J. Paediatr. Child Health (2005) 41, 215–217 Instructive Case Delayed infant death following catastrophic deterioration during breast-feeding Henry F Krous, 1,2 Amy E Chadwick 1 and Christina Stanley 3 1 Children’s Hospital and Health Center, 2 University of California, San Diego School of Medicine, and 3 Office of the Chief Medical Examiner, San Diego County, California, United States of America CASE REPORTS Case 1 A mother of unknown weight and body habitus was breast- feeding her 1-month, 14-day-old white male infant while watch- ing a movie in a theatre at approximately 17.10 hours. About 75 minutes later, the infant became fussy with efforts at a bowel movement prompting his mother to cradle him across her lap. Subsequently, at 18.30 hours, while his mother held him in her arms, he began breast-feeding again. At 18.45 hours his mother suddenly discovered him unresponsive, apneic, not moving and with ‘red fluid’ coming out of his nose. This sequence of events was corroborated by direct discussion with the mother. Car- diorespiratory resuscitation (CPR) was initiated at the theatre by a bystander and was maintained during transfer first to an adult hospital where he arrived at 19.04 hours and then to Children’s Hospital, San Diego where he arrived at 19.57 hours. During this entire interval he remained hypotensive despite continuous intensive care. Bradycardia ensued, and after discussion with his parents, medical support was discontinued, and he was pro- nounced dead at 23.45 hours on the day of admission. He was the first born of a woman whose pregnancy was full term and complicated only by swelling of her feet and ankles. Fe- tal tachycardia prompted Caesarean section delivery. Following delivery, he experienced ‘grunting’ for 15 minutes. Antibiotics were administered for 2 days and then discontinued. Postnatal cardiac arrhythmias were not identified. His immunizations were current. During his short life, he was exclusively breast-fed. He was not exposed to gestational or postnatal cigarette smoke. Toxicologic studies of pre-mortem blood were negative for alcohol, acetone, benzodiazepines, methanol, isopropanol, co- caine metabolites, opiates, methamphetamine and fentanyl; the basic and acid/neutral screens were also negative. Post-mortem examination revealed the crown-heel length was between the 50th and 75th percentile. The pertinent findings were acute ischemic encephalopathy, pulmonary hyaline mem- branes and multifocal myocardial haemorrhages, all of which were considered complications of prolonged hypotension and deterioration preceding death. Facial, conjunctival, pleural and thymic petechiae were not present. Facial, oropharyngeal and upper airway anatomy was normal. Gross and micro- scopic evidence of gastric aspiration, pneumonia, meningitis, Correspondence: Dr Henry F Krous, Children’s Hospital and Health Center, 3020 Children’s Way, MC5007 San Diego, CA 92123. Fax: 858 966 8087; email: hkrous@chsd.org Accepted for publication 14 October 2004. encephalitis, neoplasms, congenital malformations, trauma and metabolic disorders were not identified. Screening of post-mortem blood using tandem mass spec- trometry was negative for metabolic disorders, including defects in fatty acid oxidation. Carbon monoxide was not identified in post-mortem blood. Post-mortem vitreous electrolyte analyses were unrevealing. Pre-mortem and post-mortem blood cultures grew no organisms. Case 2 While shopping in a large store, a mother whose physical description is unknown carried her 1-month, 11-day-old male infant in a baby sling. His mother interpreted his fussiness as hunger and began breast-feeding him while walking in the sec- ond floor of the store. The mother was aware of her son feeding until she boarded an escalator to go to the first floor, at which time the infant stopped nursing but ‘maintained a good latch’ as they descended. The mother continued to shop, then went to remove the infant from her breast and noticed a small drop of blood in one of his nares. She noted his generalized pallor and unbuttoned the sling to discover him apneic. Assistance was sought and CPR was initiated at the store and maintained by emergency medical technicians until he was admitted to a lo- cal hospital emergency department. Despite intensive medical support, he progressively deteriorated and died on the fourth hospital day. His past medical history revealed that he was born 2 weeks prematurely and his perinatal course was complicated by res- piratory distress that resolved by the seventh day of life. Three days after his discharge from the hospital, he was readmitted for jaundice that resolved after 2 days of treatment. Salicylic acid, methamphetamine, acetaminophen, alcohol, cocaine, opiates and phencyclidine were not detected and the basic drug screen was negative in a pre-mortem blood specimen. Post-mortem examination revealed the crown-heel length was between the 10th and 25th percentile. Relevant findings in- cluded myocardial necrosis, diffuse alveolar damage, acute tubu- lar necrosis, generalized oedema and severe thymic atrophy, all of which are consistent with death delayed following 4 days of prolonged hypotension, progressive clinical deterioration and in- tensive medical support. Retinal haemorrhages were not present. The anatomy of the face, oropharynx and upper airway was