Does SIDS Exist?

Jon R. Thogmartin, M.D.District 6 Medical Examiner

Executive Director, Pinellas County Forensic Laboratory

Disclosure

● I have no relationships or conflicts of interest related to this presentation or activity

Learning Objectives

1. Explain basic death investigation principles

2. Define cause and manner of death3. Describe the typical circumstances of

death and cause of death in healthy sleeping infants

4. Describe safe and unsafe infant sleeping practices

WHAT IS THE ROLE OF THE MEDICAL EXAMINER IN INFANT DEATH

INVESTIGATIONS?● STATUTE 406-UNIFORM M.E. LAW THROUGHOUT

FLORIDA● INVESTIGATE TRAUMATIC AND UNEXPLAINED DEATHS

(AMONG OTHERS)● BY LAW, ALL SUDDEN UNEXPECTED INFANT DEATHS

MUST BE REPORTED TO THE MEDICAL EXAMINER ● THE M.E. WILL DETERMINE CAUSE AND MANNER

OF DEATH

CAUSE OF DEATH● THE PHYSIOLOGIC PROCESS,

DISEASE, OR INJURY THAT RESULTS IN DEATH

● GUNSHOT WOUND, ASPHYXIA, MENINGITIS, PNEUMONIA, ETC ARE ALL CAUSES OF DEATH.

MANNER OF DEATH

● THE WAY IN WHICH DEATH CAME ABOUT

● THE CIRCUMSTANCES OF DEATH

MANNERS OF DEATH IN FLORIDA

● HOMICIDE ● SUICIDE● ACCIDENT● NATURAL ● UNDETERMINED

Healthy Infants That Die During Sleep

● Infant that is between the ages of 1-4 months old dies during a period of sleep

● These events occur in a home or daycare (crib, bassinet, bed)

● Almost never in other circumstances

What about witnessed deaths?

● ***Infants generally do not mysteriously die in the arms of an adult while the ADULT IS AWAKE***

• If they do the baby is found to be ill or to have been murdered

Scene Investigation

● Obtain information of the circumstances● Focus on the body● Assess the surroundings● Compare reports of circumstances to

findings of surroundings and decedent

Interesting DemographicsPinellas Birth Rates •74% Caucasian•17% African-American• 9% Other

Infant Sleep-Related Deaths •57% (22/39) Caucasian•44% (17/39) African-American

✓Sleep-related deaths are nearly 3 ½ times more prevalent among African-American infants✓All 39 infant deaths occurred within the first 8 months of life✓Majority were bottle-fed (82%) vs. breastfed (18%)

Where Deaths

Occurred In The County

Death Location•85% (33/39) occurred in Mid- & South Pinellas County•15% (7/39) occurred in North Pinellas County

Where Deaths Occurred In The Home

Sleep Surface Where Deaths Occurred

•61% Adult Bed•28% Crib/Bassinet

•8% Sofa•3% Other (i.e. – Air Mattress)

95% (37/39) had access to an approved safe sleep surface such as a crib, bassinet,

or pack n’ play; more than half chose to sleep with their baby in bed

BIBLE 1 KINGS (3:16-27)

History of Unexpected Infant Death

● 1600’S ITALY-thought the cause sleeping infant deaths was suffocation

● ARCUCCIO-A protective device of wood and iron designed to protect infants from overlaying and other causes of suffocation

● Penalty for not using the “little arch” was EXCOMMUNICATION

History of Unexpected Infant Death

● Certainly just can’t be as simple as overlay or suffocation!

● LATE 1800’S THEORIZED TO BE CAUSED BY ENLARGED THYMUS “STATUS THYMOLYMPHATICUS”

● 1930’s -1940’s BACK TO SUFFOCATION AGAIN● 1945- Suffocation/Asphyxia downplayed

again

History of Unexpected Infant Death

● 1963- FIRST MEETING AMONG EXPERTS REGARDING UNEXPLAINED INFANT DEATHS

● 1969- SECOND INTERNATIONAL MEETING FUNDED BY NICHHD. ARRIVED AT NAME AND DEFINITION TO DESCRIBE THESE UNEXPECTED UNEXPLAINED INFANT DEATHS =

SUDDEN INFANT DEATH SYNDROME

SUDDEN INFANT DEATH SYNDROME● 1969: The sudden death of any infant of young child,

which is unexpected by history, and in which a thorough postmortem examination fails to demonstrate an adequate cause of death

● Newest: Sudden Infant Death Syndrome is defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history.

● “Death scene” added in 1989**** WHY??

SIDS VS ASPHYXIA● THE AUTOPSY FINDINGS OF SIDS AND

ASPHYXIA ARE virtually IDENTICAL● Both have negative or nonspecific

findings● Differentiated by circumstances

SIDS=Diagnosis by exclusion● Natural disease

processes must be excluded.

