Sudden Infant Death Syndrome

Updated: May 16, 2022
Author: Lynn Barkley Burnett, MD, EdD, JD; Chief Editor: Kirsten A Bechtel, MD 


Practice Essentials

Sudden unexpected infant deaths (SUIDs) are deaths in infants younger than 12 months of age that occur suddenly, unexpectedly, and without obvious cause. Sudden infant death syndrome (SIDS), the leading cause of SUID in the United States, is diagnosed only after a thorough investigation of the scene, interview of caregivers, and a complete forensic autopsy. Development of Emergency Department guidelines for the reporting and evaluation of SUID, in collaboration with the local medical examiner and child death review teams, will enable ED practitioners to collect important information in a compassionate manner that will be valuable to the investigating personnel.

The image below illustrates the incidence of SIDS in the United States, 1985-2008.

Depiction of changes in sudden infant death syndro Depiction of changes in sudden infant death syndrome (SIDS) incidence in United States before and after "Back to Sleep" campaign. Line plot (secondary y-axis) depicts combined proportion of infants placed for sleep in supine and side-sleep positions, as determined by annual federal telephone survey of infant sleep position. AAP = American Academy of Pediatrics; NICHD = National Institutes of Child Health and Human Development; NISP = National Infant Sleep Position.


Sudden Unexpected Infant Deaths (SUIDs)

Sudden unexpected infant deaths (SUIDs) are specified as deaths in infants younger than 12 months of age that occur suddenly, unexpectedly, and without obvious cause in the ED. These cases require a complete investigation of the environmental circumstances at the time of death and a forensic autopsy. In the United States, approximately 4,500 infants die suddenly of no immediately obvious cause every year; about half of these deaths are due to SIDS, the leading cause of all infant deaths.[1]

Sudden Infant Death Syndrome (SIDS)

SIDS is defined as the sudden, unexpected death of an infant less than 1 year of age that cannot be explained despite a thorough investigation, including a complete autopsy, examination of the death scene, and review of the clinical and social history. SIDS is the leading cause of death among infants aged 1–12 months, and is the third leading cause overall of infant mortality in the United States. SIDS may occur in infants and children younger than 16 months of age, but the peak incidence is between 2 and 4 months of age.[1] Although the overall rate of SIDS in the United States has declined by more than 50% since 1990, rates for non-Hispanic Black and American Indian/Alaska Native infants remain disproportionately higher than the rest of the US population.[1]

SIDS should not be used as an emergency department diagnosis. It is more accurate to use “Sudden Unexpected Infant Death” if there is no external evidence of injury to the infant and no scene information to suggest another cause of death.[2] To confirm the diagnosis of SIDS, a complete forensic autopsy needs to be performed, using information gathered from the scene investigation, interview of caregivers and review of medical and social history. After a thorough case investigation, some of these SUIDs may be explained. Poisoning, metabolic disorders, hyper- or hypothermia, child abuse and neglect resulting in homicide, and suffocation are all explainable, but much less common, causes of SUID.

The medical examiner’s diagnosis of SIDS is one of exclusion. Recently the pathological diagnosis of SIDS was revised by an expert panel of pediatric and forensic pathologists and pediatricians; they developed a new, general definition of SIDS for administrative and vital statistics purposes.[3] Another category, unclassified sudden infant deaths, was introduced for cases that do not meet the criteria for a diagnosis of SIDS and for which alternative diagnoses of natural or unnatural conditions were equivocal. 

The discovery of morphological differences in the brainstem of infants who have died from SIDS indicates that such cases may represent immature development of centers responsible for arousal, cardiovascular, and respiratory functions. When the cardiorespiratory system becomes compromised due to noxious environmental conditions (hypoxia, hypercarbia) during sleep, such infants may not become aroused to defend against these conditions, resulting in sudden death.[4, 5, 6, 7] This has lead to the development of the “triple risk model for SIDS”: underlying vulnerability in the infant; critical stage of development; and exogenous stressor.[7]

Even when a thorough investigation is conducted, it may be difficult to separate SIDS from other types of SUIDs, especially unintentional suffocation in an adult bed.[8]

When cases of SIDS are identified after a complete forensic investigation, it may be found that multiple modifiable environmental factors likely contributed to the infant’s sudden death, such as prone sleep position, bed sharing with another adult/child, and maternal smoking.[9, 10]

Signs and symptoms

Live patients may be seen following a brief resolved unexplained events (BRUE, formally called apparent life-threatening event ALTE). BRUE survivors share many risk factors for SUID; however, debate exists as to whether BRUEs are interrupted SUIDS events, separate phenomena, or SUIDS-related events.

The observations most commonly reported with brief resolved unexplained events (BRUE) are as follows:

  • Cyanosis (50-60%)

  • Breathing difficulties (50%)

  • Abnormal limb movements (35%)

After a BRUE, many patients present to the emergency department (ED) in no acute distress. In 50% of these infants, physical examination is entirely normal. Pyrexia is documented in 25% of patients, infection in 25%.

The following questions should be asked:

  • Did the infant have a foreign body, trauma, or ingestion?

  • Does the infant have a history of apnea?

  • What activity did the infant exhibit before the BRUE?

  • What was the time and amount of the last meal?

  • Was the baby asleep or awake?

  • What was the child’s position?

  • What was observed first?

  • What was the period of apnea (in seconds)?

  • Did the infant change color?

  • What was the baby’s tone (eg, limp, stiff, or shaking)?

  • What was the duration of the event?

  • What was done (eg, cardiopulmonary resuscitation [CPR]), and how was it done?

The classic presentation of SIDS begins with an infant who is put to bed, typically after breastfeeding or bottle-feeding. Checks of the baby at varying intervals are unremarkable, but the baby is found dead, usually in the position in which he or she had been placed at bedtime or naptime. Although most of infants are apparently healthy, many parents state that their babies "were not themselves" in the hours before death.

Efforts must be made to distinguish death from death by suffocation (as in abuse). Such efforts should take the following into account:

  • The circumstances surrounding the infant’s death

  • The course of pregnancy, delivery, and infancy

  • Previous involvement of law enforcement or child protective services

Care should be taken at the scene of death to examine for signs of environmental factors that may have contributed to the death.

Several physical findings may help distinguish suspected infanticide. Findings consistent with SIDS include the following:

  • Serosanguineous watery, frothy, or mucoid discharge from mouth or nose

  • Reddish-blue mottling on the face and dependent portions of the body

  • Marks on pressure points of the body

  • Well-cared-for appearance, with no significant skin trauma

  • No environmental contribution to the unexpected death (i.e. unsafe sleeping environment)

Findings that raise the suspicion of child abuse include the following:

  • Malnutrition or neglect

  • Cutaneous injuries, traumatic lesions, or abnormalities of the head or body

  • Distribution of hypostasis indicating that the child was in a different position from that stated

  • Pressure ischemia over the nose and mouth

In addition to bruising, the following may be observed:

  • Pinch or human bite marks

  • Wounds in different stages of healing

  • Scalds or burns, including those caused by cigarettes

  • Fractures, particularly if of different ages

  • Pupillary changes

See Presentation for more detail.


If the infant is seen after a brief resolved unexplained events (BRUE), workup includes the following:

  • Appropriate blood and urine tests

  • Radiography and computed tomography (CT) when warranted

  • A 12-lead electrocardiogram (ECG)

  • Electroencephalography (EEG), if indicated by findings from the history or physical examination

  • In patients younger than 2 months and those with significant evidence of infection, a complete septic workup

A diagnosis of SIDS is established by excluding recognizable causes of sudden unexplained infant death (SUID). The necessary data set includes information obtained from the scene of death, infant and family medical and social history, and autopsy examination

See Workup for more detail.


Infants who have experienced a BRUE must be transported to the ED, even those who appear well when examined by emergency medical services (EMS) personnel. Initial care includes the following:

  • Resuscitation and general stabilization

  • Cardiac and respiratory monitoring, including arterial oxygen saturation

  • Blood glucose determination

All infants presenting with nontrivial apnea or BRUEs associated with cyanosis or alterations in mental status or tone should be admitted. Inpatient evaluation may include the following:

  • Electroencephalography (EEG)

  • Evaluation for gastroesophageal reflux (GER) or swallowing incoordination

  • Cultures for occult infection

  • Pneumography

  • Polysomnography

  • Arterial blood gas determination

  • Upper airway studies to identify suspected obstruction

  • Electrocardiography (ECG), echocardiography, and other studies

Transfer is indicated if inpatient facilities are not available to meet the patient’s needs for monitoring and critical care.

In the setting of a sudden unexpected infant death (SUID), health professionals must do the following:

  • Communicate with and inform the family in a compassionate, empathic, supportive, and nonaccusatory manner

  • Simultaneously, conduct a thorough investigation of the death

Suggested measures for preventing SIDS include the following:

  • Start prenatal care early

  • Avoid cigarettes, alcohol, and other drugs while pregnant

  • If possible, breastfeed the baby

  • Burp the baby during and after feedings, especially before putting the baby to sleep

  • Place the baby on a firm, flat mattress in a safety-approved crib; avoid pillows, blankets, sheepskins, foam pads, or water beds

  • Do not restrain the baby during sleep

  • Consider using a fan in the infant’s room to improve ventilation

See Treatment and Medication for more detail.


Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year that remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and a review of the clinical history. Cases that fail to meet this definition, including those without a postmortem investigation, should not be classified as SIDS; cases that include autopsy and careful investigation but remain unresolved may be designated as undetermined or unexplained.

Some changes in terminology have occurred.[11] Sudden unexpected infant death (SUID), has been used as an umbrella term under which “pure” SIDS would fall (eg, the unexpected death of a supine sleeping infant in whom the autopsy reveals no lethal lesion and the death scene investigation excludes potential asphyxiating stressors). The unavailability of a universally accepted classification scheme poses challenges for researchers, clinicians, and aggrieved families.

It has been suggested that the pathogenesis of SIDS involves a persistence of fetal reflex responses into early infancy, during which enhanced inhibitory and depressed excitatory cardiorespiratory reflex responses to local stressors are present, leading to sudden death during sleep in otherwise normal-appearing infants.[12] The defects in these critical life-sustaining neural pathways likely arise during fetal development and, in some cases, are further influenced by prenatal and postnatal exposure to cigarette smoke and alcohol.[13, 14]

The sudden demise of an infant, thankfully, is not a common occurrence. SIDS predominates as the single leading cause of unexpected deaths in infancy; however, alternative diagnoses are identified in as many as 15-25% of SUIDs. In most series, SIDS accounts for 35-55% of deaths within the postneonatal period (ie, age 1 month to 1 year). Despite intensive study and advances in the understanding of associated factors, the specific cause or causes of SIDS remain unknown.

The diagnosis of SIDS is one of exclusion and thus should be demystified, with the specific evidence in each infant death subject to careful and complete examination. Although death from SIDS is much more common than death from child abuse, the possibility of homicide, nevertheless, is an omnipresent etiologic overlay. Presentation of an infant with a life-threatening event thus creates many unique challenges for emergency physicians and has a high potential for producing cognitive dissonance.

Elicitation of the history of present illness, vital to every workup, may reveal inconsistencies that raise the suspicion of human agency as the underlying cause of the infant’s condition. Physical examination directed toward the identification of medical problems may reveal evidence of intentional trauma.

Treatment of physiologic instability must be conducted simultaneously with efforts aimed at identifying and preserving potential physical evidence. Even emotional support of the parents, which is integral to comprehensive medical management and compassionate medical practice, should be carried out in a manner that does not compromise possible subsequent legal proceedings.

Informing parents of the death of a child is cited as the most stressful experience physicians confront in emergency settings. These events often are compounded by feelings of guilt and inadequacy, which many physicians experience after an unsuccessful pediatric resuscitation. These reactions may be markedly different, qualitatively and quantitatively, from the emotions generally experienced in other crises.


Although multiple hypotheses have been proposed as the pathophysiologic mechanisms responsible for SIDS, none have been proven. The triple-risk model, proposed by Filiano and Kinney, suggests that SIDS represents an intersection of factors, including the following[15] :

  • A vulnerable infant possessing intrinsic abnormalities in cardiorespiratory control

  • A critical period in the development of homeostatic control mechanisms

  • Exogenous extrinsic stressors (triggering factors)

SIDS rarely occurs in infants who are risk free or those who have only one risk factor. Ostfeld et al (2010) report that in one study, 96.3% of decedents had 1 to 7 risk factors, with 78.3% having 2 to 7.[16] In another report, 57% of SIDS infants had one intrinsic risk factor and 2 extrinsic factors.[17]

Death occurs when vulnerable infants are subjected to stressors at times when normal defense mechanisms may be structurally, functionally, or developmentally deficient.

The triple-risk model allows for the possibility of multiple stressors and for heterogeneous underlying vulnerabilities that manifest as SUID. Epidemiologic data suggest that genetic factors play a role, and many studies have attempted to identify SIDS-associated genes.[18] A copious literature implicates various genes, encoded proteins, and signaling pathways in the pathogenesis of SIDS, including central nervous system (CNS) pathways, cardiac channelopathies, immune dysfunction, metabolic pathways, and nicotine responses.

