Hazardous infant and early childhood sleeping environments and death scene examination

Infant death resulting from sharing a cot with a 10-year-old boy

An infant may die from unintentional suffocation if their exhausted, or inebriated or sedated mothers fall asleep while breast feeding or just sharing a bed and roll over on to them. The mother wakes up to find the baby dead in the morning. Diagnosis is complex due to minuscule autopsy findings and denial by parents about overlaying although it was accidental. Unusually, in this case, the baby was "over layed" by a young male child from the same family. The female baby was found listless next morning by her mother and died after three months of treatment. Death circumstances, non-sudden outcome, and unusual circumstances of overlaying the baby.

The National Association of Medical Examiners Position Paper on the Investigation and Certification of Pediatric Deaths From Environmental Neglect

ABSTRACT

Pediatric deaths that occur because of environmental neglect often involve 4 common scenarios: (1) hyperthermia due to environmental exposure, (2) ingestion of an accessible drug or poison, (3) unwitnessed/unsupervised drownings, and (4) unsafe sleep practices. Given the same fact pattern, the manner of death will vary from accident to homicide to undetermined based on local custom and/or the certifier's training and experience. Medical examiner/coroner death certifications are administrative public health determinations made for vital statistical purposes. Because the manner of death is an opinion, it is understandable that manner determinations may vary among practitioners. No prosecutor, judge, or jury is bound by the opinions expressed on the death certificate. This position paper does not dictate how these deaths should be certified. Rather, it describes the challenges of the investigations and manner determinations in these deaths. It provides specific criteria that may improve consistency of certification. Because pediatric deaths often are of public interest, this paper provides the medical examiner/coroner with a professional overview of such manner determination issues to assist various stakeholders in understanding these challenges and variations.

The role of pathologists in increasing knowledge of safe sleep practices for infants

Recent studies have evaluated parental knowledge of safe sleeping practices for their infants by using follow-up questionnaires at postnatal obstetric clinic visits. While many parents increase their knowledge of the key features of safe sleeping during antenatal visits, a significant number subsequently fail to adhere to guidelines. An additional way to assess parental understanding of safe and unsafe sleeping practices may be to incorporate information from pathological evaluations of infants who do not survive. Specifically, information from careful investigations of death scenes and meticulous autopsy examinations may be a useful way to complement clinical surveys so that the chances of assisting parents in future with their understanding of safe infant sleep practices will be maximised.

Infection and sudden lethal upper airway occlusion - An overview

A multitude of conditions may cause acute and unexpected upper airway compromise in both children and adults. These include mechanical blockage of the airways either from internal obstructions due to inhaled food or foreign objects, or from external compression. In addition, kinking of the airway in cases of positional asphyxia may compromise aeration. Infections represent another cause of airway narrowing with the potential for occlusion. The case of a 64-year-old man with acute laryngo-epiglottitis is used to demonstrate that death may occur from infections in previously structurally-normal airways. Infections may compromise respiration due to acute airway occlusion from intraluminal material/mucus, mural abscesses or from acutely inflamed and oedematous mucosa with adherent tenacious mucopurulent secretions. External compression from nearby abscesses may also critically narrow air passages.

Changing diagnostic patterns in cases of sudden and unexpected natural death in infants and young children: 1994-2018

AIM

To determine whether there has been a change in the incidence and type of conditions causing sudden and unexpected natural death in infants and young children in recent years.

METHODS

A search was undertaken of pathology records at Forensic Science SA in Adelaide, Australia for all cases of sudden and unexpected natural death in children aged less than 10 years at the time of death over two time periods: 1994-1998 and 2014-2018.

RESULTS

Overall, 136 cases were identified consisting of 81 boys and 55 girls (M:F = 16:11; age range 0-9 years). No difference was shown in the numbers of sudden unexplained deaths in infants and young children between the two time periods (80 vs. 56; p = 0.18). A trend was shown for a prominent decrease in SIDS cases (55 vs. 12) with an increase in undetermined cases, <1 year (5 vs. 18). However, when the two categories were combined there was no statistical difference between the two periods (60/80 vs. 30/56) (p = 0.26), although a decrease in numbers had occurred.