● Drugs must be excluded.

● Trauma must be excluded.

SUDDEN INFANT DEATH SYNDROMEEQUALS

An unknown cause of death

All external causes and natural disease ruled out

SUDDEN INFANT DEATH SYNDROME

● DURING THE 70’s AND 80’s, AMERICA CHASED APNEA

● Others pursued common sense● DISCOVERED GREAT REDUCTIONS IN DEATHS

WHEN INFANTS WERE PLACED ON THEIR BACKS AND SIDES AS OPPOSED TO ON THE STOMACH.

CHANGE IN INFANT POSITION RECOMMENDATIONS

● 1992 - THE AMERICAN ACADEMY OF PEDIATRICS RECOMMENDS SUPINE SLEEPING

● 1994 - AAP LAUCHES “BACK TO SLEEP” CAMPAIGN RECOMMENDING BABIES BE PLACED TO SLEEP ON THEIR BACKS OR LESS PREFERABLY THEIR SIDES

U.S. ANNUAL SIDS RATE

Let’s us now add to the chaos!SUID!

SUID: from the CDC

● Sudden Unexpected Infant Deaths are defined as deaths in infants less than 1 year of age that occur suddenly and unexpectedly, and whose cause of death are not immediately obvious prior to investigation.

● SUID is not a cause of death!● SUID has caused PROBLEMS!

SUDDEN UNEXPECTED INFANT DEATH(From the CDC)

SUID IS A CIRCUMSTANCE OF DEATH

Oops!

Homicide

Oops!Subtle Accidental Trauma

We forgotThese!

SUDDEN UNEXPECTED INFANT DEATH(From the CDC)

➢ SUID has caused mass confusion➢ CDC = the “U” is “unexpected” ➢ Many medical examiners and coroners

routinely use the “U” as “unexplained” and use SUID as a cause of death virtually synonymous with SIDS

➢ The two have different definitions➢ UNEXPECTED VS UNEXPLAINED

SUID vs SUIDI vs SUID

● SUID (NAME/others): Sudden unexplained infant death (SUID) applies to the death of an infant less than one year of age, in which investigation, autopsy, medical history review, and appropriate laboratory testing fails to identify a specific cause of death. SUID includes cases that meet the definition of Sudden Infant Death Syndrome.

But wait there’s more!SUID vs SUID vs SUIDI

● SUIDI: SUDDEN UNEXPLAINED INFANT DEATH INVESTIGATION-(!) featured on the CDC website and describes the process of investigating infant deaths

Nomenclature of Infant DeathsOH MY! What a mess

● SIDS: Sudden Infant Death Syndrome● SUID: Sudden Unexpected Infant Death● SUID: Sudden Unexplained Infant Death● SUIDI: Sudden Unexpected Infant Death Investigation● SIDWC: Sudden Infant Death While Co-sleeping● Other variations, etc etc● Why???

Common sense

Age at Death

● Why are most ALL deaths 4 months old or less?● What significant event happens at 4-5 months?

Please! Let us have some common sense

SIDS Damage

● Blameless seemingly complex diagnosis applied to simple phenomena

● If an infant death incorrectly diagnosed, what is the result?

● What if this misdiagnosis is common?● What if this misdiagnosis is easy and

popular?

SADS

● What would happen with adult sudden death cases if FP’s had the ability to diagnose SUDDEN ADULT DEATH SYNDROME ?

● Would be work as hard on those cases as we do now?

FAMILIAL SIDS

DOES IT EXIST?

MULTIPLE SIDS IN ONE FAMILY

● ONE SIDS IS TRAGIC● TWO SIDS IS SUSPICIOUS● THREE SIDS IS HOMICIDE

1 MONTH OLD WHITE FEMALE (late 1990’s)

● Sleeping face down in day care play pen

● Extra foam mattress underneath bedding

● Clearly face down with blanching lividity of face

● COD=SIDS

1 MONTH OLD WHITE FEMALE Repeat death ~5 years later

● Repeat death in same day care in same play pen 5 years later

● COD= Positional Asphyxia

● Earlier case amended● SIDS is BLAMELESS AND

CAN’T BE PREVENTED?…RIGHT?

4 MONTH OLD WHITE MALE

● Put to sleep prone on a comforter on the floor by a baby sitter

● Found 17 hours later face down completely covered by the comforter with bloody expectorant on his face and on the comforter.

4 MONTH OLD WHITE

4 MONTH OLD WHITE MALEAUTOPSY FINDINGS

● DEHYDRATION● PROLIFERATIVE GLOMERULONEPHRITIS● CENTRAL NERVOUS SYSTEM DYSMATURITY

● CAUSE OF DEATH?● SIDS!

