Sudden infant death syndrome: a subject of medicolegal research

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.     

婴儿猝死综合征的法医学鉴定

近20多年来,婴儿猝死综合征（sudden infant death syndrome,SIDS）一直是西方发达国家医学界尤其是法医学和儿科学领域研究的热点。目前,随着对SIDS广泛而深入的研究,对其病因、发病特点、危险因素以及致病机制等都有了更明确的认识。虽说近年来SIDS的发病率已有明显下降,在欧美洲、澳洲等发达国家,SIDS仍然是导致1个月到1岁婴儿死亡的首要原因。在亚洲国家和地区,尤其是发展中国家SIDS的报道很少见。本文通过总结文献并结合美国马里兰州近20年（1990—2006）来对SIDS的调查研究资料,介绍SIDS的发展历史、研究现状和新的发展趋势,并对SIDS法医学鉴定程序及鉴定要素进行讨论。     

Sudden infant death syndrome (SIDS)--standardised investigations and classification: recommendations

Sudden infant death syndrome (SIDS) still accounts for considerable numbers of unexpected infant deaths in many countries. While numerous theories have been advanced to explain these events, it is increasingly clear that this group of infant deaths results from the complex interaction of a variety of heritable and idiosyncratic endogenous factors interacting with exogenous factors. This has been elegantly summarised in the "three hit" or "triple risk" model. Contradictions and lack of consistencies in the literature have arisen from diverse autopsy approaches, variable applications of diagnostic criteria and inconsistent use of definitions. An approach to sudden infant death is outlined with discussion of appropriate tissue sampling, ancillary investigations and the use of controls in research projects. Standardisation of infant death investigations with the application of uniform definitions and protocols will ensure optimal investigation of individual cases and enable international comparisons of trends.     

Nonnatural death masquerading as SIDS (sudden infant death syndrome)

This article relates our experiences with accidental and homicidal deaths in reported sudden infant death syndrome (SIDS) cases. Our intent is to alert personnel in medical and health-related professions as well as death investigators (coroners, law enforcement officials, etc.) that a thorough scene investigation and history need to be obtained when a child's death has been reported, since this may modify the type of autopsy to be performed. It should not be assumed that all children less than 1 year of age who die suddenly die from SIDS.     

Sarcomeric gene mutations in sudden infant death syndrome (SIDS)

In developed countries, sudden infant death syndrome (SIDS) represents the most prevalent cause of death in children between 1 month and 1 year of age. SIDS is a diagnosis of exclusion, a negative autopsy which requires the absence of structural organ disease. Although investigators have confirmed that a significant percentage of SIDS cases are actually channelopathies, no data have been made available as to whether other sudden cardiac death-associated diseases, such as hypertrophic cardiomyopathy (HCM), could be responsible for some cases of SIDS. The presence of a genetic mutation in the sarcomeric protein usually affects the force of contraction of the myocyte, whose weakness is compensated with progressive hypertrophy and disarray. However, it is unclear whether in the most incipient forms, that is, first years of life, the lack of these phenotypes still confers a risk of arrhythmogenesis. The main goal of the present study is to wonder whether genetic defects in the sarcomeric proteins, previously associated with HCM, could be responsible for SIDS. We have analysed 286 SIDS cases for the most common genes implicated in HCM in adults. A total of 680 mutations localised in 16 genes were analysed by semi-automated matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDITOF-MS) using the Sequenom MassARRAY(?) System. Ten subjects with completely normal hearts showed mutated alleles at nine of the genetic variants analysed, and one additional novel mutation was detected by conventional sequencing. Therefore, a genetic mutation associated with HCM may cause sudden cardiac death in the absence of an identifiable phenotype.     

Intrathoracic and subconjunctival petechiae in sudden infant death syndrome (SIDS)

The frequency and density of intrathoracic and subconjunctival petechiae was studied in 250 cases of SIDS and 69 controls. The control group included 37 infants with natural and 32 infants with traumatic causes of death. Intrathoracic petechiae were found significantly more frequently in the SIDS group (91.2% SIDS; 42% controls; p < 0.001) and were present at a higher density (p < 0.001). Subepicardial and thymic petechiae were detected at high density in older SIDS infants. Subconjunctival petechiae were low in density and found only in 2.4% of the SIDS group but they were detected in 8.1% of the natural death group and 21.9% (p < 0.05) of the lethal trauma group. Subconjunctival petechiae were found at highest density in strangulation. Intrathoracic petechiae are commonly found in SIDS but are not specific for SIDS. Subconjunctival petechiae are typical but not specific for strangulation. In SIDS, subconjunctival petechiae are rare and appear at low density.     

