Unexplained Infant Death Research Articles

The disparity in infant mortality outcomes based on duration of tobacco smoke in pregnancy

Smoking is an important public health burden. In pregnancy, it has been linked to fetal growth restriction, preterm birth, and sudden unexplained infant death. The objective of this study is to determine whether the duration of smoking in pregnancy results in differences in risk of infant mortality.

Risk Factors for Sudden Infant Death in North Carolina.

Background: Sudden infant death syndrome (SIDS) is the sudden, unexplained death of infants <1 year old. SIDS remains a leading cause of death in US infants. We aim to identify associations between SIDS and race/ethnicity, birth weight/gestational age, and socioeconomic/environmental factors in North Carolina (NC) to help identify infants at risk for SIDS.Methods and Results: In this IRB-approved study, infant mortality 2007–2016 and death certificate-linked natality 2007–2014 were obtained from the NC Department of Health and Human Services. General, NC natality statistics 2007–2016 were obtained from CDC Wonder. Association between SIDS/total infant death and covariates (below) were calculated. Total infant mortality decreased 2007–2016 by an average of 14 deaths/100,000 live births per year, while SIDS incidence remained constant. Risk ratios of SIDS/total infant deaths, standardized to Non-Hispanic White, were 1.76/2.41 for Non-Hispanic Black and 0.49/0.97 for Hispanic infants. Increased SIDS risk was significantly and independently associated with male infant sex, Non-Hispanic Black maternal race/ethnicity, young maternal age, low prenatal care, gestational age <39 weeks, birthweight <2500 g, low maternal education, and maternal tobacco use (p < 0.01). Maternal previous children now deceased also trended toward association with increased SIDS risk.Conclusions: A thorough SIDS risk assessment should include maternal, socioeconomic, and environmental risk factors as these are associated with SIDS in our population.

Memory-Efficient AI Algorithm for Infant Sleeping Death Syndrome Detection in Smart Buildings

Artificial intelligence (AI) is fundamentally transforming smart buildings by increasing energy efficiency and operational productivity, improving life experience, and providing better healthcare services. Sudden Infant Death Syndrome (SIDS) is an unexpected and unexplained death of infants under one year old. Previous research reports that sleeping on the back can significantly reduce the risk of SIDS. Existing sensor-based wearable or touchable monitors have serious drawbacks such as inconvenience and false alarm, so they are not attractive in monitoring infant sleeping postures. Several recent studies use a camera, portable electronics, and AI algorithm to monitor the sleep postures of infants. However, there are two major bottlenecks that prevent AI from detecting potential baby sleeping hazards in smart buildings. In order to overcome these bottlenecks, in this work, we create a complete dataset containing 10,240 day and night vision samples, and use post-training weight quantization to solve the huge memory demand problem. Experimental results verify the effectiveness and benefits of our proposed idea. Compared with the state-of-the-art AI algorithms in the literature, the proposed method reduces memory footprint by at least 89%, while achieving a similar high detection accuracy of about 90%. Our proposed AI algorithm only requires 6.4 MB of memory space, while other existing AI algorithms for sleep posture detection require 58.2 MB to 275 MB of memory space. This comparison shows that the memory is reduced by at least 9 times without sacrificing the detection accuracy. Therefore, our proposed memory-efficient AI algorithm has great potential to be deployed and to run on edge devices, such as micro-controllers and Raspberry Pi, which have low memory footprint, limited power budget, and constrained computing resources.

Understanding the Obstacles and Influences in Adopting Infant Safe Sleep Practices

