Sudden Unexpected Infant Death Certification Inconsistent

Veronica Hackethal, MD

June 05, 2017

US medical examiners and coroners inconsistently investigate and classify sudden unexpected infant deaths (SUIDs), according to a study published online June 5 in Pediatrics.

The results suggest that lack of uniformity in certifying infant deaths may impede surveillance and prevention efforts.

"Variability in cause-of-death determination practices influences how SUID are ultimately reported and classified for surveillance and research purposes. This variability negatively impacts our knowledge of the causes of infant mortality as well as our ability to monitor and prevent future deaths effectively," Carrie Shapiro-Mendoza, PhD, MPH, from the Centers for Disease Control and Prevention in Atlanta, Georgia, and colleagues write.

Many cases of SUID go unwitnessed because they happen while the infant is sleeping, which can hinder investigations about the cause of death. In particular, a detailed description of the sleep environment and evidence of airway obstruction are important for distinguishing among sudden infant death syndrome (SIDS), accidental suffocation, and other causes.   

Although death investigation guidelines do exist, how well investigators follow them remains unknown.

To study the issue, the researchers randomly selected 801 medical examiners and coroners for a nationally represented survey conducted between January and November 2014.  The survey asked respondents to classify SUID according to four hypothetical scenarios. It also asked them to describe the evidence and investigative procedures they use to determine cause of death.

The study had a response rate of 60.3% (483 surveys returned), of which 47.1% (n = 377) were complete and could be used for the analysis.

Classification of infant deaths varied by scenario. Three of the scenarios concerned potential airway obstruction in infants with negative autopsy findings. In these scenarios, respondents classified the death as suffocation/asphyxia in 61% to 69% of cases. 

The fourth scenario portrayed a healthy infant who was sleeping in a safe environment and had negative autopsy findings. For this scenario, 38% of respondents classified the death as SIDS and 30% classified it as SUID.

A follow-up question unrelated to the fourth scenario revealed that just 50% of respondents used the SIDS classification in their general practices. Respondents who used the term "SIDS" employed a range of definitions.

Types of evidence and investigative procedures for determining cause of death also varied. Full autopsy, toxicology studies, and medical history review are considered the three essential elements of a SUID investigation. These were conducted by 88%, 84.5%, and 81.7% of respondents, respectively.  Ninety-four percent of respondents used routine death scene investigations.

The study may have been limited by a relatively low response rate. Also, the study used hypothetical rather than actual scenarios, so responses may not reveal real-life practices. Finally, the survey responses relied on preselected options and may not have completely captured the respondents' decision-making process.

The authors emphasize the promotion of standardized practices to improve the reliability and accuracy of determining the cause of infant death. In particular, they highlight differentiating between suffocation/asphyxia and other types of SUID, such as overlay, wedging, and neck compression/hanging.

"Findings from this study may inform future strategies promoting standardized

practices for medicolegal cause-of death determination, especially for SUID," they conclude.

Three authors were employees of Battelle during data collection for the study. The remaining authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 5, 2017. Abstract

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