharyngeal flora.

Hemorrhagic shock and encephalopathy syndrome

Hemorrhagic shock and encephalopathy syndrome (HSES) is a devastating symptom complex that affects previously healthy infants and is associated with significant mortality and neurologic morbidity. The syndrome was first reported less than ten years ago, and there continues to be debate regarding whether HSES actually represents a distinct clinical entity or instead is a manifestation of heat illness, occult sepsis or endotoxic shock, or perhaps toxic ingestion. Nevertheless, the signs and symptoms described as HSES present in a typical fashion in the emergency department with sudden onset of shock, encephalopathy, seizures, and coagulopathy. Even with the initiation of intensive support in the ED, the outcome is probably dismal. We describe a case of HSES and review the presentation, proposed etiologies, and management of this catastrophic illness.

How mothers keep their babies warm

Details of room temperature, clothing, and bedding used by night and by day and in winter and in summer were recorded for 649 babies aged 8 to 26 weeks. Room temperature at night was significantly related to outside temperature and duration of heating. Total insulation was significantly related to outside temperature and to minimum room temperature, but there was wide variation in insulation at the same room temperature. High levels of insulation for a given room temperature were found particularly at night and in winter, and were associated with the use of thick or doubled duvets and with swaddling. At least half the babies threw off some or all of their bedding at night, and at least a quarter sweated. Younger mothers and mothers in the lower social groups put more bedclothes over their babies, and the latter also kept their rooms warmer. Many mothers kept their babies warmer during infections.

Sudden infant deaths and cold weather: was the rise in infant mortality in 1986 in England and Wales due to the weather?

Using the daily number of deaths due to sudden infant death syndrome in England and Wales from 1979 to 1985, and the daily temperature recorded at the London Weather Centre, two models were constructed, one including a temperature term and one without it, and the models used to predict the mortality in 1986. It was found that the model using temperature had a slightly better predictive power and successfully accounted for the increased mortality in February 1986. Thus, we conclude that the excess mortality of February 1986 was associated with the unusually cold weather during that month.

C-reactive protein and prealbumin in suspected sudden infant death syndrome

This study investigated the levels of C-reactive protein (CRP) and prealbumin in 87 infants suspected of dying from sudden infant death syndrome (SIDS). These proteins change rapidly, within 24 hr, in patients who have an acute phase response, especially a response resulting from bacterial infection. In addition, prealbumin is sensitive to a recent reduction of protein or calorie intake. Eighty patients were determined to have typical SIDS. Only four of these had a minimal increase in CRP (0.8-2 mg/dl), and in none could an explanation be found. Seven patients were uncovered who had a significant infection, four of whom had prominent CRP elevations. Prealbumin was not decreased in the SIDS population. We conclude that there is no evidence that the acute inflammatory response is activated in infants dying of SIDS. An elevation of CRP above 2 mg/dl should prompt additional studies to find the cause. There is also no evidence of a recent, significant decrease in nutrition in these patients.

Preventing the sudden infant death syndrome

Current efforts in the US to prevent the sudden infant death syndrome (SIDS) are largely based on pneumocardiogram screening and home apnoea monitoring. This technology does not prevent most SIDS deaths because the screening procedures lack the sensitivity and specificity needed to identify most high risk infants. In the UK the largest efforts to prevent SIDS have been based on infant health surveillance. These efforts appear to have been ineffective and along with the US failures highlight the need for new strategies to prevent SIDS. One strategy might be to develop methods to avoid known risk factors for SIDS. Prominent among these risk factors are cigarette smoking and the use of psychotropic drugs during pregnancy, overheating and infections in infants. Possible approaches to avoid these and other risks are described in the present paper.

Child care practices and the sudden infant death syndrome

Southern New Zealand has one of the highest reported rates of the sudden infant death syndrome (SIDS) in the world. Data were collected on 49 infants who died from SIDS in the Dunedin and Invercargill Health Districts of southern New Zealand. Forty-two of the families were interviewed at home following the loss of their infant. In the week prior to death, 17 infants (40%) had an upper respiratory tract infection, although in 11 of these infants their infection had apparently resolved at least 24 h prior to death. Thirty infants (71%) had their faces down into the bedding or their heads covered with bedding. Thirty-four infants (81%) were found dead in the prone position, whereas 49% of New Zealand infants aged 3 months would be expected to sleep prone. Sleep position and the terminal position of the head in relation to SIDS requires further study.

Haemorrhagic shock encephalopathy

Three children suffered from acute onset of convulsions and progressive coma associated with hyperpyrexia, profound shock and generalized bleeding tendency. No causative agent could be identified. Despite aggressive resuscitation they all died. Post-mortem examination revealed cerebral oedema, petechial haemorrhages of the gut, lungs and kidneys, and a generalized depletion of lymphocytes in the lymphoid organs. Features were compatible with haemorrhagic shock encephalopathy, which is a highly fatal disease. The possible role of hyperpyrexia in its pathophysiology is discussed. More careful case identification and research in various possible aetiological factors may help elucidate its pathogenesis.

