Pulmonary intra-alveolar hemorrhage in SIDS and suffocation

The differentiation of SIDS from accidental or inflicted suffocation may be impossible in some cases. Severe pulmonary intra-alveolar hemorrhage has been suggested as a potential marker for such differentiation. Our aims are to: (1) Compare pulmonary hemorrhage in SIDS and a control group comprised of infants whose deaths were attributed to accidental or inflicted suffocation. (2) Review individual cases with the most severe pulmonary hemorrhage regardless of the cause of death, and (3) Assess the effect of age, bedsharing, cardiopulmonary resuscitation, and postmortem interval, with regard to the severity of pulmonary hemorrhage in SIDS cases. We conducted a retrospective study of all postneonatal cases accessioned by the Office of the Medical Examiner in San Diego County, California who died of SIDS or suffocation between 1999 and 2004. A total of 444 cases of sudden infant death caused by SIDS (405), accidental suffocation (36), and inflicted suffocation (3) from the San Diego SIDS/SUDC Research Project database were compared using a semiquantitative measure of pulmonary intra-alveolar hemorrhage [absent (0) to severe (4)]. Grades 3 or 4 pulmonary hemorrhage occurred in 33% of deaths attributed to suffocation, but in only 11% of the SIDS cases, however, all grades of pulmonary hemorrhage occurred in both groups. Therefore, our results indicate that the severity of pulmonary hemorrhage cannot be used in isolation to determine the cause or manner of sudden infant death. Among SIDS cases, those with a higher pulmonary hemorrhage grade (3 or 4) were more likely to bedshare, and with more than one co-sleeper, than those with a lower pulmonary hemorrhage grade (0 or 1). We conclude that each case must be evaluated on its own merits after thorough review of the medical history, circumstances of death, and postmortem findings.     

Fatal asphyxial episodes in the very young: classification and diagnostic issues

Infants and young children are exposed to a relatively limited range of circumstances that may result in accidental or inflicted asphyxial deaths. These usually involve situations that interfere with oxygen uptake by the blood, or that decrease the amount of circulating oxygen. Typically infants and toddlers asphyxiate in sleeping accidents where they smother when their external airways are covered, hang when clothing is caught on projections inside cots, or wedge when they slip between mattresses and walls. Overlaying may cause asphyxiation due to a combination of airway occlusion and mechanical asphyxia, as may inflicted asphyxia with a pillow. The diagnosis of asphyxiation in infancy is difficult as there are usually no positive findings at autopsy and so differentiating asphyxiation from sudden infant death syndrome (SIDS) based purely on the pathological features will usually not be possible. Similarly, the autopsy findings in inflicted and accidental suffocation will often be identical. Classifications of asphyxia are sometimes confusing as particular types of asphyxiating events may involve several processes and so it may not be possible to precisely compartmentalize a specific incident. For this reason asphyxial events have been classified as being due to: insufficient oxygen availability in the surrounding environment, critical reduction of oxygen transfer from the atmosphere to the blood, impairment of oxygen transport in the circulating blood, or compromise of cellular oxygen uptake. The range of possible findings at the death scene and autopsy are reviewed, and the likelihood of finding markers/indicators of asphyxia is discussed. The conclusion that asphyxiation has occurred often has to be made by integrating aspects of the history, scene, and autopsy, while recognizing that none of these are necessarily pathognomonic, and also by excluding other possibilities. However, even after full investigation a diagnosis of asphyxia may not be possible and a number of issues concerning possible lethal terminal mechanisms may remain unresolved.     

