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To the Editor.—
The article by Malloy and MacDorman in the May 2005 issue of Pediatrics, Changes in the Classification of Sudden Unexpected Infant Deaths: United States, 1992–2001,1 provides evidence for a pattern that we have noted in Louisiana in recent years. The authors note that since 1992, there has been a substantial reduction in sudden infant death syndrome (SIDS) deaths, most likely related to the marked reduction in prone-sleep-position prevalence. However, the lack of decline in the postneonatal mortality rate from 1999 to 2001 suggests that reclassification of SIDS cases is now occurring. It is interesting to note that the observations of Malloy and MacDormand predate the new classification system for SIDS recently proposed by Krous et al and an international consensus panel of SIDS experts.2 The newly proposed classification seeks to address some of the very concerns raised in the article by Malloy and MacDormand.
In Louisiana, we have noted a similar trend. Since 1994, autopsy and death-scene investigation (DSI) reports and autopsies for infants dying suddenly and unexpectedly in Louisiana have been reviewed by the medical director for the Louisiana SIDS Risk Reduction Program (LSRRP). In recent years, there seems to be a move away from a diagnosis of SIDS toward other causes on the part of coroners. In particular, DSI reports have disclosed circumstances suggesting inadvertent suffocation in a number of cases that previously would have been attributed to SIDS. Coroners seem to be paying more heed to these findings as the number of reported infant deaths from suffocation in Louisiana has risen while the number of deaths attributed to SIDS has declined in a reciprocal fashion (2001–2002 data). The DSI in such cases often documents that the infant was placed on a couch or other inappropriate, soft, adult bedding either alone or cosleeping with multiple partners. Kemp and co-workers3 noted that the odds ratio for sudden unexpected infant death (SUID) increased 17-fold for infants sleeping on couches and eightfold for infants sleeping in an adult bed compared with cribs.
Since the LSRRP began training DSI investigators and implemented the use of the Centers for Disease Control Sudden Unexplained Infant Death Report Form (SUIDRF),4 the quality and quantity of information received by the LSRRP also improved. However, although the DSIs have been helpful to the LSRRP, they seem to have been less so for the forensic pathologists performing the autopsies. To have the autopsy performed by a certified forensic pathologist, the remains are often transported a considerable distance. The DSI report is often not available to the forensic pathologist before the isolated autopsy findings that are reported to the coroner. This situation may result in an inconsistent classification of SIDS by the coroner and incorrect cause of infant death certification. As a recent example, an overlay suffocation of an infant, observed by a relative who was first on the death scene, was reported on the DSI but was classified as SIDS as a result of overlay by the coroner on the infant's death certificate.
We have also observed that although DSIs are generally being completed, the quality of the report seems to be affected by the timing and circumstances surrounding its preparation. Infants who are found dead at home generally have a DSI completed within hours of death, usually with the infant body still in place and the scene relatively undisturbed. Unfortunately, though, for infants whose death occurs at a local hospital after unsuccessful resuscitation, the DSIs are not as helpful. The delay in preparing the DSI and the frequent lack of doll reenactment hampers the collection of critical data, particularly the location and position of the infant at the time of discovery.
Malloy and MacDorman conclude that a more standardized approach to certifying sudden infant death is necessary to better discern trends in infant mortality. We agree and look forward to additional refinements of the SUIDIRF by the Centers for Disease Control and Prevention and a more wide-spread use of the revised classification system for SUID described by an international consensus panel of experts.2 Together, these tools should improve our understanding of this continuing medical mystery in pediatrics. Standardization, precision, and better and quicker communication of the DSI and autopsy findings may also help us focus our risk-reduction efforts more on adverse environmental, child care, and parenting factors, which may contribute more to SUID (eg, accidental suffocation, positional asphyxia, wedging, overlay, choking, and aspiration) than to classic SIDS.
It also may be relevant to note that in England and Wales, although the SIDS numbers had dropped dramatically, from 1400 to 200 per year, the covert infanticide numbers remained the same during the 1990s.5 Nonaccidental suffocation is certainly one of the possible methods of covert infant homicide, and it is very difficult to determine as a cause by autopsy alone. Those additional findings support the critical need to perform and report a timely, standardized, and thorough infant DSI to the forensic pathologist who performs the SUID autopsy.
REFERENCES
Related articles in Pediatrics:
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