Half Century Since SIDS: A Reappraisal of Terminology.

After a sudden infant death, parents and caregivers need accurate and open communication about why their infant died. Communicating tragic news about a child's death to families and caregivers is difficult. Shared and consistent terminology is essential for pediatricians, other physicians, and nonphysician clinicians to improve communication with families and among themselves. When families do not have complete information about why their child died, pediatricians will not be able to support them through the process and make appropriate referrals for pediatric specialty and mental health care. Families can only speculate about the cause and may blame themselves or others for the infant's death. The terminology used to describe infant deaths that occur suddenly and unexpectedly includes an assortment of terms that vary across and among pediatrician, other physician, or nonphysician clinician disciplines. Having consistent terminology is critical to improve the understanding of the etiology, pathophysiology, and epidemiology of these deaths and communicate with families. A lack of consistent terminology also makes it difficult to reliably monitor trends in mortality and hampers the ability to develop effective interventions. This report describes the history of sudden infant death terminology and summarizes the debate over the terminology and the resulting diagnostic shift of these deaths. This information is to assist pediatricians, other physicians, and nonphysician clinicians in caring for families during this difficult time. The importance of consistent terminology is outlined, followed by a summary of progress toward consensus. Recommendations for pediatricians, other physicians, and nonphysician clinicians are proposed.

Identifying Child Abuse Fatalities During Infancy.

When a healthy infant dies suddenly and unexpectedly, it is critical to correctly determine if the death was caused by child abuse or neglect. Sudden unexpected infant deaths should be comprehensively investigated, ancillary tests and forensic procedures should be used to more-accurately identify the cause of death, and parents deserve to be approached in a nonaccusatory manner during the investigation. Missing a child abuse death can place other children at risk, and inappropriately approaching a sleep-related death as maltreatment can result in inappropriate criminal and protective services investigations. Communities can learn from these deaths by using multidisciplinary child death reviews. Pediatricians can support families during investigation, advocate for and support state policies that require autopsies and scene investigation, and advocate for establishing comprehensive and fully funded child death investigation and reviews at the local and state levels. Additional funding is also needed for research to advance our ability to prevent these deaths.

Living victims of strangulation: a 10-year review of cases in a metropolitan community.

The prevalence of reported domestic violence or intimate partner violence has greatly increased, with approximately 1.5 million women violently assaulted annually in the United States by an intimate partner. Strangulation is often seen in violence against women, including domestic violence cases. Strangulation is defined as "a form of asphyxia characterized by closure of the blood vessels or air passages of the neck as a result of external pressure on the neck." This is a 10-year case review of 102 living victims of strangulation who underwent medicolegal evaluation at the Clinical Forensic Medicine Program at a State Medical Examiner's Office serving Southern Indiana and all of Kentucky. The majority of victims (79%) were strangled by an intimate partner, and manual strangulation was the most common method (83%). A total of 38 victims (38%) described a history of domestic violence, and the same number lost consciousness while being strangled. Nine (9%) women were pregnant at the time of the attack, while 13 (13%) had a history of being sexually abused in addition to being strangled. A paucity of cases involved only strangulation, as most of the victims were subjected to myriad forms of blunt force trauma which included not only the head and neck but also other bodily regions. This is a unique presentation of strangulation of living persons as most evidence of strangulation in the forensic literature has been derived from postmortem examinations of the victims. This comprehensive study discussing the examination of a living strangulation victim offers valuable insight into the mechanism and the physical findings involved in the strangulation process.

Methadone toxicity fatalities: a review of medical examiner cases in a large metropolitan area.