Cytomegalie der Kopfspeicheldrüsen bei SIDS

Zusammenfassung Es erfolgte eine retrospektive mikromorphologische Analyse der Glandula parotis und/oder der Glandula submandibularis von 180 plötzlichen Kindstodesfällen in Berlin und 75 Fällen in Hamburg. Erfaßt wurden Fälle der letzten 10 Jahre mit einem Alter zwischen 2 Wochen und einem Lebensjahr. — Typische CMV-Einschlußkörper wurden im Berliner Material in 18 Fällen (10%; Mädchen mehr als Jungen) und im Hamburger Material in 6 Fällen (7%; Jungen mehr als Mädchen) diagnostiziert. Während die meisten SIDS-Fälle sich im zweiten und dritten Lebensmonat ereigneten, war bei den CMV-Infektionen kein Altersgipfel festzustellen. Virusmaterial war mit immunhistochemischen Unterschungen sowie in-situ-Hybridisierung auch in histologisch unauffälligen Zellen nachzuweisen. — Unter Berücksichtigung der bekannten klinischen und epidemiologischen Daten zur Cytomegalie stellt die Diagnose einer lokalisierten Infektion der Kopf-speicheldrüsen keine befriedigende Erklärung für den plötzlichen Tod der Säuglinge dar; diese Befunde sind jedoch besonders beachtenswert als Hinweis auf eine Schwäche des Immunsystems.     

The potential role of bacterial toxins in Sudden Infant Death Syndrome (SIDS)

Summary Toxigenic bacteria have been implicated in some cases of Sudden Infant Death Syndrome (SIDS). Although there is not much evidence thatClostridia spp. are associated with SIDS in Britain, strains ofStaphylococcus aureus producing pyrogenic toxins have been isolated from significant numbers of these infants at autopsy. The pyrogenic toxins, produced by some strains of group AStreptococcus pyogenes as well as staphylococci, are powerful superantigens that have significant physiological effects including induction of fever > 38°C. In this article, interactions between genetic and environmental factors that might enhance colonization of epithelial surfaces by toxigenic staphylococci are analyzed: infant's expression of Lewis^a antigen which acts as a receptor for some microorganisms; viral infections; the effect of mother's smoking on susceptibility to respiratory infection. Based on epidemiological findings and laboratory investigations, a hypothesis is proposed to explain how bacteria producing pyrogenic toxins might contribute to some cot deaths.     

Petechial hemorrhages and unexpected infant death

The significance of petechial hemorrhages in cases of unexpected infant death remains uncertain. While intrathoracic petechiae occur in the majority of cases of sudden infant death syndrome (SIDS), their relationship to terminal mechanisms has been debated. Facial, conjunctival and external upper chest petechiae are not a feature of SIDS and raise the possibility of underlying illness such as sepsis, or of forceful coughing or vomiting. Alternatively the presence of cutaneous or conjunctival petchiae may suggest trauma or asphyxia due to chest or neck compression. Given the possibility of alternative mechanisms of death it is preferable to designate the cause and manner of death as 'undetermined', rather than 'SIDS', when petechiae are found in unusual locations.     

Vergleichende histologische und hormonelle Untersuchungen der Schilddrüse unter besonderer Berücksichtigung des plötzlichen Kindstodes (SIDS)

Zusammenfassung Bei 53 Todesfällen, davon 12 SIDS-Fälle, bei denen innerhalb 18 Std post mortem Blut entnommen werden konnte, wurden die Schilddrüsenhormone T₄, FT₄, T₃ und FT₃ bestimmt (ELISA und RIA). Bei 43 dieser Fälle (11 × SIDS, 32 Kontrollfälle) konnten die Hormonwerte mit den entsprechenden histologischen Schilddrüsenbefunden verglichen werden.In beiden Gruppen lagen die nahezu identischen T₄ und FT₄-Mittelwerte im Normbereich. Die Werte für T₃ und FT₃ waren hingegen in der SIDS-Gruppe um das 3,7 bzw. 1,9fache gegenüber den mittleren Werten der Kontrollgruppe erhöht. Entsprechend zeigten die histologischen Untersuchungen in der Gruppe der plötzlichen Kindstodesfälle überwiegend stark aktivierte und weitgehend entspeicherte Follikel, während innerhalb der Kontrollgruppe fast ausschließlich regelrecht kolloidhaltige Follikelstrukturen beobachtet werden konnten. Bei vorliegender Befundkonstellation ist eine postmortale T₄-T₃-Konversion und auch eine verstärkte agonale Hormonsekretion als alleinige Ursache der erhöhten T₃ und FT₃-Werte nicht anzunehmen. Bei den SIDS-Fällen sind als Ursache der hormonellen und histologischen Schilddrüsenbefunde chronische bzw. chronisch-rezidivierende Streß-Situationen zu vermuten. Hierzu werden differentialdiagnostische Überlegungen angestellt. Frühpostmortale erhöhte T₃- und FT₃-Konzentrationen bei gleichzeitiger Kolloidentspeicherung der Schilddrüse stellen einen diagnostischen Hinweis auf einen plötzlichen Kindstod dar.Auszugsweise auf der 64. Tagung der Deutschen Gesellschaft für Rechtsmedizin vorgetragen. Hamburg, 7.–11.09.1985     

