Abstract □ 124

Child abuse and negligence can present as sudden unexpected death in infancy. In the past few years, some cases of child abuse have received wide public attention through the media. But what is exactly the prevalence of child abuse or negligence in cases that present as sudden unexpected death? It is only through a study of all cases of sudden death occurring in a population that we can gain a clear idea of the prevalence of such a diagnosis.

In the province of Quebec (Canada), we have organised a centralised system of data collection for all infants dying suddenly and unexpectedly in the first 18 months of life. The investigation of the circumstances of death is standardised and an autopsy is almost always performed (up to 99% in recent years). Our system works with the provincial coroner's office and all cases of sudden unexpected death are investigated.

In a review of data accumulated between 1987 and 1986, we identified 623 cases of SUDS in the first 18 months of life. We retained only the deaths that were initially reported (before the investigation and autopsy) as sudden and totally unexpected in infants with no previous pathology. The death scene investigation, the past medical history, and the full autopsy reports were reviewed with the help of a team of pathologists with paediatric expertise to ensure the most accurate diagnosis. In 80% of 623 cases of sudden and unexpected death, the diagnosis was SIDS. Infection was the most common non-SIDS diagnosis (7.1% of all SUDS), followed by cardiovascular anomalies (2.7%), child abuse or negligence (2.4%), metabolic or genetic disorders (2.1%), and miscellaneous causes (CNS disorder, myopathy, congenital malformation: 6%). The incidence of child abuse and negligence in our population was 0.017 per 1000 live births -a rate 30 times lower than our SIDS rate.

In the past two years, a more complete review process for all cases of sudden unexpected death has been put in place. The team of specialist includes: child abuse professionals, social workers, forensic pathologists, members of the criminal investigation unit. Results from the reviews of that committee should be available shortly and will provide a more precise picture of the phenomenon of child abuse.

Because the rate of SIDS has declined world wide following the campaign aimed at decreasing sleeping in non-supine positions, the proportion of non- SIDS deaths in cases of SUDS will increase world wide. This situation might highlight the cases of child abuse and negligence, even without any true increase in incidence. The danger will be that parents of SUDS victims will be at greater risk of being considered suspect and may be investigated harshly thus adding to their suffering. It is our hope that the combined results of death review committees throughout the world will shed some light on the characteristics of families implicated in such cases of child abuse and negligence and better orient the investigation.