CONCLUSION

Analysis of numbers of fatalities reported from medicolegal institutes should be undertaken with an awareness of the potential effect of diagnostic shift.

Social and environmental risk factors for unintentional suffocation among infants in China: a descriptive analysis

Background

This retrospective study aimed to determine the epidemiological features of deaths caused by unintentional suffocation among infants in China.

Methods

The data used in this study were obtained from China’s Under 5 Child Mortality Surveillance System (U5CMSS) from October 1, 2015, to September 30, 2016. A total of 377 children under 1 year of age who died from unintentional suffocation were included in the survey. Primary caregivers were interviewed individually using the Unintentional Suffocation Mortality among Children under 5 Questionnaire. EpiData was used to establish the database, and the results were analysed using SPSS 22.0.

Results

Most (85.9%) unintentional infant suffocations occurred in rural areas, and 67.5% occurred in infants 0 to 3 months old. Among the primary caregivers of the infants, most (82.7%) had a junior middle school education or below, and 83.1% of them lacked unintentional suffocation first aid skills. Of the 377 unintentional suffocated-infant deaths, the causes of death were accidental suffocation and strangulation in bed (ASSB) (193, 51.2%), inhalation suffocation (154, 40.8%), other unintentional suffocation (6, 1.6%), and unknown (24, 6.4%). Among the infant deaths due to ASSB, overlaying (88.6%) was the most frequently reported circumstance. A total of 93.8% of cases reported occurred during co-sleeping/bed sharing with parents, and in 72.8% of the cases, the infants were covered with the same quilt as their parents. In our study, most inhalation suffocation deaths (88.3%) involved liquid food (such as breast milk and formula milk). A total of 80.5% of infant deaths reportedly occurred after eating; in 28.2% of those cases, the infants were held upright and patted by their caregivers, and 57.2% of them were laid down to sleep immediately after eating.

Conclusions

To reduce the occurrence of unintentional suffocation, local government should strengthen knowledge and awareness of unintentional suffocation prevention and safety among parents and caregivers. Additionally, health care providers should educate parents and caregivers about safety issues of unintentional suffocation, and relevant policies should be introduced to provide environments and activities that reduce the risk of suffocation, such as promoting the Safe to Sleep Campaign. It is important to enhance the focus on infant unintentional suffocation as a health issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02925-4.

Hanging and near hanging in children: injury patterns and a clinical approach to early management

Near hanging refers to survival following suspension by the neck. This is a devastating injury which can lead to mortality or serious long-term morbidity. Children and young people present to emergency departments following accidental or deliberate near hanging. This article describes the patterns of injury, the initial management and important prognostic factors.

Hinged Lids and Fatal Head Entrapment in Early Childhood

Young children are at risk of head entrapment because they often do not understand potentially dangerous situations or have the intellectual or physical capabilities to self-extricate. Two cases of head entrapment due to hinged lids are presented to demonstrate another rare lethal situation specific to the very young. Case 1 was a 14-month-old boy found suspended by his neck in a semikneeling position under a toilet seat. A horizontal linear bruise measuring 0.6 × 20 mm was present on the right side of the neck with petechial hemorrhages of the forehead. Death was due to neck compression from head entrapment with aspiration of gastric contents. Case 2 was a 17-month-old girl found suspended by her neck from the side of her crib by a hinged cover. A horizontal linear bruise measuring 10 × 50 mm was present immediately below the suprasternal notch with numerous petechial hemorrhages of the conjunctivae and face. Death was due to neck compression from head entrapment. Although these cases are very rare, they do show the potential danger that hinged lids may present to toddlers. Autopsy evaluations require comparisons of injuries with the structure and edges of the entrapping device/object.

