Unexplained Infant Death Research Articles

Unexplained Infant Deaths Without Unsafe Sleep Factors: 2011 to 2020.

To describe sudden unexpected infant deaths (SUIDs) occurring in safe sleep environments and explore differences in selected characteristics. We examined SUID from 22 jurisdictions from 2011 to 2020 and classified them as unexplained, no unsafe sleep factors (U-NUSF). Data were derived from the Sudden Unexpected Infant Death and Sudden Death in the Young Case Registry, a population-based Centers for Disease Control and Prevention surveillance system built on the National Center for Fatality Review and Prevention's child death review program. SUID classified as U-NUSF included infants who were (1) awake, under supervision, and witnessed to become unresponsive or (2) found unresponsive in a safe sleep environment after sleep (unwitnessed). We calculated frequencies and percentages for demographics, birth and environmental characteristics, medical history, and death investigation findings. Most of the 117 U-NUSF SUID occurred before 4 months of age. Witnessed deaths most commonly occurred at <1 month of age (28%), whereas unwitnessed deaths most commonly occurred at ages 2 to 3 months (44%) Among all U-NUSF, 69% occurred in the infant's home (62% witnessed, 77% unwitnessed). All unwitnessed deaths occurred in a crib; most witnessed deaths occurred while being held (54%) or in a car seat traveling (18%). Most infants (84%) had no history of abuse or neglect. Abnormal autopsy findings were reported in 46% of deaths (49% witnessed, 42% unwitnessed). Characterizing these deaths is key to advancing our knowledge of SUID etiology. Our study revealed a heterogeneous group of infants, suggesting physiologic, genetic, or environmental etiologies.

Cardiac rhabdomyoma: an uncommon culprit in sudden infant death

Sudden death in infants remains a common and poorly understood cause of childhood mortality in the USA. Pediatric cardiac tumors, although rare, may underlie some cases of unexplained sudden infant death. Autopsy is a crucial diagnostic step in these cases, as both gross and microscopic examination of the heart may uncover occult cardiac tumors. Rhabdomyomas are the most common cardiac tumors in childhood and may result in arrythmia and sudden death. We present a case of sudden death in a healthy 5-month-old infant which initially appeared “SIDS-like” until thorough histological analysis revealed an underlying cardiac rhabdomyoma. The case is of particular importance in that the gross examination of the heart was considered completely normal, and the tumor only involved certain portions of the heart microscopically. Had a single random section of myocardium been the only heart section examined microscopically, the diagnosis might have been missed. This case emphasizes the importance of thorough microscopic examination in infant cases, especially in cases where the heart appears grossly normal.

Unexplained infant death in Houston, TX: A 17-year retrospective

SIDS/SUID (henceforth referred to as SIDS) is a leading cause of neonate death, taking the lives of ~10 infants every day in the US alone. SIDS is defined as the death of an infant for which no cause of death can be determined after a complete autopsy, death scene investigation, and medical history review, all of which makes SIDS a very diffcult disease to study. Death scene investigations have identified several contributing environmental factors. However, etiological investigation has been complicated by inconsistencies in classification of death by medical examiners or coroners and unreliable resources for law enforcement to complete death scene investigations, which leads to epidemiological studies often lacking rigor or suffcient data. Using data from Child Fatality Review Team (CFRT) of Harris County, the Medical Examiner’s Offce, and the Texas Department of State Health Services, we performed a retrospective analysis of 17-years of SIDS cases in Harris County, Texas. We applied a novel birth rate correction for SIDS rates over the first year of life. Associations were tested using a Tukey HSD and linear regression models with co-linear factors considered. To focus on biologically unexplained SIDS cases, we subsetted our dataset to only include SIDS and Undetermined causes of death. Our preliminary data includes 1,094 cases comprised of ~43% black, ~32% Hispanic, ~20% white, ~3% Asian, and ~0.4% unknown and 57% male infants. Distribution of death across the first 12 months of life shows a peak of death around 2 months of age. We do not see an association with month or season in the raw SIDS data nor when using our novel correction for birth rates. When we apply the standard per 1,000 live births normalization, we see a significant increase in Spring and Winter. We also report race-dependent significant differences in yearly and monthly case numbers, male-to-female ratios, and age at death and additional significant race-dependent associations between SIDS cases and adults diagnosed with asthma, income level, and overcrowding based on Zip Code. This dataset represents one of the most racially and socio-economically diverse in the United States. Our data suggests that standard trends may be driven by majority white datasets and that response to socioeconomic stress varies by race/ ethnicity, which leads to differences in risk between classically described minority groups. NIH: 1F32HL160073-01A1, R01HL130249 44617-S4. BCM McNair Scholar Program, March of Dimes Basil O'Connor Research Award, Parker B. Francis Fellowship, CJ Foundation for SIDS. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Exploring the Relationship between Psychosocial Risk Factors and Sudden Unexplained Infant Death: A Study of Autopsy Cases from a Perspective of Child Welfare

