Thus, this 5-year study included 244 autopsied children who suddenly died due to natural causes in Egypt. Globally, the autopsy series that are concerned with unexpected natural pediatric deaths are scarce (Winkel et al. 2014; Bryant et al. 2022). Additionally, childhood is a long period that extends up to 18 years old. Childhood consists of developmental stages and each has its characteristics. Most autopsy-based studies are either restricted to certain pediatric age categories, such as neonates and infants (Weber et al. 2008; Özkara et al. 2009). Others included all pediatric deaths from birth to adulthood as a single group (Parham et al. 2003).
The current study included the full spectrum of natural unexpected pediatric deaths along with the categorization of cases into 3 age groups including neonates, infants, and children, which is in agreement with the study design of Tumer et al. (2005) who conducted their study in the Council of Forensic Medicine, Ankara for 5 years.
More than half of the cases in the present research constituted neonates. Considering that the neonates, who died within days of their birth, often did not have confirmed antemortem diagnoses of their serious disorders, especially in developing countries, such as Egypt (Pugliese-Garcia et al. 2020). Inadequate perinatal care with a subsequent defective diagnosis of fatal pathologies could explain the high percentage of autopsied neonates in the current study.
Conversely, in Turkey, Tumer et al. (2005) stated that neonates constituted only 25.77% of the cases. The relatively small proportion of medicolegal autopsies in neonates could be attributed to advances in perinatal health care in Turkey that identify potentially fatal diseases during life (Alparslan and Demirel, 2013). Thus, enhancing maternal sanitation, increasing awareness of the risks of preterm labor, and providing improved health and neonatal care are necessary in Egypt.
The current study revealed male dominance with a male-to-female ratio of 1.5:1. Similarly, Tumer et al. (2005) and Kaenjua and Srettabunjong (2012) reported a male-to-female ratio of 1.48:1 and 1.3:1, respectively.
A lot of classifications were adopted for sudden deaths during childhood. The current study followed an updated classification adopted by the WHO in ICD-11 that assigned unexpected deaths to “explained,” “unexplained,” and “undetermined” (Goldstein et al. 2019). “Explained” cases are referred to as explained natural deaths, which constituted 74.2% of cases because nonnatural deaths were excluded from the current study. The cause of death remained unknown in 25.8% (13.9% unexplained death and 11.9% undetermined death). Similarly, Bryant et al. (2022) who conducted their autopsy-based study in hospitals of the UK for 20 years explained the cause of death in 74% of pediatric deaths. Nevertheless, Wren et al. (2000) and Tumer et al. (2005) explained the cause of death in 85% and 80.42% of autopsied children, respectively.
Regarding unexplained deaths, the present study revealed that half of the infant deaths were unexplained, which could be described as unexplained SUDI or SIDS. The current result is congruent with the autopsy-based study findings conducted by Weber et al. (2008) who assigned 63% of infancy deaths as unexplained SUDI. Conversely, Parks et al. (2021) conducted a population-based survey and assigned 82% as unexplained infant deaths. A high percentage of unexplained deaths is an inevitable limitation to the nonconduction of the autopsy. Thus, pathologies that are diagnosed only during autopsy could be missed. Therefore, unexplained SUDI or SIDS should not be diagnosed in the absence of a comprehensive autopsy.
Unfortunately, to date, SIDS results in a significant proportion of deaths during infancy worldwide despite the improvement in healthcare and medical research. The etiology of SIDS is unknown, but it is considered a multifactorial disorder (DiMaio and Molina, 2022; Tan and Byard, 2022).
Infection is one of the leading causes of death during childhood considering explained deaths. Thus, the current study analyzed infection-related deaths that were responsible for nearly one-third of explained natural deaths. Of infection-related deaths, 60% occurred above the age of 1 year. Recently, Bryant et al. (2022) demonstrated infection as the most common cause of death in children aged > 1 year, accounting for 46% of all deaths and 62.2% of explained deaths that coincide with the current results. This research suggests that reforms in public health are needed, including improved sanitation and immunization programs, to reduce the infection problem. Another example of a shift that relates to a general improvement in housing and standards of living, nutrition, and improved health care is the accessibility of antibiotics for infectious disease treatment (Ferreras-Antolín et al. 2020).
In the current study, respiratory tract infections represented 61.8% of infection-related deaths and respiratory system affection was responsible for 64% of explained deaths. Similarly, Weber et al. (2008) revealed that infections, particularly pneumonia, was responsible for 58% of the explained pediatric deaths. Additionally, Du Toit-Prinsloo et al. (2011) pointed pneumonia as one of the most common causes of unexpected death during childhood.
The current study included 46 cases of death in abandoned children with no available data. The cause of death is undetermined in nearly two-thirds of cases. Similarly, Li et al. (2012) reported death in 27 abandoned babies in a 5-year retrospective study in Shanghai, China, with a significant difficulty in determining the cause of death.
In the present study, the prodromes before death were reported in more than half (51.2%) of unexpected natural pediatric deaths. History of respiratory difficulties and fever were the most common alarming signs. The high incidence of respiratory distress and fever is related to many cases of fatal infections, particularly pneumonia.
In this study, alarming manifestations were absent in nearly a third (29.9%) of unexpected natural deaths. Moreover, the cause of death of nearly half of them was unexplained. The most commonly identified causes that led to death without prodromes were congenital anomalies and anaphylactic shock. Studies reported that congenital malformations, especially in the heart, are not usually manifested during life and were diagnosed for the first time during autopsy (Sheppard, 2020; Fnon et al. 2021). Anaphylactic shock has an abrupt onset and rapidly progressive course; thus, prodromes are not usually reported in cases of fatal anaphylaxis (Greenberger et al. 2007).
This research shed light on forensic medicine practice in Egypt as autopsy procedures are done by forensic medical examiners, whereas pathological examination of retained samples is conducted with forensic pathologists. All forensic experts in EFMA are well-trained and work harmoniously to conduct post-mortem examinations adequately (Kharoshah et al. 2011; State Information Service, 2021). It is worth mentioning that in jurisdictions in developed Western countries, the forensic practice is different as forensic pathologists always carry out the entire procedure, starting with the external examination (Al-Waheeb et al. 2015).
The current study was restricted to the sudden natural pediatric deaths referred to the pathology unit of EFMA. However, the present results serve as a valuable reference dataset for deaths in different developmental stages in Egypt. From a forensic perspective, the present study guides forensic practitioners in managing child deaths. Clinically, early diagnosis of potentially fatal diseases might decrease the possibility of death.