Types of Objects in the Sleep Environment Associated With Infant Suffocation and Strangulation

OBJECTIVE

To investigate the circumstances of death and types and roles of objects present in the sleep environment at the time of death for infants who died from suffocation or strangulation during sleep.

METHODS

This study analyzed 1736 reported incidents of accidental suffocation and strangulation in bed (ASSB) of infants younger than 1 year of age. These fatalities occurred from 2000 through 2012 and were reported to the United States Consumer Product Safety Commission.

RESULTS

The mean age of ASSB death was 3.76 months (SD, 2.51). Infants younger than 5 months accounted for 67.3% (1168 of 1736) of all reported fatalities and 58.3% (1009 of 1731) were male. Deceased infants were often found in a crib or bassinet (30.6%; 383 of 1253) or in the prone orientation (84.9%; 595 of 701). The most common objects associated with infant ASSB were pillows (24.5%; 425 of 1736), mattresses (21.0%; 364 of 1736), blankets (13.1%; 228 of 1736), and walls (11.5%; 199 of 1736). Wedged (43.3%; 616 of 1424) or positioned on top of an object (25.9%; 369 of 1424) were the most common positions associated with death. Infants were often found wedged between a mattress and wall (30.2%; 181 of 599) or oriented face-down or prone on top of a pillow (52.2%; 187 of 358). Sleep surface sharing was associated with 6.5% (112 of 1736) of ASSB deaths.

CONCLUSIONS

Pillows and blankets are objects in sleep environments frequently associated with unintentional suffocation and strangulation of infants. Increased efforts should be made to remove these and other objects from sleep environments of infants.

An Approach to the Classification of Apparent Asphyxial Infant Deaths

Recent evidence indicates that with thorough, high quality death investigations and autopsies, forensic pathologists have recognized that many unexpected infant deaths are, in fact, asphyxial in nature. With this recognition has come a commensurate decrease in, and in some cases, abolition of, the label "sudden infant death syndrome" (SIDS). Current controversies often pertain to how and why some infant deaths are determined to be asphyxial in nature and whether or not apparent asphyxial circumstances are risk factors for SIDS, or rather, harbingers of asphyxial deaths. In an effort to sidestep these controversies, some forensic pathologists elected to instead use the noncommittal label "sudden unexpected infant death" (SUID), leading to the unfortunate consequence of SUID - like SIDS - gaining notoriety as an actual disease that could be diagnosed, studied, and ultimately cured. Although it is not possible to provide death certification guidance for every conceivable type of unexpected infant death, we recognize and propose a simple classification system for overarching themes that cover the vast majority of cases where infants die suddenly and unexpectedly.

Sleep-Related Infant Deaths in Victoria: A Retrospective Case Series Study

BACKGROUND

There is general agreement that in some circumstances, sharing a sleep surface of any kind with an infant increases the risk of sudden unexpected death in infancy. There is a paucity of research conducted in Australia examining this issue. This study examines the frequency and distribution of sleep-related infant deaths in a defined population, and reports the proportion that occurred in the context of bed-sharing.

METHODS

A retrospective population-based case series study was conducted of infants (≤365 days) who died in a sleeping context during the period 1 January 2008 to 31 December 2010 in the state of Victoria, Australia. Information about the infant, caregiver, sleeping environment and bed-sharing was collected from a review of the coroner's death investigation record.

RESULTS

During the 3-year study period, 72 infant deaths occurred in a sleeping context. Of these, 33 (45.8 %) occurred in the context of bed-sharing: n = 7 in 2008; n = 11 in 2009; and n = 15 in 2010. Further analysis of the 33 deaths occurring in the context of bed-sharing showed that in this group, bed-sharing was largely intentional, habitual and most often involved the mother as one of the parties.

CONCLUSIONS

Given the case series nature of the study design, a causal relationship between bed-sharing and infant death could not be inferred. However the fact that nearly half of all sleep-related deaths occurred in the context of bed-sharing, provides strong support for the need to undertake definitive analytic studies in Australia so that evidence-based advice can be provided to families regarding the safety of bed-sharing practices.