Background About 3,500 infants die annually within their first year of life from Sudden Unexplained Infant Death (SUID) and its subset Sudden Infants Death Syndrome (SIDS), making it the single leading cause of infant mortality in the U.S. Evidence indicates adherence to infant Safe Sleep Guidelines developed by the American Academy of Pediatrics (AAP) reduces these mortality rates. Still, since an initial decline following the 1994 guidelines introduction, SIDS rates have leveled, and SUID rates have increased. In addition, SUID rates per 100,000 live births are twice as high among Black and Native American infants than white. The AAP last updated the guidelines in 2016 and is scheduled to issue the next updated guidelines in late 2021. Objective To examine perceptions of the AAP guidelines held by parents and health care providers as they relate to guidelines comprehension and compliance, and to share this information with the AAP 2021 guidelines task force. Methods First Candle commissioned a qualitative research study in 2020, consisting of three online focus groups in three different states to identify perceptions and potential barriers to guidelines adoption by family members and providers, the outcomes of which were shared with the AAP for review as its guidelines task force develops the updated version to be released in 2021. Results Regarding how the AAP guidelines were viewed, there were responses across geographic and sociocultural variation regarding varying levels of general comprehension and trust in them, depending on the resource and acceptance of the language used. Additional factors were the emotional and practical realities of parenting, cultural and family traditions, and the belief that parental volition in decision-making is important. Conclusion Evidence-based protocols regarding infant safe sleep practices and their impact on reducing infant mortality rates may have proven value. Still, professional caregivers and family members feel that more cultural context and personal relevance are needed in presentation and communication if families are to trust and consider them for adoption and compliance.

A Retrospective Study of Parent’s First-Hand Experience of Premonitions and Other Anomalous Aspects of the SIDS Phenomenon: A potential “SIDS early warning system?”

Introduction The main purpose of this study is to determine the incidence of premonition in SIDS parents vs. Non-SIDS/Control Group parents and to test for a number of other anomalous "markers" noted anecdotally by decades of in the field observation. Evidence of premonition and these other "markers" as consistent elements of the SIDS phenomenon could serve as an "early warning system" for a future SIDS event if confirmed by larger studies. Methodology Both groups of SIDS parents and Control parent participants completed electronic questionnaires on the SurveyMonkey platform for statistical analysis. Results The results of this pilot study indicated statistically significant differences between the SIDS parent and Non-SIDS control study groups for premonition and a set of other anomalous markers. Conclusion The authors believe that this pilot study of premonition and other markers may provide an "early-warning" system for an impending SIDS event if confirmed with future larger studies. Importance: This pilot study confirms results of the value of premonition as well as other anomalous observations by parents whose infants may be at risk for a SIDS event. This study deserves to be confirmed by larger studies and, if so, confirmed indicates a reliable "early warning system" for an impending SIDS event. We face the problem if this SIDS event represents the small percentage of infants who will die of SIDS, even if a diagnostic evaluation and management, including hospital admission and monitoring, may not prevent death from SIDS. However, if this premonition is predictive of Sudden Unexplained Infant Death (SUID) secondary to a potentially preventable etiology, this infant death may be preventable.

Spectral motherhood and maternal grieving: language and sudden unexplained death in infancy in Australian juvenile fiction

ABSTRACT Written by adults for children, children’s literature plays a significant role in shaping readers’ identities and worldviews, including those relating to gender and death. In two Australian children’s novels, The Shape (2000) by Diane Bates and The Naming of Tishkin Silk (2003) by Glenda Millard, the generic depiction of motherhood meets new representational agendas relating to sudden unexplained death in infancy and grieving at a politically charged price. Primarily drawing on an Irigarayian theory relating to motherhood, and patriarchal language and discourse, this paper argues that the depressed mothers in these two novels function as spectral figures, whose absent presence and present absence haunt both the child protagonists and the texts. Moreover, the fictional mothers’ healing is dependent on their relationship to their surviving children, which ensures that ideologies of motherhood are contained within patriarchal discourses in these texts for children.

Characterising Post-mortem Bacterial Translocation Under Clinical Conditions Using 16S rRNA Gene Sequencing in Two Animal Models.