Unexpected perinatal death and sudden infant death syndrome (SIDS): anatomopathologic and legal aspects

This work intends to be a review of the recent histopathological findings elicited by research into sudden and unexpected perinatal death and sudden infant death syndrome (SIDS) that have dictated a novel approach to the inherent problems by pathologists, especially those entrusted with forensic medical authority. The new approach stems from the recent advances made in the understanding of neuro- and/or cardiac-conduction-system diseases present in unexpected perinatal death and SIDS. These demand that an accurate morphologic examination be performed of these structures, which modulate respiratory, cardiovascular, digestive, and arousal activities, in all victims of sudden death. A histopathologic study of an ample register of cases of victims of sudden death, either perinatally or in early infancy, has demonstrated frequent alterations both of the autonomic nervous system (especially hypoplasia of the arcuate nucleus) and of the cardiac conduction system (accessory atrioventricular pathways). The present research provides an in-depth study of the many still-controversial aspects underlying perinatal unexpected death and SIDS and is recommended for professionals working in the forensic field, whose greater insight into this problem will allow more complete medicolegal documentation.     

Acallosal brain in sudden infant death syndrome (SIDS).

A definitive explanation of "crib" or "cot" death remains unknown. An unusual incidental autopsy finding of agenesis of the corpus callosum in a case presenting as "near miss" sudden infant death syndrome (SIDS) is discussed. Hitherto, only a single case associated with SIDS has been reported in the literature. The condition may be easily missed outside the interest in neuropathology.     

Sudden infant death syndrome in Japan

Two autopsied cases are presented, one involving a 5-month-old infant, and a 6-month-old infant both of whom died suddenly and unexpectedly. The incidence of sudden infant death syndrome in Japan is 1.2 per 1,000 babies live births. Among all cases autopsied in the departments of legal or forensic medicine in 78 universities or colleges of Japan, the incidence was 15 (0.5%) per 3,329 in 1984 and 20 (0.6%) per 3,150 in 1985.     

Toxic environmental factors in sudden infant death (SIDS)

The increasing number of discussions on the influence of toxic environmental factors, including SIDS, prompted systematic postmortem chemical-toxicological investigations to be carried out on 54 SIDS cases and 2 control cases of the same age group. Tissue levels of arsenic, lead, cadmium, mercury, and pentachlorphenol, as well as other organic noxious agents, were measured in several organs. In addition, the COHb concentrations were determined. In spite of the widely scattered values, the extreme levels measured and the arithmetic means and median averages of As, Pb, Cd, Hg, PCP, and COHb had no more range in concentrations than can be expected for toxic effects - according to present knowledge anyway. It was observed that infants from an urban environment showed no greater concentration of noxious agents than did infants from rural regions. There were also no differences between SIDS cases and the controls, nor was there a correlation between infections of the respiratory system that are often morphologically detected - including laryngitis - and higher concentrations of these agents in the organs of SIDS cases.     

Sudden infant death due to asplenia syndrome

An apparently healthy 80-day-old boy died suddenly for no apparent reason. The autopsy revealed that the patient had had congenital asplenia, extensive cardiovascular anomalies, and other organ malformations, including trisegmented lungs, hypoplasia of the corpus callosum and cranial bones, a symmetrical liver, accessory hepatic tissue in the adrenal glands, malrotation of the intestine, and hypoplasia of the greater omentum.     

An hepatic metabolic profile in sudden infant death (SIDS)

Levels of 18 enzymes and metabolites were measured in liver obtained at autopsy from 41 infants, 28 of whom were found unexpectedly dead at home. Four infants had meningitis, 11 had pathologic findings not clearly sufficient to explain death (SUD), and 13 were considered totally unexplained pathologically (SIDS). The possible contributions of postmortem interval, age and diet to the results are reviewed. No characteristic metabolic profile was recognized amongst SUD and SIDS groups. It is speculated that the amount of glycogen found in liver may provide insight into premortal events and reflect the rapidity of the death mechanism. Five individuals (20%) were suspected of having major metabolic abnormality including glycogenosis (1), urea cycle defect (1), and possibly abnormal levels of carnitine palmityl transferase (3).     