QT interval hypothesis

Although both prolongation of the QT interval (long QT syndrome [LQTS]) and shortening of the QT interval (short QT syndrome [SQTS]) are associated with increased risk of cardiac arrhythmia and sudden death, it is QT prolongation that has received the greatest attention in SIDS.[19] Clinically, these dysrhythmias may present as syncope, seizures, or sudden cardiac death. According to conservative estimates, 30-35% of infants who subsequently die of SIDS have prolongation of the QT interval in the first week of life.

The QT interval is heart rate−dependent and is calculated according to Bazett’s formula. Prolongation of the corrected QT interval (QTc) is a marker of reduced cardiac electrical stability and is strongly associated with SIDS. Some clinicians consider the QTc to be prolonged when it exceeds 440 msec; others consider it to be prolonged when it exceeds 450-475 msec.

The QTc increases during the second month of life but returns to values recorded at birth by the sixth month. These findings are derived from a large prospective study of infants born over a 19-year period, and another study, which together examined more than 40,000 infants. The odds ratio for SIDS among all infants with prolonged QTc was 41:1; for boys, the odds ratio was approximately 47:1.

Prolongation of the QTc may act as an arrhythmogenic substrate that requires other postnatal factors to trigger development of life-threatening arrhythmias. The trigger is usually a sudden increase in sympathetic activity, which, during the first year of life, may have a number of causes, including sudden noise, apnea leading to a chemoreceptive reflex, exposure to cold, and rapid eye movement (REM) sleep and arousal.

Developmental alteration in cardiac sympathetic innervation is one hypothesis proposed to explain QTc prolongation. Such innervation continues after birth for approximately 6 months. Occasionally, right and left sympathetic nerves develop at different rates, creating a temporary neural imbalance. During this stage, a sudden increase in sympathetic activity may cause a lethal arrhythmia in these electrically unstable hearts. This is most commonly the torsades de pointes variant of ventricular tachycardia, due to early after-depolarizations.

A second hypothesis proposes a variant of congenital LQTS. Patients with this syndrome are at high risk for sudden death, especially under conditions of stress, but also during sleep.

Congenital LQTS has several distinct genetic forms or may arise as a spontaneous mutation. An autosomal dominant form (Romano-Ward) and an autosomal recessive form (Jervell and Lange-Nielsen) are recognized. The latter is associated with sensorineural deafness. LQTS may also occur sporadically. The genes encoding ion-channel proteins regulating sodium and potassium ion flux have been described. Multiple mutations involving 8 genes on 5 separate chromosomes have been identified to date.[20, 21, 22, 23, 24]

A long-term prospective study, involving 34,442 newborns over an 18-year period, explored the relation of QTc prolongation to SIDS.[25] Within this large cohort, 24 infant deaths occurred that were attributed to SIDS. Twelve of the 24 infants exhibited prolongation of the QT interval on their newborn electrocardiogram (ECG). The authors suggested that these deaths might have been preventable with medications (beta-blockers) known to suppress the development of the fatal dysrhythmias associated with QTc prolongation.

Although other traditional SIDS risk factors (eg, prone sleeping position, maternal smoking, and bed sharing) have odds ratios markedly lower than that observed with QTc prolongation, the American Academy of Pediatrics considers it unlikely that this electrical irregularity explains more than a small minority of SIDS cases. Future studies will help to determine whether targeted or population-based screening for QTc prolongation among newborns is the best evidence-based strategy.

Hypoxia/apnea hypothesis

Apnea (cessation of respiratory airflow) can be manifested in several different forms, including the following:

  • Brief Resolved Unexplained Events (BRUE) 

  • Periodic breathing

  • Pathologic apnea

  • Apnea of prematurity

  • Apnea of infancy

Definitions of these terms (see below) are based on those promulgated by the National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, supplemented as noted.

A BRUE (previously called apparent life-threatening event) is frightening to observe and is characterized by some combination of apnea (central, occasionally obstructive), color change (usually cyanotic or pallid, occasionally erythematous or plethoric), marked change in muscle tone (usually limpness), choking, or gagging. In some cases, observers fear the infant has died. BRUE survivors share many risk factors for SIDS and are at increased risk for the syndrome; however, debate exists as to whether BRUEs are interrupted SIDS events, separate phenomena, or SIDS-related events.

The estimated frequency of BRUE among healthy term infants is 1-3%. A potential relation between SUID and BRUE is suggested by the observation that the risk of subsequent death among infants experiencing a BRUE is 1-2%. The risk increases to 4% for infants whose BRUE is associated with respiratory syncytial virus (RSV) infection and rises to 8-10% for infants who experience BRUE during sleep or require some form of cardiopulmonary resuscitation (CPR). Among infants with SIDS, only 5% have a history of a BRUE preceding the death.

Approximately 25-30% of BRUEs remain unexplained even after a thorough evaluation. The most conditions commonly associated with BRUE include gastroesophageal reflux disease (GERD), lower respiratory tract infection (bronchiolitis), pertussis, urinary tract infection (UTI), respiratory control disorder, and seizure. Less common causes include cardiac dysrhythmia (LQTS), anemia, structural CNS anomaly, and cardiac or airway anomaly.

Periodic breathing is a breathing pattern in which 3 or more respiratory pauses of more than 3 seconds’ duration are separated by less than 20 seconds of respiration between pauses. This breathing pattern can be normal.

Pathologic apnea involves an abnormal pause in respiration. A respiratory pause is abnormal if it is prolonged (>20 sec) or if it is associated with cyanosis; abrupt, marked pallor; hypotonia; or bradycardia.

Apnea of prematurity is characterized by periodic breathing with pathologic apnea in a premature infant. Apnea of prematurity usually ceases by 37 weeks’ gestation (postmenstrual dating) but occasionally persists for several weeks past term.

Apnea of infancy is characterized by an unexplained episode of cessation of breathing for 20 seconds or longer or by a briefer respiratory pause associated with cyanosis, pallor, marked hypotonia, or bradycardia. This term is generally applied to infants who are older than 37 weeks’ gestational age at the onset of pathologic apnea. Typically, their BRUEs are idiopathic but are considered to be related to apnea. Accordingly, the apnea of infancy classification is generally reserved for those infants for whom no specific BRUE cause can be identified.

Several anatomic and physiologic findings support the role of apnea in SIDS. SIDS, despite its name, is not always sudden.

Meny et al reviewed data from 6 infants who died while on home monitors.[26] Of the 6 deaths, 3 were ascribed to SIDS. All SIDS patients had bradycardia that preceded (n = 2) or occurred simultaneously with (n = 1) central apnea; 1 had tachycardia before bradycardia. The monitor printout of 1 patient showed a slow decrease in heart rate for about 2 hours before death. One infant who had rapid CPR could not be revived, which suggested that myocardial depression secondary to hypoxemia may have preceded the bradycardia.

Other evidence also implicates hypoxia (acute and chronic) in SIDS. Hypoxanthine, a marker of tissue hypoxia, is elevated in the vitreous humor of patients who die of SIDS as compared with control subjects who die suddenly. This adds biochemical support to the concept that in some cases, SIDS is a relatively slow process. In addition, a number of infants who die of SIDS manifest necropathologic evidence of chronic hypoxia, including changes in the bronchiolar walls, pulmonary neuroendocrine cells in the lungs, and elevated fetal hemoglobin levels.

Alveolar hypoxia stimulates pulmonary vasoconstriction and, eventually, pulmonary vascular smooth muscle cell hyperplasia. Muscularity of the pulmonary vasculature causes pulmonary vasoconstriction, increased right ventricular afterload, and heart failure with more tissue hypoxia. Arterial hypoxemia and ischemia result in astrogliosis of the brainstem, which promotes hypoventilation and further astrogliosis.

Another significant autopsy finding is pleural petechiae, whose formation reflects acute hypoxia in a physiologically intact infant. Hypoxic asphyxia in newborns occurs in the following well-defined stages:

  • Stage 1 - Tachypnea for 60-90 seconds followed by apparent loss of consciousness, passage of urine, and no respiratory effort

  • Stage II - Deep, gasping respiratory efforts separated by 10-second periods of respiratory silence

  • Stage III - Formation of pleural petechiae, ultimately resulting in cessation of gasping

  • Stage IV – Death, if resuscitation is not initiated

The latter stages of asphyxia are triggered when arterial oxygen tension (PaO2) falls toward zero. Asphyxia may occur with the airway open, partially occluded, or closed.

Although SIDS autopsies often demonstrate no pathologic findings, most infants who die of SIDS have an extremely large number of petechiae. Their presence suggests that repeated episodes of asphyxia occurred in a period of hours to days before death, causing recurrent gasping episodes with associated petechiae formation. Studies in newborn animals have shown that metabolic recovery from asphyxia takes hours. Thus, repeated asphyxia episodes that were previously self-limited by arousal and autoresuscitation might eventually prove fatal.

In general, apnea may be classified into the following 3 basic types:

  • Central or diaphragmatic (ie, no respiratory effort)

  • Obstructive (usually due to upper airway obstruction)

  • Mixed

Whereas short central apnea (< 15 sec) can be normal at all ages, prolonged apnea that disrupts physiologic function is never normal. Some pathologic evidence and ample theoretical evidence support central apnea as a cause of SIDS and obstructive apnea as playing an associated, if not key, role in some infants. Expiratory apnea (lung collapse) also has been proposed as a cause of SIDS; however, necropathologic evidence of its presence is found in only a small minority of cases.

Obstructive apnea

Developing infants have normal sites of anatomic and physiologic vulnerability that, alone or combined, may transiently predispose to airway obstruction. Among these vulnerabilities are the following:

  • Shallow hypopharynx

  • Cephalad position of the tongue and epiglottis

  • More compliant rib cage

Positioning may predispose the newborn to upper airway obstruction as well. Although infants with anatomic anomalies are at particular risk, obstruction may also occur in those with normal anatomy. Most infants are obligate nasal breathers for the first few months of life. The nares flare anteriorly, with the nose forming no protrusion. Four to 6 months represents the period of cardinal transition from nose breathing to mouth breathing.[27]

Hypoxemia of sufficient severity to produce electroencephalographic (EEG) evidence of cerebral hypoxia does not begin until 60-70 seconds after the onset of obstruction. Although infants placed in the prone position on a level sleeping surface may turn their faces to maintain oxygen flow, respiratory obstruction with compression of the nose and backward displacement of the mobile mandible has been implicated as a cause of asphyxia in the prone position.

Gastroesophageal reflux (GER) may play a role in obstructive apnea as well. Regurgitation increases mucosal adhesive forces, a development of particular significance with the more pliable airways of infants. The occurrence of this phenomenon in infants who have laryngeal inflammation secondary to chronic regurgitation increases the risk of obstructive apnea.

Central apnea

Unlike older children and adults, normal neonates and infants may exhibit a reflexlike apneic response to a number of physiologic and pathophysiologic conditions, such as hypoxia, hypoglycemia, intracranial bleeding, infection, some toxins, and stimulation of the upper larynx.

Studies of the cry characteristics of SIDS siblings demonstrate hyperadductional vibratory behavior of the vocal fold.[28] The acid regurgitated in GER may affect a putative laryngochemoreceptor, causing respiratory pause, airway closure, and swallowing. This may result in an awake apneic event, which is not uncommonly reported by parents.

Such apneic responses are probably due to incomplete development of the CNS, increased vagal tone, and decreased respiratory muscle reserve. Although no statistical association has been established between such episodes of apnea and SIDS, the potential for the immature nervous system to interrupt its respiratory cycle easily may be a critical precondition for SIDS shared by all normal infants.

Infants with subclinical dysfunction of the autonomic nervous system or those undergoing physiologic stress may be predisposed to fatal evolution of an otherwise benign episode of apnea. Hypoxia, hypercarbia, and other noxious stimuli normally cause arousal and generalized alertness of the musculoskeletal and nervous systems, in addition to tachypnea and gasping. This development is followed by cycles of apnea alternating with a gasp.

SIDS is rare during the first month of life, perhaps in part because neonates have better aerobic capacity than older infants and a gasp may raise their PaO2 to over 20 mm Hg and allow them to continue breathing. If such is not the case, each gasp becomes weaker than the preceding one, until terminal apnea and death occur. Indirect evidence suggests that slowly progressive hypoxia inhibits protective ventilatory reflexes in normal infants. When these infants are acutely rechallenged, hypoventilation and apnea result, rather than a tachypneic response.

Acquired ventilatory dysfunction may explain the chronic tissue hypoxia seen in many infants who die of SIDS. Several, but not all, studies suggest that at-risk infants have subclinical ventilatory impairment that is midway between normal infants and those with central hypoventilation syndrome. Infants who demonstrate diminished ventilatory response to hypoxia and hypercapnia have significantly diminished arousal response. Such diminished arousal response is correlated with future episodes of apnea that require resuscitation.

Death may result during abnormal sleep, from dysfunction of the brainstem, or during normal sleep, when a pathophysiologic setting incites a lethal cascade of events. Diminished arousal response has been identified in newborns who subsequently suffer a BRUE, as well as in asymptomatic siblings of infants who died of SIDS, which suggests that some cases are congenital. Such diminished arousal also may be seen in some healthy infants (who do not have impaired ventilation).

