A practical approach to suspicious death in infancy--a personal view.

This quotation, taken from the account of King Solomon’s judgement in a case of disputed motherhood, is often cited as the first example of sudden infant death syndrome (SIDS). I view this claim with increasing scepticism. The child was only a few days old. Both the women involved were of a profession associated with “at risk” children. The child was left in the care of an unqualified minder, and one suspects that there were other visitors to the disorderly house as well. It is minor details such as these that should raise awareness in the mind of any pathologist called upon to investigate the death of an infant under 12 months old. In an ideal world, all sudden and unexpected deaths in childhood would be investigated by paediatric pathologists, forensic pathologists with some paediatric experience, or ideally the two working as a team. I am mindful of Clothier’s recommendations following the case of Nurse Beverley Allitt, but unconvinced by his insistence that a paediatric pathologist should investigate all such cases. In the foreseeable future it is unlikely that there will be suYcient paediatric or forensic pathologists to implement Clothier. The majority of these deaths will be referred to the coroner, procurator fiscal, or other appropriate law oYcer (or should be), but the necropsies will be performed by general hospital pathologists, many of whom—but by no means all—will have a declared interest in paediatric pathology. Over the last few years there has been a dramatic fall in the incidence of SIDS. This improvement is owing to several factors— better antenatal care, better management of infants at risk by reason of prematurity or birth trauma, and better postnatal care, advice, and supervision. The “Back to Sleep” campaign which followed the death of the television presenter Anne Diamond’s child, Sebastian, in 1991 has produced the most dramatic fall. Similar campaigns in New Zealand, Australia, and the United States have also met with gratifying success. It is diYcult to ascertain the exact number of SIDS-type deaths; in 1994 the figures from the Central Statistical OYce for England and Wales were 331, but rose by 6% in 1996. There is currently a tendency among some pathologists, certainly in my own department, to classify an increasing number of these deaths as “not ascertained.” It has always been suspected, although those suspicions have only been uttered in muted tones, that unlawful acts by parents or carers account for a substantial minority of sudden infant deaths. Wilczynski first brought the issue to prominence in 1994 and expanded further upon the work in 1997. She reviewed the necropsy reports and surrounding circumstances of a large number of infant deaths, and estimated that the true figure for homicide in England and Wales under the age of one year could be of the order of 150 deaths a year. I take the view that she was overpessimistic, but I am certain that the true annual figures are considerably higher than the 50 to 80 claimed at diVerent times by the Home OYce, the NSPCC, and other concerned agencies over the last decade. If we also accept that the number of cases of proven deliberate harm to infants remains fairly constant from year to year, this means that, as the overall numbers of sudden infant deaths fall, a greater proportion of their total will be “suspicious,” and will require very detailed investigation. A recent infant death necropsy protocol from Ontario, Canada, carried on its first page the message, printed in bold, “THINK DIRTY!,” and advised all concerned to treat every so called SIDS death as a possible homicide until proved otherwise—a view which I strongly support. I accept that this is a minority opinion, strongly opposed by many coroners, pathologists, and even some police oYcers, but its implementation has brought unexpected cases to light. There are now readily available detailed protocols for the necropsy examination of cases of sudden death in infancy (as provided, for example, by the Confidential Enquiry into Stillbirth and Deaths in Infancy (CESDI)). 8 I do not propose to rehearse them here. I would merely emphasise and support the need for full histological examination (despite the coroners’ inability, or in some cases reluctance, to pay), appropriate toxicology, microbiology, and biochemical investigations. However, I must stress that if there is any suspicion whatsoever that the child might have been harmed, vitreous humour should not be taken “blind” at the commencement of the examination. It may become far more important that the eyes be preserved for fixation and histological examinJ Clin Pathol 1998;51:561–563 561