The evidential value of intra-alveolar haemosiderin-macrophages in cases of sudden infant death syndrome (SIDS)

This study aimed to determine the effect of cocaine on the development and growth of immature and adult blowflies, in an attempt to better understand the impacts of such effects on postmortem interval (PMI) estimation. Twice the lethal dose of cocaine was injected into rabbits. The control animals were injected only with saline solution. Experimental and control rabbits were autopsied, and portions of their livers were exposed to newly eclosed larvae of Chrysomya putoria and Chrysomya albiceps. Larvae were weighed individually every 6 h, up 54 h of exposure. The larvae were then placed on an artificial diet to continue their development. Pupariation time, adult emergence and adult longevity were also analysed. The larvae of both species that fed on the cocaine-containing livers developed faster than those that fed on the livers of the control animals, leading to the conclusion that cocaine influences and stimulates larval growth. The difference in growth between the control and treated flies was best observed from 12 h of exposure onward. This finding has important implications for forensic investigations.     

Dicyclomine in the sudden infant death syndrome (SIDS)--a cause of death or an incidental finding?

We report a case of a small infant apparently dying of the Sudden Infant Death Syndrome (SIDS) with a postmortem blood dicyclomine level of 200 ng/mL. Review of the literature and the comparison with blood dicyclomine values from four rabbits given equivalent doses suggests that a blood dicyclomine value of 200 ng/mL probably is in the therapeutic range for infants. Although safely used for years for infantile colic, recently, the administration of dicyclomine has been related to acute episodes of apnea, seizures, and coma. In the absence of those acute reactions, we feel that a 200-ng/mL blood dicyclomine level in a child dying of apparent SIDS should not prevent categorization of the death as SIDS.     

Sudden infant death syndrome: measurement of total and specific serum immunoglobulin E (IgE)

Postmortem evaluation of total and specific serum immunoglobulin E (IgE) antibody levels by the paper radio immuno sorbent test (PRIST) and radio allergo sorbent test (RAST), respectively, revealed that there was no significant elevations in total circulating IgE or in specific IgE antibodies to house dust, Dermatophagoides farinae (house dust mite), Alterarnia tenuis (mold), or milk proteins for sudden infant death syndrome (SIDS) victims when compared to a control group.     

Sudden infant death syndrome. Morphology update for forensic pathologists--1985

Herein presented are current concepts regarding the sudden infant death syndrome (SIDS) including a definition of the phenomenon and a discussion of its present role in post-neonatal mortality in this country, a few of the recently published results (both clinical and morphological) of the NICHD Cooperative Epidemiologic Study, a report on the status of the so-called "Tissue-Markers for Hypoxia" and a summary of other recent morphologic observations.     

Immunohistochemical techniques improve the diagnosis of myocarditis in cases of suspected sudden infant death syndrome (SIDS)

Immunohistochemical techniques have improved the diagnosis of myocarditis. In a post mortem study, eight specimens in each case of the formalin-fixed and paraffin-embedded hearts of 20 suspected cases of sudden infant death syndrome (SIDS) were investigated with traditional hematoxylin-eosin staining and immunohistochemical methods. The hematoxylin-eosin stained specimens were examined for myocarditis according to the Dallas criteria; only in one case was a myocarditis diagnosed. The subsequent definition of the major histocompatibility complex class II antigens (HLA-DP,DQ,DR and HLA-DR), known to be enhanced in cases of myocarditis, the quantification of leucocytes with leucocyte common antigen (LCA) and characterization and quantification of T-lymphocytes using a specific marker (CD-3) allowed the definite diagnosis of myocarditis in three additional cases, six cases were found with moderate changes and ten cases without signs of inflammation.     

监禁中猝死综合征

监禁中猝死综合征是由于高度紧张或躁动状态下,以及其他因素诸如酒精或其他药物的使用、犯人自身的生理情况、特定的强制性体位等因素共同作用下,发生被监禁人员死亡。由于其发生意外,缺乏特征性的尸检结果和毒物分析结果,而成为法医病理学工作者在法医鉴定实践工作中遇到的一个难题。本文总结了相关的危险因素,如犯人的精神状况、药物的使用、被擒拿时所处的体位以及肥胖等,为有效地预防此类事件的发生和法医鉴定工作提供参考。