The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies

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n.callMethod.apply(n,arguments):n.queue.push(arguments)} ;if(!f._fbq)f._fbq=n; n.push=n;n.loaded=!0;n.version='2.0';n.queue=[];t=b.createElement(e);t.async=!0; t.src=v;s=b.getElementsByTagName(e)[0];s.parentNode.insertBefore(t,s)}(window, document,'script','https://connect.facebook.net/en_US/fbevents.js'); fbq('init', '1641728616063202'); fbq('track', "PixelInitialized", {}); Skip to content Gates Open Research file_upload Submit via VeriXiv search clear search menu close clear Search Browse Gateways & Collections How to Publish Submit via VeriXiv My Submissions Article Guidelines Article Guidelines (New Versions) Open Data, Software and Code Guidelines Open Data and Accessible Source Materials Guidelines (HSS) Prepublication Checks Production Process Posters and Slides Guidelines Document Guidelines Publication Charges Finding Article Reviewers About How it Works For Reviewers Our Advisors Policies Glossary FAQs For Developers Contact Blog My Account Submissions Content and Tracking Alerts My Details Sign In Submit via VeriXiv { "@context": "https://schema.org", "@type": "ScholarlyArticle", "mainEntityOfPage": { "@type": "WebPage", "@id": "https://gatesopenresearch.org/articles/7-46" }, "headline": "The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal...", "datePublished": "2023-02-15T11:24:07", "dateModified": "2023-02-15T11:24:07", "author": [ { "@type": "Person", "name": "Godwin K. Osei-Poku" }, { "@type": "Person", "name": "Lawrence Mwananyanda" }, { "@type": "Person", "name": "Patricia A. Elliott" }, { "@type": "Person", "name": "William B. MacLeod" }, { "@type": "Person", "name": "Somwe Wa Somwe" }, { "@type": "Person", "name": "Rachel C. Pieciak" }, { "@type": "Person", "name": "Christopher J. Gill" } ], "publisher": { "@type": "Organization", "name": "Gates Open Research", "logo": { "@type": "ImageObject", "url": "https://gatesopenresearch.org/img/AMP/Gates_image.png", "height": 600, "width": 47 } }, "image": { "@type": "ImageObject", "url": "https://gatesopenresearch.org/img/AMP/Gates_image.png", "height": 1200, "width": 94 }, "description": "Background: The contribution of sudden unexpected infant death (SUID) has received little attention in global health. The objective of this study was to estimate the burden of SUID in Lusaka, Zambia. Methods: Verbal autopsies were conducted on infants who died in Lusaka, between 2017 and 2020. From these, we performed a qualitative analysis of the free text narratives of the final series of events leading to each infant’s death and classified these as symptomatic deaths or SUID. Any narrative that described an infant who was otherwise healthy with no antecedent illness prior to death and found dead in bed after a sleep episode was classified as SUID. We used logistic regression to test for statistical differences between asymptomatic deaths and SUIDs on key infant, maternal and other risk factors of SUIDs. Results: Eight hundred and nine verbal autopsies were conducted with families of decedent infants younger than six months of age. A total of 92.6% (749/809) had presented with symptoms prior to death, whereas 7.4% (60/809) died without preceding symptoms or obvious cause of death. Of these, 16/60 were compatible with accidental suffocation deaths, and 54/60 appeared to be sudden infant death syndrome. SUID deaths were concentrated in infants younger than two months of age with peak age of one to two months. Age at death was the only significant factor in multivariate analysis. Infants aged between one and two months had 2.84 increased odds of suspected SUIDs compared to infants in the first month of life (aOR = 2.84, 95% CI: 1.31, 6.16). Conclusions: Our findings suggest SUID could be accounting for a significant proportion of infant deaths in Zambia, but this cause of infant mortality is going unrecognized. Public health interventions in Zambia, and Africa more broadly, are likely overlooking SUIDs as an important cause of infant mortality." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://gatesopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://gatesopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://gatesopenresearch.org/articles/7-46/v1", "name": "The apparent burden of unexplained sudden infant deaths in Lusaka,..." } } ] } Home Browse The apparent burden of unexplained sudden infant deaths in Lusaka,... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Osei-Poku GK, Mwananyanda L, Elliott PA et al. The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.12688/gatesopenres.14303.