Infants who are born between 24 hours and 1 year of age require extreme caution in their care due to their fragility. However, if there are multiple risk factors associated with the infant, caretaker, household, and surrounding circumstances, providing proper and appropriate care becomes problematic. This difficulty in caring for infants can contribute to abuse, neglect, or even death. This study investigates unexplained infant deaths that occur in the presence of multiple psychosocial risk factors. This study aimed to explore the relationship between various psychosocial risk factors and sudden, unexplained infant deaths. We examined nine cases from the autopsy archive of the National Forensic Service using a statistical approach. Among these cases, three were subject to legal action, while six were closed without further legal process. Although it was difficult to establish a clear relationship between death and abuse or neglect in the six cases, all were found to have experienced a harsh environment that was similar to abuse or neglect. We discuss the implications of our findings for understanding infant deaths and legal outcomes and propose a new framework to understand the deaths of infants.

94 Understanding Parental Behaviours Related to Infant Sleep Environment

Abstract Introduction/Background Sudden unexplained death in infants continues to make up a significant proportion of infant deaths. Despite wide dissemination of Canadian Paediatric Society and American Academy of Paediatrics safe sleep recommendations, studies demonstrate significant caregiver nonadherence to the recommendations. Few studies have examined caregiver reasons for low uptake of recommendations. There is an urgent need to understand these issues not only for individual providers counseling about sleep, but also for implementation of public health initiatives which attempt to target parental behaviour change. Objectives Our study aimed to explore parental perceptions, beliefs and influences regarding safe infant sleep environment and factors contributing to parental behaviour related to sleep environment. Design/Methods A qualitative study utilizing ground theory methodology was conducted with in-depth individual interviews of 14 parents of infants less than six months admitted to a large paediatric hospital in Toronto, Canada. Data collection occurred from November 2017 to January 2018, until a saturation of themes was reached. Interview transcripts were analyzed for recurrent and emergent themes and a coding structure was developed. Results Interviews with caregivers were completed, and a range of sleep locations and environments were described. Most caregivers reported that a bassinet or crib was the main sleeping location, but most infants were also placed in other locations at various times, including infant swings, couches, and bed-sharing with caregivers. Three dominant themes affecting decision-making about sleep location were identified: 1. safety, 2. feasibility and convenience and, 3. perception of infant preference and developmental needs. These factors were often present simultaneously in parental decision-making, frequently acting in opposition to one another. Caregivers’ methods of mitigating harm were often counter to recommendations, such as using pillows to prevent rolling. Information sources regarding sleep choices typically included family, friends, healthcare providers and media. Most caregivers placed greater significance on healthcare recommendations than the advice of family members. Conclusion This study identified key factors that impact caregivers’ decision-making regarding infant sleep. These results can inform healthcare providers counselling about safe sleep recommendations and public health interventions aimed at increasing adherence to safe sleep recommendations and reducing preventable infant deaths.

Qualitative assessment of infant sleep practices and other risk factors of sudden infant death syndrome (SIDS) among mothers in Lusaka, Zambia

