Unexpected Death In Children Research Articles

Increased carotid intima media thickness and cardiac biomarkers in HIV infected children

To assess carotid intima media thickness (IMT) and cardiac biomarkers in HIV infected children on antiretroviral therapy (ART). This was a single site, cross sectional, controlled observational study. We assessed carotid IMT, homocysteine, high-sensitivity C-reactive protein and myeloperoxidase levels in HIV infected children on stable ART for >or= 6 months. Carotid IMT was reported as internal carotid artery (ICA) and common carotid artery (CCA) thickness; left and right sides were measured separately. Groups were compared using appropriate two-sample tests. Of the 62 subjects enrolled, 31 were HIV positive (50%), 66% were female, and 69% were African-American. Median CD4% was 32% and 26 patients (84%) had HIV-1 RNA< 400 copies/ml. Sixteen patients had been taking protease inhibitors for a median duration of 27 months. None had hypertension or smoked. HIV infected children had higher HOMA-IR, waist-to-hip ratio, cholesterol, triglycerides, myeloperoxidase and lower homocysteine levels. Left and right CCA IMT, and left and right ICA IMT were significantly higher in the HIV infected group. Significant predictors of carotid IMT measurements in uninfected controls were body mass index and homocysteine, but only the duration of ARV therapy was predictive of IMT in the HIV infected group. Higher levels of carotid IMT and some cardiac markers were found in ART treated HIV infected children when compared to matched uninfected controls. These results suggest that HIV infected children receiving ART may be at increased risk of cardiovascular disease.

Syncope and Sudden Death in the Athlete

Sudden unexpected death in an athlete is a rare but devastating event. When it occurs, it has a lasting and serious impact on the family, the school, and the community in which the athlete lived. This article will examine the epidemiology of sudden unexpected death in children and adolescents as well as explore the etiologies most commonly encountered. Syncope in an athlete is equally as frightening and may be an early indicator of a possible fatal event if not fully evaluated. The preparticipation physical examination is one possible tool that may decrease the frequency of these untimely events. The association between syncope, the preparticipation examination, and sudden unexpected death in the athlete will be explored.

Sudden Unexpected Death in Childhood Associated with Cardiac Rhabdomyoma, Involuting Adrenal Ganglioneuroma, and Megalencephaly: Another Expression of Tuberous Sclerosis?

We report a 9-year-old, previously healthy girl who died suddenly and unexpectedly and was found at postmortem examination to have a cardiac rhabdomyoma, megalencephaly, and an involuting adrenal ganglioneuroma. Her death was possibly caused by a fatal cardiac arrhythmia resulting from interference of the ventricular septal rhabdomyoma with the cardiac conduction fibers. Her extended family history included a variety of disorders, including cleft lip and palate and ill-defined cardiac and neurologic diseases. The constellation of her autopsy findings suggested a diagnosis of tuberous sclerosis, for which there are gene defects that can be identified in surviving family members.

Radiography after unexpected death in infants and children compared to autopsy

Postmortem radiography may reveal skeletal and soft-tissue abnormalities of importance for the diagnosis of cause of death. To review the radiographs of children under 3 years of age who had died suddenly and unexpectedly. To compare the radiological and autopsy findings evaluating possible differences in children dying of SIDS and of an explainable cause. A total of 110 consecutive skeletal surveys performed between 1998 and 2002 were reviewed. All but one were performed before autopsy and comprised AP views of the appendicular and axial skeleton and thorax/abdomen, lateral views of the axial skeleton and thorax, and two oblique views of the ribs. Radiography and autopsy findings were compared. Causes of death were classified as SIDS/borderline SIDS (n = 52) and non-SIDS (n = 58), with one case of abuse. In 102 infants there were 150 pathological findings, 88 involving the chest, 24 skeletal, and 38 miscellaneous findings. The radiological-pathological agreement was poor concerning pulmonary findings. Skeletal findings were sometimes important for the final diagnosis. Radiography revealed many skeletal and soft-tissue findings. Pulmonary pathology was most frequently found, but showed poor agreement with autopsy findings. Recognizing skeletal findings related to abuse is important, as these may escape recognition at autopsy.

