Sudden infant death in a tropical environment: Singapore's experience

A total of 206 cases of sudden infant deaths examined at the Institute of Science and Forensic Medicine, Singapore, over a 5 year period (1989–1993) were identified to assess the pattern of sudden death in this age group, which was subdivided into the neonatal and post-neonatal periods. A total of 34% (70) of infant deaths occurred in neonatal life and the remaining 66% (136) in the post-neonatal period; 90% of the neonatal deaths were natural, of which over half were due to congenital heart disease and complications of prematurity. Unnatural deaths in this period were uncommon, there being only seven such deaths. In the post-neonatal period, unnatural deaths constituted 25% of the total with trauma and aspiration heading the list. Natural deaths in the post-neonatal period are predominantly due to infections (34%) and a group of sudden natural deaths with minimal findings (31%). The latter group may arguably represent cases of Sudden Infant Death Syndrome (SIDS). The yearly incidence of this group in our study varied between 0.08 to 0.2 per 1000 live births, which is considerably lower than the incidence quoted for Western populations. The criteria for the classification and the impact of sudden infant deaths in Asian countries are discussed.     

Comparative analysis of differences by gender in sudden infant death syndrome in Hungary and Japan

We examined the sex ratio in sudden infant death syndrome (SIDS) cases in Hungary, in Tokyo and Japan between 1985 and 1996. From all the infant death cases in Hungary 395 (240 male, 155 female) were SIDS (odds ratio (OR)=1.179, with 95% confidence interval (CI)=0.961, 1.446), in Japan 4348 (2550 male, 1798 female) were SIDS (OR=1.145, with 95% CI=1.076, 1.218) and in Tokyo 307 (178 male, 129 female) were SIDS (OR=1.128, with 95% CI=0.894, 1.423). Male infants showed a significantly higher birth rate than females. The male infants are more vulnerable (p<0.005), however, higher mortality among male infants should not be considered a characteristic feature for SIDS.     

38例单纯型脑干损伤法医学尸检的回顾性研究

目的报道38例原发性单纯型脑干损伤致死案例法医学尸检所见的脑干损伤、致伤方式和致伤物等特点,并探讨在法医学鉴定中的意义。方法从208例脑干损伤死亡法医学尸检案例中,挑选出38例符合单纯型脑干损伤的案例,分析单纯型脑干损伤发生的案情、损伤的部位和类型等特点。结果38例中男性占绝大多数,农民明显多于其它人员;大多发生于纠纷斗殴中;头部拳击伤18例(47.4%);头皮挫伤19例(50.0%);头皮挫裂创9例(23.7%);未见头皮损伤7例(18.4%);受伤当时昏迷并很快死亡者34例(89.5%);其损伤为局灶性挫伤出血,有32例(84.2%)肉眼未能辨认出,镜检见小灶性出血:其中,桥脑18例(47.4%)、延脑10例(26.3%)、中脑4例(10.5%)、桥脑和延脑均有出血6例(15.8%)。结论原发性单纯型脑干损伤不仅存在,而且能致人死亡;应引起同行的重视。     

Infanticide: is its incidence among postneonatal infant deaths increasing?: an 18-year population-based analysis in California

The decline in the incidence of sudden infant death syndrome (SIDS) and recent recommendations regarding the differentiation of SIDS and child abuse has generated speculation that some cases of infanticide were misdiagnosed as SIDS. The aims of this study were to determine the change in incidences and proportions of postneonatal deaths from all causes, SIDS, and infanticide in California over an 18-year interval encompassing years before and after the Back to Sleep campaign. Selected postneonatal mortality data from 1981 through 1998 obtained from the California Department of Health Services were analyzed and graphically displayed. The total postneonatal mortality and incidence of SIDS deaths per 100,000 live births decreased 45% and 66%, respectively, during the study interval; the incidence of infanticide remained low. The ratio of infanticide to SIDS increased from 4.3 per 100 in 1981 to 10.2 per 100 in 1998. Infanticide deaths, as a percentage of the total number of postneonatal deaths, increased slightly from the first to the second half of the study interval but never rose above 3.2%. It is concluded that this increased percentage is due to a decrease in SIDS deaths and not to an actual increase in infanticide deaths.     

Fatal dog maulings associated with infant swings

We present three cases of fatal dog maulings of infants placed in mobile infant swings, a phenomenon not previously described in the literature. In each case, the victim was left in a mobile swing, unsupervised by an adult, and the attacking dog was a family pet. Case 1 involved an 18-day-old male infant attacked by a pit bull; Case 2 involved a 3-month-old male infant attacked by a Chow Chow and/or a Dachshund, and Case 3 involved an 18-day-old female infant attacked by a Labrador-pit bull mix. These cases not only underscore the importance of not leaving young children unattended in the presence of pet dogs, but also raise the possibility that mobile swings may trigger a predatory response in dogs and thus may represent an additional risk factor for dog attack.     

