Rutty, G. N.; Sawicka, Z. M.D.
To the Editor:
We read with interest the article by Collins concerning infant death by overlaying and wedging, and we wish to consider further several points raised by this article (1).
First, we agree with the author that overlaying and wedging are true entities, which have been documented, as highlighted in the article, since the time of the Old Testament. However, the historical term overlaying is a poor one because it is unlikely, in the case of infants who die in bed, that the cosleeper rolls on top of the infant. In fact, in the case of those dying on a settee, the infant is often found dead on top of the chest of the caretaker rather than being wedged in the settee, although this latter mechanism has been well described. Because the death is a form of mechanical asphyxia, possibly because of occlusion of the external air orifices by contact either with the body of the cosleeper(s) or with the bed clothing itself (for example, a duvet, although some refute this (2)), or because of a wedging mechanism, similar to that which may occur on the settee, especially when the infant is placed between two adults in a bed, then a term such as bed-related or bedclothes-related d eath (for those in bed) or settee-related death (for those on the settee) are possibly better terms to consider to describe the form of the death, with the mode being that of mechanical asphyxia.
These deaths should not be termed sudden infant death syndrome (SIDS) or cot death. First, the term SIDS is often taken as meaning that the death was “natural.” Although there is no legal definition of a “natural” death, it has been defined as “a normal progression of a natural illness, where death flows purely from a naturally occurring disease without any significant element of human intervention” (3). According to this definition, these deaths are not natural but are often accidental. Although the latter is often the case, there is still a piece of English law within the Children and Young Persons Act that still makes it an offense to sleep in a bed while under the influence of alcohol and to “overlay” the infant (4). This act, however, makes no reference to the caretaker being under the influence of drugs of abuse or being on a settee. Because the autopsy findings in these cases are similar to, if not at times indistinguishable from, intentional smothering, care must always be expressed when dealing with these deaths. We agree that the presence of perioral pallor, contusions, and abrasions to the nose and mouth areas should start alarm bells ringing that this is a death caused neither by SIDS or by accidental asphyxia.
The diagnosis of SIDS is based on negative results of scene and autopsy examination. Because many of these deaths have no apparent scene or autopsy findings, the cause of death could be considered as SIDS, and some would use this term. However, we recommend that this term not be used but rather that the cause of death should be given as “unascertained,” because—as outlined above—if SIDS is then taken to mean “natural,” how can one exclude the intentional smothering? Having said this, we add that in our experience these deaths do in fact often have a clear clinical history of the circumstances surrounding the death, as well as positive scene and autopsy findings. A careful scene examination will often reveal blood-staining on the bedding or the settee at the point of contact of the infant’s face (5). This observation may be used to confirm or refute a caretaker’s account of where the infant was at the time of the death. Blood-staining is often seen on the upper aspect of the clothing that the infant was wearing at the time of its death; as with the bedding, it has emanated from the nose and mouth area. These areas are often cleared away by the caretaker or those who are first to attend the infant at the scene or in the emergency room (6). This finding may be subsequently identified to have been present only if the right questions are asked retrospectively. There may be no intent to deceive with this action but rather one to present the deceased in a peaceful state after death. Thus, all bedding and clothing must be examined in these deaths, either by a scene visit or at the autopsy room. This must, however, be done tactfully because the arrival of police officers and the treatment of the death as a scene of crime, although potentially warranted, may cause lasting mental anguish to the already devastated caretakers. The United States system of nurse death scene investigators and nurse coroners may have an advantage over other systems used in the world to investigate child death because nurses can use their clinical and forensic expertise to balance the need to talk to and care for the grieving relatives and yet perform a thorough professional death scene investigation. If resuscitation is attempted, blood-stained frothy fluid may be seen within the endotracheal tube, which should be left in situ or recovered before autopsy for examination by the pathologist. Intraalveolar hemorrhage can be prominent, and hemosiderin-laden macrophages may be seen in the lungs of those who have previously coslept but survived (7,8).
It may be of interest that a larger retrospective study has just been completed from the same time period using data from the Medical Examiners Office, South Carolina, USA, and the Medico-Legal Center, Sheffield, England. Despite the separation of the two sites by the Atlantic Ocean, comparative patterns have been observed in relation to these deaths and the scene and autopsy findings, as well as details about the infants and caretakers. Although there are arguments revolving around religious and cultural attitudes to bed sharing as well as the need for parental bonding, these deaths are ultimately avoidable. Although research into these deaths is required and yet difficult to conduct, a campaign of public awareness about the potential risks of cosleeping is warranted.
G. N. Rutty
Z. Sawicka, M.D.
1. Collins KA. Death by overlaying and wedging: A 15-year retrospective study. Am J Forensic Med Pathol 2001; 22: 155–9.
2. Mitchell EA, Williams SM, Taylor BJ. Use of duvets and the risk of sudden infant death syndrome. Arch Dis Child 1999; 81: 117–9.
3. Unnatural deaths. In Dorries C, ed. Coroners courts: a guide to law and practice. Chichester, UK: John Wiley and Sons, 1999: 30.
4. Childrens and Young Persons Act. London: HMSO, 1933.
5. Carter N, Rutty GN. Invoking sudden infant death syndrome in cosleeping may be misleading. BMJ 2000; 321: 1019.
6. Green MA. Investigation of unexpected child death. In Rutty GN, ed. Essentials of autopsy practice. Vol 1. London: Springer, 2001: 97–120.
7. Yukawa N, Carter N, Rutty G, Green MA. Intra-alveolar haemorrhage in sudden infant death syndrome: A cause for concern? J Clin Pathol 1999; 52: 581–7.
8. Becroft DM, Lockett BK. Intra-alveolar pulmonary siderophages in sudden infant death: A marker for previous imposed suffocation. Pathology 1997; 29: 60–3.
© 2002 Lippincott Williams & Wilkins, Inc.