Prone sleeping results in hypoxemia and hypercarbia, findings that attach special significance to these abnormal responses to subclinical hypoxemia and hypercarbia and their possible relation to SIDS.

Infants at risk have a relative inability to awaken and remain awake from all stages of sleep. Term infants have more episodes of nonperiodic apnea during rapid-eye-movement (REM) sleep, which is autonomically active, than during quiet sleep.

Relaxation of respiratory and accessory muscles has been documented in conjunction with skeletal muscle relaxation during REM sleep. Infants who subsequently died of SIDS had significantly more REM-associated obstructive breathing events; however, sleep-related airway obstruction did not occur in high-risk infants as long as there was arousal. Increased respiratory effort, occasionally with transient obstructive apnea, has been noted during quiet, non-REM sleep.

Critical diaphragm failure

Siren and Siren (2011) propose a critical diaphragm failure theory of SIDS (SIDS-CDF),[29] and present the following rationale:

  • Prone sleeping significantly increases the workload on the diaphragm

  • Infants younger than 6 months have undeveloped respiratory muscles that are susceptible to CDF. At approximately age 6 months, the infant diaphragm achieves the same fiber composition and pressure-generating capacity as the adult diaphragm

  • The younger the infant, the smaller the oxidative capacity of the respiratory muscles, and consequently a greater risk of respiratory muscle fatigue (low-birth-weight infants or premature infants have a 4 times greater risk of SIDS than do full-term infants)

  • Systemic infection can induce significant reduction in the adenosine triphosphate (ATP)–generating capacity of diaphragmatic muscle tissue, and even minor infections can significantly decrease diaphragmatic strength

  • Intercostal muscles show both phasic and tonic inhibition during REM sleep that renders them largely or totally inactive; while incapacitation of the intercostal muscles is usually not lethal, bilateral diaphragmatic paralysis usually eventuates in respiratory failure; off further significance, a 3-month-old spends 38% of sleep time in REM phase, whereas a premature infant spends 80%

A study by Männikkö et al reported that four (1·4%) of the 278 infants in the SIDS cohort had a rare functionally disruptive SCN4A variant compared with none (0%) of 729 ethnically matched controls (p=0·0057).[30]

Other hypotheses

Behavioral disability

Developmental disability of infantile neurorespiratory control is posited, occurring during the transition period when protective subcortical reflexes are no longer present and voluntary defensive responses mediated via the cortex (ie, those that allow reestablishment of ventilation when it has been compromised) have not yet been sufficiently learned.

This hypothesis proposes that infants so affected manifest global passivity from ill-defined constitutional, arousal, or behavioral disabilities. Those infants, in turn, have less opportunity to respond, learn, and benefit from experience, including early exposure to normal (partial or brief) airway obstructions.

Primary autonomic nervous system instability

This theory proposes that apnea and bradycardia are the result of primary autonomic dysfunction or sympathetic imbalance.

Defective neuronal development, receptor deficiency, and genetic polymorphism

Numerous structural and functional nerve cell abnormalities have been described in infants with SIDS. Evidence suggesting delayed development of the brain stem has been demonstrated in 2 studies in which elevated dendritic spine counts were noted among infants who have died of SIDS.[31, 32] Reductions in the degree of myelination of specific brain regions of infants with SIDS provide further evidence of defective neuronal development.

Several studies have demonstrated neurotransmitter abnormalities in infants with SIDS.[33, 34, 35, 36] Studies of brainstem nuclei taken from babies who died of SIDS have revealed deficiencies in muscarinic receptors (whose neurotransmitter is acetylcholine), kainite receptors (whose neurotransmitter is glutamate), and lysergic acid receptors (whose neurotransmitter is serotonin).[12]

The receptor deficiencies were found to be concentrated in nuclei that control cardiorespiratory response to a variety of stimuli.[12] These receptor deficiencies were noted much more frequently in SIDS victims than in babies dying of other causes. For example, 60-70% of SIDS babies had serotonin receptor defects. It is unlikely that any single defect is solely responsible for SIDS.

The medullary serotonin system (5-HT) is thought to play a key role in autonomic nervous system regulation of cardiorespiratory control, the sleep-wake cycle, and thermoregulation.[37, 38, 39] Autopsy-derived data and animal model studies have helped to identify key structural and functional components of these pathways and their potential relationships to SIDS.[14, 40, 41, 42, 43, 44, 45, 12]

Genetic polymorphisms have been described in association with defects in components of serotonin-binding neural pathways.[46, 47] Polymorphisms in the serotonin transporter promoter genes were identified more often in SIDS patients than in control subjects.[48]

Harrington et al found that the activity of butyrylcholinesterase (BChE), which plays a role in autonomic function, was significantly decreased in infants who died of SIDS, compared with living infants and those who died of other causes. BChE activity was measured in dried blood spots obtained shortly after birth.[49]

Ten cardiac channelopathy susceptibility genes are implicated in SIDS.[50] At least 1 in 5 SIDS victims carries a mutation in a cardiac ion channel–related gene, of which the majority are a malignant phenotype.[24] It has been postulated that latent functional defects may only become malignant in the presence of certain conditions, such as acidosis or high temperature. For example, several immunologic polymorphisms that facilitate uncontrolled inflammatory responses are more frequently found in SIDS victims versus controls. One hypothesis is that pathogenic toxins may give rise to an overwhelming proinflammatory cytokine response that then causes the altered physiology resulting in death. Altered cytokine response has also been suggested as a pathophysiologic mechanism by which cigarette smoke can contribute to SIDS.

Mutations in genes responsible for encoding the cardiac potassium channels can cause LQTS or SQTS, either of which may result in increased risk for ventricular arrhythmias and sudden cardiac death.[19] Such genetic mutations are found in 5-10% of SIDS cases.

In addition to LQTS, other heritable cardiac arrhythmia syndromes (eg, Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia) account for 10-15% of SIDS cases. Most SIDS-related mutations occur in the cardiac sodium channel.[51] The polymorphism S1103Y-SCN5A is associated with increased susceptibility to ventricular arrhythmia and has a prevalence of 13% among African Americans (who have the second highest rate of SIDS in the US). Infants homozygous for Y1103 were found to have a 24-fold increased risk of SIDS.

The sodium proton exchanger subtype 3 system (NHE3) plays a role in controlling breathing.[52] Animal studies showed that alveolar ventilation during wakefulness is inversely correlated with expression of NHE3 mRNA in the brainstem; thus, NHE3 expression seems to be related to the set point of normal breathing. This set point is one of the keys to the stability of respiration during sleep. A study of the brainstems of infants who died of SIDS revealed elevated NHE3 expression, suggesting that this might be a causative factor in SIDS.

Vertebral artery compression

Anatomic dissections have demonstrated that the vertebral arteries of infants are vulnerable to compression on neck extension or rotation. The structural factors productive of such compression are as follows:

  • The lateral mass on the superior surface of C1 is small and does not provide a good means of preventing downward compression of the vertebral arteries

  • The arch of the atlas is smaller than the foramen magnum and may invert up into the foramen magnum during neck extension, with resultant compression of the vertebral arteries

  • The ligamentous support for the atlanto-occipital junction is poorly formed, with greater mobility in infants than in adults

  • The vertebral artery lies exposed on the surface of C1 and not in a bony groove as in adults

  • The posterior atlanto-occipital membrane is often thick and compresses the vertebral artery during extension because of its position immediately above the vertebral artery

In approximately 40% of infants, flow in one vertebral artery is less than half that in the contralateral vessel; thus, if the larger vessel is occluded, the brainstem is jeopardized much more than it would be if flow were bilaterally equal. If both vertebral arteries are compressed, flow continues, given normal anatomy, via the posterior communicating arteries of the internal carotids. However, flow through the posterior communicating arteries in infants is only 13% of basilar artery flow, and the brainstem is thereby placed at risk.


The peak incidence of SIDS is during the second to fourth months of life. Around the third month, a decrease is seen in the passive immunity conferred by the mother, as the infant’s immune system is activated. Early active immunity triggers localized immunologic responses to several substances, including respiratory irritants and infectious agents, with the potential for bronchospasm, pulmonary edema, and cytokine-mediated effects (eg, fever).

Raised concentrations of immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) have been recovered from infants who died of SIDS but not from infants who died from explained causes.


The peak incidence of SIDS coincides with critical periods in the development of the immune system; at such a time, the infant might be transiently vulnerable to lethal infection. SIDS incidence increases in the winter, during viral epidemics in a community, and 2 weeks after viral infection.

Compared with healthy control infants and infants who died of known causes, infants who died of SIDS are more likely to harbor toxigenic bacteria, such as Escherichia coli, Staphylococcus aureus, and Clostridium difficile, as well as influenza virus and respiratory syncytial virus (RSV). Most strongly implicated is RSV, which is well known for its association with central apnea. Approximately 70% of infants with SIDS have a history of recent mild upper respiratory or gastrointestinal (GI) tract illness in the days preceding death.

Elevated interleukin (IL)-6 levels have been identified in the cerebrospinal fluid (CSF) of SIDS infants.[53] Abnormal IL-6 receptor expression on serotonin-binding neurons within the arcuate nucleus of the medulla (a region involved in carbon dioxide sensing and in the mediation of responses of heart rate, respiration, blood pressure, and arousal to changes in carbon dioxide) has been noted.[54] These findings suggest a role for infection in modifying life-sustaining responses to asphyxial stressors in the sleep microenvironment.[13]

Defects of fatty acid beta-oxidation

Severe fatty change in the liver is noted at autopsy in a small proportion of SUID cases. Such change may be observed in various conditions, including severe dehydration associated with an enterocolitis, systemic sepsis, or inherited metabolic disorders. Previously, as many as 10% of SIDS deaths were thought to be due to definable inherited metabolic diseases.

In the fed state, glucose is the primary substrate for energy metabolism. In the fasted state, fat replaces glucose as a source of fuel. Long-chain fatty acids are mobilized from adipose tissue and are metabolized within the mitochondrion by progressive beta-oxidation. The first steps in the processing of fats are facilitated by acyl-CoA dehydrogenases. Three distinct acyl-CoA dehydrogenases have been identified, with varying affinities for long-, medium-, and short-chain fatty acids. Inherited defects of all 3 dehydrogenases are now recognized.

The most common disorder of fatty acid beta-oxidation is medium-chain acyl-CoA dehydrogenase deficiency (MCADD). MCADD is an autosomal recessive disorder. Studies of its molecular basis have demonstrated that in approximately 90% of those affected, the condition is caused by a single point mutation (G-985).[55] Use of polymerase chain reaction (PCR) techniques to determine the frequency of the G-985 mutation in SIDS and control populations has failed to demonstrate the homozygous condition in SIDS.

Affected children typically present within the first 2 years of life with altered mental status and hypoglycemia brought on by periods of reduced nutritional intake associated with acute viral respiratory or GI illnesses. Previously, as many as 25% of children affected with MCADD were estimated to have presented with sudden unexpected death.

In most US centers and many centers worldwide, MCADD testing has been incorporated into expanded newborn metabolic screening programs. Tandem mass spectrometry blood spot screening established an incidence of MCADD of 1:14,600 (95% confidence interval [CI], 1:13,500-1:15,900) in 8.2 million newborns worldwide. Other prospective screening studies identified the prevalence of 1:8930[56] and 1:12,000.[57] Most children identified by newborn screening do well, but adverse outcomes have not been entirely avoided.[58]

Defects in fatty acid beta-oxidation should be considered in instances of sudden death associated with fatty change of the liver on autopsy or in situations of SIDS with atypical features (eg, early neonatal death, death in children older than 1 year, or a history of SIDS within a family).

Unstable homeostatic control

It has been proposed that SIDS results from a developmental malfunction of brainstem centers that control respiratory or cardiac functions during sleep. This malfunction occurs as the body’s thermostats change from fetal to mature mode, usually during the second to third months of life.

At some point, in healthy infants aged 8-16 weeks, 2 sleep-related temperature patterns emerge: a precipitous drop in rectal temperature amounting to several tenths of a degree Celsius, followed by hourly oscillations throughout sleep. These temperature fluctuations are thought to herald maturation of the brainstem during months 2-4 of life (which is also the peak period for the occurrence of SIDS).

Temperature maturation occurs earlier (closer to 8 weeks than 16 weeks) in infants who are breastfed and firstborn, who sleep in a lateral or supine position, whose mothers are older, and who are born into more affluent families (all factors associated with decreased incidence of SIDS). Oyen et al posit that preterm babies probably have a delay in their vulnerable period, because they die later than term infants do (mean ages at death, 19.6 weeks and 15 weeks, respectively).[59]

As the baby grows, heightened metabolism and increasing body fat prompt a shift from the neonate’s susceptibility to cold stress to the infant’s increased vulnerability to heat stress. The shift occurs at about the same time as the highest risk for SIDS. This hyperthermic response may be aggravated by the increased metabolism seen during the early stages of a viral infection, as well as via IL-mediated vasoconstriction. Thus, even small elevations in body temperature can profoundly affect the respiratory rate, resulting in hypoventilation and apnea.