Accidental mechanical asphyxia of children in Germany between 2000 and 2008

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

Fatal accidental hanging by a high-chair waist strap in a 2-year-old girl

High chairs are commonly used to feed children after 6 months. Related injuries are oftentime minor and rarely leading to death. We describe a case of a 2-year-old female child who used to jump alone on her high chair and also had the habit to fasten the straps by herself. Her mother found her hanging by the waist straps. A thorough investigation showed that she climbed her high chair and fastened the waist straps but not the crotch one. The girl slid down into the seat, trapping her neck in the waist straps and thus resulting in hanging. In here, we concluded that the victim's death was caused by asphyxia, itself, caused by accidental hanging. The present case is of a special interest because of the rare similar cases reported. This case suggests that a correct restraint use and a close supervision would have prevented such a fatal issue.

Accidental hanging deaths in children in Konya, Turkey between 1998 and 2007

In general, hanging cases are the result of suicide, and accidental and homicidal hanging cases are rarely seen. This study retrospectively investigated 4571 death examinations and autopsies that were performed at The Konya Branch of the Forensic Medicine Council (Turkey) between 1998 and 2007; hanging was involved in 201 (6.5%) of the cases. There were a total of 13 accidental hanging cases, where 12 of these involved children. In seven of the cases, the accidental hanging involved a scarf that wraps around swing-like cradles and is intended to prevent infants from falling down. It was concluded that accidental hanging deaths can be reduced by replacing swing-like cradles with cribs that are designed for children, removing ropes in and around the house, and preventing children from reaching and/or playing with rope-like objects.

The brainstem and serotonin in the sudden infant death syndrome

The sudden infant death syndrome (SIDS) is the sudden death of an infant under one year of age that is typically associated with sleep and that remains unexplained after a complete autopsy and death scene investigation. A leading hypothesis about its pathogenesis is that many cases result from defects in brainstem-mediated protective responses to homeostatic stressors occurring during sleep in a critical developmental period. Here we review the evidence for the brainstem hypothesis in SIDS with a focus upon abnormalities related to the neurotransmitter serotonin in the medulla oblongata, as these are the most robust pathologic findings to date. In this context, we synthesize the human autopsy data with genetic, whole-animal, and cellular data concerning the function and development of the medullary serotonergic system. These emerging data suggest an important underlying mechanism in SIDS that may help lead to identification of infants at risk and specific interventions to prevent death.

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.

Risk factors associated with sudden unexplained infant death: a prospective study of infant care practices in Kentucky

OBJECTIVE

To ascertain the prevalence of infant care practices in a metropolitan community in the United States with attention to feeding routines and modifiable risk factors associated with sudden unexplained infant death (specifically, prone sleeping position, bed sharing, and maternal smoking).

METHODS

We conducted an initial face-to-face meeting followed by a telephone survey of 189 women who gave birth at a level I hospital in Kentucky between October 14 and November 10, 2002, and whose infants were placed in the well-infant nursery. The survey, composed of questions pertaining to infant care practices, was addressed to the women at 1 and 6 months postpartum.

RESULTS

A total of 185 (93.9%) women participated in the survey at 1 month, and 147 (75.1%) mothers contributed at 6 months. The racial/ethnic composition of the study was 56.1% white, 30.2% black, and 16.4% biracial, Asian, or Hispanic. More than half of the infants (50.8%) shared the same bed with their mother at 1 month, which dramatically decreased to 17.7% at 6 months. Bed sharing was significantly more common among black families compared with white families at both 1 month (adjusted odds ratio [OR]: 5.94; 95% confidence interval [CI]: 2.71-13.02) and 6 months (adjusted OR: 5.43; 95% CI: 2.05-14.35). Compared with other races, white parents were more likely to place their infants on their back before sleep at both 1 and 6 months. Black parents were significantly less likely to place their infants on their back at 6 months compared with white parents (adjusted OR: 0.14; 95% CI: 0.06-0.33). One infant succumbed to sudden infant death syndrome at 3 months of age, and another infant died suddenly and unexpectedly at 9 months of age. Both were bed sharing specifically with 1 adult in the former and with 2 children in the latter.

