“The AAP’s Committee
on Child Abuse and Neglect decided to reissue and update the guidelines because
of some recent well-validated reports of infanticide that was confused with SIDS,”
Kent P. Hymel, MD, told RESPIRATORY REVIEWS.
National campaigns to reduce prone sleeping during infancy have dramatically decreased
the prevalence of SIDS in this country and elsewhere. “We were concerned
that as the frequency of true SIDS cases is declining, the percentage of cases
of sudden and unexpected death that may represent homicide may actually be increasing,”
said Dr. Hymel, a member of the Committee on Child Abuse and Neglect.
According to Dr. Hymel, “The
AAP statement is intended to provide pediatricians and primary care physicians
with a set of written guidelines that will allow them to balance the need for
a thorough case evaluation and the equally important need to treat families with
compassion and support at the time of a sudden and unexpected death of an infant.”
The new AAP guidelines state
that a preliminary diagnosis of “probable SIDS” can be made when a previously
healthy infant has died unexpectedly and there is no external evidence of injury.
However, a definitive diagnosis of SIDS is appropriate only when all other possible
causes of death have been ruled out after a thorough postmortem examination, death
scene investigation, and review of case records.
In addition, postmortem findings
should be compatible with SIDS. Potential findings may include evidence of terminal
motor activity, such as clenched fists; a serosanguineous, watery, frothy, or
mucoid discharge from the nose or mouth; and skin mottling. Postmortem lividity
in dependent portions of the infant’s body is also common. Although not diagnostic,
intrathoracic petechiae are found in 80% to 85% of SIDS cases. Dr. Hymel
cautioned that “none of these findings are specific to SIDS.” They support,
but do not prove, the diagnosis.
Of course, not all cases of
sudden infant death result from either SIDS or child abuse. Radiographic surveys
may reveal skeletal abnormalities indicative of a naturally occurring illness.
Inborn errors of metabolism have also been linked with some cases of unexplained
infant death; blood tests or analysis of other bodily fluids or tissues can help
diagnose such a problem.
“SIDS truly is a diagnosis
of exclusion,” stressed Dr. Hymel, Associate Clinical Professor of Pediatrics
at the University of Virginia, and Medical Director of the Pediatric Forensic
Assessment and Consultation Team at Inova Fairfax Hospital in Virginia. “It
is essentially the admission by the medical community and the investigative community
that we have thoroughly and exhaustively studied the infant’s death and find
absolutely no explanation. Only then can the parents be assured that the risk
for SIDS in subsequent children is not likely increased.”
Although it is impossible
to distinguish at autopsy between SIDS and accidental or deliberate asphyxiation
with a soft object, the AAP guidelines suggest that several specific circumstances
should raise suspicion:
• Infant’s age of
6 months or older.
• Previous unexpected
or unexplained deaths of one or more siblings.
• Simultaneous or nearly
simultaneous death of twins.
• Blood on the infant’s
nose or mouth.
• Previous recurrent
cyanosis, apnea, or apparent life-threatening events while under the care of the
same person.
• Previous death of infants
under the care of the same unrelated person.
When results of an autopsy
and careful investigation are inconclusive, it may be appropriate to designate
the cause of death as undetermined. According to the AAP guidelines, examples
of undetermined causes of death include suspected but unproven cases of infection,
metabolic disease, accidental asphyxiation, and child abuse.
—Deborah
L. O’Connor