Triggering factors

Vulnerable periods in brainstem maturation may be critical when associated with the prone sleeping position. In this position, infants often sleep with the face down, especially in response to cold stimulus to the face.

Healthy infants aged 6 months or younger were studied as they slept in the prone position on soft and firm bedding. Even though all of the infants were able to turn their heads from this position, they slept face down an average of 14% of total sleep time on hard bedding and 35% on soft bedding. Babies aged 13-24 weeks (the time of peak risk for SIDS) are more mobile than younger infants are; however, they may not have the motor ability to extricate themselves from dangerous positions (eg, face down on soft bedding).[59]

A study of infants aged 3-37 weeks who never slept on their stomachs found that the infants did not learn the behaviors that could reduce their risk of SIDS if they were prone. When the researchers placed a comforter over a foam rubber mattress directly under the babies’ faces, all babies awoke after about 5 minutes and sought fresher air. Those experienced in sleeping prone lifted and turned their heads to the side; however, those inexperienced in sleeping prone only nuzzled the bedding or briefly lifted their heads and then resumed sleeping face down.

An infant sleeping prone, surrounded by a soft mattress, blankets, or other bedding—and possibly sleeping in the same bed with adults and compressed by or between large bodies—is in an environment that predisposes to progressive increase in carbon dioxide-rich, oxygen-poor air. The normal responses to rebreathing expired air are increased ventilation and arousal. Repetitive exposure to hypoxia causes a blunting of arousal and autonomic response[60] ; with normal responses blunted, hypoxia and hypercarbia may proceed unchecked.

A study using the cadavers of infants aged 6-9 weeks who were found dead in their cribs measured resistance to airflow pumped through the upper respiratory tract. When the body was placed face down on a pillow on various types of bedding, respiratory resistance increased 30- to 40-fold. Moisture of respiration, regurgitated milk, and mucus from the nostrils may dampen bedding material, increasing the obstructive effect when this material is compressed against the mouth and nose. When the pillow was damp, mean pressure increased by 235%.

Thermal stress and rebreathing of carbon dioxide may be interrelated as contributors to SIDS. Hyperpnea secondary to rebreathing increases the production of heat; rebreathing of warmed, expired air reduces respiratory heat exchange and enhances thermal stress; heat stress is presumably associated with an increased production of carbon dioxide, which could increase the risk of suffocation.

Sleeping in a hyperthermic environment also may alter the response to hypoxia or hypercarbia. An inadequate response to a critical incident may precipitate SIDS in a vulnerable infant who has acquired deficits in arousal or other physiologic aberrations in utero that are enhanced during postnatal development.

The dangers of prone sleeping also may stem from more episodes of quiet sleep, sleep for longer periods with fewer arousals, and decreased ability to lose heat, which is a phenomenon that may be enhanced by a heated room, excessive wrapping, fever, or illness.

In view of the relationship between the risk of SIDS and increased temperature, it is reasonable to ask, Why does the incidence of SIDS increase in cold temperature? Evidence suggests that autonomic dysfunction in at-risk infants is greatest at the lowest ambient temperature, even though body temperature remains normal. This cold-induced autonomic dysfunction may explain the association between SIDS and the cold ambient temperatures of winter.

An interesting correlation between several of the factors discussed above and the possibility of vertebral artery compression has been suggested. For example, in the prone sleeping position, infants who have the ability to do so will attempt to clear their nose from bedding by extending or rotating their head. These are the exact neck positions potentially productive of vertebral artery compression with resultant brainstem ischemia.

During the first months of life, the infant brainstem is particularly vulnerable to ischemia as a result of blood flow lagging behind the rapidly growing brainstem. SIDS is not common before the age of 1 month or after the age of 6 months. In the first month of life, infants may lack both the strength and the coordination to rotate or extend their heads to the degree required for compression of the vertebral artery. By age 6 months, however, the adverse anatomy that may predispose to arterial compression has begun to resolve.

The vertebral arteries arise from the subclavian arteries; thus, the vertebrobasilar circulation is in competition with the vascular beds of the upper extremities for flow. Heating of the limbs has the potential to increase blood flow to the upper extremities by 4-5 times the norm, thus potentially diverting blood flow that would otherwise go to the vertebral arteries and necessitating vasodilation of the vertebrobasilar system to maintain constant flow to the posterior fossa.

Passive smoking has been found to impair vasodilatation in young adults. Should a similar mechanism be operative in infants, the vertebral arteries may lack the ability to dilate adequately to prevent subclavian steal resulting from overheating.

Synthesis of pathogenetic hypotheses

SIDS is probably caused by maldevelopment, or delayed maturation, of the neural network in the brainstem that operates to affect arousal and physiologic responses to life-threatening events during sleep.[61]

Most cases of SIDS probably result from a lethal sequence of events initiated by a temporary defect in neural control of either respiratory or cardiac function during vulnerable periods in the maturation of respiratory control, sleep-wake development, and thermoregulation. Cardiorespiratory function, arousal and gasp reflexes, autonomic mechanisms, chemoreceptor sensitivity, thermoregulation, and sleep control are all controlled by the medullary and related structures of the brainstem.

Autopsy examinations of the brainstems of infants with a diagnosis of SIDS have demonstrated hypoplasia or decreased neurotransmitter binding of the arcuate nucleus, the region of the brain believed to be involved with hypercapnic ventilatory response, chemosensitivity, and blood pressure responses.

The exact nature of the possible brainstem dysfunction is unknown. One hypothesis involves exaggeration of the postulated developmental lag between loss of infantile protective neuroreflexes and development of mature integrative connections in the brainstem. Another proposes that brainstem dysfunction may be congenital or may be the result of arrested maturation of the otherwise normal brain by an internal or external agent. If this hypothesis is true, SIDS is an acquired, and therefore potentially preventable, cause of death.

Yet another hypothesis is that SIDS is the result of a transient physiologically vulnerable period during maturation of a normal CNS, in which the coincidence of several risk factors may cause apnea and death.

Regardless of the exact mechanism or mechanisms responsible, it can be theorized that the infant responds to a range of stimuli, insults, and risk factors with prolonged apnea, bradycardia, and death. This theory sets the stage for a spectrum of brainstem pathologies that include the following:

  • Infants with normally functioning brainstems who are at no risk for SIDS, no matter the nature or the quantity of risk factors

  • Infants with relatively minor brainstem dysfunction who will develop prolonged apnea and die only in the presence of multiple risk factors

  • Infants with greater brainstem dysfunction who require only 1 additional risk factor (eg, additional warmth and decreased air circulation resulting from an extra blanket or benign viral infection that causes a relatively minor subglottic airway obstruction)

  • Infants at the far end of the continuum whose brainstems are so dysfunctional that they will have virtually unprovoked SIDS

This theory can incorporate other proposed SIDS mechanisms, such as abnormal infantile respiratory patterns leading to apnea, exaggerated vagal response to GER, sleep disorders, and autonomic dysfunction. It also can account for the variable epidemiologic and pathophysiologic findings and the frequent lack of demonstrable pathology at autopsy.


Over 70 different causes of SIDS have been proposed, and there is frequent disagreement in the literature regarding the relative risk (or absence thereof) posed by disparate conditions. Several authors classify risk factors into groups such as the following:

  • Biologic factors (eg, deficiency in asphyxial arousal)

  • Maternal factors (eg, drug use during pregnancy, unmarried, anemia during pregnancy, weight gain < 20 lb during pregnancy, urinary tract infection during pregnancy),

  • Epidemiologic factors (eg, prone sleeping position and lower socioeconomic status)

Infants at increased risk for SIDS include term infants who have had a BRUE, premature infants of low birth weight, infants of substance-abusing mothers, and infants with apnea of infancy.

To identify which risk factors are specific for SIDS, rather than characteristic of postneonatal deaths in general, data were reviewed on 11,734 infants. In this population, 649 deaths had been attributed to SIDS, and 1221 postneonatal deaths had been attributed to other causes. Factors examined included the following:

  • Black race

  • Very low birth weight (< 1500 g) and low birth weight (< 2500 g)

  • Gestational age of less than 37 weeks at birth

  • 5-minute Apgar score lower than 7

  • Male sex

  • More than 2 previous pregnancies

  • Maternal age younger than 20 years

  • Maternal education level less than 12 years

  • Multiple births

  • Maternal smoking during pregnancy

Perinatal and sociodemographic risk factors were not independently associated with SIDS. Of the risk factors examined, only maternal smoking during pregnancy was independently associated with SIDS.

Despite extensive workup, no definitive cause can be found for more than 50% of BRUEs.

Biologic factors

Prematurity and low birth weight

One in 5 infants dying of SIDS is premature.[62]

Low birth weight, whether resulting from premature birth or from other causes, is associated with a maturational delay in the ability to turn the head to the face-down position. The face-down position is not desired, but turning out of this position is a skill that is perfected only after development of the ability to turn face down.[63] If low birth weight could be prevented, as many as 16.2% of SIDS deaths could be avoided. In a study by Esani et al, 9% of infants with a BRUE were small for their gestational age, versus 19% who died of SIDS.[62]


In the general population, 1-3% of infants experience a BRUE. Of all infants who die of SIDS, 5-7% have a history of BRUE.[62] A large study that reviewed all types of BRUEs found a 1% risk of subsequent SIDS. These data should be interpreted within the context that most studies of BRUEs and SIDS have excluded infants with a history of prematurity, chronic lung disease, or congenital heart disease.

Strong data associate “serious” BRUEs (those that were experienced during sleep or necessitated vigorous stimulation or CPR) and SIDS. Infants with such a BRUE have an 8-10% risk of SIDS. Infants with a history of more than 1 serious BRUE have a 28% risk of SIDS despite use of home monitoring.

Among the causes of BRUEs are infection (5-40%, depending on the season), laryngeal chemoreceptor stimulation secondary to GER (20%), and seizures and other neurologic disorders (15-20%). Cardiac dysrhythmias and abuse (including Munchausen syndrome by proxy) should also be included in the differential diagnosis. Cyanotic congenital heart disease generally presents in the first few weeks of life, with difficulty in feeding, poor weight gain, and diaphoresis.

Anecdotal, pathologic, physiologic, and epidemiologic data suggest that apnea of infancy is a risk factor for SIDS, though there is no conclusive evidence. Patients with apnea of infancy have a mortality in the range of 2-6%. The rate climbs to 10% for infants who manifest apnea during sleep on 1-2 occasions; the risk of death triples if there are more than 2 incidents.

Only 2-4% of infants who die of SIDS have a record of apnea of prematurity.

Regurgitation of gastric contents with acidic pH can cause reflexive apnea with resultant hypoxia. Although autoresuscitation might be possible in the absence of regurgitation, it is not possible when regurgitation has occurred.[64]


At the time of death, 30-50% of otherwise healthy infants have an acute infection, such as gastroenteritis, otitis media, or, in particular, upper respiratory tract infection (URTI). Infantile botulism may be the cause of 5-10% of sudden infant deaths. Of particular note, RSV is associated with life-threatening apneic episodes, particularly in premature infants and those with a history of apnea. During RSV season, the virus reported causes as many as 40% of BRUEs.

In older male infants, there appears to be an association between infection and SIDS. Approximately 65% of SIDS deaths occur in autumn and winter, and infection may play a role in these deaths. Lazoff and Kauffman maintain that SIDS is not associated with changes in core body temperature; this view is not universal.[65] The incidence of SIDS increases with colder outdoor temperature and warmer indoor (room) temperature.

Other factors

Berkowitz reported a higher incidence of SIDS in infants with residual bronchopulmonary dysplasia (11% of premature infants in 1 study)[66] ; however, Gausche maintained that infants with bronchopulmonary dysplasia are not at increased risk for SIDS.[67]

Increased apoptosis in the brainstem of SIDS infants has been found to be affected by postconceptional age, male gender, prone sleep position, and exposure to cigarette smoke.[68] The increased cell death in the dorsal column nuclei could result in dampening or loss in relay of touch and proprioception, creating difficulty when an infant in the prone position attempts to turn into the supine position.

Familial factors

Maternal characteristics

A study from New Zealand suggests that infants who are not breastfed are at increased risk for SIDS. Other studies, conducted in countries with a low incidence of SIDS, have failed to demonstrate a similar correlation.

In a study reported by Esani et al, the mothers of SIDS infants were more likely to be young (11% were aged 18 years or younger) than were the mothers of infants who experienced a BRUE (5% were aged 18 years or younger).[62]

In 3 studies, a link was found between SIDS and maternal psychiatric disorders.[69] ; 2 of them reported a link between SIDS and postnatal depression, and 1 identified a link between a history of depression in the year before birth and a (statistically nonsignificant) trend toward an association between SIDS and depression after birth.

Maternal smoking and drug use

Cigarette smoking during pregnancy is highly significant as a risk factor in the pathogenesis of SIDS. In the 1980s, the smoking rate among SIDS mothers was reported to be 70%, whereas it decreased to 42% in the 1990s.[70] The incidence of SIDS is 7 times higher among infants whose mothers smoked more than 1 pack per day during pregnancy. A risk factor independent of prenatal exposure to tobacco is the chronic exposure to cigarette smoke that infants experience when parents smoke. Infants so exposed demonstrate a modest increase in SIDS.