Sudden Unexpected Death in Children with Heart Disease

To review a mortality database, and identify all sudden unexpected deaths in patients followed by the cardiac program. Retrospective review of prospectively maintained database. Over 8 years, we identified 80 sudden unexpected deaths, among which there were sufficient data in 69 (24 females). Patients died at a median age of 17.2 months (28 days-18.8 years). Forty-six patients had 2 functional ventricles and 23 had received palliation for a single-functional ventricle. Patients with a single ventricle died at a younger age (median 120 days; 28 days-17.2 years) and sooner after last assessment (median 27 days; 1-146 days) than patients in the biventricular group (median age 2 years; 43 days-18.8 years; median time since last assessment 49 days, 1 days-1 year) (P < .01; P = .01). Thrombosis was the most common cause (61%) of death in the single-ventricle group. Arrhythmia or presumed arrhythmia was the most common cause (46%) of death in the biventricular group. Fifty-one patients had undergone surgery. Six patients had primary electrophysiological disease, and 5 had cardiomyopathy. Eight deaths occurred in patients with pulmonary vascular disease. Our study demonstrates that sudden unexpected death occurred at a frequency of at least 10 patients per year over an 8-year period with 55,730 patient encounters. We were able to determine a clinical cause of death in most patients. Arrhythmias (30%) and pulmonary vascular disease (13%) are important causes of sudden death. Simple aortic valve disease and hypertrophic cardiomyopathy are rare (4%) causes of sudden death in childhood. Infants and young children with surgical shunts comprise 23% of sudden unexpected deaths that occur within a month of the last evaluation. Close surveillance of these patients is warranted.

Virological analysis in the diagnosis of sudden children death: A medico-legal approach

Infections are considered to be an important cause of unexpected death in children. It has also been assumed that respiratory viruses are involved in the genesis of sudden infant death syndrome (SIDS). The Spanish National Institute of Toxicology and Forensic Sciences act as the forensic reference centre for Spain. We analyse the experience of this centre in the virological study of 64 cases of sudden children death where viral serology, virological cultures, herpesviruses polymerase chain reaction (PCR) and electron microscopy were performed. According to pathological findings, death could only be attributed to an adenovirus infection in one amygdalitis with upper airways stenosis and asphyxia. Human herpes virus 6 (HHV-6) was detected by PCR in one case with pathological findings characteristic of SIDS. Recent infection by respiratory syncytial virus (RSV), Epstein–Barr virus (EBV) and cytomegalovirus (CMV) were also detected. Meanwhile, 85.9% of the cases yielded negative viral results. Twenty-eight infants were finally categorised as SIDS. Pathological findings of infection were detected in 12 patients despite the negativity of viral analyses. Although viral infection is an uncommon cause of sudden children death, a complete microbiological investigation will help to solve the puzzle of SIDS. Definitive guidelines for microbiological analyses need to be updated whilst new pathogens are discovered or new techniques are implemented in order to clarify unsolved cases.

Sudden death in children due to intracranial mass lesion

Intracranial causes of sudden and unexpected death in children are uncommon and are usually due to trauma, epilepsy or to catastrophic haemorrhage associated with neoplasms or vascular malformations. We sought to review the presenting symptoms and signs of intracranial mass lesions that led to sudden death to guide clinicians in early identification of these potentially treatable conditions. All cases of sudden unexpected death attributed to intracranial mass lesion that occurred from 1996 to 2002 at the Oxford Radcliffe Hospitals, NHS Trust, were reviewed. During the study period, six children, aged between 10 weeks and 12 years, died suddenly with intracranial mass lesions other than haematomas. All of them were unsuspected of having a neurological disease prior to death. All patients were found to have an intracranial mass lesion. There were colloid cyst (n=2), glioblastoma multiform (n=1), primitive neuro-ectodermal tumour (n=1), pyogenic abscess (n=1) and histologically unverified tumour (n=1). Presenting features included headache and vomiting in four cases, vomiting longer than 1 week in three and lethargy in four cases. Three patients were misdiagnosed with viral illness. The case series highlights a life-threatening but misleading presentation of intracranial mass lesions. The diagnosis of viral illness should be made cautiously when headache and vomiting occur in the absence of focal complaints. A history of vomiting exceeding a few days duration warrants further investigation. Persistent lethargy should be considered a neurological rather than a non-specific clinical sign.

