Volume 218 - Issue 6
Serious gaps in the investigation of sudden unexpected deaths in infancy in Australia
Author: Paul N Goldwater
Med J Aust 2023; 218 (6): 252-253. || doi: 10.5694/mja2.51884
Published online: 3 April 2023
Published online: 3 April 2023
SUDI investigations should be led by coroners, supported by experienced paediatric pathologists
Jeffery and colleagues examined how sudden unexpected deaths in infancy (SUDI) are investigated in Australia in a questionnaire‐based study,1 reported in this issue of the MJA. They unsurprisingly exposed gaps in the process and unsuitable approaches to investigating these deaths. As Jeffery and colleagues note, the definition of SUDI encompasses all cases in which an infant dies (or suffers a collapse that leads to death) before the age of twelve months, the death could not have been anticipated 24 hours earlier, and no medical cause is apparent. The SUDI definition includes all such deaths, whether they are subsequently explained or not, and thus encompasses sudden infant death syndrome (SIDS), a diagnosis that requires a complete investigation, including history, death scene investigation, and full autopsy. In the absence of generally recognised causes, the investigation of SUDI is a special situation: each case is a subject of research or a problem to be solved.
Most cases in Australia fall within the purview of the police and the state coroner. While their questionnaire methodology had inherent limitations, Jeffery and colleagues found that police‐led investigation fell short of evidence‐based standards. Obvious problems are related to inadequate resources and the lack of a national approach to investigating unexpected deaths in infancy, including a national autopsy protocol. In some states, forensic institutions perform autopsies under the jurisdiction of the coroner. Only one employs a paediatric pathologist for this purpose, despite the fact that SUDI autopsy is a specialist procedure. Problems arise when pathologists without relevant specialist expertise overlook key aspects or misinterpret important findings; this can result in unsafe legal outcomes.
In 1989, the late SIDS expert forensic pathologist Professor John Hilton discussed the fact that the investigation of SIDS is encumbered by unusual limitations.2 These limitations are pertinent to the study by Jeffery and colleagues, including ethical questions regarding consent for obtaining and retaining tissue, and difficulty in obtaining suitable control material for meaningful research.
The specific causes of many cases of SUDI and SIDS remain unknown, despite the resources of 21st century science. Limitations to their investigation may play a role, but there are a number of plausible research hypotheses, especially that centred on the homeostatic control of breathing, arousal, and cardiac function.3 However, it is worrying that few neuropathological or neurotransmitter findings have been linked with SIDS risk factors.4 In contrast, the list of risk factors linked with infection‐based hypotheses (eg, the bacterial toxin hypothesis)5,6 is extensive,7,8 especially strong associations with prone sleeping and the type of sleeping surface.9,10,11 Achieving clarification may require, as demanded by Jeffery and colleagues, the implementation of core components of international standards, such as those recommended by the Kennedy Report,12 including a standardised autopsy protocol. Doing so would maximise the probability that the cause of death is elucidated, and ensure that risk factors are identified, parents and families receive immediate and ongoing support, and the consequences of incorrect diagnosis are avoided. SUDI investigations should be led by coroners, supported by experienced paediatric pathologists playing pivotal roles. A national database of SUDI data could also be helpful for research and monitoring standards, but this will require dedicated financial support.
Competing interests
No relevant disclosures.
References
- Jeffery HE, Carberry AE, Gordon A, Arbuckle S. The investigation of sudden unexpected deaths in infancy in Australia. Med J Aust 2023; 218: 262‐263.
- Hilton JMN. The pathology of the sudden infant death syndrome. In J. K. Mason, editor. Paediatric forensic medicine and pathology. Dordrecht: Springer Science+Business Media, 1989; pp. 156‐164.
- Filiano JJ, Kinney HC. A perspective on neuropathologic findings in victims of the sudden infant death syndrome: the triple‐risk model. Biol Neonate 1994; 65: 194‐197.
- Oehmichen, M. Recent neuropathologic research in sudden infant death syndrome. A critical review with special consideration of the brain stem. In: Maehly A, Williams R, editors. Forensic science progress, volume 4. Berlin, Heidelberg: Springer; pp. 127‐139.
- Morris JA, Haran D, Smith A. Hypothesis: common bacterial toxins are a possible cause of the sudden infant death syndrome. Med Hypotheses 1987; 22: 211–222.
- Blackwell CC, Gordon AE, James VS, et al. The role of bacterial toxins in sudden infant death syndrome (SIDS). Int J Med Microbiol 2002; 291: 561‐570.
- Blackwell C, Moscovis S, Hall S, et al. Exploring the risk factors for sudden infant deaths and their role in inflammatory responses to infection. Front Immunol 2015; 6: 44.
- Goldwater PN. Infection: the neglected paradigm in SIDS research. Arch Dis Child 2017; 102: 767‐772.
- Ponsonby AL, Dwyer T, Gibbons LE, et al. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med 1993; 329: 377‐382.
- Helweg‐Larsen K, Lundemose J, Øyen N, et al. Interactions of infectious symptoms and modifiable risk factors in sudden infant death syndrome. The Nordic Epidemiological SIDS study. Acta Pædiatrica 1999; 88: 521‐527.
- Goldwater PN. SIDS, prone sleep position and infection: an overlooked epidemiological link in current SIDS research? Key evidence for the “infection hypothesis”. Med Hypotheses 2020; 144: 110114.
- Royal College of Pathologists (United Kingdom). Sudden unexpected death in infancy and childhood: multi‐agency guidelines for care and investigation. 2nd edition. Nov 2016. https://www.rcpath.org/uploads/assets/874ae50e‐c754‐4933‐995a804e0ef728a4/Sudden‐unexpected‐death‐in‐infancy‐and‐childhood‐2e.pdf
Provenance: Commissioned, not externally reviewed.