Unnatural causes of sudden unexpected deaths initially thought to be sudden infant death syndrome

The aim of this clinicopathological study was to determine the frequency of infant deaths due to unnatural causes among cases of sudden and unexpected infant death. Nine institutes of legal medicine in Germany that took part in the German study on Sudden Infant Death Syndrome (GeSID), representing 35% of the German territory, investigated in a 3-year period (from 1998 to 2001) 339 cases of infant death that were not expected to be due to unnatural causes from the first external examination. All cases were investigated by complete, standardised, post-mortem examination including death scene investigation, autopsy, histology, toxicology and neuropathology. The frequency of unnatural deaths was 5.0% (n=17). The causes of death were head injury (n=7), suffocation (n=5), poisoning (n=2), neglect (n=2) and septicaemia due to aspiration of a foreign body (n=1). Two deaths were unsuspected accidents and 12 were due to infanticide. In 3 cases, it was not possible to differentiate between accidental death and infanticide. A complete postmortem examination including an analysis of the clinical history, death scene investigation, autopsy, histology, toxicology, and neuropathology is mandatory to differentiate sudden and unexpected deaths due to natural causes (e.g. SIDS) and cases of unnatural death.Contributors at Institutes of Legal Medicine: U. Deml, Friedrich-Alexander-University, Erlangen; A. Freislederer, University Duisburg-Essen, Essen; S. Heide, Martin-Luther-University, Halle; H.-J. Kaatsch, S. Ritz-Timme, Christian-Albrechts-University, Kiel; K.-P. Larsch, A. Fiegut, Medizinische Hochschule Hannover, Hannover; H.W. Leukel, Johann-Wolfgang-Goethe-University, Frankfurt am Main; C. Ortmann, Friedrich-Schiller-University, Jena; R. Penning, Ludwig-Maximilians-University, Munich.     

Evaluation of the Reid index in infants and cases of SIDS

The Reid index is an instrument for the evaluation of chronic bronchitis. The thickness of the mucosa and of its gland layer are measured and the relationship is expressed as a gland/wall ratio. Specimens were obtained from 124 autopsies from the German National Study on SIDS (GeSID). The cases were divided into three groups: group 1 typical SIDS (n=47), group 2 SIDS with signs of mild inflammation of the respiratory tract (n=50) and group 3 unnatural death controls (n=23). The Reid index was measured in sections from the trachea, bifurcation/main bronchi and bronchioli (staining HE and PAS). The Reid index was remarkably constant throughout the different levels of the respiratory tract (standard deviation range 0.06–0.10). A comparison of the three groups did not show statistically significant differences. Group 1: mean Reid index trachea 0.37, bifurcation/main bronchi 0.38, bronchioli 0.39. Group 2: mean Reid index trachea 0.40, bifurcation/main bronchi 0.38, bronchioli 0.38. Group 3: mean Reid index trachea 0.39, bifurcation/main bronchi 0.38, bronchioli 0.41. It can be concluded that the dimensions of bronchial glands do not vary in cases of SIDS as compared to controls. This demonstrates that the Reid index has no significance in the vast majority of SIDS cases and that acute inflammation commonly does not produce an elevated Reid index. In addition, the Reid index was confirmed to be a valid intrument to study the respiratory tract including the trachea due to its stability and it was found that the Reid index is age-dependent: compared to adults, the ratios in infants were higher.     

