Sudden Unexpected Infant Death Certification in New York City: Intra-Agency Guideline Compliance and Variables that May Influence Death Certification.

INTRODUCTION:Differences in certification of similar sudden infant deaths exists among forensic pathologists. This study sought to measure adherence to intra-agency guidelines for infant death certification in one jurisdiction and describe variables that may be associated with the differentiation of sudden infant death syndrome (SIDS), asphyxia, and undetermined death certifications. METHODS:A retrospective study of deaths at the New York City Office of Chief Medical Examiner identified 427 sudden infant deaths with investigation and autopsy whose cause of death was ruled SIDS, asphyxia, or undetermined. Cases were reviewed for number and types of risk factors for asphyxia, demonstrable evidence of asphyxia, potential competing causes of death, and a doll reenactment. Descriptive and statistical analysis was performed. RESULTS:Of 427 deaths, the causes of 100 deaths (23.4%) were ruled asphyxia; 43 (10.0%) SIDS; and 284 (66.5%) undetermined. Forensic pathologists conformed to agency guidelines in 406 deaths (95.1%). Three or more risk factors for asphyxia were found in 328 deaths (76.8%). Demonstrable evidence of asphyxia (40.7%) was most associated with a certification of asphyxia. A potential competing cause of death (20%) was most associated with undetermined. A doll reenactment had little association with certification type. DISCUSSION:Guidelines in one agency were effective at limiting incorrect SIDS diagnoses. The interpretation of risk factors can be subjective. Diagnostic overlap occurred in deaths certified differently as SIDS, asphyxia, and undetermined, despite similar findings. Elimination of SIDS as a certification option and better guidelines that help differentiate asphyxia and undetermined deaths are recommended for improved infant death certification.