Sudden Unexpected Child Deaths: Forensic Autopsy Results in Cases of Sudden Deaths During a 5-year Period

The aim of the present study was to determine the incidence of various causes of sudden unexpected child deaths (SUCD) and to assess the importance of an autopsy in predicting the likelihood of finding a cause of death. A retrospective analysis of autopsy findings in 97 cases of SUCD between the ages of 0--11 years was undertaken at the Council of Forensic Medicine, Ankara during a 5-year period (1995--2000). Cases were classified as explained causes (80.42 per cent) and sudden infant death syndrome (SIDS) (19.58 per cent). A total of 25.77 per cent of the deaths occurred in the neonatal period, 45.31 per cent of them in the first year of life and the remaining 28.86 per cent after 1 year of life. The causes of neonatal deaths were respiratory pathology (five cases), birth complications (four cases), gastrointestinal pathology (one case), homicide (10 cases), and SIDS (five cases). The incidence of SIDS in the newborn period was 33 per cent. The incidence of unexplained causes of deaths in the postneonatal period was 31 per cent and the causes of deaths were respiratory pathology (15 cases), aspiration (five cases), gastrointestinal pathology (four cases), SIDS (14 cases), and other causes (four cases). The study of an entire population provides more reliable data regarding causes of sudden unexpected child deaths than does the study of small groups and it is also recommended that in addition to a through evaluation, a detailed autopsy must be performed for each case in experienced centers.

Sudden Unexpected Death in Childhood: A Report of 50 Cases

Sudden unexplained death in childhood (SUDC) is rare, with a reported incidence in the United States of 1.5 deaths per 100,000 live births compared with 56 deaths per 100,000 live births for sudden infant death syndrome in 2001. The objectives of this study include a proposal for a general definition for SUDC and presentation of 36 cases of SUDC and 14 cases of sudden unexpected death in childhood. Cases were accrued through referrals or unsolicited via our Web page (http://www.sudc.org ). Our analyses tentatively suggest a SUDC profile characterized by cases being 1 to 3 years in age, predominantly male, and frequently having a personal and family history of seizures that are often associated with a fever. A history of recent minor head trauma is not uncommon. They are usually born at term as singletons and occasionally have a family history of sudden infant death syndrome or SUDC. Most are found prone, often with their face straight down into the sleep surface. Minor findings are commonly seen at postmortem examination but do not explain their deaths. Comprehensive review of the medical history and circumstances of death and performance of a complete postmortem examination including ancillary studies and extensive histologic sampling of the brain are critical in determining the cause of death in these cases of sudden unexpected childhood death. Legislation enabling research and formation of a multicenter research team is recommended to unravel the mystery of SUDC.

Cardiovascular Health Promotion in the Schools

Cardiovascular disease (CVD) is a major cause of morbidity and premature mortality in men and women in the United States, most of the industrialized world, and many developing countries.1 Primary prevention of CVD beginning in early childhood is supported by extensive evidence culled from epidemiological, clinical, and laboratory studies.2–16 Taken together, these data provided the impetus for the American Heart Association (AHA) Guidelines for Primary Prevention of Atherosclerotic Cardiovascular Disease Beginning in Childhood17 and support the need for population-based approaches to cardiovascular health promotion and risk reduction. Specifically, the population-based approach, which is aimed at modifying the food and physical activity environments of children, is an important concomitant to the high-risk approach because without the proper environment, the high-risk strategy cannot be optimally implemented. School health programs initiated in preschool and extending through high school have the potential to influence the cardiovascular health of the majority of US children and youth. Toward this goal, this statement is intended for health and education professionals, child health advocates, policymakers, and community leaders who are interested in optimizing the school environment as an integral part of population-based strategies designed to promote cardiovascular health for all US children and youth and reduce the risk and public health burden of CVD. Several lines of evidence underscore the importance of primary prevention of CVD beginning in childhood and the need for population-based approaches to cardiovascular health promotion and risk reduction. Autopsy studies (after the unexpected deaths of children and youth)2–5 document significant positive associations between established risk factors and the presence and extent of atherosclerotic lesions in the aorta and coronary arteries of children and youth. Specifically, data from the Bogalusa Heart Study3,4 and the Pathobiological Determinants of Atherosclerosis in Youth (PDAY)2,5 study link potentially modifiable risk factors, including atherogenic …

Sudden unexpected death in children with a previously diagnosed cardiovascular disorder