Over the past several years, Medical Examiners in Kentucky and around the nation have observed a dramatic rise in drug intoxication deaths involving the prescription medication methadone. This documented rise in methadone-related deaths requires a better understanding of methadone's pathophysiology and the ways it contributes to significantly increase morbidity and mortality. This study reviews 176 fatalities ascribed to methadone toxicity by the Office of the Chief Medical Examiner in Kentucky between 2000 and 2004. Postmortem toxicological analysis recorded a more than 10-fold increase in methadone toxicity fatalities, rising from 6 cases in 2000 to 68 cases in 2003. Of the 176 methadone-related fatalities, methadone was the only drug detected in postmortem blood and urine toxicological analyses in 11 (6.25%) cases. The mean methadone blood concentration of all 176 cases was 0.535 mg / L (0.02-4.0). The following psychoactive medications were detected: antidepressants (39.8%), benzodiazepines (32.4%), and other opioids in addition to methadone (27.8%). Cannabinoids were detected in 44 (28.4%) cases and cocaine or metabolite in 34 (21.9%) cases. Of the 95 cases with a known history of methadone use, 46 (48.4%) involved prescription by private physician. The interpretation of blood methadone concentrations alone or combined with other psychoactive drugs requires consideration of the subject's potential chronic use of and tolerance to the drug. A thorough investigation into the practices of procurement and use/abuse of methadone is essential to arrive at the proper designation of the cause of death.

Is SIDS on the rise??

OBJECTIVE: Sudden Infant Death Syndrome (SIDS) is defined as a diagnosis of exclusion, after an evaluation of the medical history, complete postmortem examination, and scene investigation. The diagnosis of SIDS in many sudden and unexplained infant deaths has not been consistently applied nationally or, prior to July 2003, in the state of Kentucky. In order to better standardize practices in formulating the diagnosis of SIDS in cases of sudden and unexpected infant deaths, all of the Kentucky medical examiners formed a working group to collectively standardize the classification of this enigmatic type of infant death. METHODS: We conducted a retrospective review (2000-2004) of infants < 1 year who underwent complete historical review, circumstantial investigation, postmortem examination, and toxicological analysis performed at the Medical Examiners' Offices in Kentucky encompassing all deaths certified as Sudden Infant Death Syndrome, positional asphyxia, overlay, and undetermined cause and manner of death. RESULTS: A total of 417 cases were deemed sudden unexplained infant deaths after postmortem examination at the Medical Examiners' Offices in Kentucky between 2000 and 2004. A total of 237 (56.8%) infants had been bedsharing with at least one other person when found. Prior to the SIDS classification policy change in July 2003, a significantly greater number of sudden unexpected infant death cases were deemed undetermined in both cause and manner in contrast to a smaller number classified as SIDS. After the policy change, the number of deaths classified as SIDS greatly surpassed the number classified as undetermined. CONCLUSIONS: The increase in the number of deaths consistent with SIDS and a reciprocal decline in cases reported as undetermined cause and manner of death in Kentucky is due to the uniformity and standardization of terminology, rather than an actual increase in the number of infant deaths. The Kentucky policy in July 2003 has been invaluable in ensuring uniform criteria in the diagnosis of SIDS and other categories of sudden unexpected death in infants < 1 year.

A functional approach to sudden unexplained infant deaths.

There is a great deal of variation in the methods and wording used by medical examiners in the medicolegal investigation and certification of infant deaths. This paper was created by the NAME Ad Hoc Committee on Sudden Unexplained Infant Death to address several specific issues, namely: * To establish a functional approach to the investigation of sudden unexplained infant deaths; * To outline a "bare minimum" set of recommendations to define the scope of investigation required; * To recommend methods and wording to be used when certifying infant deaths; * To develop a list of potential stressors or possible external causes of death that should be identified and reported on the death certificate and/or within a medical examiner/coroner office database. This paper was electronically posted for NAME member review and comment for a period of 30 days. The paper was further revised based on member comments and then submitted to the NAME board of directors in the fall of 2005 prior to the annual meeting. This text of this paper was officially approved and endorsed by the NAME board of directors on October 14, 2005, at the annual meeting in Los Angeles, CA.

Clinical forensic medicine introduction for healthcare providers.

