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When a child 12 months of age or older dies unexpectedly and no one can figure out why, the death goes into a catch-all mystery basket called “sudden unexplained death in childhood” (SUDC). The Centers for Disease Control and Prevention (CDC) says that close to 400 children died suddenly and without a clear cause of death in 2017 and 2018, respectively, but a new study in the Journal of the American Medical Association (JAMA) questions the CDC’s figures. According to the university researchers and medical and forensic experts authoring the study, widespread inconsistencies in death certification mean that the U.S. public health agency is almost certainly underestimating how often such deaths occur.

Boys represent the majority of SUDC cases, and the risk is more than two-fold greater for African American children than for other groups. And though the CDC tracks the unexpected fatalities through age 18, the average age of death is two years (32 months in the JAMA study). Nearly all affected children are born full-term, having been developing normally and “in their state of usual good health prior to death” — which happens mostly during sleep. Without much of anything to go on, the unpredictable deaths, according to the JAMA study’s lead author, “elude … scientific understanding.”

Dysfunctional death records

According to professionals who work with death records, the “process for creating and registering causes of death for public records is a complicated, convoluted, and politicized one” that results in a “mostly uninvestigated and inaccurate picture of what causes a death.” The JAMA study’s review of 100 autopsied cases referred to the SUDC Registry and Research Collaborative for additional investigation (92% from the U.S. and 8% from Canada or the UK) bears out this observation. After combing through medical records, death scene investigations, autopsy findings, ancillary tests and available genetic data, the authors show that for four out of ten SUDC cases reviewed, their cause-of-death determination did not match the original verdict, with even more disagreement (61% of cases) about how to interpret lab findings. Not only did many of the death certificates put forth causes “that weren’t supportable on further inspection,” but notably, the reviewers considered 28 deaths to be “unexplained” that the original certifiers had termed “accidental” or “natural.”

The JAMA authors and other experts highlight a number of failings of the death certification process as it pertains to SUDC. They cite:

  • A “dire shortage” of practicing and available medical examiners in the U.S.: After the National Research Council flagged the shortage in 2009, the opioid epidemic created a “glut of cases” that has exacerbated the problems. In February of this year, the New York Times reported that chief medical examiners in large metropolitan areas “have resigned in protest over intolerable case loads and insufficient funding and resources.” A recent multistate analysis by CDC researchers of “sudden death in the young” (SDY) found that medical examiners declining cases was a common reason for the absence of autopsy results.
  • Inadequate attention to organ histology: Although the brain and heart are frequently implicated in sudden death, the JAMA authors found that examinations of the two organs frequently were “substandard” —  at least 28% of the time for the brain and 21% of the time for the heart. Tissue findings for the brain and heart represented key areas of disagreement between the original pathologists and the reviewers. In the CDC’s recent review of SDY cases, “possible cardiac” deaths were a frequent reason for classifying a sudden childhood death as “unexplained.”
  • Pressure to come up with an explanation: The JAMA authors suggest that investigators may prefer to pin sudden child deaths on accidental or natural causes or minor pathologies such as bronchitis — rather than pronouncing a death “unexplained” — out of a desire “to avoid the limbo of an unexplained certification” and the appearance of an “incomplete investigation” or one in which “information was overlooked.” Quoting one medical examiner as stating “I had to put something down,” they observe that “real or perceived pressure to identify a [cause of death] may lead some to unwarranted determinations.”

Vaccination — “overlooked” information

Childhood mortality researchers have noted that even when autopsy and ancillary data are available, a significant number of sudden unexpected childhood deaths tend to remain unexplained. In late 2019, Japanese forensic pathologists writing in the American Journal of Forensic Medicine and Pathology highlighted one potential cause of sudden death that American researchers typically ignore or dismiss: vaccination.

Pointing out that reviews of death certificates alone are likely to be “unproductive” for investigatory purposes, the Japanese forensic experts surveyed autopsy files to assess the potential relationship between sudden infant death and vaccination in children age two and under. Among the young children for whom vaccination history was available, 22% had died within seven days and 25% within a month of receiving one or more vaccines. The Haemophilus influenzae type b (Hib) vaccine was the “most frequent vaccine cited as the last immunization before death,” a finding consistent with the numerous studies from around the world that have reported infant deaths following vaccination with Hib-containing pentavalent or hexavalent vaccines. Though acknowledging the difficulty of judging whether a fatal outcome is “truly related to vaccination” — as well as the near impossibility of disentangling which of many co-administered vaccines might be responsible — the Japanese authors assert that “suspicious cases do exist” and urge forensic pathologists to factor vaccination into their analysis on a routine basis rather than waiting for parents to raise questions.

