eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Sudden Infant Death Syndrome: Differential Diagnoses & Workup

Author: Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Clinical Faculty, Community Medical Centers; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program
Coauthor(s): Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Contributor Information and Disclosures

Updated: Mar 17, 2009

Differential Diagnoses

Abdominal Trauma, Blunt
Pediatrics, Meningitis and Encephalitis
Anemia, Acute
Pediatrics, Pertussis
Anemia, Chronic
Pediatrics, Pneumonia
CBRNE - Botulism
Pediatrics, Status Epilepticus
Hypocalcemia
Shock, Cardiogenic
Hyponatremia
Shock, Hemorrhagic
Hypothermia
Shock, Hypovolemic
Myocarditis
Shock, Septic
Pediatrics, Bacteremia and Sepsis
Toxicity, Alcohols
Pediatrics, Child Abuse
Toxicity, Carbon Monoxide
Pediatrics, Dehydration
Pediatrics, Hypoglycemia
Pediatrics, Inborn Errors of Metabolism

Other Problems to Be Considered

Aberrant thermoregulation
Aspiration
Brain stem tumor
Cardiac dysrhythmias
Chiari malformation type I
Choanal atresia/stenosis
CNS immaturity
Congenital central hypoventilation syndrome
Congenital heart disease
Craniofacial abnormalities
Drowning
Drug exposure
Fluid and electrolyte imbalance
GER
Hemangioma
Lymphangioma
Laryngomalacia
Mast cell activation
Neuromuscular disorders
Occult trauma
Pharyngeal/retropharyngeal mass
Poisoning
RSV
Seizures
Suffocation
Toxin exposure
Tracheoesophageal fistula
Tracheomalacia
Upper airway obstruction
Vascular malformation
Vascular ring
Vocal cord paralysis

Workup

Laboratory Studies

  • Obtain a rapid bedside glucose reading, followed by serum determination of glucose if indicated. Hypoglycemia, which is common in sepsis, may cause a confusing presentation.
  • Initial labs include a complete blood count (CBC), electrolytes, and urinalysis.
  • Hypocalcemia, hypomagnesemia, and hyperkalemia may cause respiratory dysfunction.
  • Blood urea nitrogen (BUN), creatinine, phosphate, or serum ammonia tests may be helpful.
  • Specific metabolic studies may be indicated if the patient is hypoglycemic, acidotic, or hyperammonemic.
  • Toxicologic screen can be helpful if suspected exposure to medications (potentially intentional) or drugs of abuse (occasionally bystander inhalational routes).
  • Perform a sepsis workup, with blood and urine culture, although, in the absence of suggestive findings (eg, fever), sepsis is unlikely.
    • When clinically suspected, pertussis and chlamydial cultures are appropriate.
    • Consider respiratory syncytial virus (RSV), particularly in very young infants or premature infants with respiratory symptoms.
    • Stool may be sent for clostridial culture and for botulinum toxin testing, particularly if hypotonia is found.
    • Infant botulism, a risk not limited to the ingestion of honey, is probably more frequent than generally believed.
  • Arterial blood gas may be helpful for severely ill infants or those with persistent symptoms on presentation.
    • This may reveal metabolic acidosis unexplained other than by clearance of a large lactic acid load from a clinically significant apparent life-threatening event (ALTE).
    • Metabolic acidosis raises the possibility of sepsis or metabolic deficiencies.
  • Blood and urine toxicology screens and a carbon monoxide level test are appropriate in many cases.

Imaging Studies

  • A chest x-ray (CXR) is indicated in most cases.
  • The presence of fractures in a child younger than a year, irrespective of the site, should prompt a thorough investigation to exclude child abuse.
  • It is extremely difficult to fracture the ribs of an infant during resuscitation; however, fractures do occur with relative ease when an infant's thorax is grasped abnormally.
  • Obtain anteroposterior and lateral soft tissue films of the neck if upper airway obstruction is suspected.
  • A barium swallow may be ordered if indicated by history or physical examination.
  • Skull films and CT scans may be indicated if abuse is suspected or if signs of increased intracranial pressure are present.

Other Tests

  • Obtain a 12-lead electrocardiogram (ECG).
  • Consider electroencephalogram (EEG) if indicated by history or physical examination.

Procedures

  • Patients younger than 2 months and those with significant evidence of infection should have a complete septic workup, including lumbar puncture and empiric antibiotics.

More on Pediatrics, Sudden Infant Death Syndrome

Overview: Pediatrics, Sudden Infant Death Syndrome
Differential Diagnoses & Workup: Pediatrics, Sudden Infant Death Syndrome
Treatment & Medication: Pediatrics, Sudden Infant Death Syndrome
Follow-up: Pediatrics, Sudden Infant Death Syndrome
References
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Further Reading

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Keywords

sudden infant death syndrome, SIDS, sudden infant death, crib death, cot death, long QT syndrome, ALTE, apparent life-threatening event, sudden infant death causes, back sleeping, back to sleep, sudden infant death prevention, prolonged QT interval hypothesis, apnea hypothesis, sudden unexpected death in infancy, SUDI

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Contributor Information and Disclosures

Author

Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Clinical Faculty, Community Medical Centers; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program
Lynn Barkley Burnett, EdD, MS, LLB(c) is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Association for the Advancement of Science, American Association of Suicidology, American Cancer Society, American College of Sports Medicine, American Heart Association, American Professional Society on the Abuse of Children, American Public Health Association, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, American Stroke Association, Association of Military Surgeons of the US, Christian Medical & Dental Society, European Society for Trauma and Emergency Surgery, European Society of Cardiology, European Society of Intensive Care Medicine, European Society of Paediatric and Neonatal Intensive Care, Faculty of Forensic and Legal Medicine of the Royal College of Physicians of London, International Homicide Investigators Association, New York Academy of Sciences, Royal College of Surgeons of Edinburgh, Royal Society of Medicine, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and World Association for Disaster and Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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