Background: It is known that children with previously diagnosed heart defects die suddenly. The causes of death are often unknown. Objective: The aim of the study was to identify all infants and children within the Netherlands with previously diagnosed heart disease who had a sudden unexpected death (SUD), and to identify the possible cause of death. Design: Retrospective, cross-sectional study. Patients and setting: All children (<19 years) with a previously diagnosed heart defect and SUD between January 1990 and June 2001 in seven out of eight tertiary centres in the Netherlands were identified using the hospital databases. We excluded patients receiving compassionate care. Diagnoses, clinical status and circumstances of death were sought from case notes and post mortem reports. Deaths were classified as of cardiac or non-cardiac origin. Results: We identified 150 cases of SUD (89 male) at a median age of 2.3 years (range 18 days–18.9 years); 49/150 patients (33%) were ≤1 year. Diagnostic categories included left to right shunts ( N=34, 14 ≤1 year), cyanotic lesions ( N=38, 13 ≤1 yar), cardiomyopathy ( N=11, 2 ≤1 year), univentricular heart ( N=24, 10 ≤1 year), obstructive lesions ( N=11, 3 ≤1 year), arrhythmia ( N=8, 0 ≤1 year), and miscellaneous defects ( N=18, 5 ≤1 year). 108/150 patients (72%) had been operated of whom 61 (57%) had corrective surgery. Of the infants with SUD, 32/49 (65%) had undergone surgery (11 corrective); 76/101 older children had undergone previous surgery (50 corrective). 114/150 children (76%) died of a cardiac cause. Causes of death were arryhythmia (59), heart failure (25), shunt occlusion (10), pulmonary hypertensive crisis (8) and acute myocardial infarction (4). 30/49 infants (61%) died of a cardiac cause; causes of death included arrythmia (10), heart failure (8), shunt occlusion (7), acute myocardial infarction (2). Conclusions: SUD in children with heart defects were predominantly of cardiac origin. Pumpfailure and arrhythmias were the terminal events in a significant number of patients in the entire population.

The potential for QT prolongation by antiepileptic drugs in children

Cardiac arrhythmia may be one of the major causes of sudden unexpected death in children with epilepsy. We assessed drug-induced QT prolongation to establish whether the use of antiepileptic drugs contributes to sudden unexpected death. A total of 178 children with epilepsy (93 males and 85 females, with ages ranging from 1 month to 18.9 years; mean age 7.0 ± 4.1 years) were involved in the study. The QT intervals were manually measured and corrected using Fridericia's formula (QTFc = QT/RR 1/3). The mean corrected QT interval (QTc) of 152 children on antiepileptic drugs during the study period was 0.40 ± 0.03 s, and for 26 age-matched, antiepileptic drug-free control patients it was 0.40 ± 0.03 s. The mean QTc of the children with monotherapy was 0.40 ± 0.03 s for the valproate group (n = 42), 0.39 ± 0.02 s for the carbamazepine/oxcarbazepine group (n = 34), and 0.40 ± 0.02 s for the topiramate group (n = 26), respectively. There was no statistically significant difference among the groups as assessed by analysis of variance. In addition, there was no significant difference between the monotherapy group (n = 109; 0.40 ± 0.02 s) and the polytherapy group (n = 43; 0.39 ± 0.03 s). Major antiepileptic drugs may not precipitate prolongation of the QT interval into sudden unexpected death in children with epilepsy, however further studies are required.

Learning how to handle emotionally challenging situations: the context of effective reflection

This paper reports how, through reflective collaboration between two students, a practitioner and a health lecturer, prospective professional nurses can develop and implement effective strategies to deal with emotionally challenging situations. Using the example of unexpected child death, issues affecting the support for the student provided in both clinical and formal educational settings are explored. The ability to apply a previous learning experience in a further critical situation was found to be dependent on cultural and contextual changes. Following on from the student experience it is demonstrated how learning about emotionally challenging situations can be achieved through reflection in conjunction with supportive processes provided by both practice and education. A supportive network in place for practitioners supporting students needs to be facilitated through mechanisms such as clinical supervision. The new Diploma in Nursing curriculum is examined for its potential to provide a seamless transitional support network from early student experience to experienced practitioner and throughout a career of life-long learning. There is a need for research that critically examines whether the developing system of reflection in education and practice is effective in helping students learn about emotionally challenging situations.

Advances in clinical forensic medicine.