Sudden unexpected death in infancy (SUDI) is the sudden and unexpected death of an apparently healthy infant occurring within the first year of life where the cause is not immediately obvious. It is believed that a proportion of unexplained infant deaths are due to an infection that remains undiagnosed. The interpretation of post-mortem microbiology results is difficult due to the potential false-positives, a source of which is post-mortem bacterial translocation. Post-mortem bacterial translocation is the spread of viable bacteria from highly colonised sites to extra-intestinal tissues. We hypothesise that although post-mortem bacterial translocation occurs, when carcasses are kept under controlled routine clinical conditions it is not extensive and can be defined using 16S rRNA gene sequencing. With this knowledge, implementation of the 16S rRNA gene sequencing technique into routine clinical diagnostics would allow a more reliable retrospective diagnosis of ante-mortem infection. Therefore, the aim of this study was to establish the extent of post-mortem bacterial translocation in two animal models to establish a baseline sequencing signal for the post-mortem process. To do this we used 16S rRNA gene sequencing in two animal models over a 2 week period to investigate (1) the bacterial community succession in regions of high bacterial colonisation, and (2) the bacterial presence in visceral tissues routinely sampled during autopsy for microbiological investigation. We found no evidence for significant and consistent post-mortem bacterial translocation in the mouse model. Although bacteria were detected in tissues in the piglet model, we did not find significant and consistent evidence for post-mortem bacterial translocation from the gastrointestinal tract or nasal cavity. These data do not support the concept of significant post-mortem translocation as part of the normal post-mortem process.

Explaining Sudden Unexpected Infant Deaths, 2011-2017.

Sudden unexpected infant death (SUID) represents a broad group of explained and unexplained infant deaths (<1 year old). Explaining why SUID occurs is critical to understanding etiology and prevention. Death certificate data cannot differentiate explained from unexplained SUID cases nor describe the surrounding circumstances. We report SUID rates by explained and unexplained categories and describe demographics and history of recent injury or illness using the Centers for Disease Control and Prevention SUID Case Registry. The registry is a population-based surveillance system built on Child Death Review programs. Data are derived from multiple sources, including death certificates, scene investigations, and autopsy reports. Cases included SUIDs reported by states or jurisdictions participating in the registry during 2011-2017. Cases were classified into explained and unexplained categories by using the registry's classification system. Frequencies, percentages, and mortality rates per 100 000 live births were calculated. Of the 4929 SUID cases, 82% were categorized as unexplained. Among all cases, 73% had complete case information. Most SUIDs (72%) occurred in an unsafe sleep environment. The SUID mortality rate was 97.3 per 100 000 live births. Among explained and possible suffocation deaths, ∼75% resulted from airway obstruction attributed to soft bedding. Unsafe sleep factors were common in explained and unexplained SUID cases, but deaths could only be classified as explained suffocation for ∼20% of cases. Further analysis of unexplained deaths, including continued improvements to death scene investigation and documentation, may generate hypotheses for physiologic and genetic research, advance our understanding of gaps in SUID investigation, and enhance our understanding of infants at highest risk.

On Adapting to Remote Learning for Healthcare Professionals

The article focuses on COVID-19 pandemic has changed and continues to change our health outlook, risk behaviors, and daily activities and for clinicians and health education professionals, it has forced us to be open to new ways of working with each other and with those we serve Topics include the mission is to reduce the rate of infant mortality due to Sudden Unexplained Infant Death (SUID), which includes Sudden Infant Death Syndrome and Accidental Strangulation and Suffocation in Bed

Silver nanoparticles in the fetal brain: new perspectives in understanding the pathogenesis of unexplained stillbirths.

We report, for the first time, the surprising presence of toxic nanoparticles, especially silver, in the brain of a fetus, who died unexpectedly at the end of a regular pregnancy. After an accurate autopsy, including the examination of the fetal annexes, an in-depth anatomopathological study of the nervous system and a search by scanning electron microscopy of nanoparticles in the brain, we highlighted the sequence of events that may have led to this fetal death, triggered primarily by the transition of nanosized xenobiotics from the mother to the fetal bloodstream. From this report emerges the importance of considering the search of nanosubstances in the brain during routine investigations following unexpected and unexplained fetal and infant deaths.

Vaccines and sudden infant death: An analysis of the VAERS database 1990-2019 and review of the medical literature.