Early neuropathologic changes in autonomic pathways are noted with prenatal exposure to maternal smoking.[71] Research implicates prenatal exposure to nicotine in the alteration of the infant’s arousal mechanism, a possible explanation for the increased risk for SIDS associated with prone sleeping position. Decreased volume and compliance of the lung, and decreased heart rate variability in response to stress, are also reported.[71]

Data indicate that if women refrained from smoking (a completely modifiable risk factor) during pregnancy, as many as 30-46.7% of SIDS deaths might be prevented.

Abuse of drugs other than nicotine is less strongly associated with SIDS. Prenatal exposure to cocaine may cause cocaine-induced maturational delay. Term newborns exposed to cocaine prenatally have respiratory instability similar to that seen in preterm infants not exposed to cocaine. The risk posed by heroin—or, in particular, the synthetic narcotic methadone—is higher than that conferred by cocaine.

Research reported in 2007 found a greatly increased risk of SIDS among infants born to HIV-infected mothers who used opioids during pregnancy.[72] The SIDS rate of 14.9 per 1000 live births did not appear to be mediated by prematurity, low birth weight, perinatal HIV infection, or antiretroviral drug exposure. The investigators noted that QT-interval prolongation has been observed in methadone maintenance patients, raising the possibility that a similar phenomenon may have been operative in these SIDS deaths.[72]

O’Leary and colleagues (2013) report that 16.4-25% of SIDS deaths are the result of maternal alcohol use.[73]

Caffeine can cross the placental barrier and reach the fetus, an effect potentiated in the third trimester, when caffeine elimination from the mother is reduced about 3-fold. Ford et al first reported an association between caffeine intake in pregnancy and SIDS,[74] documenting heavy caffeine consumption throughout pregnancy in 14% of control mothers and in 28% of mothers whose infants died from SIDS.

Some studies have found an association between caffeine intake and low birth weight and spontaneous abortion. Withdrawal from caffeine at birth can induce apnea in newborns. Even though caffeine has a respiratory stimulant effect, maternal caffeine use during pregnancy has been associated with central apnea in infants. This raises the possibility that the fetal respiratory center may be altered in the presence of high caffeine concentrations, only to be left with an inadequate respiratory drive when exposed to stressors in the absence of caffeine.

The pathophysiologic mechanism may involve adenosine receptor sites in the brainstem. Long-term caffeine exposure causes an increase in the number of adenosine receptors, with caffeine serving as a competitive antagonist. Adenosine, which can induce respiratory depression in newborn animals, is produced during episodes of severe hypoxia. Prior in utero exposure to caffeine may increase the vulnerability of an infant who is exposed to episodes of hypoxia after birth.

After adjustments are made for confounding variables (eg, maternal smoking), the relative risk of SIDS for infants born to mothers with heavy caffeine use (defined as consumption of more than 400 mg/day, as in 4 cups of coffee or 10 cups of tea or glasses of cola) is 1.30 for the first trimester, 1.46 for the third trimester, and 1.65 for heavy caffeine use throughout pregnancy.

Risk for siblings

The incidence of SIDS is higher in multiple births, with twins or triplets having a rate 2.5 times that of singleton babies. According to Gausche, the incidence for triplets is 8.3 cases per 1000 infants.[67]

Gausche further states that siblings of an infant who dies of SIDS are not at increased risk for SIDS.[67] Reece supports this view and reports that when families matched for maternal age and birth rank are compared, there is no statistically significant difference in SIDS rate or total infant mortality between families with a history of SIDS and those without such a history.[75] Other authors, however, indicate that siblings of infants who have succumbed to SIDS are in fact at higher risk.

Some studies have found that siblings of an infant who dies of SIDS have approximately a 5-fold increased risk of death from SIDS and a 6-fold increase in risk of death from other causes, though it should be noted that the research design of these studies has been criticized. The theory advanced is that siblings would be affected both by genetic factors and by the environmental milieu that may have contributed to the death of the first infant.[76]

Epidemiologic factors

Many of the epidemiologic risk factors for SIDS and other causes of infant mortality are identical.

Sleeping position and bedtime environment

According to Gilbert-Barness et al, unequivocal evidence indicates that a substantial number (by some estimates, as many as 73.7%) of deaths from SIDS can be prevented by avoiding the prone sleeping position, particularly on any type of soft bedding.[77] As pointed out by Lazoff and Kauffman, however, prone sleeping is common in Hong Kong and Sweden, both of which have a very low incidence of SIDS.[65]

Oyen et al reported that the combined effect of nonsupine sleeping and other prenatal and maternal risk factors carried very high SIDS risks.[59] The combination of prone sleeping and birth weight lower than 2500 g was far greater than the sum of the risk from each risk factor alone. In infants aged 13-24 weeks, the combined effect of nonsupine sleeping and lower birth weight carried the highest risk for SIDS.

A study by Ackerman et al examined 15 fatalities in which infants aged 3 months or younger were placed face down in a level, suspended rocking cradle.[78] In 14 of the cases, a locking pin to prevent cradle movement was not used. Whether because the cradle was set in motion, or because infants shifted to one end of the cradle during normal sleep movements, Infants were typically found lying in the dependent end, with the head pressed against the mesh, a position that makes it harder to move or turn the head.

Although the rocking cradles involved in these deaths have been removed from the US market, those already sold may still be passed on from one baby to another or bought secondhand. Such cradles constitute a potentially lethal sleeping environment unless the locking mechanism is used.

Sleeping in the same bed with a parent and sleeping on a soft surface or polystyrene-filled cushion also have been implicated as risk factors for SIDS.

A meta-analysis by Pease et al researched SIDS risk for infants swaddled for sleep. The study concluded that current advice to avoid front or side positions for sleep especially applies to infants who are swaddled as the risk for SIDS may increase.[79, 80]

Child care

Overall, 2 of every 3 infants are in nonparental child care for varying periods of time. About 50% are cared for by relatives, 10% are cared for by an in-home baby sitter, and 40% are in some other form of organized child care.

The overall reduction in SIDS deaths has not been mirrored in childcare settings, where the incidence of SIDS remains higher. It is thought that this difference may be attributable to infants still being placed prone by a nonparental caregiver. This practice carries great potential risk because when an infant is placed in a prone sleep position to which he or she is not accustomed, the risk of SIDS increases by as much as 18 times.[61]

Child abuse

The circumstances surrounding mistreatment of a child may range from a sudden isolated loss of control by a parent, to long-standing premeditated acts intended to harm the child. Multiple personal, familial, and environmental pressures may accumulate to push parents or other caregivers beyond the thresholds of restraint. Consequently, there is a need for a thorough and competent death investigation that must include an evaluation of the infant and family medical history and review of the scene of death to distinguish natural from nonnatural infant deaths.

Several features have been identified that may aid in making this distinction. A study of 81 covert nonnatural infant deaths documented the following:

  • 77% of the infants had a history of a BRUE manifesting as apnea, cyanosis, marked pallor, loss of muscle tone, or seizure

  • 48% had been hospitalized within the week preceding the death

  • Evidence of either somatization disorder or Munchausen syndrome was present in 48% of the perpetrators

  • At autopsy, 43% of the infants were found with frank blood within or around the nose or mouth, as opposed to the common serosanguineous discharge that may be present in SIDS

  • Unusual bruises or petechiae on the face or neck were observed in 14% of the nonnatural deaths

  • Alveolar hemosiderin-laden macrophages (HLMs) were found in histologic sections of the lung, reflecting previous pulmonary hemorrhage; the presence of HLMs, though not diagnostic, is more common in infants who have experienced abusive trauma[81]

Lazoff et al reported that 10-25% of apparent SIDS cases are actually homicides[65] and that human agency is causal in as many as 33% of infant deaths in families with multiple cases of apparent SIDS.[82] Samuels et al reported that child abuse was the cause of BRUEs in 33% of patients who received cardiopulmonary resuscitation.[83]

In a landmark study, Southall et al used covert video recordings to study 39 infants (median age, 9 months; range, 2-44 months), most of whom were referred for evaluation of a BRUE.[84] Of the 39 suspected cases, 33 involved abuse. Intentional suffocation was documented in 30 cases, with poisonings, deliberate fracture, and other emotional and physical abuse identified in the remainder. The first BRUE occurred at a median age of 3.6 months (corrected for expected date of delivery).

Of the 41 siblings of the suspect patients, 12 died, with 11 of the deaths attributed to SIDS.[84] When parents were confronted with video surveillance evidence, 4 of them admitted to the deliberate suffocation of 8 of the children. In comparison, of the 52 siblings of the 46 control subjects, 2 died, with SIDS listed as the cause of 1 death. The high number of deaths in siblings is evidence of the long-term risk posed to children in severely dysfunctional families.


United States statistics

In spring 1992, a multiagency statement directed by officials at the National Institutes of Child Health and Human Development (NICHD) was issued, informing health care providers and the general public that a supine sleep position could significantly reduce SIDS. In spring 1994, this was followed by the federal “Back to Sleep” campaign (see the image below),[85] sponsored by the NICHD, the American Academy of Pediatrics (AAP), the Association of SIDS and Infant Mortality Programs (ASIP), the SIDS Alliance, and the United States Public Health Service.

Adapted from American Academy of Pediatrics Task F Adapted from American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. Nov 2005;116(5):1245-55.

After the “Back to Sleep” campaign, federal SIDS researchers carried out annual surveys to examine how infant sleep practices and SIDS rates have changed. These studies, conducted by NICHD, demonstrated that the rate of prone sleeping for infants decreased from approximately 75% in 1992 to a low of 11.3% in 2002. The observation that the rate of prone sleeping increased to 14.5% in 2008 is of some concern.

Since 1992, SIDS rates have fallen by approximately 58% in the United States (see the image below). In 1992, the incidence of SIDS was 1.2 cases per 1000 live births; in 2004, the incidence had dropped to 0.51.[12] In 2004, 2246 deaths were certified as SIDS, accounting for 8% of infant deaths.[86] In 2006, the National Center for Health Statistics reported a total of 2323 SIDS deaths nationwide, for an incidence of 0.54 per 1000 live births.

Depiction of changes in sudden infant death syndro Depiction of changes in sudden infant death syndrome (SIDS) incidence in United States before and after "Back to Sleep" campaign. Line plot (secondary y-axis) depicts combined proportion of infants placed for sleep in supine and side-sleep positions, as determined by annual federal telephone survey of infant sleep position. AAP = American Academy of Pediatrics; NICHD = National Institutes of Child Health and Human Development; NISP = National Infant Sleep Position.

Simultaneously with this decrease in SIDS, postneonatal mortalities associated with several other causes of sudden unexpected death have increased significantly, particularly since 1999.[61, 87, 88, 89] It is postulated that some deaths previously classified as SIDS are now being more correctly categorized[90] and that the true SIDS rate since 1999 may be static.[61] A survey of medical examiners and coroners in 6 jurisdictions found that most used to certify many more deaths as SIDS than they do now.[71]

Although cases of true SIDS are decreasing, concern exists that the proportion of unexplained infant deaths resulting from child abuse may be increasing. Notably, the AAP estimates that the incidence of infanticide among cases designated as SIDS ranges from less than 1% to 5%.

International statistics

Significant reductions in the prevalence of SIDS have been observed worldwide, though rates of decline have leveled off in the past few years.[91] These changes followed public health campaigns that emphasized the use of the supine sleep position as a simple means of lowering the risk of SIDS. These campaigns began in overseas centers in the late 1980s.[92, 93]

In many Asian countries, the current incidence of SIDS is 0.04 per 1000 live births. Japan has a rate of 0.09/1000,[71] and Hong Kong has a rate of approximately 0.2/1000. Some Scandinavian countries have rates in the range of 0.1-0.06/1000.[71] In Italy, the incidence is 0.7/1000. Before the recommendation of the supine sleeping position, the incidence of SIDS United Kingdom was 3.5/1000; this figure is now 0.41/1000.[71] . The incidence in New Zealand was once approximately 4.5/1000 but is now 0.8/1000.[71]

In many of these countries, rates of prone sleeping have fallen to 2-5%. As an illustration of the impact of this single factor, Dwyer et al estimated that 70% of the overall decline in SIDS rates could be attributed to a change to the supine sleep position.[94] They further noted that of 38 additional infant care variables studied, no other individual factor explained more than 7% of the overall decline in SIDS.[95]

With a change to supine sleep for infants, cigarette smoke exposure has emerged as one of the most important potentially modifiable risk factors for SIDS. Infants of mothers who smoke have a 2-fold to 5-fold higher risk of SIDS,[96] and postnatal smoking by one or both parents has been identified as an independent SIDS risk factor.[97] Despite emphasis within “Back to Sleep” campaigns on avoidance of cigarette smoke exposure (prenatal and postnatal), rates of maternal smoking during pregnancy have changed little in most countries.