Clinical forensic medicine is the branch of medicine that deals specifically with cases involving both legal and medical aspects of patient care. A forensic evaluation refers to the detection, collection, and preservation of evidence. Pattern injury recognition, interpretation of injuries, documentation of testimonial and injuries (including photography), reporting requirements, and regulations are all vital components of a forensic evaluation, but are rarely the topic of discussion in training hospitals. Medical professionals working in prehospital care and acute care settings are likely to encounter perplexing forensic issues related to child abuse, sexual assault, or unexpected childhood death in their practice. This article focuses on the most recent insights related to sexual assault and forensic evidence as it relates to successful prosecution, shaken baby syndrome, and pediatric nonaccidental thermal injury. Also reviewed are the most current publications related to clinical forensic medicine for the year 2002, incorporating practical clinical tips from the most informative articles from the past decade.

American heart association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood

Atherosclerotic cardiovascular disease remains the leading cause of both death and disability in North America. Evidence that most cardiovascular disease is preventable led to development of the American Heart Association’s initial “Guide to the Primary Prevention of Cardiovascular Disease” in 1996 and the updated version in 2002. Those guidelines do not address prevention in children, a group for whom primary prevention should hold the most promise. Emergence of multiple lines of evidence with regard to the importance of known risk factors for atherosclerotic disease in children and young adults has provided the impetus to develop guidelines for primary prevention in this young population. Pathological studies have shown that both the presence and extent of atherosclerotic lesions at autopsy after unexpected death of children and young adults correlate positively and significantly with established risk factors, namely low-density lipoprotein cholesterol, triglycerides, systolic and diastolic blood pressure, body mass index, and presence of cigarette smoking. Findings from the Bogalusa study indicate that as the number of cardiovascular risk factors increases, so does the pathological evidence for atherosclerosis in the aorta and coronary arteries beginning in early childhood. Electron beam computed tomography of coronary artery calcium and increased carotid artery intima-media thickness, an ultrasound measure of carotid artery atherosclerosis, have been evaluated in 29- to 39-year-olds monitored from 4 years of age. Significant risk predictors for coronary artery calcium were obesity and elevated blood pressure in childhood and increased body mass index and dyslipidemia as young adults. Multiple epidemiological studies have demonstrated a disturbing increase in the prevalence of obesity beginning in childhood, with at least 22% of 6- to 17-year-olds diagnosed as overweight. This is a cause for particular concern because of the strong association between obesity and hypertension, dyslipidemia, and type II diabetes mellitus beginning in childhood. Long-term follow-up studies have demonstrated …

Incidence of autopsy findings in unexpected deaths of children and adolescents.

Studies in various settings reveal that a significant percentage of autopsies demonstrate findings that were not previously clinically diagnosed. In the pediatric and adolescent age group, forensic examinations comprise a large percentage of total autopsies performed. We hypothesized that a similar number of previously undiagnosed findings would be present in this population and thus reviewed a series of autopsy reports from the Medical Examiners Office in the Arkansas Crime Laboratory. During 1997 through 1999, we performed 439 complete forensic autopsies on children and adolescents (age range 1 day to 19 years; median 18 months). Previously undiagnosed lesions were found in 173 (39%). Of these subjects, 68 (39%) had clinically significant pathology, 60 (35%) had insignificant pathology, and 45 (26%) had pathology of undetermined significance. Thirty-six subjects had lesions expected from a previously diagnosed condition. Of the total number of lesions found, 168 were inflammatory, 58 were congenital anomalies (48 unexpected), and 88 comprised miscellaneous other conditions. Infants <6 months of age were significantly more likely to have a previously undiagnosed lesson than children > 6 months (P <0.0001). Previously undiagnosed findings, mostly inflammatory, occur relatively frequently in pediatric and adolescent forensic autopsies and are more likely to occur in infants.

Postmortem radiography after unexpected death in neonates, infants, and children: should imaging be routine?