BackgroundThere is very little information on the beliefs and perceptions of mothers about SIDS and its related risk factors in Africa. To better understand parental decisions about infant sleep practices and other risk factors for SIDS, we conducted focus group discussions (FGDs) with mothers of infants in Lusaka, Zambia.MethodsFGDs involved 35 purposively sampled mothers aged 18–49 years. FGDs were conducted using a semi-structured interview guide in the local language, Nyanja. These were translated, transcribed verbatim into English, and then coded and analyzed using thematic analysis in NVivo 12.ResultsSix FGDs were conducted with 35 mothers in April-May 2021 across two study sites. FGD Participants were generally aware of sudden unexplained infant deaths, with several describing stories of apparent SIDS in the community. The side sleeping position was preferred and perceived to be safer for the infant with most believing the supine position posed an aspiration or choking risk to the infant. Bedsharing was also preferred and perceived to be convenient for breastfeeding and monitoring of the infant. Experienced family members such as grandmothers and mothers-in-law, and health care workers were frequently cited as sources of information on infant sleep position. A heightened awareness of the infant’s sleeping environment was suggested as a mechanism to prevent SIDS and smothering.ConclusionsDecisions about bedsharing and infant sleep position were guided by maternal beliefs and perceptions about what is convenient for breastfeeding and safer for the infant. These concerns are vital to designing tailored interventions to address sleep-related sudden infant losses in Zambia. Public health campaigns with tailored messages that address these concerns are likely to be effective at ensuring optimal uptake of safe sleep recommendations.

The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies

Background: The contribution of sudden unexpected infant death (SUID) has received little attention in global health. The objective of this study was to estimate the burden of SUID in Lusaka, Zambia. Methods: Verbal autopsies were conducted on infants who died in Lusaka, between 2017 and 2020. From these, we performed a qualitative analysis of the free text narratives of the final series of events leading to each infant’s death and classified these as symptomatic deaths or SUID. Any narrative that described an infant who was otherwise healthy with no antecedent illness prior to death and found dead in bed after a sleep episode was classified as SUID. We used logistic regression to test for statistical differences between asymptomatic deaths and SUIDs on key infant, maternal and other risk factors of SUIDs. Results: Eight hundred and nine verbal autopsies were conducted with families of decedent infants younger than six months of age. A total of 92.6% (749/809) had presented with symptoms prior to death, whereas 7.4% (60/809) died without preceding symptoms or obvious cause of death. Of these, 16/60 were compatible with accidental suffocation deaths, and 54/60 appeared to be sudden infant death syndrome. SUID deaths were concentrated in infants younger than two months of age with peak age of one to two months. Age at death was the only significant factor in multivariate analysis. Infants aged between one and two months had 2.84 increased odds of suspected SUIDs compared to infants in the first month of life (aOR = 2.84, 95% CI: 1.31, 6.16). Conclusions: Our findings suggest SUID could be accounting for a significant proportion of infant deaths in Zambia, but this cause of infant mortality is going unrecognized. Public health interventions in Zambia, and Africa more broadly, are likely overlooking SUIDs as an important cause of infant mortality.

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

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

Risk of Postneonatal Infant Mortality Associated With Prior Founded Allegations of Child Abuse.

Context: There are ∼7500 postneonatal deaths (28 days to under 1 year) in the US annually, of which a majority are preventable. Previous studies have reported a child's prior encounter with child protective services (CPS) as a risk factor for preventable death but few studies have evaluated this in relation to subsequent postneonatal deaths. Objective: To measure the association between prior reports of child abuse and subsequent postneonatal death. Study Design/Analysis: Secondary data analysis from the case-control Chicago Infant Mortality Study (CIMS). Conditional logistic regression modeling determined the odds of postneonatal death when there was a founded prior allegation. Setting and Population Studied: CIMS included all sudden, unexplained infant deaths up to 1 year in Chicago (November 1993-April 1996) (n=469), and matched living controls (n=472). Information on prior child abuse reports and outcomes was obtained through the Illinois Department of Children and Family Services (DCFS) State Central Registry for each case and control. Instrument: Cause of death was determined by Cook County Medical Examiners based on autopsy, death scene investigation and review of the medical history. DCFS database was searched on infant's name, mother's name, screening number and other identifiers. Only "founded" allegations that occurred prior to the date of death (cases) and date of interview (controls) were included Outcome measures: Founded allegations for cases by cause of death. Odds of death by prior allegations and other socio-demographic factors. Results: DCFS founded allegations were identified in 119 cases (25%) and/or their families and in 35 controls (7%; OR = 4.25, 95% CI, 2.86, 6.35). There were no clear patterns when frequency of allegations was analyzed by cause of death. Families with founded allegations were almost 4 times more likely to experience a postneonatal death (aOR =3.79, 95% CI, 1.56, 9.10). Lower maternal education, age, inadequate prenatal care and infant-parent bedsharing were also associated with higher odds of postneonatal death. Conclusions: Child protective services involvement is an opportunity for education to help reduce the incidence of potentially preventable infant deaths. Families should have access to appropriate acute and preventive care and receive ongoing education about child abuse prevention, infant safety, reducing the risk of preventable deaths such as SIDS, and when to seek medical attention.