Other infant care practices have been found capable of modifying the risk of SIDS, as follows:

  • Bed-sharing may lead to compromise of an infant’s airway, especially before the age of 3-4 months[98, 99, 100, 101] ; sharing a couch or sofa is associated with an unusually high risk for SIDS and should be avoided

  • Room-sharing reduces SIDS risk by 50%[102]

  • The effect of breastfeeding on SIDS risk varies; in a German infant cohort, breastfeeding reduced the risk of SIDS by approximately 50% at all ages throughout infancy[103]

  • Pacifier (dummy) use may reduce the risk of SIDS[104, 105, 106]

  • Overbundling of infants during sleep should be avoided; this advice appears to be more important for prone-sleeping infants than for supine-sleeping infants

  • Covering the infant’s head with bedding or bed clothing is a risk factor for SIDS[107, 108] ; it is estimated that avoidance of head covering could reduce SIDS deaths by more than one quarter

After "Back to Sleep" initiatives in Germany, Vennemann et al reexamined SIDS risk factors and noted that although only 4.1% of infants slept prone, those infants were at high risk for SIDS.[109] Infants unaccustomed to sleeping prone were at very high risk, as were those who turned to prone. Bed-sharing, duvets, sleeping prone on a sheepskin, sleeping in the house of a friend or a relative, and sleeping in the living room increased the risk of SIDS. Pacifier use during sleep continued to be associated with a significantly reduced risk of SIDS.

Age-related demographics

About two-thirds of SIDS deaths occur in infants aged 2-4 months. Ninety percent of deaths occur in children younger than 6 months, and 95% of deaths occur in children younger than 8 months; few occur in children younger than 1 month or older than 8 months. This age-at-death profile suggests a relation to neurobiologic components of infant development (see Pathophysiology). Slightly higher proportions of SIDS-certified deaths occurring in the neonatal period and after 6 months were reported in 2001 than were reported in 1992.[61]

Sex-related demographics

Approximately 60-70% of SIDS deaths occur in males. Despite other notable changes in SIDS epidemiology, the male-to-female ratio has remained relatively unchanged in most population studies.

Race-related demographics

Risk among racial and ethnic groups in the United States varies substantially. In 2003, SIDS rates were highest for American Indian/Alaskan Native and non-Hispanic Black mothers—2.5 and 2.2 times higher, respectively, than the rate for non-Hispanic white mothers. African Americans are twice as likely to place infants prone for sleep, and they are also twice as likely to bed-share than other racial groups are.[71]

In contrasted, the SIDS rate for Mexican mothers was 51% lower than the rate for non-Hispanic white mothers, and the SIDS rate for Central American and South American mothers was 62% lower.[110] The following data have been reported for the incidence of SIDS in various racial and ethnic groups (as number of cases per 1000 live births):

  • Central Americans and South Americans - 0.20

  • Asian/Pacific Islanders - 0.28

  • Mexicans - 0.24

  • Puerto Ricans - 0.53

  • Whites - 0.51

  • African Americans - 1.08

  • American Indian - 1.24

These variations remain unexplained but appear to be independent of other risk factors, such as low birth weight, young maternal age, or high parity. They appear to mirror those observed for infant mortality in general.

Patient Education

Physicians should use appropriate opportunities to provide education to parents about the prevention of SIDS, including the supine sleep position, prevention of overheating, and nonsmoking. Knowledge of various theories concerning the etiology of SIDS, as well as the limitations of current understanding, is useful in parental discussions concerning BRUEs and SIDS. When an infant has died, it is helpful to provide parents with information about SIDS and the telephone number of a local SIDS support group (if one exists).

The following organizations are useful resources for information on SIDS and related issues:

NICHD Back to Sleep Campaign, 31 Center Drive, Room 2A32, Bethesda, MD 20892-2425; 301- 496-5133; toll-free: 800-505-CRIB; fax: 301-496-7101

American Academy of Pediatrics

Association of SIDS and Infant Mortality Programs

National SIDS/Infant Death Resource Center/Project IMPACT (NSIDRC), 8280 Greensboro Drive, Suite 300, McLean, VA 22102; 202-687-7466; toll-free: 866-866-7437;

Centers for Disease Control and Prevention

For patient education resources, see the Children’s Health Center and the Mental Health Center, as well as Sudden Infant Death Syndrome (SIDS), Bruises, and Grief and Bereavement.




The classic presentation of sudden infant death syndrome (SIDS) begins with an infant who is put to bed, typically after breastfeeding or bottle-feeding. Checks of the baby at varying intervals are unremarkable, but the baby is found dead, usually in the position in which he or she had been placed at bedtime or naptime. Although most of infants are apparently healthy, many parents state that their babies “were not themselves” in the hours before death. Diarrhea, vomiting, and listlessness have been reported in the 2 weeks before death.

The observations most commonly reported with Brief Resolved Unexplained Events (BRUEs: formerly Apparent Life-Threatening Events)  are as follows:

  • Cyanosis (50-60%)

  • Breathing difficulties (50%)

  • Abnormal limb movements (35%)

Antecedent events may provide an indication regarding the etiology, particularly the relation of the BRUE to feeding or descriptions suggestive of seizure.

After efforts have been made to calm the parents, it is important to determine the exact time sequence before and during the event by taking a detailed history. The following questions should be asked:

  • Did the infant have a foreign body, trauma, or ingestion?

  • Does the infant have a history of apnea?

  • What activity did the infant exhibit before the BRUE? Apnea following paroxysmal cough, in an infant with upper respiratory infection, suggests pertussis; arching with apnea after feeding—with or without milk or formula in the oronasal passages—suggests gastroesophageal reflux (GER)

  • What was the time and amount of the last meal? Parents may misinterpret postprandial regurgitation as a life-threatening event

  • Was the baby asleep or awake? GER may occur in an awake infant after feeding

  • What was the child’s position?

  • What was observed first? Chest wall movement and effort in respiration, in the absence of airflow, indicates obstructive apnea, whereas the absence of chest wall movement, respiratory effort, and airflow is consistent with central apnea

  • What was the period of apnea (in seconds)? Most healthy babies momentarily stop breathing when they are asleep

  • Did the infant change color? If the patient turned blue, ask "how blue?", inquire as to lighting in the room, and ascertain the location of the cyanosis; some healthy babies appear to turn blue around the mouth when crying, and acrocyanosis or color change during defecation may be misinterpreted as a life-threatening event

  • What was the baby’s tone (eg, limp, stiff, or shaking)? Stiffening or clonic movement followed by apnea suggests postictal apnea

  • What was the duration of the event?

  • What was done (eg, cardiopulmonary resuscitation [CPR]), and how was it done? Carefully question parents or other witnesses about their efforts to revive the baby; the absence of a need for resuscitative effort is consistent with a benign cause, whereas the need for respiratory resuscitation or CPR suggests a more serious cause

Children are poorly served if abuse is not considered in the differential diagnosis of infants with BRUEs. Autopsy cannot distinguish death due to SIDS from death by suffocation. However, certain elements of the history may raise a suspicion of abuse, though none of these elements is pathognomonic.

Circumstances surrounding death

Findings consistent with SIDS are as follows:

  • Apparently healthy infant who is fed, put to bed, and found lifeless

  • Silent death

  • Emergency medical services (EMS) resuscitation unsuccessful

  • Age at death younger than 7 months (90% of cases; peak incidence, 2-4 months)

Findings that raise the suspicion of child abuse are as follows:

  • History that is atypical for SIDS, discrepant, or unclear

  • Prolonged interval between bedtime and death

  • Age at death 6 months or older

Course of pregnancy, delivery, and infancy

Findings consistent with SIDS are as follows:

  • Prenatal care ranging from minimal to maximal

  • A history of cigarette use during pregnancy, as well as premature delivery or low birth weight is reported.

  • Subtle defects in feeding, crying, and neurologic status (eg, hypotonia, lethargy, and irritability) may have been present. Other factors include

  • Diminished postneonatal height and weight gain

  • Twins or triplets

  • Thrush, pneumonia, spitting, GER, tachypnea, tachycardia, and cyanosis

  • Greater likelihood of previous hospital admission

Findings that raise the suspicion of child abuse are as follows:

  • Unwanted pregnancy

  • Little or no prenatal care

  • Late arrival for delivery or birth outside a hospital

  • No well-baby care or few visits; no immunizations

  • Use of alcohol or other drugs during and after pregnancy

  • Infant described as hard to care for or discipline

  • Deviant feeding practices

  • Previous unexplained medical disorders (eg, seizures)

  • Previous episodes of apnea in the presence of the same person

Previous infant deaths in family

The following is consistent with SIDS:

  • First, unexplained, and unexpected infant death

Findings that raise the suspicion of child abuse are as follows:

  • Reese – More than 1 previous unexplained or unexpected infant death

  • Committee on Child Abuse and Neglect – Previous unexpected or unexplained death(s) of 1 or more siblings while under the care of the same unrelated person

Previous involvement of law enforcement or child protective services

Child abuse should be considered in cases where 1 or more family members have been arrested for violent behavior 2 or more times.

Physical Examination

Care should be taken at the scene of death to examine for signs of obstruction of the external airways, accidental entrapment of the head, or other environmental factors (eg, ambient temperature or a source of heating for carbon monoxide exposures) that may have contributed to the death.

Clinical assessment after brief resolved unexplained events

After a BRUE, many patients present to the emergency department (ED) in no acute distress. In 50% of these infants, physical examination is entirely normal. Pyrexia is documented in 25% of patients presenting to the ED; infection is noted in 25%.

The literature has varying recommendations concerning the extensiveness of the ED workup of an apparently healthy infant who presents following a BRUE. Agreement does exist regarding elicitation of a detailed history and performance of a thorough physical examination. Findings from the history and physical examination should enable the physician to determine if the child had a BRUE and whether the apneic episode was central, obstructive, or mixed.

Examine the patient after all clothing has been removed. Direct the physical examination toward identifying congenital anomalies of the heart or central nervous system (CNS) and recognizing dysmorphic features indicative of a congenital syndrome. Findings of poor muscle tone or irregular respirations indicate a true BRUE.

Truncal bruising and other lesions

Most accidental bruising occurs over bony prominences. Contusions in “soft” sites (eg, cheeks or trunk) suggest abuse. An examination of babies with accidental bruises revealed no infant with a contusion measuring more than 10 mm in any diameter; some infants did have more than 1 contusion.

Development of a contusion is determined by a number of factors, including degree of blunt force applied to the skin, tissue density, tissue vascularity, fragility of blood vessels, and amount of blood escaping into surrounding tissues.

On a given person, bruises of identical age and cause may not appear as the same color and may not change at the same rate. Red, blue, purple, or black bruises may occur at any time between 1 hour after the causal trauma and resolution of the contusion. The presence of red coloration therefore has no bearing on the age of the bruise. A bruise with any yellow must be older than 18 hours. Aside from describing bruises that are yellow, brown, or green as older, it is difficult to specify age any further.

The following may be observed:

  • Pinch or human bite marks

  • Wounds in different stages of healing

  • Scalds or burns, including those caused by cigarettes

  • Fractures, particularly if of different ages

  • Pupillary changes

Retinal hemorrhages, though strongly associated with inflicted head injury (shaken impact syndrome), are not specific for that diagnosis. They may be seen in accidental trauma, subarachnoid hemorrhage, sepsis, coagulopathy, severe hypertension, and galactosemia (albeit rarely), as well as after resuscitation, in conjunction with papilledema, and in as many as 40% of vaginally delivered newborns, with resolution taking up to 1 month after birth.

Southall et al noted frank bleeding from the nose or mouth in 11 of 38 suspected child abuse cases but in none of the 46 control subjects (children with recurrent BRUE attributable to a natural medical cause).[84]

Contribution of clinical examination to death investigation

In the case of a deceased infant, the National Association of Medical Examiners makes it very clear that “medical examiners and coroners have the sole legal authority to investigate deaths that are sudden, unexpected, unexplained, and potentially due to external causes such as injury” and that “examination or manipulation of the deceased body by child maltreatment experts without proper statutory authority or family permission may constitute a tort or be a violation of criminal law.”

If an infant arrives in cardiopulmonary arrest, relevant findings from a clinical examination conducted during the course of a resuscitation attempt should be carefully documented in the chart. Such findings will complement the autopsy and other components of the death investigation. The clinical examination should address many of the same elements indicated for assessment of a BRUE, modified as appropriate for the unresponsive patient.

Autopsy findings

At autopsy, the infant usually exhibits signs of normal hydration and nutrition, which is evidence of proper care. No signs of obvious or occult trauma should be present. Gross examination of the organs generally reveals no evidence of a congenital abnormality or acquired disease process consistent with a recognizable cause of death.

Intrathoracic petechiae are typically present on the surfaces of the thymus, pleura, and epicardium.[111] The frequency and severity of petechiae have been noted to be similar regardless of whether infants were discovered face down on the sleep surface, face up, or face to the side. This finding suggests that centrally mediated airway failure, such as that seen with apnea or failed gasping rather than external airway obstruction, is likely in SIDS.[112]

Microscopic examination may reveal minor inflammatory changes within the tracheobronchial tree or signs of passive congestion of the organs. Very mild myocardial lymphocyte and macrophage infiltration with scattered necrotic cardiomyocytes may be seen in SIDS; this is not considered to be pathologic.[113] Histologically, the thymus and adrenal glands are normal.