The San Diego definition of SIDS: practical application and comparison with the GeSID classification

The new definition of the term sudden infant death syndrome (SIDS) and the criteria introduced in San Diego for the subclassification of cases have been used to re-classify the first 100 consecutive cases of sudden and unexpected infant deaths that were registered with the German SIDS study (GeSID). Although there are 30 different variables that have to be considered in the general and stratified sections of the San Diego definition, it is practical, in particular, as an international standard to perform scientific studies. The comparison of the San Diego definition and the classification used for GeSID shows similarities in the methods but differences in the criteria used. Nevertheless, the numbers of cases classified as SIDS and borderline SIDS are similar (San Diego n=69, GeSID n=74). The SIDS IA criteria of the San Diego definition were not fulfilled by any case because metabolic screening and vitreous chemistry were not included in the GeSID investigation scheme. An important advantage of the San Diego definition is the introduction of the category of unclassified sudden infant death, which includes cases for which no autopsy was performed. This demonstrates that such cases cannot be classified as SIDS. In conclusion, we recommend the universal acceptance and use of the San Diego SIDS definition.     

Morphological and immunohistochemical studies of the pituitary in Sudden Infant Death Syndrome (SIDS)

Summary The morphological structure and immunohistochemical reactions of 100 pituitaries from cases of SIDS children (58 males and 42 females, average age 5.34 ±3.12 months) were studied. Controls consisted of 19 pituitaries from children (14 males and 5 females, average age 5.63 ± 2.52 months) with a clearly identifiable cause of death e.g. drowning or strangulation. The microscopical and immunohistochemical studies for identifying pituitary cell types revealed normally developed organs. Unspecific necroses and haemorrhages were observed in 2 cases of SIDS but in none of the controls. Hyperaemia was detected in 51 (30 male/21 female) cases of SIDS. No significant differences were found in the distribution of microfollicles (54%), cysts of the intermediate zone (14%), persistency of the Ratlike's pouch (44%), Erdheim's squamous epithelium (8%) or heterotopic salivary glands (3%). The semiquantitative immunohistochemical evaluations of the different cell types showed no significant variations from the control group. The pattern of distribution of the intracytoplasmic vacuolisations of the ACTH and gonadotropic cells showed no significant differences. Folliculo-stellate cells were either not demonstrable — commensurate with age — or showed a normal distribution. The results for both study groups may be defined as consequences of terminal agony, but failed to reveal the cause of the sudden infant death. Dedicated to Prof. Dr. H. D. Herrmann (Hamburg) on the occasion of his 60th birthday     

Periventrikuläre fettige Metamorphose der Neuroglia — Ein morphologisches Substrat beim SIDS

Zusammenfassung Im Rahmen histologischer Untersuchungen wurde in 7 von 15 Fällen von SIDS eine massive fettige Metamorphose der Gliazellen des periventrikulären frontalen Marklagers vorgefunden. Eine Kontrollgruppe von 6 Kleinkindern (Alter unter 1 Jahr), die infolge eines anderen natürlichen oder gewaltsamen Todes gestorben waren, wies in keinem Fall diese morphologischen Veränderungen auf. Dünnschichtchromatographische Analysen der beim SIDS in den Gliazellen gespeicherten Lipide ergab einen hohen Anteil von Cholesterinestern, während jener in der Kontrollgruppe stets nieder war. Die fettige Gliametamorphose wird als morphologisches Substrat einer geringgradigen Schädigung unterschiedlicher Ätiologie der metabolisch besonders aktiven, noch unreifen Gliazellen der periventrikulären Marksubstanz in Erwägung gezogen.     

Is the incidence of SIDS increasing in Asia?

