Sudden Infant Death in the George Sherman Infant Care Center: Who did it?

September 15, 1997

Scene 1: First phone call

Setting: The Infant Care Director calls up a staff member, Alex, to relay some distressing news

Director: I thought they'd never leave! They photographed the entire nursery, each crib, asking questions about whether the babies are put down to sleep on their stomach or their back, and how often they are checked on. They checked windows and measured air flow -- asked us why we didn't have the air conditioning on. Why? It's a beautiful day, those windows let in plenty of air. They even tore open a pillow, said they needed a fiber sample!

Alex: We passed state inspection last month -- with flying colors. Was this about -- the kid who--?

Director: Lawyers for the Hamilton's. The parents want to sue about Elroy.

Alex: Oh, man. This is awful. I've been feeling bad enough about this as it is. I'll never forget the moment I walked by his crib, didn't see anything moving, his face was down, pressed into a pillow so I thought at first he was just sleeping deeply -- but Beth Israel Hospital certified the cause of death to be that crib death thing -- some kind of breathing problem that just strikes infants randomly.

Director: The parents want to charge negligence and wrongful death. You know those parents were always snooty about this place, after A-One Infant Care put them on a 2 year waiting list. They complained because we weren't talking to Elroy enough -- but a 4 month old baby doesn't need a constant barrage of speech. Caregivers should let their infants signal when stimulation is needed.

Alex: Yeah, well, that mom does what she wants. She even lit up a cigarette in here when she waiting for me to get Elroy, even though the place is plastered with no-smoking signs. I told her to put it out and she just went outside.

Director: Hmm, I think the father smokes too. Environmental smoke can contribute to respiratory problems -- thought to be one of the precursors to Sudden Infant Death Syndrome. If we could show that this child had risk factors... Alex, feel like some research? We've got a case to build.

Alex: Research? Look, I have my own classes to prepare---

Director: Do you want us to close down because of legal costs?

Alex: Ok, what do you want?

Director: First, some general background: what causes infants to just stop breathing while they're sleeping. Second: what are the risk factors, and does little Elroy have any of them?

Scene 2:

The director and Alex are seated in the director's office, going over charts and research reports.

Alex: Elroy stopped breathing while face down with his head in a pillow. It says here that a common cause of respiratory failure is when infants are placed to sleep head down. If the mattress is very soft, the infant's head makes a pocket. Infants can still breathe, but if the pocket is deep enough to collect their exhaled breath, they eventually breaths in lethal level of carbon dioxide and suffocate. The fiber fill of some pillows and mattresses are suppose to make this possibility more likely.

Director: I heard about this a few years ago. We don't give infants pillows, and we always put them down to sleep on their backs.

Alex: A four-month old isn't motorically developed enough to turn himself over from his back to his stomach, but if he was put down on his side, he could have turned himself onto his side.

Director: The Hamiltons could try to nail us with that mistake. What about mattress fiber content?

Alex: I called the mattress manufacturer, and our fiber is on the infant approved list.

Director: Hmm.... so babies die from breathing in their own exhaled air. You know, it's hard to suffocate someone. If you want to suffocate someone in their sleep with a pillow over their head, you've got to have the physical strength to overpower their struggles -- that's because of an automatic struggling process.

Alex: I was about to read you what I have on that. It's called the rage reflex, struggling and crying that happens whenever breathing is blocked. See, it all has to do with brain maturation. Between 1 month and 4 months of age --

Director: Oh, yeah. The most common age for dying of SIDS is 2 to 3 months. I saw you had a graph of that here.

Alex: Elroy was 4 months, so he's a bit past the peak danger period.

Director: What makes the 2-3 month period the most dangerous time?

Alex: It's a brain development thing. Humans have two brains--

Director: Yeah, the left and right hemispheres.

Alex Well, humans do have that, but here they are talking about two different kinds of brains, the reptilian brain and the mamamlian brains. Humans have both. The reptilian brain is concerned with aspects of survival: feeding, getting out of danger, mating.

Director: And all the automatic aspects, such as breathing.

Alex: Breathing too, everything. But when mammals evolved, they grew a new layer, called the cortex, on top of the reptilian brain. This came to control the lower brain centers by inhibiting them. So, instead of just reacting to the environment automatically, the cortex would allow thinking and reasoning to control behavior.

Director: (reading from text) It says in this book that the subcortex is born already functioning, but the cortex is immature, non-functioning. Over the first four months of life, the cortex matures. It starts to take over the functions of the subcortex, by inhibiting them. So this is a period when control is passed from one brain system to another. The cortex takes over the functions that were previously automatically controlled by the reptilian brain.

Alex: So we can consciously control our breathing -- like we can hold our breath.

Director: Like passing a baton in a relay race, there is room for mistakes to happen, like if one person gives up control of the baton before the next runner is ready to take over. Transfer of control in any system is a period where slip-ups can happen. So we're back to risk factors. What can make a problem more likely in this period where two brain system are competing for control of breathing reflexes and the rage reflex? Could it be an inherited thing?

Alex: For a long time it was thought that SIDS runs in families, because of some high-profile cases in which as many as 6 siblings died of SIDS. But when researchers tried to nail down a genetic tendency, they couldn't. They found that but the incidence of SIDS in identical twins is the same as in fraternal twins. This suggested the risk factor for SIDS might be something environmental in the families, such as poor prenatal care, or something else that would lead to poorly development brain mechanisms.

Phone rings. Director picks it up.

Director: Hello? Oh, Cheng-Chi, thanks for getting back to me. ... Yes, I thought you would know a lot about this.... On the genetic issue.... child abuse? That wouldn't be relevant here, but please explain.... Ok, thanks a lot. Bye.

hangs up

Director My friend in Sergeant's infant lab actually had some information pertinent to what you just talking about it. It seems that a small percentage of SIDS cases are actually willful harm, usually done by the mother. So it was something environmental in the families -- but not prenatal care, post-natal child abuse. There's a story about this in the Health/Science section of the Sept 15, 1997 Boston Globe. But we know the parents were hours away when Elroy died so I doubt this is a case of Munchausen by proxy.

Alex: Ok, back to risk factors, we already have one: parental smoking. Even a cold, which normally isn't life-threatening, could lead to respiratory distress and a breathing blockage. Without a good rage reflex, that breathing blockage leads to suffocation.

Director: Remember the parents kept Elroy out of the center the two weeks before he died. They said they were away on vacation. Did Elroy have a cold that weak?

Alex: I'm off to get hold of his medical records.

Scene 3:

Setting: Alex and Director again on the phone

Alex: Elroy didn't have a cold, instead he was on vacation with his parents. I did find some useful information from the autopsy report. There was evidence that Elroy had been fed honey the morning he died. This is known to be a source of toxin, which probably caused infant botulism, which can cause partial nerve paralysis. The nerve paralysis is what then makes it difficult to recover from an episode of breathing blockage.

Director: Well, it is a tragedy that he died, but this child had multiple risk factors. I think we will be cleared of any wrong doing.

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copyright 1997 C. L. Harris