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] Godwin K. Osei-Poku https://orcid.org/0000-0003-3594-5330 1 , Lawrence Mwananyanda 1 , Patricia A. Elliott 2 , [...] William B. MacLeod https://orcid.org/0000-0001-8003-8874 1 , Somwe Wa Somwe https://orcid.org/0000-0001-7217-4382 3 , Rachel C. Pieciak https://orcid.org/0000-0002-1514-5320 1 , Christopher J. Gill https://orcid.org/0000-0003-3353-0617 1 Godwin K. Osei-Poku https://orcid.org/0000-0003-3594-5330 1 , Lawrence Mwananyanda 1 , [...] Patricia A. Elliott 2 , William B. MacLeod https://orcid.org/0000-0001-8003-8874 1 , Somwe Wa Somwe https://orcid.org/0000-0001-7217-4382 3 , Rachel C. Pieciak https://orcid.org/0000-0002-1514-5320 1 , Christopher J. Gill https://orcid.org/0000-0003-3353-0617 1 PUBLISHED 15 Feb 2023 Author details Author details 1 Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA 2 Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, 02118, USA 3 Department of Pediatrics, School of Medicine, University of Zambia, Lusaka, Lusaka Province, 00260, Zambia Godwin K. Osei-Poku Roles: Conceptualization, Formal Analysis, Writing – Original Draft Preparation, Writing – Review & Editing Lawrence Mwananyanda Roles: Investigation, Project Administration, Writing – Review & Editing Patricia A. Elliott Roles: Methodology, Supervision, Validation, Writing – Review & Editing William B. MacLeod Roles: Data Curation, Formal Analysis, Methodology, Writing – Review & Editing Somwe Wa Somwe Roles: Methodology, Supervision, Validation, Writing – Review & Editing Rachel C. Pieciak Roles: Project Administration, Writing – Review & Editing Christopher J. Gill Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background: The contribution of sudden unexpected infant death (SUID) has received little attention in global health. The objective of this study was to estimate the burden of SUID in Lusaka, Zambia. Methods: Verbal autopsies were conducted on infants who died in Lusaka, between 2017 and 2020. From these, we performed a qualitative analysis of the free text narratives of the final series of events leading to each infant’s death and classified these as symptomatic deaths or SUID. Any narrative that described an infant who was otherwise healthy with no antecedent illness prior to death and found dead in bed after a sleep episode was classified as SUID. We used logistic regression to test for statistical differences between asymptomatic deaths and SUIDs on key infant, maternal and other risk factors of SUIDs. Results: Eight hundred and nine verbal autopsies were conducted with families of decedent infants younger than six months of age. A total of 92.6% (749/809) had presented with symptoms prior to death, whereas 7.4% (60/809) died without preceding symptoms or obvious cause of death. Of these, 16/60 were compatible with accidental suffocation deaths, and 54/60 appeared to be sudden infant death syndrome. SUID deaths were concentrated in infants younger than two months of age with peak age of one to two months. Age at death was the only significant factor in multivariate analysis. Infants aged between one and two months had 2.84 increased odds of suspected SUIDs compared to infants in the first month of life (aOR = 2.84, 95% CI: 1.31, 6.16). Conclusions: Our findings suggest SUID could be accounting for a significant proportion of infant deaths in Zambia, but this cause of infant mortality is going unrecognized. Public health interventions in Zambia, and Africa more broadly, are likely overlooking SUIDs as an important cause of infant mortality. READ ALL READ LESS Keywords sudden unexpected infant death (SUID), sudden infant death syndrome (SIDS), verbal autopsy Corresponding Author(s) Godwin K. Osei-Poku ( [email protected] ) Close Corresponding author: Godwin K. Osei-Poku Competing interests: No competing interests were disclosed. Grant information: The ZPRIME study was supported by the Gates Foundation [OPP1163027]. The funder had no role in the development of this manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2023 Osei-Poku GK et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Osei-Poku GK, Mwananyanda L, Elliott PA et al. The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.12688/gatesopenres.14303.1 ) First published: 15 Feb 2023, 7 :46 ( https://doi.org/10.12688/gatesopenres.14303.1 ) Latest published: 15 Feb 2023, 7 :46 ( https://doi.org/10.12688/gatesopenres.14303.1 ) Introduction Child mortality rates in sub-Saharan Africa are particularly high. In 2019, more than half of the global under-five mortalities occurred in sub-Saharan Africa 1 . Nearly one child in 13 dies before reaching the age of five in sub-Saharan Africa 1 . The risk of dying before the age of five is almost 20 times higher in sub-Saharan Africa compared to countries in other WHO regions 1 . Sadly, most of these deaths are preventable. Zambia like other countries in Africa is similarly burdened by high rates of child mortality. In 2018, the under-five mortality rate in Zambia was estimated to be 61 per 1000 live births, nearly two times the global under-five mortality rate 2 . A total of 69% of