CONCLUSIONS

Bed sharing and prone placement were more common among black infants. Breastfeeding was infrequent in all races. This prospective study additionally offers a unique perspective into the risk factors associated with sudden infant death syndrome and sudden unexplained infant death associated with bed sharing by examining the survey responses of 2 mothers before the death of their infants combined with a complete postmortem examination, scene analysis, and historical investigation.

Sudden infant death syndrome: overview and update

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

Fatal unintentional traumatic asphyxia in childhood

OBJECTIVE

The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood.

METHODS

Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years.

RESULTS

Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases).

CONCLUSIONS

Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.

Infant-furniture-related injuries among preschool children in New Zealand, 1987-1996

OBJECTIVE

To describe the epidemiology of infant-furniture-related fatalities and hospitalizations in New Zealand, for children aged 0-4 years.

METHODS

Infant-furniture-related deaths and hospitalizations were selected from the New Zealand Health Information Service databases for the 10-year period 1987-1996. Intentional injuries were excluded.

RESULTS

Forty-three fatalities were identified. Twenty-two fatalities (51%) occurred in cots, while 13 (30%) occurred in beds. Other products involved were prams, push chairs, high chairs, car seats, portable cots and walkers. A total of 1679 infants were hospitalized through infant-furniture-related injuries. Increasing trends in hospitalizations for baby walkers, beds and bunks were observed.

CONCLUSIONS

On average, four infants die each year from injuries related to infant furniture, and hospitalizations from injuries associated with infant furniture use are increasing. Mandatory standards are one measure to reduce these numbers, but education is also necessary.

Car window entrapment and accidental childhood asphyxia

A 3-year-old boy was found hanging from a partly opened car window. Attempted resuscitation was unsuccessful. Postmortem reconstruction of events leading up to death indicated that the boy had slipped while standing on his tricycle and entrapped his head as he was attempting either to look into the car, or to climb in through the window. While it is not always possible to completely secure childhood environments, open cars should not be regarded as safe places for young children to play in or around when an adult is not in attendance. To minimize the chance of injury or death to children from parked cars, young children should be removed from vehicles and all windows and doors securely closed and locked, if they are to be left in the vicinity of the car to play unsupervised.

Changing trends in the diagnosis of sudden infant death

A study of 114 consecutive cases of unexpected infant death that occurred in South Australia over a 5-year period from January 1994 to December 1998 was undertaken. There were 45 deaths attributed to sudden infant death syndrome (SIDS), 19 to natural causes, 21 to accidents. and 5 to homicides; 24 cases were listed as "undetermined." Although there has been a genuine and continued decline in SIDS numbers in this population, there has also been an increase in the diagnosis of cases of accidental asphyxia due to unsafe sleeping environments and of cases in which the family background and autopsy findings suggested more complex mechanisms. The change in diagnostic profile has followed the introduction of more rigorous clinical history review, death scene examination, and autopsy testing. Thus, although diagnostic outcomes have altered in this population, it is more likely the result of more careful interpretation of the extensive investigations that are now undertaken rather than arbitrary reclassification.

Accidental childhood death and the role of the pathologist

The following study provides an overview of accidental childhood death. This study is based on a review of 369 cases of fatal childhood accidents taken from the records of the Department of Histopathology, Women's and Children's Hospital, Adelaide, Australia, over a 34-year period from 1963 to 1996. Data provide information on deaths due to motor vehicle accidents, drownings, accidental asphyxia, burns, poisonings, electrocution, and miscellaneous trauma. In addition, certain categories have undergone further examination, including asphyxial deaths due to unsafe sleeping environments and unsafe eating practices, drowning deaths, and deaths on farms, following identification of significant child safety problems in these areas as part of the "Keeping Your Baby and Child Safe" program. Previously unrecognized dangers to children detected through this program include mesh-sided cots, V-shaped pillows, and certain types of stroller-prams. The production of information pamphlets and packages for parents and the recall of certain dangerous products following recommendations made by pathologists demonstrate that pediatric and forensic pathologists have an important role to play in preventive medicine issues and in formulating public health strategies.