Homicide as a cause of the sudden infant death syndrome

The homicidal asphyxiation of a 10 1/2-month-old male infant and the attempted asphyxiation of his 4-month-old sibling, documented by parental confession, is presented as evidence that murder may sometimes be mistaken as sudden infant death syndrome (SIDS). A review of the literature of the relationship between murder and SIDS deaths reveals the suspicions of some physicians but few published cases; this reflects not only the difficulties of making a determination of murder by suffocation, since no injuries may be present, but also a lack of awareness among physicians who must evaluate infant deaths. It is recommended that murder should be considered in the differential diagnosis of sudden, unexpected death in infants and that the autopsy should include full-body x-rays and at least an initial look at the social history of the child.     

Prevalence of HIV-1 antibodies in drug addicts autopsied at the University Institute of Forensic Pathology in Copenhagen 1988-1991.

In the period 1988-1991 the HIV-1 antibody test was performed in a total of 389 autopsied drug addicts. The HIV-1 incidence rose from 6% in 1988 to 14% in 1990 and 14% in 1991. There was no significant difference between the cumulated incidence in males and females. The HIV-1-positive addicts were compared to the HIV-1 negative addicts as regards mean age, duration of abuse, residence and cause and manner of death. Except for residence, where significantly more HIV-1-positive than negative addicts lived in Copenhagen, there were no significant differences between the two groups. In about one-third of the HIV-1-positive cases, equal both for males and females, the HIV-1-positivity was not known beforehand. The results are discussed in relation to the findings in other countries and to the findings in selected groups of living addicts in Copenhagen. It is concluded, that the diagnosis of HIV-1 infection in autopsied drug addicts is important from epidemiologic and hygienic points of view.     

The epidemiological study on registered cases of sudden infant death syndrome (SIDS) in Tokyo: examination of the effect of autopsy on diagnosis of SIDS and the mortality statistics in Japan

In the United States and most of European countries, a diagnosis of sudden infant death syndrome (SIDS) may be given only after an autopsy has been performed. Under the new definition of SIDS in Japan, an autopsy is now mandatory for the diagnosis of SIDS. However, according to the official records on autopsies, the proportion of autopsy for sudden infant death in Japan is still low (less than 30%). If a physician suspects SIDS from a review of the patient's medical history and medical findings, he can write 'suspected SIDS' as the cause of death on the death certificate without performing an autopsy. Such a clinical diagnosis is entered in the Vital Statistics section by the Japanese Ministry of Health and Welfare. In this report, a comparative epidemiological survey of registered cases of SIDS--after autopsy and with no autopsy--was carried out by examining the data from the death certificates registered by the Japanese Ministry of Health and Welfare (vital statistics in Tokyo from January 1979 to December 1996). There were 369 cases of SIDS registered in Tokyo. We found 247 diagnosed after autopsy (66.9%) and 122 with no autopsy (33.1%). The following epidemiological variables were used: address of the deceased (a specific area in Tokyo), sex, year of death, time of death, month of death, age at death, occupation of householders, and place of death. There were epidemiological differences at the 0.05 significance level between registered cases diagnosed after autopsy and those diagnosed without autopsies, as follows: year (P=0.016) and place of death (P=0.037). In addition, there were slight epidemiological differences at the 0.10 significance level between registered cases diagnosed after autopsy and with no autopsy, as follows: month of death (P=0.076) and age at death (P=0.082). This suggests that the quality of diagnosis of SIDS is not completely guaranteed. With respect to the area of residence, the incidence of SIDS is high in those areas where autopsy is performed frequently. In Tokyo, the medical examiner system is enforced only in the urban area and there is a possibility that SIDS is being underdiagnosed in the rural area of the Metropolitan Tokyo. It is likely that the diagnosis of SIDS without autopsy will influence the quality of SIDS diagnoses. The administrative inadequacy in the autopsy system in Japan should be corrected to improve the accuracy of SIDS diagnosis.     

Investigation of sudden infant deaths in the State of Maryland (1990-2000)

