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Comment & Response
October 2016

The Disappearance of Sudden Infant Death Syndrome

Author Affiliations
  • 1Chief Medical Examiner, Wayne County, Detroit, Michigan
JAMA Pediatr. 2016;170(10):1025-1026. doi:10.1001/jamapediatrics.2016.1811

To the Editor Cutz’s Viewpoint1 “The Disappearance of Sudden Infant Death Syndrome: Has the Clock Turned Back?” contains misconceptions about forensic pathology and the investigation of sudden infant death. Forensic pathologists are not trained to seek out “causes of trauma and unnatural deaths, not to diagnose medical conditions.”1 Rather, they are pathologists first, with training in pediatric pathology as part of residency. The Office of the Wayne County Medical Examiner, with a medium to large volume, does between 200 and 240 postnatal autopsies of all kinds per year, many more than even large training programs, and is well versed in pediatric pathology. More than half of the case load is natural disease, not trauma, and often is rare and difficult to diagnose. That the diagnosis of sudden infant death syndrome is in decline is owing in large part to public health intervention, an effect described even before the American Academy of Pediatrics “Back to Sleep” campaign.2 Simple interventions such as washing hands to prevent flu transmission, washing wounds with soap and water, and using mosquito nets for malaria may not be sexy or get grant money, but they work. To say that advocacy groups that fund research and reform “death investigation practices” are disappearing is uninformed. There is still plenty of research going on, much of it confirming that these infants have no pathologic changes.3 Often, the research is meaningless and describes findings no one can reproduce. When one looks at the body of research in sudden infant death over the past 30 years and the different findings it has produced (both morphologic and physiologic) that have been described as potential explanations for these deaths, not a single one has proven to be pathognomonic or diagnostic. Dr Cutz is correct that the recommendations of the San Diego protocol4 are widely ignored, if not forgotten or unknown, because it is an abomination that legitimizes shoddy death scene investigation. I have never met someone who does basic research regarding an as-yet-undefined etiology in sudden infant death who actually also investigates these deaths. These investigations are a messy, often tedious endeavor. The significant decrease in sudden infant death syndrome over the past 20 years with the American Academy of Pediatrics “Back to Sleep” Campaign is an unchallenged public health success, achieved without an “etiologic” diagnosis.5 If nothing else, this demonstrates that the as-yet-undefined etiology is not the mystery that some people think. As in much in life, often the simplest explanation is best.

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