COVID-19 has provided an interesting and positive “natural experiment” illustrating the correlation between vaccination and sudden infant and child deaths. As Health Choice wrote in June, amid the near universal lockdowns this spring, deaths in very young children fell by roughly 30%, around the same time that public health officials observed a sharp decline in the well-child visits at which routine vaccination takes place. Cheering the fact that over 200 young lives have been saved each week, Health Choice suggests that this outcome “calls into question the very actions — widespread, mandated vaccines for all — that the infectious disease and public health community have been pushing for years.”

One red flag: febrile seizures

While underscoring the overall good health of the deceased children whose records they reviewed, the JAMA authors did identify personal or family history of febrile seizures as a possible red flag for sudden childhood death. (This contrasts with the unwarranted assurances of many child health experts that febrile seizures are nothing to worry about.) In a prior analysis of 391 SUDC cases among 1-6-year-olds (also published in JAMA), the same research group found that 29% of the children had a history of febrile seizures, “a more than 10-fold greater rate than among the general population.” In their 2020 study, they go so far as to hypothesize a possible correlation with sudden unexpected death in epilepsy (SUDEP) — citing “subtle abnormal [brain] development” in some SUDC children (which could be either the cause or the result of seizures) — but they say nary a word about vaccines.

Nonetheless, the role of vaccination as a risk factor for febrile seizures should, by now, be common knowledge. A 2013 study by Italian researchers, for example, frankly described vaccines as the second leading cause of febrile seizures and worried about the “public apprehension” that this fact might cause. Vaccine package inserts show that 19 different vaccines — including influenza vaccines and most of the other formulations on the childhood vaccine schedule — have given rise to febrile seizures either in clinical trials or post-marketing. In 2010, Australia suspended use of a seasonal influenza vaccine in children under age five after many experienced “unforeseen severe febrile reactions and febrile seizures.”

Interestingly, a related fatal condition dubbed “sudden arrhythmia death syndrome” (SADS) — a sudden heart rhythm disruption that kills about 4,000 children, teens or young adults each year — has as one of its top warning signs a history of fainting. Like febrile seizures, fainting (syncope) is a frequent post-vaccination reaction, associated with 27 different vaccines. Fainting is particularly common in adolescent and young adult vaccine recipients. The CDC’s website describes “a trend of increasing syncope reports that coincided with the licensure of 3 vaccines for adolescents: human papillomavirus (HPV), MenACWY [meningitis], and Tdap [tetanus, diphtheria and pertussis].” Package inserts link all three types of vaccine to deaths in infants and young people.

Circular reasoning

Where sudden childhood deaths and vaccination are concerned, circular reasoning abounds. For example, CDC researchers have unblushingly cited the fact that “a large number of vaccines are given to young children (often simultaneously) at scheduled well-child visits” as their rationale for attributing deaths that occur “in close temporal association following vaccination” to “chance alone,” even while admitting that most of the deaths reported to the Vaccine Adverse Event Reporting System (VAERS) are in very young children. According to the public health agency, though 79% of the children whose deaths were reported to VAERS through 2013 received multiple same-day vaccines, “no concerning pattern was noted.”

The JAMA authors’ finding of a lack of concordance between original death certifications and their expert review is concerning given that CDC mortality statistics “are compiled from information that originates in [medical examiners’] offices.” As the New York Times puts it, “the medicolegal death investigation system . . . is the primary source of data that drives our understanding of what’s killing us that shouldn’t be.” According to one death records professional, it is only the “incredibly rare” and “very principled” individual — someone willing to go “above and beyond the call of protocol” and “think outside the box of their standard procedures” — who is likely to record a vaccine adverse reaction on the death certificate, and even then, not as the primary underlying cause. Until that situation changes, “unexplained” will remain the unsatisfying operative word in many determinations of sudden childhood death.