The incidence of SIDS in western countries has decreased since the late 1980s after active SIDS prevention campaigns. By contrast, both Taiwan and Japan have reported an increase in incidences. In this report data from England, Wales, Scotland, Northern Ireland, Japan and Hong Kong are analysed. Regression coefficient and linearity of regression tests were used to determine if there was any significant increase or decrease in post-neonatal mortality (PNNM), SIDS mortality and mortality among infants 1–5 months old. A statistically significant decrease in SIDS was recognized in England, Wales, Scotland and Northern Ireland, whereas statistically significant increases were noted for Japan and Hong Kong. However in Japan and Hong Kong both the PNNM and mortality of infants between 1–5 months in age fell significantly, suggesting that the increased SIDS rates could be due to a change in diagnostic labelling. Further study will be required to determine whether this increase in the incidence of SIDS is genuine or only an artifact. Received: 12 June 1997 / Accepted in revised form: 27 January 1998     

Zur Problematik schädigender Umwelteinflüsse beim plötzlichen Kindstod (SIDS)

Zusammenfassung Wegen der zunehmenden Diskussion über schädigende Umwelteinflüsse auch bei plötzlichen Kindstodesfällen (SIDS) wurden systematische chemisch-toxikologische Untersuchungen bei 54 obduzierten SIDS-Fällen und 2 altersgleichen Kontrollfällen durchgeführt. Die Analysen erstreckten sich auf die Konzentrationsbestimmung von Arsen, Blei, Cadmium, Quecksilber und Pentachlorphenol sowie andere organische Noxen in jeweils mehreren Organen und auf COHb im Leichenblut. Trotz variierender, teils stark streuender Analyseergebnisse lagen sowohl die gemessenen Extremwerte wie auch die arithmetischen Mittelwerte und die Medianwerte in einem Konzentrationsbereich, dem nach bisheriger Kenntnis keine toxikologische Relevanz zukommt. Es ließ sich nicht feststellen, daß bei Kindern aus städtischem Milieu eine höhere Belastung mit den untersuchten Schadstoffgruppen stattgefunden hatte als bei jenen aus ländlicher Region. Unterschiede zwischen SIDS-Fällen und Kontrollfällen bestanden nicht. Es ergab sich auch keine Korrelation zwischen den häufig morphologisch nachgewiesenen Atemwegsinfekten einschließlich einer Laryngitis und höheren Schadstoffkonzentrationen in den Organen der SIDS-Fälle.     

Intrathoracic petechiae in SIDS: a retrospective population-based 15-year study

Intrathoracic petechiae (IP), the most common gross finding in sudden infant death syndrome (SIDS) cases at autopsy, suggest upper airway obstruction (UAO) occurs during the terminal event. If true, IP would be expected more frequently among SIDS cases found face down compared to other face positions. We compare the rates of IP in SIDS cases found face down versus other face positions. A retrospective 15-year review of IP among all cases of SIDS occurring from 1991 through 2005 accessioned by the San Diego County Medical Examiner’s Office was conducted. The presence or absence of IP was based on both gross and microscopic observations of the thoracic organs. The severity of thymic petechiae was scored semiquantitatively from microscopic observations. There were 489 SIDS cases during the study period. Sixteen of these were excluded because their deaths had been delayed by initially successful cardiopulmonary resuscitation. Among the remaining 473 SIDS cases, face position when found was specifically described for 332 (70%). Of 122 cases found face down, 112 (92%) had IP, compared to 85% (179) of 210 infants found with the face up or to the side (P = 0.06). The groups were not different with respect to age or gender, but the racial distribution was significantly different (P = 0.004). African-American infants comprised 28% of the found face down group compared to only 12% of the face up or side group. Our data do not support a role for external UAO caused by face positioning directly into the sleep surface in SIDS, but are consistent with internal UAO associated with apnea or gasping before dying of SIDS.     