Extreme hyperpyrexia in childhood. Presentation similar to hemorrhagic shock and encephalopathy

The authors report the cases of five previously well children, aged 8 to 33 months, who were seen over a 14-year period, with admission temperatures in excess of 42.0 degrees C (107.6 degrees F). Four of the patients died. Each child had a similar clinical illness in which the hyperpyrexia played a critical role. Negative blood, cerebrospinal fluid, and stool cultures excluded bacterial sepsis as a possible etiology. This illness is similar, if not identical, to the newly described syndrome of hemorrhagic shock and encephalopathy (HSES) reported in European and American infants.

Hemorrhagic shock and encephalopathy: clinical, pathologic, and biochemical features

To further define the clinical, pathologic, and biochemical features of hemorrhagic shock and encephalopathy syndrome, we studied 25 affected children (aged 3 months to 14 years) admitted to a single center between 1982 and 1985. A prodromal illness comprising vomiting, diarrhea, listlessness, and fever was present in 84% of the cases. Acute onset of shock, convulsions and coma, bleeding (or laboratory evidence of disseminated intravascular coagulation), elevated plasma activity of hepatic enzymes, acidosis, and impaired renal function was present in every case. Twenty patients died, and all the survivors are neurologically damaged. At postmortem examination, intravascular microthrombi coexisting with hemorrhages and petechiae were found in most organs. Centrilobular liver necrosis and cerebral edema were prominent features. No microbiologic cause for the disorder was identified, but decreased plasma levels of the protease inhibitors alpha 1-antitrypsin and alpha 2-macroglobulin, together with increased levels of circulating proteolytic enzymes, were frequently present. An overrepresentation of the uncommon variant phenotypes of alpha 1-antitrypsin was found in first-degree relatives of affected patients (four had the MZ phenotype, and one each the MS or MC phenotype, of 19 relatives studied). Abnormal accumulation of alpha 1-antitrypsin was detected immunohistochemically in the livers of six of the patients. Defective protease inhibitor production or release may be involved in the pathogenesis of the disorder.

Sleeping position and infant bedding may predispose to hyperthermia and the sudden infant death syndrome

Southern New Zealnd has one of the highest postneonatal mortality rates in the developed world (8.1/1000 livebirths) and 77% of these deaths are attributed to the sudden infant death syndrome (SIDS). Both hyperthermia and sleeping position have previously been implicated in SIDS. A theoretical model to estimate the thermal balance of infants used here shows that the head, and particularly the face, becomes the main route for heat loss when thick clothing and bedding are used. This thermoregulatory role could be compromised by the prone sleeping position. It is postulated that particular cultural combinations of infant care practices (sleeping position, clothing, bedding, and room heating) may facilitate hyperthermia and explain widely disparate rates of SIDS in different countries and ethnic groups.

Haemorrhagic shock-encephalopathy syndrome: plasmapheresis as a therapeutic approach

We present the case of a 4.5-week-old boy with acute encephalopathy, shock, intestinal bleeding and disseminated intravascular coagulation. The clinical course and typical laboratory parameters were compatible with a diagnosis of haemorrhagic shock-encephalopathy syndrome (HSE). Immediate shock treatment, repeated haemodialysis and plasmapheresis did not prevent a fatal outcome 4 days after the onset of clinical symptoms.

Death-scene investigation in sudden infant death

We conducted death-scene investigations in 26 consecutive cases in which a presumptive diagnosis of sudden infant death syndrome (SIDS) was made and the infants were brought to the emergency room of the Kings County Hospital Center between October 1983 and January 1985. In six cases, we observed strong circumstantial evidence of accidental death. In 18 other cases, we discovered various possible causes of death other than SIDS, including accidental asphyxiation by an object in the crib or bassinet, smothering by overlying while sharing a bed, hyperthermia, and shaken baby syndrome. This study suggests that many sudden deaths of infants have a definable cause that can be revealed by careful investigation of the death scene and that the extremely high rate of SIDS (4.2 per 1000 live births) reported in the population of low socioeconomic status served by Kings County Hospital Center should be questioned.

Dress and care of infants in health and illness

The mothers of 199 infants (mean age 36.7 days) were interviewed to determine how the infant was dressed and wrapped, and how the mother would deal with illness. These data were related to measures of the infant's toe and underarm temperatures and demographic information about the family. The data did not support the hypothesis that infants with particular types of clothing or bedding were at risk of overheating and shows that most mothers dress their infants appropriately. Mothers' ideas about management of illness were often inappropriate particularly in lower socioeducational groups.

Hemorrhagic shock and encephalopathy: further description of a new syndrome

Abrupt onset of coma, seizures, severe shock, and hyperpyrexia occurred in two previously healthy children. Their illnesses closely resembled a clinical syndrome of uncertain cause, the hemorrhagic shock and encephalopathy syndrome. Our patients had striking similarities to as well as certain differences from reported patients. Based on the similarities, we believe our two cases represent additional occurrences of the syndrome. Based on the differences, we conclude that the syndrome should be labeled "shock and encephalopathy syndrome" and that the prognosis may be improved by early aggressive treatment of shock.