Clinical forensic medicine (CFM) is "the application of appropriate forensic practices and principles, heretofore reserved for use by the pathologist at autopsy, to living patients in a clinical setting." "Living forensic" patients include survivors of trauma and potentially catastrophic experiences resulting in injury. CFM arose from "clinically" affirming that not all abuse or assault victims sustain fatal injuries. Appropriate medical documentation and interpretation of physical findings may aid law enforcement and/or social services in the legal evaluation of a case or situation. Additionally, timely collection of pertinent evidence may be performed as the case necessitates.

Forensic examination of pediatric patients.

In cases of suspected child abuse, a thorough history and physical exam utilizing clinical forensic principles are essential in distinguishing accidental from inflicted trauma. The Division of Clinical Forensic Medicine (CFM) incorporates a multidisciplinary team approach to the investigation of child abuse. Inclued are members of Child Protecton Services (CPS), law enforcement, and healthcare services who aid in the evaluation of child victims of abuse. The following is a brief overview of the comprehensive discipline of CFM, which highlights "Red Flags" for the non-forensic healthcare provider in ascertaining if a patient may be a victim of child abuse. Sexual abuue is not discussed in this limited report.

Risk factors associated with sudden unexplained infant death: a prospective study of infant care practices in Kentucky.

OBJECTIVE: To ascertain the prevalence of infant care practices in a metropolitan community in the United States with attention to feeding routines and modifiable risk factors associated with sudden unexplained infant death (specifically, prone sleeping position, bed sharing, and maternal smoking). METHODS: We conducted an initial face-to-face meeting followed by a telephone survey of 189 women who gave birth at a level I hospital in Kentucky between October 14 and November 10, 2002, and whose infants were placed in the well-infant nursery. The survey, composed of questions pertaining to infant care practices, was addressed to the women at 1 and 6 months postpartum. RESULTS: A total of 185 (93.9%) women participated in the survey at 1 month, and 147 (75.1%) mothers contributed at 6 months. The racial/ethnic composition of the study was 56.1% white, 30.2% black, and 16.4% biracial, Asian, or Hispanic. More than half of the infants (50.8%) shared the same bed with their mother at 1 month, which dramatically decreased to 17.7% at 6 months. Bed sharing was significantly more common among black families compared with white families at both 1 month (adjusted odds ratio [OR]: 5.94; 95% confidence interval [CI]: 2.71-13.02) and 6 months (adjusted OR: 5.43; 95% CI: 2.05-14.35). Compared with other races, white parents were more likely to place their infants on their back before sleep at both 1 and 6 months. Black parents were significantly less likely to place their infants on their back at 6 months compared with white parents (adjusted OR: 0.14; 95% CI: 0.06-0.33). One infant succumbed to sudden infant death syndrome at 3 months of age, and another infant died suddenly and unexpectedly at 9 months of age. Both were bed sharing specifically with 1 adult in the former and with 2 children in the latter. CONCLUSIONS: Bed sharing and prone placement were more common among black infants. Breastfeeding was infrequent in all races. This prospective study additionally offers a unique perspective into the risk factors associated with sudden infant death syndrome and sudden unexplained infant death associated with bed sharing by examining the survey responses of 2 mothers before the death of their infants combined with a complete postmortem examination, scene analysis, and historical investigation.

Cosleeping and sudden unexpected infant deaths in Kentucky: a 10-year retrospective case review.

This retrospective case review investigates modifiable risk factors in sudden unexpected infant deaths, including those attributed to sudden infant death syndrome, and examines the impact of cosleeping with adults or siblings. The study examines sudden unexpected infant deaths from 1991 to 2000 in the state of Kentucky, excluding homicides and deaths from identifiable natural causes. Meta-analysis provides a cosleeping prevalence control in normal infants. Based on the findings described herein, we conclude that cosleeping may represent a risk factor in sudden unexpected infant deaths and that a full scene investigation, including whether the infant was cosleeping, should be sought in all cases of sudden infant death.

Fatal intravenous injection of potassium in hospitalized patients.

We describe 4 cases of fatal intravenous injection of potassium in the hospital setting. These cases illustrate the subtlety of findings in such deaths and remind the forensic pathologist to consider this type of event in sudden, unexpected death of hospitalized patients.