SIDS versus infanticide

In addition to the abnormalities described (see above), several physical findings may help distinguish SIDS from suspected infanticide. Findings consistent with SIDS include the following:

  • Serosanguineous watery, frothy, or mucoid discharge from mouth or nose

  • Reddish-blue mottling from postmortem lividity on the face and dependent portions of the body

  • Marks on pressure points of the body

  • Well-cared-for appearance, with no significant skin trauma

Findings that raise the suspicion of child abuse include the following:

  • Malnutrition or neglect

  • Cutaneous injuries, traumatic lesions, or abnormalities of the head or body (eg, of the conjunctiva, fundi, scalp, oral cavity, ears, neck, trunk, anogenital region, or extremities, including fractures)

  • Distribution of hypostasis indicating that the child was in a different position from that stated

  • Pressure ischemia over the nose and mouth

Absence of physical stigmata does not prove that the death was natural. So-called gentle battering occurs when a physical act leaves no mark, as when a hand or pillow is placed over the face or when the infant is placed face down on a pillow or soft mattress, occasionally without any criminal intent (eg, to stifle a cry). Physical examination of SIDS infants may reveal evidence of terminal motor activity (eg, clenched fists).

It is important not to misinterpret postmortem changes or physical findings often seen in SIDS-related deaths (eg, by confusing postmortem lividity or anal dilatation with trauma secondary to abuse).



Diagnostic Considerations

A clinician untrained in forensic medicine may inadvertently overlook or destroy gross or trace evidence. Furthermore, misinterpretation of physical injuries or other objective evidence may lead to an inaccurate opinion that, if documented on the chart, may pose considerable problems when used in future court proceedings.

Tragic consequences can follow the misattribution of an infant’s death. One example is that of a young African American couple who were criminally charged after a medical examiner indicated that their baby had died of abandonment—even though autopsy findings were consistent with SIDS and there were no signs of abuse or neglect. The couple spent 6 months in jail because they were unable to post bond before the charges were dismissed.

Similarly egregious examples may be found at the other end of the spectrum, as illustrated by the case of Mary Beth Tining. Only when Tining was charged with the smothering death of her adopted daughter was it discovered that 8 of her biologic children had died, their deaths having been attributed to SIDS or other natural causes. A similar case is that of Waneta Hoyt, who was convicted in 1995 of murdering her 5 children between 1965 and 1971, all of whom were described as having succumbed to SIDS.

In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Aberrant thermoregulation

  • Brain stem tumor

  • Cardiac dysrhythmias

  • Chiari malformation type I

  • Choanal atresia/stenosis

  • Central nervous system immaturity

  • Congenital central hypoventilation syndrome

  • Congenital heart disease

  • Craniofacial abnormalities

  • Disorders of cardiorespiratory control

  • Drowning

  • Drug exposure

  • Fluid and electrolyte imbalance

  • Gastroesophageal reflux

  • Heat injury

  • Hemangioma

  • Lymphangioma

  • Laryngomalacia

  • Mast cell activation

  • Neuromuscular disorders

  • Occult trauma

  • Pharyngeal/retropharyngeal mass

  • Poisoning

  • Respiratory syncytial virus infection

  • Seizures

  • Shaken infant impact syndrome or nonaccidental trauma

  • Suffocation

  • Toxin exposure

  • Tracheobronchial or esophageal foreign bodies

  • Tracheoesophageal fistula

  • Tracheomalacia

  • Upper airway obstruction

  • Vascular malformation

  • Vascular ring

  • Vocal cord paralysis

Differential Diagnoses



Approach Considerations

An infant who is discovered lifeless may be transported by the family or by first-response personnel to the nearest hospital emergency department (ED). In a growing number of cases, when signs of death are obvious, the infant's death may be declared at the scene by first responders. Local medical examiner or coroner protocol should be followed in either instance. In many jurisdictions, specific infant death investigation guidelines exist and should be followed by prehospital or ED staff when an infant death has occurred.

A diagnosis of sudden infant death syndrome (SIDS) is established by excluding recognizable causes of sudden unexplained infant death (SUID). The necessary data set includes information obtained from the scene of death, infant and family medical and social history, and autopsy examination. Guidelines for the autopsy examination, including gross and microscopic dissections, and the role of toxicologic, microbiologic, radiographic, and other special procedures, are detailed by Krous and others.[114]

After careful analysis of information obtained from the complete postmortem evaluation, including death scene and historic information, SIDS emerges as the single leading cause of death among unexpected deaths in infancy; however, alternative diagnoses are identified in as many as 15-25% of SUIDs. The principal non-SIDS categories of SUID are as follows:

  • Infectious diseases

  • Metabolic abnormalities

  • Environmental factors

  • Structural (congenital) cardiac, respiratory, and central nervous system (CNS) lesions

If the infant is seen after an apparent life-threatening event (ALTE), workup includes appropriate blood and urine tests, as well as radiography and computed tomography when warranted. A 12-lead electrocardiogram (ECG) should be obtained. Electroencephalography (EEG) should be considered if indicated by findings from the history or physical examination. Patients younger than 2 months and those with significant evidence of infection should have a complete septic workup, including lumbar puncture and empiric antibiotics.

Laboratory Studies

For a living patient, initial laboratory studies include a complete blood count (CBC), electrolyte concentrations, and urinalysis.

A rapid bedside glucose reading should be obtained, followed by serum determination of glucose if indicated. Hypoglycemia, which is common in sepsis, may cause a confusing presentation. 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 screening can be helpful if exposure to medications (potentially intentional) or drugs of abuse is suspected. In many jurisdictions, toxicologic screening of serum and vitreous electrolyte analysis are routinely performed as part of the postmortem evaluation. If not routinely performed, obtain appropriate specimens and retain them for potential analysis.

A sepsis workup, with blood and urine culture, should be performed, though sepsis is unlikely in the absence of suggestive findings (eg, fever). Pertussis and chlamydial cultures should be obtained when appropriate. Respiratory syncytial virus (RSV) infection should be considered, 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 is probably a more common possibility than is generally believed.

Arterial blood gas determination may be helpful for infants who are severely ill or who have persistent symptoms on presentation. This may reveal metabolic acidosis that cannot be explained in any other way 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.

Radiography and Computed Tomography

Whole-body radiographs may be obtained to evaluate for evidence of skeletal trauma. Special coned-down radiographic views may be necessary to further delineate subtle metaphyseal corner fractures of the long bones seen with nonaccidental forms of trauma.

A chest x-ray 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.

Anteroposterior and lateral soft tissue films of the neck should be obtained if upper airway obstruction is suspected. A barium swallow may be ordered if indicated by history or physical examination.

Radiographs and computed tomography (CT) scans of the skull may be indicated if abuse is suspected or if signs of increased intracranial pressure are present.


In a series of 800 consecutive cases of SUID,[115] 6% of the infants had a neuropathologic cause of death. Almost all had clinical histories or gross brain findings at autopsy suggesting the cause of death. In only 2 cases (< 1%) did brain histology alone determine the cause of death in the absence of a "neurologic history" or clearly evident macroscopic abnormalities.

In the absence of macroscopic abnormalities or a suggestive clinical history, formal histologic examination of the brain rarely determines the cause of death in SUID. A significant clinical history or the presence of abnormal gross brain findings should prompt a standardized histologic study of formalin-fixed brain tissue; the yield of histologic abnormalities is increased in these circumstances.



Initial Emergency Care After Apparent Life-Threatening Event

Paramedics and other emergency medical services (EMS) personnel should be familiar with the historical factors and observations indicative of an apparent life-threatening event (ALTE). Infants who have experienced an ALTE must be transported to the emergency department (ED); this is true even of infants who appear well when examined by EMS personnel.

For the infant found in cardiorespiratory arrest, the first priority is life support via attention to the ABCs (A irway, B reathing, C irculation) and other medical interventions as appropriate. In the absence of postmortem lividity or other signs of obvious death, infants must be transported to the hospital to ensure full resuscitative attempts.

Observations made by EMS personnel at the scene may assist in the investigation. Such observations should include the following:

  • Location and position of the infant, including the type of surface on which the body lies, the body temperature, the degree of rigor mortis (if present), and any marks and bruises

  • Type of bed or crib used and any defects

  • Amount and position of clothing and bedding materials

  • Presence of toys, pillows, or other objects that may cause asphyxiation

  • Condition of the residence

  • Temperature of the room in which the infant was found

  • Type of ventilation and heating

  • Presence of children or others

  • Reactions of caretakers and others at the scene

In the ED, post-ALTE care includes resuscitation and general stabilization. The patient should be placed on cardiac and respiratory monitoring, including arterial oxygen saturation. The blood glucose level should be determined; hypoglycemia may be associated with apnea, with or without seizure.

The objectives of the workup are to identify “serious” ALTEs and to attempt to establish the cause of the ALTE. ALTE alone is not a definitive diagnosis; a more specific final diagnosis (eg, ALTE secondary to seizure) is preferred. In many instances, however, such specificity cannot be achieved, and the final diagnosis is idiopathic ALTE or ALTE of undetermined etiology. On a cautionary note, the diagnosis of ALTE secondary to reflux is one of exclusion. Ideally, this diagnosis should be made only after a period of observation and reflux monitoring.

Inpatient Management of Patient With Apnea or Apparent Life-Threatening Event

All infants presenting with nontrivial apnea or ALTEs associated with cyanosis or alterations in mental status or tone should be admitted. Infants who experienced a brief choking episode during feeding or choking associated with a suspected reflux episode can be safely discharged home after a period of observation.

Higher-risk groups include infants who meet the criteria for an ALTE with occurrence during sleep, those in whom cyanosis was observed, those with a history of previous events, and those who required vigorous stimulation or any type of resuscitation.

Stable children may be admitted to the floor with a continuous cardiorespiratory monitor to determine frequency and length of apnea and associated bradydysrhythmias. Infants who required any type of resuscitative measures should be monitored in a pediatric intensive care unit or, if appropriate (according to the severity of the event), in a pediatric step-down unit.

Inpatient evaluation may include the following:

  • Electroencephalography (EEG; seizures may cause or result from apnea)

  • Evaluation for gastroesophageal reflux (GER) or swallowing incoordination

  • Cultures for occult infection

  • Pneumography

  • Polysomnography

  • Arterial blood gas determination

  • Upper airway studies to identify suspected obstruction

  • Electrocardiography (ECG), echocardiography, and other studies to identify congenital heart disease

Transfer is indicated if inpatient facilities are not available to meet the patient’s needs for monitoring and critical care.

Procedures After Infant Death

Parents’ reactions to a child’s death encompass the spectrum of negative human emotion, from silence to hysteria. They often experience intense guilt, even when there is no reason for such recriminations. On the other hand, many abusive parents are charming and attractive people who can evade and deceive professionals representing multiple disciplines. They may appear to be caring and kind in the presence of professionals, though video surveillance may show them becoming cruel and sadistic within seconds of being alone with a child.

In the setting of a sudden unexpected infant death (SUID), health professionals must be compassionate, empathic, supportive, and nonaccusatory, while simultaneously conducting a thorough investigation of the death. Health professionals experience many of the same emotions as the parents (eg, guilt, anger, sadness, self-reproach, shock). Consideration should be given to critical incident stress debriefing after an infant death (or after any other particularly stressful case).

If the infant is pronounced dead, inform the family in a quiet environment. Refer to the child by name, not as “the baby.” Detailing resuscitative efforts before telling the parents of the death is not helpful and may engender parents’ resentment. Specifically and directly, tell parents that their child has died; use of words such as “dead” or “died” avoids the confusion that may result from gentler terms (eg, “passed on.” Expressions of sorrow and sympathy are appropriate and desirable, but avoid statements such as “I know how you feel.”

Explain to the family the local procedure that is followed after the death, including autopsy and death investigation by local authorities. Follow the protocol of the local medical examiner or coroner’s office concerning retention or removal of an endotracheal tube or lines for vascular access.

In the absence of indications of significant antecedent illness, inconsistencies in the history, or obvious evidence of injuries, inform parents that their child’s demise is an SUID and that classification of the type of SUID can be established only through review of records, thorough scene investigation, and complete postmortem examination. Emphasize that although SIDS is one type of SUID, a final diagnosis of SIDS may be made only by excluding all other causes of death. Reassure the family members that if the final diagnosis is that of SIDS, there was nothing they could have done to prevent the death (although keep in mind steps that may reduce the potential of SIDS in the family’s other children; a very fine line to be navigated). Emphasize to them that intense feelings of grief are normal and that resources are available for support.

It may be appropriate to encourage the parents and family to see and hold the infant if they feel that they are able to do so. However, some coroner or medical examiner offices do not want the infant’s body left alone with the family, and they also do not want family members to hold the infant until a medicolegal death investigator has arrived. Local policy should be followed and, where appropriate, diplomatically explained to the family.

A comprehensive infant death investigation may require the coroner or medical examiner to call on the expertise of emergency physicians, pediatricians, pediatric pathologists, radiologists, pediatric neuropathologists, and other medical specialists, in addition to the medicolegal death investigator and forensic pathologist.

