PEDIATRICS Vol. 115 No. 3 March 2005, pp. 823a-824 (doi:10.1542/peds.2004-2743)
National Standard for Death-Scene Investigation of Sudden, Unexpected Infant Deaths in the United States: In Reply
Siri Hauge Opdal, PhDTorleiv Ole Rognum, MD
Institute of Forensic Medicine,
Rikshospitalet,
0027 Oslo, Norway
As Tomashek et al state, it is of outstanding importance to have uniform diagnostic criteria when diagnosing sudden infant death syndrome (SIDS) and other causes of sudden, unexpected infant death. Otherwise, any comparison of SIDS rates and research results from different countries, or even different hospitals within 1 country, is impossible.
In the Nordic countries, the SIDS epidemic hit differently among the countries: Norway and Denmark reached very high SIDS rates, Sweden experienced less increase, and Finland had almost no increase at all. Therefore, in 1990 the Nordic Council of Ministers initiated the "NORD SIDS" project. The aim was to investigate both the increase in SIDS rates and the discrepancy between the countries. The first milestone for the pathologists involved was the agreement of the common Nordic exclusion criteria for SIDS.1 During the following years, a blind reproducibility study was performed. Ten forensic pathologists were involved in blind reexamination of 127 randomly selected cases from 10 forensic centers throughout Scandinavia. Cases were selected from the 1970s, 1980s, and the time after 1992. The participants received information about the history, the circumstances of death, microscopic findings, and microbiologic results, as well as essential microscopic slides. It was found that, according to the 1992 Nordic diagnostic criteria, SIDS had been underdiagnosed in the 1970s and 1980s in Finland, Denmark, and Norway but to a lesser degree in Sweden. After 1992, there was good correlation between the original diagnosis and the revised diagnosis by the panel.2 For the Nordic countries, variation in the SIDS rate was paralleled by variation in total infant mortality rate, which proves that the decline in SIDS rate after 1989 cannot be explained by shift in diagnostic practice.2
During the SIDS epidemic in Norway, 80% of all sudden infant deaths were due to SIDS. This has changed totally, and the proportion has come down to 50%. The rest of the sudden, unexpected deaths are caused by disease, accident, neglect/abuse, and murder. New knowledge about genetic diseases that may cause sudden, unexpected death has challenged routine diagnostic work.3 It is of great importance that diagnostic work on sudden infant death is not deteriorating into pseudodiagnostics (eg, positional asphyxia in cases of prone sleeping position with the face down; this situation is a risk factor but not the cause of death).
We agree with Tomashek et al that striving for common diagnostic criteria is of utmost importance. We think that the Sudden Unexplained Infant Death Investigation Report Form will be helpful when working toward consistency in diagnosing sudden, unexpected infant death. We also point to the work that is going on, on an international level, with participation from 4 continents trying to harmonize diagnostic work on sudden infant death.4–7 This work is based on the international autopsy protocol published by Krous.8 A growing body of evidence indicates that SIDS causality depends on gene-environment interactions,9 and the importance of knowledge about pregnancy and infant medical history, in addition to circumstances of death and autopsy findings, cannot be underestimated. In a recent article,10 we showed that in 19% of the sudden, unexpected infant death cases, knowledge about the history was essential for the final diagnosis.
REFERENCES
- Gregersen MRJ, Laursen H, Baandrup U, et al. Pathologic criteria for the Nordic Study of SIDS. In: Rognum TO, ed. Sudden Infant Death Syndrome, New Trends in the Nineties. Oslo, Norway: Scandinavian University Press; 1995:50–58
- Vege A, Rognum TO. Use of new Nordic criteria for classification of SIDS to re-evaluate diagnoses of sudden unexpected infant death in the Nordic countries. Acta Paediatr. 1997;86 :391 –396[Medline]
- Opdal SH, Rognum TO. The sudden infant death syndrome gene: does it exist? Pediatrics. 2004;114(4) . Available at: www.pediatrics.org/cgi/content/full/114/4/e506
- Rognum TO, Arnestad M, Bajanowski T, et al. Consensus on diagnostic criteria for the exclusion of SIDS. Nord Rettsmedisin. 2003;9 :62 –73
- Krous HF, Beckwith JB, Byard RW, et al. Sudden infant death syndrome and unclassified sudden infant deaths: a definitional and diagnostic approach.
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[Abstract/Free Full Text] - Stray-Pedersen A, Arnestad M, Opdal SH, Vege A, Rognum TO, Byard RW. Globally accepted definition and diagnostic criteria—crucial for solving the SIDS enigma. Scand J Forensic Sci. 2004;10 :70 –71
- Fleming PJ, Blair PS, Sidebotham PD, Hayler T. Investigating sudden unexpected deaths in infancy and childhood and caring for bereaved families: an integrated multiagency approach.
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[Free Full Text] - Krous HF. The international standardized autopsy protocol for sudden unexpected infant death. In: Rognum TO, ed. Sudden Infant Death Syndrome, New Trends in the Nineties. Oslo, Norway: Scandinavian University Press; 1995:81–95
- Hunt CE. Genes and sudden infant death syndrome. Pediatr Res. 2004;56 :321 –322[Medline]
- Arnestad M, Vege A, Rognum TO. Evaluation of diagnostic tools applied in the examination of sudden unexpected deaths in infancy and early childhood. Forensic Sci Int. 2002;125 :262 –268[CrossRef][Medline]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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- National Standard for Death-Scene Investigation of Sudden, Unexpected Infant Deaths in the United States
- Kay M. Tomashek, Carrie Shapiro-Mendoza, Jennifer Wingo, and Terry W. Davis
Pediatrics 2005 115: 823.[Extract] [Full Text]
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