The Office of the Chief Medical Examiner (OCME) has recorded a significant decline in the deaths of sudden infant death syndrome (SIDS) in the state of Maryland since 1994. However, infants who died of accidental or non-accidental injuries remained consistent during the same time period. This report focuses on the epidemiological characteristics and scene investigation findings of infant victims who died suddenly and unexpectedly in Maryland between 1990 and 2000. A retrospective study of OCME cases between 1990 and 2000 yielded a total of 1619 infant fatalities. 802 infant deaths were determined to be SIDS, which represented 50% of the total infant deaths in our study population. Five hundred and twenty-three (31.8%) deaths were due to natural diseases, 128 (7.9%) deaths were accidents, and 74 (4.6%) were homicides. The manner of death could not be determined after a thorough scene investigation, review of history and a complete postmortem examination in 92 (5.7%) infants. SIDS deaths most often involved infants who were male and black. The peak incidence of SIDS was between 2 and 4 months of age. The majority of SIDS infants (60%) were found unresponsive on their stomach. Among SIDS infants, 269 (33.4%) were found in bed with another person or persons (bed sharing). Of the bed-sharing SIDS cases, 182 (68%) were African-American. In the past 11 years, 52 infants died of asphyxia due to unsafe sleeping environment, such as defective cribs, ill-fitting mattresses, inappropriate bedding materials. Of the 74 homicide victims, 53 (70%) involved infants less than 6 months of age. Twenty (27%) exhibited the classical abuse syndrome characterized by repeated acts of trauma to the infants.     

Death caused by myocarditis in Wayne County, Michigan: a 9-year retrospective study

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

Oronasal blood in sudden infant death.

Oronasal secretions are observed frequently in sudden infant death syndrome (SIDS), but overt blood is uncommonly reported. The literature on oronasal blood in sudden infant death is limited. The goal of this study was to determine the frequency of oronasal blood in sudden infant deaths and to examine possible causative factors. Oronasal blood was described in 28 (7%) of 406 cases of sudden infant death. Oronasal blood could not be attributed to cardiopulmonary resuscitation in 14 cases, including 10 (3%) of 300 cases of SIDS, 2 (14%) of 14 accidental suffocation cases, and 2 (15%) of 13 undetermined cases. Eight of the 10 infants in cases of sudden infant death were bedsharing: 5 with both parents, 2 between both parents. The infant in 1 SIDS case was from a family that had had three referrals to Child Protective Services. Oronasal blood not attributable to cardiopulmonary resuscitation occurs rarely in SIDS when the infant is sleeping supine in a safe environment. Bedsharing may place infants at risk of suffocation from overlaying. Oronasal blood observed before cardiopulmonary resuscitation is given is probably of oronasal skin or mucous membrane origin and may be a sign of accidental or inflicted suffocation. Sanguineous secretions that are mucoid or frothy are likely of remote origin, such as lung alveoli. The use of an otoscope to establish the origin of oronasal blood in cases of sudden infant death is recommended.     

Alcohol in a series of medico-legally autopsied deaths in northern Norway 1973-1992

It is well established that use of alcohol increases the risk of fatal injuries. The presence of blood alcohol in autopsied deaths is regularly encountered in medico-legal practices. The aim of this study was to investigate the prevalence and concentration of alcohol in 1539 medico-legal autopsies in two counties in northern Norway in the period 1973-1992, and the reporting of acute alcohol influence among these deaths to the official cause-of-death statistics. Blood alcohol concentration (BAC) >/=0.5 per thousand (50 mg/100 ml) was found in 47.6% (n=456) of violent deaths tested, and in 93% (n=426) of these the BAC was >/=1.0 per thousand. In 17.4% (n=55) of tested natural deaths the BAC was >/=0.5 per thousand. Acute alcohol-influenced violent deaths were under-reported to the cause-of-death statistics. Deaths by motor vehicle traffic accidents did not differ from other violent deaths in this respect. The under-reporting among violent deaths was 41% in cases with BAC >/=0. 5 per thousand and 37% where the BAC was >/=1.0 per thousand during the whole period. It is concluded that post-mortem BAC >/=0.5 per thousand, should be regarded as a possible contributory cause in all violent deaths, and reported accordingly.     

The role of beta-amyloid precursor protein (beta-APP) staining in the neuropathologic evaluation of sudden infant death and in the initiation of clinical investigations of subsequent siblings

This report highlights the importance of undertaking immunohistochemical staining of the brains of infants who die unexpectedly, as it may not only assist with the evaluation of the cause of death in an individual infant but may also help with the clinical management of subsequent siblings. A 5-month-old male infant who died suddenly was found to have diffuse beta-amyloid precursor protein (beta-APP) staining in the brain, with no unusual features in his history, death scene examination, routine autopsy dissection, and ancillary tests to suggest any definite cause of death. Due to the beta-APP staining, the possibility of previous episodes of occult trauma, apparent life threatening events (ALTEs), and accidental or inflicted suffocation was raised in the autopsy report. As detailed analyses and investigations provided no supportive evidence for trauma or inflicted injury, hypoxia was clinically considered the most likely cause. Because of these concerns, sleeping oxygen saturation levels were monitored following the birth of a subsequent sibling who had normal APGAR scores and no evidence of any health problems. Oxygen desaturation to 70% occurred in association with a color change while on the postnatal ward, and a subsequent polysomnogram showed multiple episodic significant desaturations to around 80% in association with central apnea. Other testing was unremarkable. These cases demonstrate that beta-APP staining of the brain may not only provide clues as to possible mechanisms of death in pediatric forensic cases but may indicate a need for careful clinical evaluation of subsequent siblings for possible central apnea requiring oxygen therapy.     

