A risk factor is something associated with ill health, disease and death; it may predispose individuals to develop a particular disease. In most literature, accepted risk factors associated with SIDS include: prone positioning, cigarette smoking during pregnancy (and in the post-delivery period) and overheating. It is unclear where on the safe sleep continuum specific external factors identified in individual death investigations move from acting as factors that predispose to a natural death (e.g.
The DU5C considers the potential contribution of sleep related circumstances within the context of stratification of risk (based upon literature and experience).
While the DU5C recognizes the convention of not including contributing factors when the cause of death is undetermined, the committee believes that these cases are a special group and deserve a unique approach. Collection of consistently defined data sets across many death investigation systems would enable a true analysis of the key factors contributing to these deaths – if the definitions are not the same, it is difficult to compare.
The death is then reviewed by the DU5C, who will only attribute the death to SIDS if a consensus decision is reached that the case strictly meets the definition The DU5C strictly applies the definition of SIDS and excludes cases with even minor deviations.

These external factors have been defined as modifiable risk factors that predispose the infant to be directly affected by an underlying natural abnormality.
During case review by the DU5C, unsafe sleep circumstances found at the death scene preclude the death from being classified as SIDS. When it is believed that the sleep environment may have contributed to the death, it is included as a contributing factor on the Medical Certificate of Death. The committee maintains that entering potential contributing factors on the Medical Certificate of Death is more inclusive and recognizes the scope of the death investigation. There were 36 infant deaths classified as 3A (unsafe sleep circumstances) indicating that sleep circumstances may have been a contributing factor. These are cases that would benefit from further research within the scientific community that may find common underlying factors causing these deaths. Two recent articles of interest are: Sleep Environment Risks for Younger and Older Infants.

Similar to the identification of SIDS as a special group, this may allow easier identification for further case study, facilitating future research and potentially informing a public safety approach. If the investigation reveals any concerning finding, the cause of death will not be classified as SIDS. However, experience in Ontario, supported by epidemiologic data, is that sleep circumstances may be a contributing factor in many cases. This is in contrast to previous literature and the practices of some jurisdictions, where these deaths are classified as SIDS.

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