Perceptions and Use of Safe Sleep Baby Boxes at Hospital Discharge by New Mothers.

A large community hospital in South Texas began distributing safe sleep baby boxes to reduce sudden unexplained infant death (SUID) in 2017. To describe safe sleep practices among new mothers who received a safe sleep baby box at hospital discharge. An information sheet containing a link to an online survey was mailed to all women who received a safe sleep baby box prior to discharge from the hospital from January 2018 to January 2019. N = 84 women participated. Most reported using the safe sleep baby box only during nap time (n = 62, 88.6%). Only 70.2% of participants reported that baby always slept their back (n = 59). Most reported their baby did not use a pacifier (n = 62, 73.8%), and many reported they were not breastfeeding their baby (n = 38, 45.2%). Many women were not using the safe sleep baby box as intended and were not following many of the other safe sleep guidelines. Nurses should ask their patients about plans for infant safe sleep after discharge to provide individualized education or recommend specific resources to address the family's needs.

Risk Factors for Suffocation and Unexplained Causes of Infant Deaths.

Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome). We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios. We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8-51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9-4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7-12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1-2.4) among nonsupine positioned infants. We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.

The added value of molecular-based diagnostics in the African forensic medical setting.

Sudden unexpected infant death (SUDI) is reported to be an extraordinarily high burden in sub-Saharan Africa, with the incidence rate in South Africa among the highest in the world. It is common for the cause of many such infant deaths to remain unexplained even after a full medico-legal death investigation, and then to be categorised as a sudden unexplained infant death (SUID). Fortunately, advances in molecular-based diagnostics allow researchers to identify numerous underlying inherited cardiac arrhythmogenic disorders in many SUDI cases, with a predominance of variants identified in the SCN5A gene. Such cardiac arrhythmogenic-related sudden deaths generally present with no structural alterations of the heart that are macroscopically identifiable at autopsy, therefore highlighting the importance of post mortem genetic testing. We report on a significant genetic finding that was made on a SUDI case in which the cause was ascribed to an acute bacterial pneumonia but it was still subjected to post mortem genetic testing of the SCN5A gene. The literature shows that many SUDI cases diagnosed with inherited cardiac arrhythmogenic disorders have demonstrated a viral prodrome within days of their death. It is therefore not uncommon for these cardiac disorders in infants to be mistaken for flu, viral upper respiratory tract infection or pneumonia, and without the incorporation of post mortem genetic testing, any other contributory causes of these deaths are often disregarded. This study highlights the need for research reporting on the genetics of inherited cardiac disorders in Africa.

Intervention during the Perinatal Period: Synthesis of the Clinical Practice Guidelines from the French National College of Midwives.

These clinical practice guidelines from the French National College of Midwives (CNSF) are intended to define the messages and the preventive interventions to be provided to women and co-parents by the different professionals providing care to women or their children during the perinatal period. These guidelines are divided into 10 sections, corresponding to 4 themes: 1/ the adaptation of maternal behaviors (physical activity, psychoactive agents); 2/ dietarybehaviors; 3/ household exposure to toxic substances (household uses, cosmetics); 4/ promotion of child health (breastfeeding, attachment and bonding, screen use, sudden unexplained infant death, and shaken baby syndrome). We suggest a ranking to prioritize the different preventive messages for each period, to take into account professionals' time constraints.

Survey of Korean daycare personnel on safe sleep practices related to sudden unexplained infant death: a cross-sectional exploratory study.

Safe sleep practices (SSP) are among the main strategies to reduce sleep-related sudden unexplained infant death (SUID). Daycare personnel must be knowledgeable and trained in SSP related to SUID. This study explored the experience, knowledge, and confidence regarding SSP associated with SUID of daycare personnel. A cross-sectional survey was conducted with 395 staff members at 61 daycare centers to measure their experience related to SSP (10 items), related to sleep position and location, bedding materials, and other topics; knowledge of SSP (18 items); and confidence in SSP (1 item) related to SUID. A substantial proportion (23.6%) of respondents used the lateral or prone positions for infant sleep. On average, 4.5 bedding materials were used for infant sleep. Participants showed a lack of knowledge about SSP as indicated by a 56.6% knowledge of SSP related to SUID correct answer rate. Personnel who received SUID education were more knowledgeable and had more confidence regarding SSP than those who did not. More knowledge and confidence related to SSP were associated with better adherence to SSP. Standard SSP guidelines should be developed based on South Korea's culture of childcare for educating both childcare professionals and parents at home.

