Unexpected non-HIV causes of death in children born to HIV-infected mothers

Introduction. A high incidence of sudden, unexplained deaths in infants bor n to HIV-infected mothers has been noted in several epidemiologic studies. During the course of a prospective study of heart and lung disease in child ren born to HIV-infected mothers, we noted that of 5 unexpected non-HIV-rel ated deaths, 4 were attributed to traumatic events. Methods. The Pediatric Pulmonary and Cardiac Complications of Vertically Tr ansmitted HIV Infection ((PC2)-C-2) study is a multicenter, prospective inv estigation of the incidence of heart and lung disease in HIV-infected child ren. A total of 805 children were enrolled and followed for 5 to 7 years wi th serial immunologic, pulmonary and cardiac function studies. During the s tudy, a multidisciplinary committee was formed to review the cause of death for those patients who died. The committee used results of pulmonary, card iac, and laboratory tests, hospital summaries, as well as autopsy and coron ers' reports. The committee formed a consensus about the underlying and con tributing causes of death for each subject using the definitions from the 1 989 US Standard Certificate of Death. Results. A total of 121 deaths occurred during the course of the (PC2)-C-2 study. Of the 121 deaths, 5 were traumatic or sudden and unexpected and jud ged by the Mortality Review Committee to be unrelated to HIV infection. The median age at the time of death was 1.3 months and ranged from 1.2 to 37.8 months. Two infants died of trauma: a skull fracture and subdural hematoma in 1 infant and multiple skeletal fractures consistent with battered child syndrome in the other infant. The third infant died of accidental suffocat ion at home at 1.2 months of age. The fourth infant died suddenly and unexp ectedly Lit home at 1.3 months of age. The autopsy showed no sign of HIV or other infection and was consistent with sudden unexpected death or SIDS. O ne non-HIV-related death occurred when a 38-month-old child died together w ith the mother in an unwitnessed drowning. The cumulative mortality rate at tributable to trauma and sudden death at if months of age was 0.95% (95% CI : 0.02-1.87%) and the infant mortality rate was 9.5/1000 live births. Three children were born prematurely at 30, 33, and 36 weeks' gestational age, r espectively, and 3 mothers admitted using recreational drugs before or duri ng pregnancy. Discussion. These traumatic and sudden non-HIV-related deaths accounted for 4.1% (5/121) of the deaths during the entire (PC2)-C-2 study period and fo r 20% (4/20) of the deaths in the first year of life. Four deaths were attr ibutable to accidental and nonaccidental trauma rather than to other common causes of infant death. One death was a sudden unexpected death, similar t o SIDS, a leading cause of infant death in the United States. The majority of previously reported non-HIV-related deaths in infants born to HIV-infect ed mothers have been attributed to SIDS or to unexplained sudden death. in contrast with other reports, 4 of the 5 children in our series died of acci dental or nonaccidental trauma and only 1 was a sudden unexplained death. I t is unlikely that HIV exposure is related directly to the deaths described in this report; however, maternal HIV infection may be a marker for factor s that place the child at risk for sudden or traumatic death. Summary. This report suggests that children born to HIV-infected mothers ma y be at increased risk for traumatic or sudden, unexplained, non-HIV-relate d death. These children seem to be at risk regardless of their own HIV infe ction status. Furthermore, 4 of the deaths in our study occurred within the first few months of life, suggesting that this is a period of increased vu lnerability. Studies to identify associated risk factors for non-HIV-relate d deaths are needed to identify these high-risk infants. Children born to H IV-infected mothers may be more vulnerable than was recognized previously a nd may be in need of increased social services, especially in early infancy .