Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS), previously known as crib death, is the sudden unexplained death of an infant under 1 year of age. Some researchers estimate that up to 5% of SIDS deaths may actually be infanticide.^8,9 While some pediatric sudden deaths are due to abuse, neglect, or homicide, it is difficult to distinguish between SIDS and accidental asphyxiation at autopsy.^10,104 Factors suggestive of non-accidental asphyxiation include occurrence in an infant 6 months or older, previous explained or unexpected deaths of one or more siblings, simultaneous (or nearly simultaneous) death of twins, and blood in the infant’s mouth or nose.¹¹ The American Academy of Pediatrics recommends:¹¹

1. a prompt death scene investigation, including careful interviews of household members;
2. examination of the dead infant at a hospital ED by a child abuse specialist;
3. post-mortem examination within 24 hours of death; and
4. collection of medical history through interviews of key medical providers and review of records.

 Diagnosis Of Shaken-Baby Syndrome

While retinal hemorrhages occur in most shaken-baby syndrome cases, the concern has been raised that retinal hemorrhages may have poor specificity for shaken-baby syndrome. Retinal hemorrhages can occur with cytomegalovirus, rickettsia, malaria, bacterial endocarditis, thrombocytopenia, meningitis, vasculitis, carbon monoxide poisoning, severe hypertension, and normal birth, in addition to child abuse. (Retinal hemorrhages that occur as a result of birth usually resolve by about 4 weeks of age.)

Another area of controversy is whether retinal hemorrhages can occur from CPR. A study of pediatric patients who underwent CPR found that none of the 169 CPR patients had retinal hemorrhages.¹⁰⁵ Severe retinal hemorrhages (especially if bilateral or white-centered) are almost always from shaken-baby syndrome.⁷¹

The question of whether or not to dilate the pupils in order to perform a funduscopic and ophthalmology consultation is also controversial. The concern is that dilatation of the pupils will impair the ability to do serial neurologic examinations. However, it is difficult to visualize the fundus through an infant’s small pupil without mydriatic agents, and the infant’s open fontanel serves as an easily accessible pressure valve that decreases the utility of serial pupilary examinations. Thus, using mydriatic agents to help visualize the fundi at some point during the early hospital course (not necessarily in the ED by the emergency physician) has been recommended.¹⁰⁶ Because criminal prosecution of the perpetrator may depend on an accurate description of retinal hemorrhages and given that details such as whether or not the hemorrhages cover the macula or extend to the periphery of the retina may be important characteristics used to classify cases as abusive,¹⁰⁸ ophthalmology consultation is indicated for the description and documentation of retinal hemorrhages.

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