The purpose of this study was to determine whether postmortem radiography of neonates, infants, and children provides additional information that is not detected at autopsy in cases of unexpected death. Inclusion criteria for 106 consecutive postmortem skeletal surveys (1998-2000) were neonates, infants, and children 2 years old or younger with no preexisting medical condition to account for mortality. Pediatric radiologists interpreted all the radiographic examinations, which consisted of high-detail, collimated anteroposterior radiographs of the appendicular and axial skeleton, lateral radiographs of the axial skeleton, and oblique radiographs of the ribs. Imaging results were compared with those obtained from standard protocol autopsies on all children. Four categories of death were designated: homicide (i.e., abuse, n = 14), accidental (e.g., drowning, n = 28), natural (e.g., acute illness, n = 43), and undetermined (n = 21). The causes of death in the 14 child abuse victims were blunt force injuries to the intracranial (n = 11) and chest and abdominal (n = 1) areas; asphyxia (n = 1); and shaking injury (n = 1). In six (43%) of these 14 patients, radiography detected 26 extremity fractures that had not been detected at autopsy; four (67%) of these six patients had fractures of different ages that involved more than one extremity. All fractures carried a high index of suspicion of abuse. No skeletal injuries were found in cases of accidental, undetermined, and natural deaths. Postmortem radiography provides important additional information regarding the extent and chronicity of extremity trauma that may not be documented at autopsy. This finding supports the routine use of radiography in cases of suspected child abuse. Normal findings on postmortem skeletal radiography may help to distinguish cases of natural, accidental, and undetermined causes of death from those of abuse, aiding in the proper handling of these cases by medical and law enforcement personnel.

Carboxyhemoglobin (COHB) Saturations in Sudden Unexpected Deaths of Children Under Two Years of Age in Ontario

ABSTRACTCarbon monoxide (CO) saturation analysis is one of the routine toxicological examinations performed in the province of Ontario for all deaths involving children under 2 years of age where the cause of death is unknown. Carboxyhemoglobin (COHb) levels were measured in 116 cases that arrived at the Toxicology Section of the Centre of Forensic Sciences (CFS) between April 1996 and April 2000. COHb saturations in all cases were consistent with normal environmental exposure and averaged 3.0 ± 0.1% (range from 1.0% to 9.0%). There was no statistically significant effect of gender (males 3.0 ± 0.2% and females 3.0 ± 0.2%) or age group (neonates 2.8 ± 0.2%, infants 3.1 ± 0.2% and children 2.8 ± 0.3%) on COHb saturation. The present results suggest that a COHb level in a toxic range is a highly improbable finding (0 in 116 cases) in sudden unexpected deaths of children under the age of 2 years. Therefore, it is recommended that COHb levels be measured in pediatric deaths only if the case history suggests possible exposure to a CO source and/or postmortem examination reveals signs of possible CO intoxication.

Sudden unexpected death in infants under 3 months of age and vaccination status- -a case-control study.

To determine whether DTPP+Hib vaccination (diphtheria, tetanus, pertussis, poliomyelitis +/- haemophilus) increased the risk of sudden unexpected death (SUD) in children under 3 months of age. We conducted a multicentre case-control study in the 28 French 'SIDS Centers'. Case selection was based on death labelled sudden infant death syndrome (SIDS) of an infant aged between 30 and 90 days. Three living controls were selected, matched for sex, gestational age and born immediately after the victim in the same maternity unit. We identified 114 cases of SUD aged between 30 and 90 days and 341 live controls matched for age and sex and born in the same maternity unit as the case. DTPP+/-Hib immunization did not increase the risk of SUD (OR 1.08) (95% CI 0.49, 2.36) in children under 3 months of age when adjusted for sleeping position, illness in the week before death, maternal tobacco consumption, birth weight, type of mattress, breastfeeding and sex. However, low birth-weight (6.53 [2.29, 18.9]), multiple birth (5.1 [1.76, 15.13]), no breastfeeding (1.77 [1.1, 2.85]), prone sleeping position (9.8 [5, 8, 18, 9]), soft mattress (3.26 [1.69, 6.29]), recent illness (3.44 [1.84, 6.41]) and parental smoking (1.74 [1.2, 2.96]) were confirmed as risk factors in early SIDS. DTPP+/-Hib immunization is not a risk factor for early SUD. In this population, we found the same risk factors as described for SIDS.

Child neglect or tragic misadventure?

The body of a 2-month-old baby was found inside the pram where he had been left overnight. Initial assessment of the event by a paramedic unit seemed to indicate foul play, based on the presence of a prominent linear pressure mark on the child's scalp and face. Thorough police and medicolegal investigation cleared the suspect and disclosed that the death resulted from accidental positional asphyxia, related to a faulty mechanism of the pram. We advise that when examining sudden unexpected death of children, forensic investigators should be aware of the potential hazards associated with baby accessories.