Although there is considerable evidence that a subset of infants has an increased risk of sudden death after receiving vaccines, health authorities eliminated "prophylactic vaccination" as an official cause of death, so medical examiners are compelled to misclassify and conceal vaccine-related fatalities under alternate cause-of-death classifications. In this paper, the Vaccine Adverse Event Reporting System (VAERS) database was analyzed to ascertain the onset interval of infant deaths post-vaccination. Of 2605 infant deaths reported to VAERS from 1990 through 2019, 58 % clustered within 3 days post-vaccination and 78.3 % occurred within 7 days post-vaccination, confirming that infant deaths tend to occur in temporal proximity to vaccine administration. The excess of deaths during these early post-vaccination periods was statistically significant (p < 0.00001). A review of the medical literature substantiates a link between vaccines and sudden unexplained infant deaths. Several theories regarding the pathogenic mechanism behind these fatal events have been proposed, including the role of inflammatory cytokines as neuromodulators in the infant medulla preceding an abnormal response to the accumulation of carbon dioxide; fatal disorganization of respiratory control induced by adjuvants that cross the blood-brain barrier; and biochemical or synergistic toxicity due to multiple vaccines administered concurrently. While the findings in this paper are not proof of an association between infant vaccines and infant deaths, they are highly suggestive of a causal relationship.

Improving infant sleep safety via electronic health record communication: a randomized controlled trial

BackgroundWith increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines.MethodsOne hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher’s Exact test to assess group differences in guideline adherence at 2 months.ResultsOne hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25–52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28–46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI − 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface.ConclusionsUtilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices.Trial registrationName: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048; Date of Registration: September 7, 2018;Data Sharing Statement: None

Knowledge on sudden unexplained infant death-related safe sleep practices and infant cardiopulmonary resuscitation in pediatric nurses.

PurposeSudden unexplained infant death (SUID) is a major contributor to infant mortality, and pediatric nurses have the responsibility to educate parents on SUID-reducing strategies. This study was conducted to measure pediatric nurses’ knowledge of SUID-related safe sleep practices (K-SSSP) and infant cardiopulmonary resuscitation (K-ICPR).MethodsIn total, 136 pediatric nurses were administered a survey including K-SSSP (13 items), K-ICPR (5 items), confidence in K-SSSP education (1 item; 5 points), and other factors relating to SUID experiences or education.ResultsThe correct answer rates of the K-SSSP and K-ICPR were 62.6% and 62.5%, retrospectively. The mean score for confidence in K-SSSP education was 2.6±0.9. Only 18 nurses (13.2%) responded that they educated parents on the content of the K-SSSP, while 76 nurses had received education on SUID. Positive relationships were observed between K-SSSP scores and higher education, between K-ICPR scores and having own child(ren) and clinical experience, and between confidence in K-SSSP education and higher education or having one’s own child(ren). Nurses caring for newborns performed more SUID education than nurses working in other units.ConclusionThere is a profound need to implement a systemic educational program on SUID and strategies to reduce SUID for pediatric nurses.

Sudden Unexplained Infant Deaths: New Study Findings Related to Day of Life.

Sudden Unexplained Infant Deaths: New Study Findings Related to Day of Life.

Mother-Infant Co-Sleeping and Maternally Reported Infant Breathing Distress in the UK Millennium Cohort.

Mother–infant co-sleeping or bed sharing is discouraged by health organisations due to evidence that it is associated with unexplained sudden infant death. On the other hand, there is evidence that it should theoretically be beneficial for infants. One line of this evidence concerns breathing regulation, which at night is influenced by the rocking movement of the mother’s chest as she breathes. Here, the hypothesis that mother–infant co-sleeping will be associated with a lower probability of infant breathing distress is tested in the UK Millennium Cohort Study (n = 18,552 infants). Maternal, infant, family, and socio-economic covariates were included in logistic regression analysis, and in a machine learning algorithm (Random Forest) to make full use of the number of variables available in the birth cohort study data. Results from logistic regression analysis showed that co-sleeping was associated with a reduced risk of breathing difficulties (OR = 0.69, p = 0.027). The Random Forest algorithm placed high importance on socio-economic aspects of infant environment, and indicated that a number of maternal, child, and environmental variables predicted breathing distress. Co-sleeping by itself was not high in the Random Forest variable importance ranking. Together, the results suggest that co-sleeping may be associated with a modest reduction in risk of infant breathing difficulties.