脑干轴索肿胀的半定量研究

目的 探讨轴索肿胀在鉴定脑干损伤中的意义。方法 取明确死于原发性脑干损伤(36例)和脑外疾病(28例)者共64例，分为损伤组(36例)和对照组(其中死于心血管疾病12例、非心血管疾病16例)，并将其死后24h和48h前、后做尸体解剖分为2组，通过对中脑、脑桥和延脑切片、镀银染色，在100倍光镜下采用显微测微器测量每片9条最粗的轴索横径，对所得数据作方差分析、t检验统计学处理。结果 损伤组与对照组(不包括心血管疾病死亡者)相比，中脑、延脑部的轴索肿胀程度有明显差异(P＜0.05)；死后48h内解剖的损伤组与对照组相比无差异(P＞0.05)，但超过48h解剖两组有明显差异(P＜0.05)。结论 中脑、延脑部轴索肿胀与外伤有明显的相关性。轴索肿胀对判断脑干损伤有意义。需排除心血管疾病致死。     

Sudden and unexpected death of a 6-month-old baby with silent heart failure due to anomalous origin of the left coronary artery from the pulmonary artery.

A 6-month-old girl died suddenly without any previous symptoms of heart failure. Autopsy examination showed cardiomegaly (97 g) with a severely fibrotized myocardium. The left coronary artery was originating from the pulmonary artery. Histologically, the myocardium showed myocardial infarcts of different ages, as well as grossly thickened arterial branches due to increased flow in left-right shunt. We suggest that rare anomalies of the coronary arteries should be considered in the autopsies of suspected sudden infant death syndrome cases.     

Sudden death associated with a multifocal type II hemangioendothelioma of the liver in a 3-month-old infant

Sudden unexpected death in an infant caused by or associated with neoplasm is rare. We describe a case of a sudden death in an apparently healthy 3-month-old female, in which the autopsy revealed a multiple type II infantile hepatic hemangioendothelioma (IHE). This uncommon tumor has, untreated, a relatively high mortality rate, mainly due cardiac failure resulting from massive arteriovenous shunts, but the association with sudden infant death is very rare.     

The Institution of a Standardized Investigation Protocol for Sudden Infant Death in the Eastern Metropole,Cape Town,South Africa,,

The rate for the sudden infant death syndrome (SIDS) in Cape Town, South Africa, is estimated to be among the highest in the world (3.41/1000 live births). In several of these areas, including those of extreme poverty, only sporadic, nonstandardized infant autopsy, and death scene investigation (DSI) occurred. In this report, we detail a feasibility project comprising 18 autopsied infants with sudden and unexpected death whose causes of death were adjudicated according to the 1991 NICHD definitions (SIDS, n = 7; known cause of death, n = 7; and unclassified, n = 4). We instituted a standardized autopsy and infant DSI through a collaborative effort of local forensic pathology officers and clinical providers. The high standard of forensic investigation met international standards, identified preventable disease, and allowed for incorporation of research. We conclude that an effective infant autopsy and DSI protocol can be established in areas with both high sudden unexpected infant death, and elsewhere. (SUID)/SIDS risk and infrastructure challenges.     

Cocaine babies: the scourge of the '90s

Six cases of cocaine-related deaths of infants have covered the spectrum of potentially devastating effects. They include an intrauterine death of a 35-week-old fetus following acute maternal cocaine abuse; anoxic encephalopathy at birth with 3 months' vegetative survival from a similar episode; traumatic compression asphyxia in a 4-month-old; infectious cardiomyopathy with heart failure in a twin at age 21 months following maternal cocaine abuse at birth; malnutrition and dehydration in a 7-week-old during continuing cocaine abuse by the parents; and a teenage sibling's cocaine lacing of a baby milk bottle ingested by his 6-week-old brother. All the cases had positive toxicological screening for cocaine or metabolites or both in the mother at delivery or in the infant at birth, or both. There were no instances of sudden infant death syndrome (SIDS, or "crib death"). Pathologic and toxicologic, as well as birth, developmental, and social data are presented. An integrated medical, public health, law enforcement, and educational policy to prevent or at least ameliorate these tragic cases, now approaching epidemic proportions, has yet to be developed. A careful obstetrical history and examination of the mother, indication on the birth certificate of maternal drug abuse, and notification of health authorities (by birth certificate checking, among other ways) may send an early warning message to providers for intercession. Active ingestion/injection and passive inhalation by older children and teenagers require more intensive monitoring and aggressive interaction by pediatricians, social workers, school authorities, and employers.(ABSTRACT TRUNCATED AT 250 WORDS)