Sudden death of a three-month-old infant while cosleeping on a sofa

The death of the three-month-old infant in question occurred during the summer. The parents described the infant, who was born at term, as a quiet, robust and healthy baby with no past medical problems, who cried only if she was unhappy. There was little known about the perinatal history except that the mother smoked during pregnancy and still smokes. The mother has had several miscarriages and, at the time of writing, has a four-year-old daughter in good health. The three-month-old infant, who always slept on her back, usually in her parents' room, was bottle-fed. The death occurred during a heat wave. During the evening before the death, the parents consumed alcohol; the father is said to have drunk three large cans of beer, while the mother had one can. It is unclear at what time the parents went to bed. They fell asleep on the sofa in the living room. At the time, the baby was in her own bed in the parents' room. The mother was awakened by the cries of the baby at around 03:00 and fed her. Because the baby would still not sleep and was crying, the father took her with him to the sofa. The mother went to sleep in the bedroom. To keep the baby from falling, the father put her between his legs. The baby usually woke up at 08:00 and cried for food. It was only around 13:00 that the father awoke to find the baby blue and lifeless. Reanimation was ineffective, even after a prompt transfer to the hospital and attempts at full cardiopulmonary resuscitation. The autopsy performed at the medicolegal institute did not provide a cause for death. The lungs were congestive with pulmonary edema, but there were no alveolar hemorrhages, no evidence of massive thorax compression and no hemorrhagic infiltration of the tissues in the neck or thorax. There was no head trauma. The brain examination revealed none of the classical signs of anoxia or asphyxia. The conclusion of the coroner was accidental death. There are several important elements in this story: an unusual cosleeping arrangement; alcohol consumption by the parents (especially the father) before sleep; some degree of parental tiredness because the parents woke up quite late the next day; and a somewhat ‘vulnerable' infant due to exposure to maternal cigarette smoke in utero. There was also no evidence that the baby was compressed when the father woke up. However, if he was sleeping soundly because of alcohol, the baby could have died of suffocation by compression much earlier on. It is well known that asphyxia by airway obstruction can leave no external traces. The findings at autopsy were nonspecific. These types of findings are seen in babies that die with no cause identified (sudden infant death syndrome [SIDS]) and in babies with evidence of asphyxia (airway obstruction in infants wedged in restricted areas, suffocation by plastic material on the face obstructing the airway, etc) (1). Some coroners and medical examiners are reluctant to assign a diagnosis of SIDS to any death in bedsharing arrangements; moreover, there is debate in the scientific literature regarding the risks of bedsharing, an age-old tradition in many societies. It is, nevertheless, clear that some sleeping arrangements should be avoided because of an increased risk of sudden infant death (2–5). Sofa sharing, for example, is associated with one of the highest risks (OR 31, 95% CI 9 to 111) (2) when victims of sudden death are compared with an age-matched control group. Furthermore, sofa sharing with a cosleeper who has consumed alcohol is an additional risk factor for sudden death. In addition, the baby reported here had been exposed to tobacco smoke during pregnancy (and after). Currently, prone sleeping has been almost eliminated as a risk factor and maternal smoking during pregnancy has become the most important risk factor for sudden infant death (6–8). This infant usually slept on her back in her parents' room. Sleeping on the back and room sharing are protective against SIDS (2,5). As is seen in many cases of sudden infant death, parents usually comply with physician recommendations; it is in unusual circumstances, such as when travelling or when very tired (or having consumed alcohol), that they initiate other types of sleeping arrangements that are unsafe. It is also possible that the infant died of another cause. In this case, the autopsy was performed at a medicolegal institute where the pathologists were not experts in paediatric disease. A study in Quebec (9) showed clearly that when autopsies were performed by a paediatric pathologist a cause of death was found in three times as many infants as when the autopsies were performed by a pathologist with no paediatric expertise. Unfortunately, when an accidental death is suspected, the case is usually referred to a medicolegal institute. Even with this caveat, it is important to widely publicize the risks of unsafe sleeping arrangements. Scientists, physicians, and health and child care professionals are still debating whether the small risk associated with cosleeping with a nonsmoking, breastfeeding mother outweighs the benefit gained from bedsharing. The debate will likely continue for some time. Nonetheless, sofa sharing, bedsharing with persons having altered arousal conditions (eg, consumption of medication, drugs or alcohol), and bedsharing on makeshift beds with cushions and pillows are all situations with a very significant risk for sudden infant death that can be modified with public health education. It is, therefore, critical to alert parents that safe sleeping arrangements are important under all circumstances, especially if they are travelling, very tired or under the influence of substances that decrease arousal. Nobody knows the cause of SIDS, and it appears that some infants are particularly vulnerable. Because we have no means or tests with which to identify these infants, safety precautions for infant sleep must apply to everyone and at all times.

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