Post on 12-Jun-2020
Sudden Unexpected Death in Babies
Dr L du Toit-PrinslooUniversity of Pretoria
Department of Forensic Medicine
Definitions
• Unexpected death: – Not anticipated as significant possibility 24
hours before the death
• Sudden Unexpected Death in Infancy (SUDI):– Unexpected deaths of infants up to 1 year in
age at the point of presentation
• Sudden Infant Death Syndrome:– To follow…
Natural causes of unexpected childhood deaths
Infections
• Meningococcal / pneumococcal• Myocarditis• URTI• Respiratory infections• Meningitis• Septicamia• Enteroviruses
Cardiovascular system
• Congenital abnormalities• Cardiomyopathy• Endocardial fibroelastosis• Dysrhytmias
– WPW– LQTS– Brugada– ARVD
Gastrointestinal
• Fulminant gastroenteritis– Dehydration– Electrolyte disturbances
• Intestinal obstruction
Metabolic disorders
• Inborn errors of metabolism– Medium chain acyl CoA dehydrogenase
deficiency
Central nervous system
• Sudden Unexpected Death in Epilepsy (SUDEP)
• Status epilepticus
Respiratory system
• Sudden death in Asthma
Non-natural causes of death
Trauma
• Non-accidental Injury Syndrome• Head injury• Asphyxia• Accidental
– MVA– Drowning– Poisoning
Sudden Infant Death Syndrome
“SIDS is perhaps the greatest single medical mystery confronting scientists”.
Dr Cyril H. Wecht
Coroner of Allegheny County, PittsburghJnl of the American Medical Association, Jan 1996
Definition
• San Diego 2004• Sudden unexpected death• Infant < I year• Remains unexplained after thorough investigation
» Post mortem» Scene investigation» Review of the clinical history
Epidemiology
• Most common cause of death ages 1mo – 1yr• 50% of deaths 2 – 4 mo (Western societies)• Incidence 1-3/1000 live births• American Indians 6/1000; UK 2/1000; SA = ?• NB!! - abnormal as a group
»? not a single entity»sleeping position
• Factors: BABY / MOTHER / ENVIRONMENT
Table 13Number of registered infant deaths, South Africa, 1997 - 2002
6,52 887 654186 9262 13787 41697 373Total
7,3499 26836 60338217 15119 0702002
6,8451 93630 75031414 48115 9552001
7,4413 96930 43236914 25615 8072000
7,9381 90230 35946414 24215 6531999
8,6367 68931 73837614 72316 6391998
8,5318 28727 04423212 56314 2491997
TotalUnspecifiedFemalesMales
Infant deaths as percent of total deaths
Total deaths
Infant deaths under age one yearYear
Critical development
StressorVulnerable infant
Triple risk model – Kinney and Filiano
• Critical development period– 1st 6 months
• Stressor– Prone sleeping position– Soft bedding– Overheating
• Vulnerable infant– Brainstem abnormalities in protective
mechanisms against homeostatic challenges
Etiology/pathophysiology
• Chronic hypoxia / hypoxaemia• Brain stem immaturity• Neurochemical deficiency
• Respiratory / cardiac arrest
• Prone sleeping position• Airway obstruction• Cardiovascular failure (vertebral circulation)
• Cardiac remodelling / conduction (LQTS)
• Infection• Allergic• Immunisation• Cardiac• Neurological• Respiratory – central apnoea• Serotonin• Multifactorial
Pathology
• No pathognomonic lesion• Diagnosis of exclusion• Macroscopic findings:
– Petechial haemorrhages– Pulmonary edema and/or congestion– Cerebral edema and/or congestion
• Microscopic findings:– Signs indicative of chronic hypoxia/hypoxaemia
In 15% of infants who present clinically as SIDS, an adequate cause of death can
ultimately be demonstrated, with thorough investigation
The remaining 85% remain obscure and are confirmed as SIDS
Differential Diagnosis
• 1. Cardiac: Congenital valve lesions etc., Myocarditis, fibro-elastosis etc.
• 2. Pulmonary: Pneumonitis, bronchiolitis etc.• 3. Brain: Meningitis, encephalitis, A-V malform. • 4. Other:
• Trauma - NB!• Poisoning• Hepatitis• Enterocolitis• Sepsis (fulminant)• Aspiration• Heat illness / hyperthermia
Preventative measures
• No smoking
• Safe sleep environment
• No overheating
• Dummy
• Monitoring?
Medical practitioner’s role
• Appropriate attention: parental and legal perspectives
• Visit scene of death
• Review case history• No death certificate of natural causes• Autopsy:
– Thorough and complete– Histology– Toxicology– Virus and/or bacterial cultures
• Formulation of cause of death: ( = Diagnosis of exclusion)“Consistent with Sudden Infant Death Syndrome”
“In the present state of knowledge, it seems that SIDS is the final common pathway that leads to death in infants who have been compromised by a number of deleterious factors, which have to come together in one baby at one time in order to summate to a final outcome.”
Knight’s Forensic Pathology – P Saukko B Knight
Supporting families
Family support
• Set the right scene• Parents• Grandparents• Other siblings• Multi-team approach
Literature references• SIDS and Near-SIDS (Shannon) (NEJM, Vol. 306, No 16 +17, 1982)• Child Abuse, Sudden Infant Death Syndrome and Unexpected Infant
Death (Emery) (Am J Dis Ch – vol 147, October 1993)• Non-natural Death Masquerading as SIDS (Perrot) (Am J Forens
Med Pathol vol 9. No 2. 1988)• The value of a thorough protocol in the investigation of sudden infant
deaths (Sadler) (J Clin Path 1998; 51:695–699)• Finding the failure mechanism in Sudden Infant Death Syndrome
(Harper) (Nature Medicine, Vol 4, Number 2, February 1998)• Unexpected Death in Childhood – A handbook for Practitioners
Peter Sidebotham and Peter Fleming• www.sidsinternational.minerva.com.au• www.sids.org.uk