Hemoglobin F in sudden infant death syndrome: a San Diego SIDS/SUDC Research Project report

Whether levels of fetal hemoglobin (HbF), a possible marker of antecedent hypoxemia, are increased in sudden infant death syndrome (SIDS) compared to controls is unresolved. Our aims are to: (1) Compare percent fetal hemoglobin (%HbF) levels in SIDS and control cases, and (2) compare our findings with those reported in previous studies. Using Triton-acid-urea gel electrophoresis and quantitative densitometry, %HbF was determined in whole blood specimens obtained at autopsy from SIDS and control cases accessioned into the San Diego SIDS/SUDC Research Project database. The SIDS and control cases were not different with respect to mean age, gender, gestational age, method of delivery, birth weight, or mean autopsy interval; %HbF levels in SIDS and control cases were not significantly different. Given that our results were obtained using optimal methods in well-defined SIDS and control cases, we concur with others that %HbF is not elevated in SIDS.     

National Australian workshop consensus on the definition of SIDS and initiation of a uniform autopsy approach to unexpected infant and early childhood death

Following formulation of a new definition for SIDS, a workshop was convened in Canberra Australia, in March 2004, by SIDS and KIDS, Australia. Attendences included forensic and pediatric pathologists representing major institutions from all Australian States and Territories. The issues of the adoption of a uniform definition of SIDS and a standardised autopsy approach were discussed. The workshop recommended adoption of the San Diego definition of SIDS as the sudden unexpected death of an infant under one year of age, with onset of the fatal episode apparently occuring during sleep, that remains unexplained after a thorough investigation, including performance of a complete autopsy and review of the circumstances of death and the clinical history. In addition the workshop undertook to develop autopsy guidelines as national standards for the performance of infant autopsies.     

Does β-APP staining of the brain in infant bed-sharing deaths differentiate these cases from sudden infant death syndrome?

Archival cerebral tissue from infants whose deaths were attributed to sudden infant death syndrome (SIDS) from South Australia and Western Denmark were stained for β-amyloid precursor protein (β-APP) and graded according to a simple scoring chart. The resulting APP scores were correlated with sleeping situation (shared vs. alone) showing a significantly higher amount of β-APP staining in the non-bed-sharing, than in the bed-sharing infants (Mann–Whitney, Australia: p = 0.0128, Denmark: p = 0.0014, Combined: p = 0.0031). There was also a marked but non-significant difference in sex distribution between bed-sharers and non-bed-sharers with a male to female ratio of 1:1 in the first group and 2:1 in the latter. Of 48 Australian and 76 Danish SIDS infants, β-APP staining was present in 116 (94%) cases. The eight negative cases were all from the Danish cohort. This study has shown that the amount of β-APP staining was significantly higher in infants who were sleeping alone compared to those who were bed-sharing with one or more adults, in both an Australian and Danish cohort of SIDS infants. Whether this results from differences in the speed with which these infants die, differences in lethal mechanisms involving possible accidental asphyxiation in shared sleepers, or differences in the number of previous hypoxic-ischemic events, remains to be clarified.     

Lungengerüstveränderungen beim plötzlichen Kindestod (SIDS)