Tonsillar hypertrophy and prolapse in a child \u2013 is epiglottitis a predisposing factor for sudden unexpected death?

BackgroundTonsillitis, with associated tonsillar hypertrophy, is a common disease of childhood, yet it is rarely associated with sudden death due to airway obstruction. Lethal complications involving the inflamed tonsils include haemorrhage, retropharyngeal abscess and disseminated sepsis.Case presentationWe report on a case of sudden and unexpected death in an 8-year-old female who was diagnosed with and treated for tonsillitis. The child was diagnosed with acute tonsillitis 2 days prior to her collapse and was placed on a course of oral antibiotics. There were no signs of upper or lower airway obstruction. She was found to be unresponsive by her caregiver and gasping for air in her bed in the early hours of the second morning after the start of treatment. Autopsy showed massive and symmetrically enlarged palatine tonsils. The tonsils filled the pharynx almost completely. The epiglottis and laryngeal mucosa at the base of the epiglottis in the vicinity of the aryepiglottic membrane and the superior aspect of the larynx displayed red-purple discoloration, with mucosal swelling and edema. Histological examination of the palatine tonsils revealed prominent lymphoid hyperplasia, but no evidence of acute inflammation.ConclusionPalatine tonsillar hypertrophy in infants is a common feature of both viral and bacterial tonsillitis and has been postulated as a possible risk factor for Sudden and Unexplained Death in Infancy (SUDI), based on the theory of mechanical impediment of breathing by narrowing of the upper airway. The rounded shape of the tonsils may facilitate some airflow past the enlarged structures and hence protect against asphyxial death when the enlarged tonsils fill the laryngo-pharynx. Epiglottal and proximal laryngeal edema may play a more significant role in asphyxial unexpected deaths in cases of tonsillitis with tonsillar hypertrophy than previously suspected. This focusses the importance of careful examination of the epiglottis and proximal laryngeal mucosa, as part of a thorough examination of the laryngo-pharynx in cases of sudden death associated with tonsillar hypertrophy.

Using Mitochondrial Trifunctional Protein Deficiency to Understand Maternal Health.

Fatty acid oxidation disorders unfortunately can result in the sudden unexplained death of infants. Mitochondrial trifunctional protein (MTP) deficiency is one such disease where long-chain fatty acids cannot be fully oxidized through beta-oxidation which, can lead to cardiac arrythmias in an infant. Furthermore, mothers who are carrying an MTP deficient fetus have a prevalence for pregnancy complications, especially AFLP, acute fatty liver of pregnancy and HELLP syndrome. To better understand the etiology of the potential pro-arrhythmic state the MTP deficient infants may enter, we developed an in vitro model of MTP deficiency in cardiomyocytes to elucidate the underpinning molecular mechanism of this disease. Using CRISPR/Cas9, we developed MTP deficient mutant and knockout pluripotent stem cell lines. Furthermore, we generated patient derived induced pluripotent stem cell lines harboring a so-called founder mutation, the most commonly identified alteration in MTP in the population. Upon differentiating these mutant stem cells into cardiomyocytes and then challenging with fatty acids, we observed pro-arrhythmic behavior, depressed mitochondrial energetics, and elevated hydroxylated long-chain fatty acids, all perhaps expected phenotypes due to MTP deficiency. However, unexpectedly, we also identified an inability of these disease cardiomyocytes to generate mature cardiolipin. Cardiolipin is a key pillar of the powerhouse of life, mitochondria. For the first time this disease-in-a-dish model revealed the key culprit for the dramatic MTP mutant mitochondrial defects and identified potentially a second role for the enzyme HADHA in MTP. HADHA is required for the biosynthesis of functional cardiolipin and therefore healthy mitochondria. However, in the disease, defective cardiolipin results in mitochondrial abnormalities and cardiac arrythmias in infants. These studies reveal an important target for sudden infant death syndrome therapy. With this foundational work on an in vitro model of MTP deficiency and potential avenues for therapy, the next important task is to extend this model to address fetal-maternal interactions towards better governing maternal health.