Accidental asphyxia in bed in severely disabled children

OBJECTIVE

To determine whether there are specific situations which may increase the risk of accidental asphyxia during sleep in children with physical and mental disabilities.

METHODOLOGY

Review of all cases where death was attributed to accidental asphyxia caused by unsafe sleeping situations in children listed in the Department of Histopathology database over a 10-year period from March 1989 to February 1999.

RESULTS

A total of 26 cases were found (M:F, 19:7; age range, 1-48 months; average age, 7.4 months). Of those cases, two involved children with significant mental and physical impairment. Case 1: A 4-year-old boy with Klippel-Trenaunay-Weber syndrome, macrocephaly and severe developmental delay, was found dead with his head hanging over a wooden board attached to the side of his bed. Case 2: A 4-year-old boy with lissencephaly and severe developmental delay was found dead wedged between a retractable mesh cot side and the side of his bed. In both cases the devices resulting in death had been put in place to prevent the boys from falling out of bed.

CONCLUSIONS

Accidental asphyxia in physically and mentally impaired children may be caused by devices that have been used to prevent injury from falling out of bed. Careful assessment of the specific developmental problems that children suffer should be undertaken before their beds are modified. It may be safer for these children either to have no barrier, or to have drop-sided cots/beds that meet recognized safety standards.

The value of a thorough protocol in the investigation of sudden infant deaths

AIMS

To review the diagnostic value of using a thorough necropsy protocol for the investigation of sudden infant deaths, with particular emphasis on the value of routine ancillary laboratory investigations.

METHODS

The necropsy and related records of all neonatal, infant, and young childhood deaths (under three years) referred for medicolegal investigation at Dundee from 1990 to early 1998 were reviewed retrospectively. Relevant positive and negative findings were abstracted from the police reports, hospital medical records, necropsy reports, and the results of routine bacteriological, virological, toxicological, and biochemical laboratory investigations.

RESULTS

Within the study period, 63 deaths presented as apparent "cot deaths," nine as suspected homicides, nine as neonatal deaths, and 14 in some other manner. An adequate cause of death was identified on the basis of necropsy and laboratory investigations in 35% of the 63 apparent cot deaths, leaving 63% to be finally categorised as sudden infant death syndrome (SIDS). Ten (16%) of the apparent cot deaths were explained on the sole basis of unexpected positive microbiological findings, mostly pneumococcal or meningococcal meningitis and/or septicaemia. Petechial haemorrhages were identified at one or more intrathoracic site in 90% of SIDS and in 55% of explained cot deaths.

CONCLUSIONS

Early and extensive laboratory investigations performed routinely in apparent cot deaths provide an unexpectedly high positive diagnostic yield. Routine early bacteriological culture of the CSF (by cisternal puncture) and blood before necropsy should be mandatory in the investigation of all sudden infant deaths.

V-shaped pillows and unsafe infant sleeping

OBJECTIVE

To investigate the possibility that adult size V-shaped pillows may be associated with accidental asphyxial deaths in infants.

METHODOLOGY

Review was undertaken of all cases of sudden infant death presenting to the Women's and Children's Hospital in Adelaide involving infants who had been found on adult size V-shaped pillows.

RESULTS

Four cases of sudden infant death were found in which infants were found sleeping on V-shaped pillows. All of the deaths had occurred in 1995. In two of the cases the pillows were considered to be implicated in the cause of death as the potential for obstruction of the infants' airways could be demonstrated on death scene reconstruction.

CONCLUSION

Adult size V-shaped pillows may be unsafe for use in small infants who may accidentally suffocate if trapped between the two arms, or under, the pillow. The use of such pillows to maintain the body position of sleeping infants should be discouraged.