Zusammenfassung Es wird über lichtmikroskopische Befunde am Lungeninterstitium von 45 Kindern berichtet, die in den beiden ersten Lebensjahren verstorben sind. Bei 30 Fällen handelt es sich um plötzlichen Kindestod, in 15 Kontrollfällen mit gleicher Altersverteilung war die Todesursache bekannt. Folgende Färbungen wurden verwendet: HE, PAS, Berliner Blau, Elastica van Gieson, Trichrom nach Masson-Goldner, Versilberung nach Gomori und Picro-Sirius-Polarisation (modifiziert), wobei besonders Augenmerk auf Kollagen Typ I und Typ III, Reticulinfasern und Grundsubstanz gerichtet wurde. Sowohl sämtliche SIDS-Fälle als auch alle Kontrollfälle wiesen frische Alveolarschädigungen verschiedenen Ausprägungsgrades auf. Unterschiede zwischen SIDS-Fällen und Kontrollfällen fanden sich im Interstitium: die Fälle von plötzlichem Kindestod zeigten im Vergleich zu den Kontrollfällen hochsignifikant häufiger und stärker ausgeprägt Zeichen eines chronisch rezidivierenden interstitiellen Lungenödems; es fanden sich frische und ältere Lymphödeme mit reaktiver fibroplastischer Aktivität unterschiedlichen Grades bis hin zu schleichender Fibrose; die Kollagenfasern waren vermehrt, das Verhältnis von Kollagen Typ I und Typ III gestört. Diese Lungengerüstveränderungen bei den SIDS-Fällen waren ungleichmäßig und herdförmig über das Lungengewebe verteilt und reichten bis in das murale Interstitium. Derartige interstitielle Schäden können infolge Störung der Gasdiffusion und durch Veränderung der mechanischen Eigenschaften des Lungengerüstes die Lungenfunktion beeinträchtigen.     

Morphology,immunohistochemistry and morphometry of the thyroid gland in cases of sudden infant death syndrome (SIDS)

The thyroid glands of 107 SIDS victims (sudden infant death syndrome) have been studied. Controls consisted of 20 thyroid glands from infants who died of other causes (accidents, pneumonia etc.). The thyroid glands were investigated histologically, immunohistologically and morphometrically. Immunohistochemistry (S100 protein and calcitonin) and morphometry showed no significant results. Histologically, hyperemia (severe: 34 cases = 31.8%; mild: 23 cases = 21.5%), and fibrosis (45 cases = 42.1%; mild: 26 cases = 24.3%) were found. A large number of cases showed depleted follicles (87 cases 81.3%), little colloid (little: 37 cases = 34.6%; none: 9 cases = 8.4%) and desquamation (severe: 21 cases = 19.6%; abundant: 20 cases = 18.7%). Only fibrosis and depleted follicles were found more often in SIDS than in the controls (conditional logistic regression: rise of incidence for SIDS 2.9 times,P = 0.028, and 1.2 times,P = 0.051, respectively), a commoner occurrence of hyperemia in SIDS was of limited significance (P = 0.105). The alterations found can be taken as stress reactions to current or recurrent hypoxemia and the mild fibrosis indicates recurrent hypoxemia. All alterations indicate that the victims had previously suffered near death episodes. Even though the glands were handled with care, artefacts and autolysis must be taken into consideration. Neither the histological, immunohistological nor morphometrical studies of the thyroid gland gave an explanation as to the cause of death or showed any changes providing explicit help in diagnosing SIDS.     

Current recommendations on infants’ sleeping position are being followed—initial results of a population-based sentinel study on risk factors for SIDS, 1996–2006, in Hamburg,Germany

Sudden infant death syndrome (SIDS) is a target for public health care in Germany. The aim of this study was to monitor data on risk-related behavior in the population of Hamburg, Germany, in order to respond to changes quickly and to estimate the effectiveness of prevention activities. Data have been gathered using the sentinel system with repeated surveys (1996, 1998, 2001, and 2006) in pediatric practices, thus allowing an estimate of the prevalence of risk factors in an urban population, both transversally and vertically. From 1996 to 2007, the SIDS rate in Hamburg fell from 0.9/1,000 live births to 0.1. The prevalence of infants sleeping prone declined from 8.1% in 1996 to 3.5% in 2006. In this small subgroup, up to 81.7% (2006) of the caretakers were well aware of the risk of sleeping prone. The prevalence of infants sleeping on their sides fell from 55.3% in 1998 to 10.6% in 2006. The sentinel setting is suitable for gathering risk-related data on SIDS. Despite the fact that, so far, no nationwide back-to-sleep campaign has been instituted in Germany, local campaigns have proved successful in reducing prone sleeping for infants. Moreover, the substantial reduction of side sleeping within a short time span going along with a reduced SIDS rate is an indicator of the effectiveness of prevention activities on a local basis.