Using a Community Approach to Address Sudden Unexplained Infant Death

Using a Community Approach to Address Sudden Unexplained Infant Death

Using a Community Approach to Address Sudden Unexplained Infant Death

Using a Community Approach to Address Sudden Unexplained Infant Death

The Science (or Nonscience) of Research Into Sudden Infant Death Syndrome (SIDS).

This Viewpoint paper presents a timely and constructive critique of mainstream SIDS research. It is concerning that twenty-first century medical science has not provided an answer to the tragic enigma of SIDS. The paper helps explain why this is so and illustrates possible shortcomings in the investigation of Sudden Infant Death Syndrome/Sudden Unexplained Infant Death (SIDS/SUID) by mainstream researchers. Mainstream findings are often based on questionable and dogmatic assumptions that return to founding notions such as the Triple Risk Hypothesis and the contention that the mechanisms underlying SIDS/SUID are heterogeneous in nature. The paper illustrates how the pathological findings in SIDS have been under-investigated (or ignored) and that key epidemiological risk factors have slipped from memory. This apparent amnesia has resulted in failure to use these established SIDS facts to substantiate the significance of various neuropathological, neurochemical, or other research findings. These unsupported findings and their derivative hypotheses are therefore ill-founded and lack scientific rigor.ConclusionThe deficits of SIDS “science” revealed in this paper explain why the SIDS enigma has not yet been solved. To make progress in understanding SIDS, it is important that researchers, as scientists, uphold standards of research. Encouragement for new directions of research is offered.

Negotiating Infant Personhood in Death: Interpreting Atypical Burials in the Late Roman Infant and Child Cemetery at Poggio Gramignano (Italy)

The Late Antique (ca. 450 CE) infant cemetery uncovered at Poggio Gramignano near Lugnano in Teverina (Italy) has been interpreted as a catastrophic death assemblage associated with an acute epidemic of Plasmodium falciparum malaria and a resulting episode of increased infant mortality. Previous research has noted the unique mortuary ritual associated with these burials but has not adequately considered the social implications of the nonnormative burial of the infant and even fetal dead. This paper considers 10 newly uncovered burials of infants and one child from the cemetery, analyzed in situ using an archaeothanatological approach to separate postdepositional taphonomic change from the social and ritual dimensions of intentional funerary behavior. The mortuary treatment provided to these individuals suggests a possible fear of the dead, and more significantly, maternal grief and a desire for remembrance that contrasts with Roman cultural expectations surrounding the mourning of infants. The treatment of these individuals in death provides valuable and specific insight into the attitudes of this rural community’s shared stress surrounding unexplained illness, infant death, and traditional beliefs in an era of significant cultural and social transition.1

Risk of Postneonatal Infant Mortality Associated With Prior Founded Allegations of Child Abuse

This study examined the association between prior reports of child abuse and subsequent postneonatal death and differences by cause of death, using data from the Chicago Infant Mortality Study (CIMS). CIMS included all sudden, unexplained infant deaths up to 1year of age in Chicago (November 1993-April 1996), and age, race-ethnicity, and birthweight-matched living controls. Information on prior child abuse reports and outcomes was obtained through the Illinois Department of Children and Family Services (DCFS) State Central Registry for each case and control. Conditional logistic regression modeling determined the odds of postneonatal death when there was a founded prior allegation. Families with founded allegations were almost 4 times more likely to have a child die during the postneonatal period (aOR = 3.79, 95% CI, 1.56, 9.10). Child protective services involvement is an opportunity for education on safe sleep messaging to help reduce the incidence of potentially preventable infant deaths.

Unexplained Infant Deaths While on Propranolol for Treatment of Infantile Hemangiomas

Propranolol is first-line systemic therapy for infantile hemangiomas. Its use in infants has significantly increased in the last decade. It has a good safety profile, but there are concerns about side effects. We present 5 unexplained deaths of infants who were on propranolol for treatment of infantile hemangiomas.