Sudden Unexplained Infant Deaths and Day of Life 0.

* Abbreviations: SIDS — : sudden infant death syndrome SUID — : sudden unexplained infant death Fifty years ago, an extraordinary group of pathologists, pediatricians, and epidemiologists met to address the limited research and numerous diagnoses applied to unexplained, largely sleep-related pediatric deaths. Their efforts led to the identification of a new category of disease, sudden infant death syndrome (SIDS). Among the observations fueling the creation of the category was the relative sparing of neonates despite what should be increased vulnerability in the early days of life. When Dr Bruce Beckwith, the conference’s leader, asked whether anyone doubted this age-related sparing, not a single objection was raised.1 Yet, humility about what was not yet known led to broader diagnostic criteria of “any infant or young child.” Years later, SIDS was redefined as pertaining to infants <1 year of age.2 Still later, when classification practices scattered because of objections about the concept of SIDS and the varied use of alternative terminologies, the composite of sudden unexplained infant death (SUID) came to stand in.3 In this issue of Pediatrics , big data concur with the pioneering thinkers and draw the demarcation at 1 week. In “Distinct … Address correspondence to Richard D. Goldstein, MD, Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: richard.goldstein{at}childrens.harvard.edu

Intensive Care Neonates and Evidence to Support the Elimination of Hats for Safe Sleep

Although the incidence of sudden unexplained infant deaths has decreased over time with the use of safe sleep practices, one area that remains unclear is the safety of hats during infant sleep. Decrease the risk of overheating or suffocation by removing NICU infants' hats during sleep without increasing the relative risk of hypothermia during transition to an open crib. Removal of hats for routine thermoregulation, beyond the initial infant resuscitation and stabilization of NICU infant was implemented in 2015. Retrospective chart audits were conducted on all NICU infants between February 2015 and December 2016. Hypothermia (≤ 97.6°F) data during transition to an open crib was collected. Exclusion criteria included concurrent diagnosis of: sepsis, hyperbilirubinemia, congenital anomaly inhibiting infants thermoregulation and noncompliance with unit guideline for weaning infant to open crib. Over 18 months, 2.7% of infants became hypothermic (≤ 97.6°F) during transition to open crib, requiring return to isolettes. Hats were found to be unnecessary in maintaining thermoneutrality after weaning infants toan open crib in our NICU. By avoiding the use of hats in an open crib, it's possible infants will avoid overheating and a risk of suffocation, creating a safer sleep environment. The removal of hats during sleep to promote infant health should be considered for all infants.

Inconsistent classification of unexplained sudden deaths in infants and children hinders surveillance, prevention and research: recommendations from The 3rd International Congress on Sudden Infant and Child Death

This report details the proceedings and conclusions from the 3rd International Congress on Unexplained Deaths in Infants and Children, held November 26–27, 2018 at the Radcliffe Institute at Harvard University. The Congress was motivated by the increasing rejection of the diagnosis Sudden Infant Death Syndrome (SIDS) in the medical examiner community, leading to falsely depressed reported SIDS rates and undermining the validity and reliability of the diagnosis, which remains a leading cause of infant and child mortality. We describe the diagnostic shift away from SIDS and the practical issues contributing to it. The Congress was attended by major figures and opinion leaders in this area from countries significantly engaged in this problem. Four categories (International Classification of Diseases (ICD)-11 categories of MH11, MH12, MH14, PB00-PB0Z) were recommended for classification, and explicit definitions and guidance were provided for death certifiers. SIDS was reframed as unexplained sudden death in infancy or SIDS/MH11 to emphasize that either term signifies the lack of explanation following a rigorous investigation. A distinct category for children over the age of 1 was recommended (MH12). Definitions and exclusions were provided for the alternative categories of accidental asphyxia and undetermined. As recommended, unexplained sudden death in infancy or SIDS on a death certificate will code a unique, trackable entity, accurately reflecting the inability to determine a definitive explanation, while satisfying surveillance needs and reliable identification for research efforts. The conclusions will be submitted to the World Health Organization for inclusion in the upcoming ICD-11.