Co-sleeping/Bed Sharing

Dangerous Activities

Dangerous Activities?

The Argument for CO-SLEEPING

● INCREASES BREAST FEEDING● BONDING● DEVELOPMENT● SOLO-SLEEPING IS RECENT WESTERN

PHENOMENON● STUDIES BASED ON SLEEP AND RESPIRATION

MONITORING

Help!! Aaahhh!

SLEEPING INFANT DEATHS IN PALM BEACH COUNTY: A REVIEW OF OVER

200 CASES

JON R. THOGMARTIN, M.D.CHIEF MEDICAL EXAMINER

CHARLES F. SIEBERT, Jr., M.D.DEPUTY CHIEF MEDICAL EXAMINER

WILLIAM PELLAN FORENSIC INVESTIGATOR

Palm Beach County Medical Examiner Office

Findings

● SIDS over diagnosed• -circumstances often ignored

● The vast majority of infants died in unsafe sleeping circumstances

● Infants that died in safe sleeping circumstances were 3-6 times more likely to be ill

SUPINE POSITION

PRONE ON ADULT BED

PRONE ON ADULT BED

PRONE ON FIRM SURFACE

CO-SLEEPING

3 MONTH OLD BLACK FEMALE● CO-SLEEPING PRONE ON

SOFT BED BETWEEN BOTH PARENTS

● ORIGINALLY AT UPPER PORTION OF BED

● FOUND WITH FACE “STUCK” TO SHEET AT FOOT OF BED UNDER COMFORTER

3 MONTH OLD BLACK FEMALE● RECENT HISTORY OF

COLD● SCENE INVESTIGATION

SUBPOTIMAL DUE TO TRANSPORT TO HOSPITAL

● ALCOHOLIC BEVERAGE NEAR BED

● COD=ASPHYXIA

ADULT BED DANGER

7 MONTH OLD BLACK FEMALE● ASLEEP ALONE ON ADULT

BED● DURING THE NIGHT ROLLED

OFF AND WAS FOUND ON THE FLOOR WEDGED BETWEEN A DRESSER AND MIRROR

● COD=ASPHYXIA

3 MONTH OLD BLACK FEMALE● CO-SLEEPING WITH MOM IN

PRONE POSITION ON ADULT BED

● ORIGINALLY REPORTED TO BE ON BED

● LATER PD FOUND OUT BABY HAD SLIPPED OFF BED AND WEDGED BETWEEN WALL AND BED

● COD=ASPHYXIA

FLORIDA SIDS

DISTRICT 6 INFANT SLEEPING DEATHS

Alone Infants

INFANT CAUSES OF DEATH

Studies, cultures, neurotransmitters, diagnoses…complex explanations for the simple

● Metabolic testing• Rarely if ever useful

● Bacterial and viral cultures• Usually ignored without confirming histology

findings● Infant tissue banking and studies

“Sudden infant death syndrome (SIDS), the leading cause of postneonatal infant mortality…..”

Annual SIDS in San Diego

SIDS vs Undetermined

SIDS vs Undetermined vs Accident

Types of Undetermined

• CASES=61 (AVE. 5.6 YEARS OLD)• CONTROLS =15 (AVE 4.8 YEARS OLD)

• SIGNIFICANT PORTION OF CASES CAME FROM 2007 WHEN SIDS DIAGNOSIS WAS POPULAR WITHIN THE OFFICE

• MEASURING SEROTONIN IN LONG FROZEN BLOOD WITH NON-UNIFORM CASE SELECTION

SIDS dx = significant damage

● Coroners and medical examiners are able to have a popular diagnosis to rely upon in difficult cases

● Allowed/allows risky sleep practices to continue

● Repeat deaths have occurred

SIDS● THE DIAGNOSIS IS NOT COMPLETELY OBJECTIVE● SIDS diagnoses have caused more deaths● Infants rarely die in safe sleeping circumstances unless

actually sick● Other similar acronyms have caused more confusion● Many researchers NOT INVOLVED in the investigations

reach for complex explanations for common sense

RECOMMENDATIONS● BACK TO SLEEP!● Bed sharing-PROCEED WITH CAUTION

• SUPINE• SOBER• REMOVE BLANKETS/PILLOWS• WATCH THE EDGE

● THE INFANT CAN SLEEP WITH YOU, SHOULD YOU SLEEP WITH THE INFANT?

References

Thogmartin JR, Siebert CF, Pellan WA. Sleep position and bed-sharing in sudden infant deaths: An examination of autopsy findings. J Pediatrics 2001;138:212-217.

Haynes RL, et al. High serum serotonin in sudden infant death syndrome. PNAS Vo1 114, No 29 July 2018

San Diego County Medical Examiner Annual Reports http://www.sandiegocounty.gov/content/sdc/me/press/stats.html

Questions?