Issues such as baptism, grief counseling, religious support, reactions of surviving siblings, and risk of SIDS in subsequent siblings may have to be addressed. Return clothes or personal belongings to the parents, after receipt of permission from the coroner or medical examiner. In addition, a physical memento may be offered (eg, a lock of the child’s hair or a handprint or footprint).

Refer the family to a local SIDS program (US SIDS program listings are available at Association of SIDS and Infant Mortality Programs). One may wish to attend the viewing or services and send a sympathy card. Listen supportively and allow expressions of grief. Arrange to meet with the family to discuss the results of the autopsy and answer their questions. Discuss grief response to the loss. Over the longer term, remain available to families as needed. Explain that special times of grief include the anniversaries of the infant’s birth and death.


Recommendations regarding the infant’s sleep position and bedtime environment have been with a view to preventing SIDS (see the image below).

Several key recommendations related to infant slee Several key recommendations related to infant sleep position and sleep environment. Sources: American Academy of Pediatrics (AAP), National Institutes of Health and Human Development (NICHD), Consumer Product Safety Commission (CPSC), Association of SIDS and Infant Mortality Programs (ASIP). Adapted from "What is SIDS" monograph published by National Sudden Infant Death Syndrome Resource Center.

Suggested measures for preventing SIDS include the following:

  • Start prenatal care early; schedule frequent well-baby checkups, and ensure that immunizations are current

  • Avoid cigarettes, alcohol, and other drugs while pregnant; in particular, avoid exposing the baby to cigarette smoke

  • If possible, breastfeed the baby

  • Burp the baby during and after feedings, especially before putting the baby to sleep

  • Place the baby on a firm, flat mattress in a safety-approved crib; avoid pillows, blankets, sheepskins, foam pads, or water beds

  • Do not restrain the baby during sleep

  • Consider using a fan in the infant’s room to improve ventilation[116]

Back to sleep for every sleep by every care giver up until age 1 year.[17] The supine sleep position does not increase the risk of choking and aspiration in infants, even those with gastroesophageal reflux, because they have protective airway mechanisms.

Although this position is preferred for most infants, individual medical conditions might warrant that a physician recommend otherwise after weighing the relative risks and benefits. Thus it may be inappropriate for a premature baby with respiratory distress. Likewise, while the general recommendation is that infants with gastroesophageal reflux should be placed for sleep in the supine position for every sleep, there are rare exceptions, such as infants for whom the risk of death from complications of gastroesophageal reflux is greater than the risk of SIDS (ie, those with upper airway disorders, for whom airway protective mechanisms are impaired), including infants with anatomic abnormalities such as type 3 or 4 laryngeal clefts who have not undergone antireflux surgery.[17] Parents of infants with any special problems should discuss the supine sleeping position with the baby’s physician.

Side sleeping is not safe and is not advised.[17]

In Australia, New Zealand, the United Kingdom, and the Netherlands, public campaigns against the prone sleeping position were accompanied by 20-67% reductions in SIDS incidence,[77] without any increase in deaths from aspiration or other disorders resulting from use of the supine sleep position. In the United States, a substantial reduction in the use of the prone sleeping position coincided with a progressive decline in the rate of SIDS.

With reference to prevention of a cardiac cause of SIDS, Towbin and Friedman believe that ECG screening of infants at high risk for SIDS (eg, those with a family history of SIDS or long QT syndrome [LGTS] and those who have had an ALTE) is appropriate and justified.[117]

Studies from overseas centers suggest that pacifier use may reduce the risk of SIDS.[104] These simple items may have a number of positive effects, such as protecting the infant from nasal compression, enlarging the infant’s pharyngeal airway, lowering arousal thresholds, and strengthening the pharyngeal muscles responsible for maintaining the airway.[63]

The pacifier may be offered to the infant when he or she is placed for sleep; however, its use should not be forced if the infant refuses it. Once the infant is asleep, the pacifier need not be reinserted if it falls out. The pacifier should be cleaned and replaced regularly. It should not be sweetened in an effort to induce the infant to take it. For breastfed infants, pacifier introduction should be delayed for at least 1 month after birth to ensure that breastfeeding is well established.

Current evidence suggests that bed-sharing should be avoided. This practice may lead to airway compromise, as a result of suffocation by soft or loose bedding or a sleeping adult, or to overheating. Cosleeping on a couch or sofa is associated with an especially high risk for SIDS and must be avoided. Risks associated with bed sharing are greatly increased when this practice is combined with parental smoking or maternal alcohol consumption or drug use.[118]


Consultations with pediatric subspecialists should be obtained as indicated.

In addition to the medical examiner or coroner, several other key individuals should be contacted immediately after the death, as follows:

  • The infant’s primary health care providers should be notified of the death so that they may provide consolation and immediate guidance to the family; they can also provide the infant’s relevant medical history

  • If subspecialty health care providers cared for the infant, they should also be contacted for the same reasons

  • Immediate and extended family members should be contacted to assist the family with grief support

  • The family’s religious institution and chaplain staff may also be contacted to offer consolation and guidance to the family

  • In special cultural settings, family or tribal elders may be notified to assist the family following the death

Long-Term Monitoring

A 1986 consensus statement of the National Institutes of Health identified the following 3 types of patients as candidates for home monitoring:

  • Group I - Term infants with unexplained apnea of infancy, usually manifested by an ALTE or an abnormal pneumogram

  • Group II - Preterm infants who continue to demonstrate apnea or bradycardia beyond term (ie, 40 weeks post conception)

  • Group III - Subsequent siblings of 2 or more infants who died of SIDS

Other appropriate candidates include infants with bronchopulmonary dysplasia, particularly if they are oxygen-dependent, and infants requiring tracheostomy for airway support.

Monitoring devices designed for home use typically measure chest wall movement and heart rate. The most important parameter is heart rate; documented death recordings have indicated severe bradycardia before prolonged central apnea. The ability of monitors to detect bradycardia is also of significance in obstructive apnea because such a state does not cause diminished movement of the chest wall.

Death recordings show that home monitoring does not prevent death from SIDS. Parental interviews indicate that even when a home monitor was present, it was unused in at least 50% of cases. One of the reasons for this apparent inattention is that home monitors are subject to false alarms caused by infants’ shallow breathing or normal cardiac decelerations.

Meny et al report that 2 of the 3 SIDS patients they studied had monitor alarm activations to which parents did not respond for 2 hours.[26] In both cases, the lethal occasion had been preceded by a large number of false or meaningless alarms—in 1 case, 60 false alarms in a single day. Such findings suggest that parents with home monitors need training in use of these devices and in recognition of true alarms. They should be taught simple equipment maintenance and should receive instruction in cardiopulmonary resuscitation (CPR) for infants.

The estimated expense of home monitors is in the range of $3000-5000 per infant, with rental and maintenance costs in the range of $150-300. Monitoring is cost-effective in siblings of infants who have died of SIDS, but whether it is so in other infant groups remains to be determined.



Guidelines Summary

2016 American Academy of Pediatrics Updated Recommendations for a Safe Sleeping Environment

In 2016, the American Academy of Pediatrics released guidelines on sudden infant death syndrome that included the following recommendations[119, 120] :

  • AAP recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, the use of a firm sleep surface, room-sharing without bed-sharing, and the avoidance of soft bedding and overheating.

  • Additional recommendations for SIDS reduction include the avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier.

  • New evidence is presented for skin-to-skin care for newborn infants, use of bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 mo of age.

  • Offer a pacifier at nap time and at bedtime. Studies show these can reduce the risk for SIDS.

  • Infants should be immunized in accordance with AAP and CDC recommendations.

  • Provide supervised, awake tummy time daily to facilitate development.

  • Remove infants from car seats, strollers, swings, infant carriers, and infant slings, if they fall asleep in them, to reduce the risk for gastroesophageal reflux and positional plagiocephaly.

  • Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.

2013 Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) Guidelines

In its 2013 expert consensus statement on inherited primary arrhythmia syndromes, the Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) recommended that an unexplained sudden death occurring in a child younger than 1 year with negative pathological and toxicological assessment be called “sudden unexplained death in infancy” (SUDI). Additional recommendations are summarized below.[121]


  • Personal/family history and circumstances of the sudden death, along with blood and/or tissue for molecular autopsy should be collected in all cases of SUDI (Class I)
  • An arrhythmia syndrome focused molecular autopsy/postmortem genetic testing can be useful (Class IIa)
  • Considered assessment by an expert cardiac pathologist to rule out the presence of microscopic indicators of structural heart when a diagnosis of SUDI is made at autopsy. (Class IIb)

Follow-up Screening of First-degree relatives

  • First-degree relatives should undergo genetic testing whenever a pathogenic mutation in a gene associated with increased risk of sudden death is identified by molecular autopsy. Obligate carriers should be prioritized.
  • First-degree relatives with a family history of inherited heart disease should be evaluated with resting ECG and exercise stress testing. Additional tests as indicated can be useful. Those with a history of arrhythmias or syncope should be prioritized.(Class IIa)
  • Follow-up clinical assessment in young family members with a family history of inherited heart disease or other sudden unexplained death syndrome (SUDS) or SUDI death who may manifest symptoms and/or signs of the disease at an older age and in all family members whenever additional SUDS or SUDI events occur. (Class IIa)
  • Consider evaluation of first-degree relatives with resting ECG and exercise stress testing.(Class IIb)

2006 Policy on Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities

In its 2006 Policy on Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities, the Committee on Child Abuse and Neglect of the American Academy of Pediatrics (AAP) states that the death of an infant may be attributed to sudden infant death syndrome (SIDS) when all of the following are true[122] :

  • A complete autopsy is performed, including cranium and cranial contents, and autopsy findings are compatible with SIDS

  • No gross or microscopic evidence of trauma or significant disease process is present

  • No evidence of trauma exists on skeletal survey

  • Other causes of death are adequately ruled out, including meningitis, sepsis, aspiration, pneumonia, myocarditis, abdominal trauma, dehydration, fluid and electrolyte imbalance, significant congenital lesions, inborn metabolic disorders, carbon monoxide asphyxia, drowning, and burns

  • No evidence of current alcohol, drug, or toxic exposure is present

  • Thorough death scene investigation and review of the clinical history are negative

Circumstances could indicate the possibility of intentional suffocation include:

  • Recurrent cyanosis, apnea, or ALTEs occurring only while in the care of the same person;

  • Age at death older than 6 months;

  • Previous unexpected or unexplained deaths of 1 or more siblings;

  • Simultaneous or nearly simultaneous death of twins

  • Previous death of infants under the care of the same unrelated person 

  • Evidence of previous pulmonary hemorrhage (such as marked siderophages in the lung).

2016 AAP Clinical Practice Guideline on Brief Unexplained Events in Infants

In 2016, the American Academy of Pediatrics (AAP) released a new clinical practice guideline that recommended the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). The authors define BRUE as an event observed in infants younger than 1 year during which an observer reports a sudden, brief (less than one minute), but then resolved episode including at least one of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in muscle tone (hyper- or hypotonia); or altered responsiveness. The guidelines also add that a BRUE is diagnosed only when there is no explanation for a qualifying event after completion of a thorough history and physical examination. Infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or, (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered.  This clinical practice guideline is structured to promote a patient- and family-centered approach to care, reduce unnecessary and potentially costly medical interventions, improve patient outcomes, and enhance efforts at future research.[123, 124]

Forensic Investigation and Autopsy

National guidelines for infant death investigation have been developed by the US Centers for Disease Control and Prevention (CDC) and endorsed by the National Sheriffs’ Association, the National Association of Medical Examiners, the International Coroners and Medical Examiners Association, and the American Board of Medicolegal Death Investigators. The Sudden Unexplained Death in Infancy Investigation and Reporting Form (SUIDIRF) is a reporting inventory that standardizes information collected at the scene of death. The form contains 25 questions that medical examiners and coroners should ask before beginning an autopsy.[1]

The following information is collected on the SUIDIRF:

  • Investigation data.
  • Witness interview.
  • Infant’s medical history.
  • Infant’s dietary history.
  • Pregnancy history.
  • Incident scene investigation.
  • Investigation summary.
  • Investigation diagrams.
  • Summary for pathologist.


Since 1996, the American Academy of Pediatrics (AAP) has recommended infants be placed in the supine position for sleep.[61]  In 2011, the AAP issued a policy statement expanding its recommendations to ensure a safe sleeping environment for infants and to further reduce the risk for sudden infant death syndrome (SIDS).[125]  

Other key recommendations are:

  • Breastfeeding is recommended
  • Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.

  • The baby should sleep in the same room as the parents, but not in the same bed (room sharing without bed sharing).

  • Keep soft objects or loose bedding out of the crib.

  • Wedges and positioners should not be used.

  • Offer a pacifier at nap time and bedtime.

  • Avoid covering the infant's head or overheating.

  • Do not use home monitors or commercial devices marketed to reduce the risk for SIDS.

  • Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).

  • Avoid alcohol, illicit drug use and smoke exposure during pregnancy and after birth

  • Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention