Sudden infant deaths in Israel

LETTERS

384

The next question

is “Why did this little cold cause my baby to die when hundreds

of

babies have their first cold and recover in a few days to a week or two?” The answer to this question

is more

difficult.

But again the best explanation

must come from the

combination of events: the baby’s age and immunity, the severity and extent of the first infection, the degree of nasal obstruction produced by the “cold”, and the time all of these events culminate,

usually in the middle of the night when the baby is unattended.

Before the days of the polio vaccine we all got poliomyelitis two or three times in mild or inapparent

paralysis and less than 1 in 10 000 was severely paralyzed answer

to this phenomenon,

should know the known

and most of us have had it

form. Less than 1 in 100 of us got even mild

but it is an established

or died. We do not know the

fact. In my opinion

the parents

facts about SIDS and thus the tragedy may be somewhat lessen-

ed. Certainly self-incrimination

would be reduced.

What can we say about prevention of the Public Health Service recently colds or acute respiratory

of this tragic event? The Center for Disease Control reported

on 113 known viral agents which cause

illness. They sounded

a pessimistic note regarding the develop-

ment of a vaccine against these many known causes, stating that there are probably many unknown

as

causes as there are known causes. Until some active means of prevention

is forthcoming, we should consider the possibility of passive protection, thus providing the baby with additional antibodies in the form of concentrated gamma globulin throughout the high-risk months of his life. This study needs to be done in a very carefully controlled manner so that an answer may possibly be found. Another important approach is to teach the baby early in life to breathe through the mouth and thus reduce the hazards which may accompany nasal obstruction. A third approach was the suggestion of Drs Werne and Garrow, that attention “should be directed toward diminishing exposure to known sources of infection

during this highly vulnerable

Department of Pediatrics School of Medicine University of California Los Angeles, Calif (U.S.A.) Forensic Science,

period of the infant’s life.” JOHNM.ADAMS

2 (1973)383-384

Sudden infant deaths in Israel Sir: As clinicians

working

in two different

regions

of Israel and interested

in social

paediatrics, we have independently studied the frequency of the sudden infant death syndrome (SIDS). Our approaches have been somewhat different in technique. However, each investigation has led to the identical conclusion that SIDS appears to be less common in Israel than in other countries’ ,2. We recognize the limitations of our studies, particularly since they were retrospective, but they do offer some lessons and some points for consideration in assessing the reliability of other retrospective investigations and the stated frequencies of SIDS in various countries. The number of countries where SIDS

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LETTERS

incidence

has been studied

is limited

but the incidence

appears to be similar in such

eountries3. The Haifa Study was initiated

following long hospital experience

within a moderately

sized city. One of the authors (STW) was impressed by the relative rarity of two items, namely parents rushing with a dead infant to the emergency room of the centrally situated

hospital

and, among thousands

of patient-histories,

the family history

that a

baby (sibling) had been found dead in bed. This led to the collection

of data from four

different sources. 1. An analysis

of children

of medical

documents,

including

death certificates

dying

within the Haifa region during a calendar year. 2. Investigation neonatal

of deaths

within

units and followed-up

3. Scrutiny

of official

a cohort

of 5243 infants

discharged

from Haifa

until the age of two years.

notifications

of all infant

deaths up to the age of one year

during a period of four years within the cities of Jerusalem, Tel-Aviv and Haifa. 4. Review of clinical, police and pathology reports of all children dying between ages of two weeks and two years (during a period of 32 months) performed

at the National

public hospital

pathology

Institute

of Forensic

units. This retrospective

Medicine scrutiny

the

on whom autopsies were

and of a sample taken from attempted

to diagnose SIDS

on the basis of the criteria of the Seattle Congress3. Each of these four separate SIDS in this country

is between

studies supported

the impression

one-half to one-third

that the frequency

of that expected

of

on the basis of

figures from other countries. The Ashkelon

District Study has the advantage of a more clearly defined geogra.phical

area, served by one hospital

only, with excellent

integration

of preventive

and curative

health services. One of the authors (AB) has been much invol.ved in the maternal and child health units throughout the district. This greatly facilitated his study. His responsibilities also include the annual analysis and classification of infant mortality statistics for ehe district. The Ashkelon Study was based on 35 006 Jewish live births over a period of ten years, with 82 home deaths during the first year of life. An investigation of these home deaths included home visits by the author to 23 of the 24 families of infants presumed to have died with SIDS. The information revealed during the home visits indicated that only 8 (or at the most 10) of these deaths could be regarded as SIDS. This suggests an incidence of SIDS for the district about one-third of that to be expected on the basis of figures from other countries. impression that SIDS is relatively uncommon in Israel.

These results support our

However, we have reservations about the validity of some data, since our guide-line SIDS definition is: “The sudden death of any infant or young child, which is unexpected by the history, and in which a thorough post-mortem examination fails to demonstrate an adequate cause for death”3. We think these reservations may be relevant for other workers wishing to study SIDS in other regions, and they are therefore listed as follows. 1. Unavailability of neighbourhood medical services, traditional reluctance to seek immediate

medical care for a sick child and large families may lead to uncertainty

as to

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LETTERS

whether the child was in good health before the SID. The medical details obtained at the time may be inaccurate. 2. Pressure within the rural settings of isolated villages may lead to the issue of death certificates clinical

negligence reliable

for the rapid arrangement

data from the parents is excluded.

A certificate

basis of vague symptoms

autopsy may be accentuated

of a burial

and without

permit,

autopsy,

without

provided

adequate

may be signed and a diagnosis written mentioned

diagnostic

that violence or criminal

by the parents.

on the un-

These pressures

against

by very religious families.

3. The regular primary physician of the family in the town may sign a death certificate without adequate diagnostic criteria in order to spare the family the formalities, autopsy and other unpleasant events during their period of bereavement. 4. In apparently a few cases (even if a physician refuses to sign the death certificate with the diagnosis without violence

or negligence

autopsy)

was absent

of suspected

SIDS, the police may be satisfied that

and may permit burial without

autopsy,

especially if

the family raises strong religious or other objections. 5. The interpretation pathologists

of autopsy

findings

in the respiratory

tract may vary among

if agreed strict SIDS criteria are not used.

6. The terms SIDS and “Cot Deaths” may or may not be used synonymously. Despite these reservations, our data indicate the importance of a planned prospective study. The confirmation

that SIDS is less common in Israel may lead to useful studies on

possible

e.g. genetic,

related

retrospective

factors,

studies

dietetic,

have led to increased

providing more explanation

infective,

interest

given the opportunity

to discuss the circumstances preferably

The investigation

in such deaths

these

and the need for

of the death with an experienced

one with a positive outlook

of home deaths merits the combined

namely the pathologist

In themselves,

and help for the bereaved families. These families should be

patient

paediatrician,

climatic.

and

towards social paediatrics.

efforts of an interested

team,

and paediatrician. S.T. WINTER

Paediatric Department Rothschild Hospital Haifa (Israel)

A. BLOCH

Paediatric Department %arzilai Medical Center Ashkelon (Israel)

1 S.T. Winter and N.B. Emetarom, Sudden infant death: A pilot enquiry on its frequency in Israel, Ix J. Med. Sci., 9 (1973) M-451. 2 A. Bloch, Sudden infant death syndrome in the Ashkelon district: A lo-year survey, Iv. J. Med. Sci., 9 (1973) 452-458. 3 A.B. Bergman, J.B. Beckwith and C.G. Ray. (Eds), Sudden infant death syndrome, in Proceedings of the Second International Conference on Causes of Sudden Death in Infants, University of Washington Press, Seattle, 1970. Forensic Science,

2 (1973)

384-386