the country’s child mortality occurred in children under one year of age 2 . The infant mortality rate was almost four times the global infant mortality rate (42 vs 11 per 1000 live births) 2 . While infectious diseases such as pneumonia, and malaria are recognized as leading causes of child mortality in Zambia, the contribution of sleep related conditions such as sudden unexpected infant death (SUID) to child mortality is less well documented. SUID includes sudden infant death syndrome (SIDS) and accidental suffocation and strangulation in bed (ASSB). SIDS is currently one of the leading causes of preventable infant mortality in wealthier countries and is defined as the sudden unexpected death of an infant less than one year of age where cause of death remains unexplained even after an autopsy and death scene investigation, and where the event occurred after a sleep episode 3 . National infant mortality statistics in Zambia rarely include data on SIDS or SUID. The prevailing view in Zambia and most African countries is that SIDS is not an important cause of infant mortality. This need not be the case since SIDS has consistently been identified as a leading cause of infant mortality wherever it has been studied. For instance, even in South Africa, mortality due to SIDS is particularly high compared to high-income countries such as the U.S., Australia and the U.K., with estimated rates of between 3.01 to 3.70 per 1000 live births 4 , 5 . South Africa is an outlier on the African continent with relatively better socio-economic conditions compared to other countries in Africa including Zambia. SIDS rates in Zambia are likely to be higher since the socio-economic risk factors for SIDS, young maternal age, poor maternal education and low income, are prevalent in Zambia. Zambia has made tremendous progress in reducing its infant mortality rates from 107 in 1992 to 42 in 2018 2 . To sustain this progress, the contribution of less well documented causes of infant mortality such as SIDS/SUIDs need to be investigated. The objective of this study was to estimate the burden of SIDS/SUIDs in a representative African country such as Zambia using free text narratives from a modified verbal autopsy tool. To guide this study, our research question was ‘What proportion of decedent infants died suddenly and unexpectedly during sleep in Lusaka, Zambia’? Methods Study setting Data collection for this study occurred in Lusaka, the capital city of Zambia. Lusaka has a predominantly urban population (84%) of 1.7 million. It is surrounded by unofficial peri-urban compounds/towns where most of the city’s poor reside bringing the total population of Lusaka to approximately 2.4 million individuals, or roughly 1/8th of the total population of Zambia itself. A dozen primary health facilities provide health care to the population with the University Teaching Hospital (UTH) serving as the main referral facility 6 . UTH is the largest hospital in Zambia with 1655 beds and serves as the main training institution for doctors, nurses and other clinical officers 7 , 8 . Data was collected as part of the Zambian Pertussis/RSV Infant Mortality Estimation (ZPRIME) project. The ZPRIME project, a Bill and Melinda Gates sponsored project, was a post-mortem prevalence study designed to identify the proportion of deaths aged four days to less than six months that were attributable to Bordetella pertussis and respiratory syncytial virus (RSV) in Lusaka, Zambia 9 . ZPRIME enrolled deceased subjects aged four days to less than six months who died in UTH or in the community and presented at the UTH morgue 9 . Ethical approval for ZPRIME was provided by the institutional review board at the University of Zambia (Ref. No. 2017-May-053, Approval date: 07/21/2017) and Boston University Medical Center (IRB Number: H-36469, Approval date: 06/06/2017). Study population For this present study, we focus on infant deaths that occurred in the community. Verbal autopsies (VA) were conducted with families and/or caregivers of 809 decedents aged four days to six months who presented at the University Teaching Hospital Morgue (UTH) as BIDs (Brought in dead). An infant was eligible for a verbal autopsy if the infant had died: before arrival at a health facility or during receipt of outpatient care at a health facility 6 or during referral to a higher level of care without admission at a health facility 6 Data collection Data collectors trained in grief counselling conducted verbal autopsies with families of eligible infants using an abbreviated verbal autopsy tool with close ended questions about the symptoms immediately preceding the infant’s death. An open response narrative question encouraged respondents to describe, in as much detail as possible, the circumstances leading to the infant’s death. The open response field was prompted by the question: “Now, using your own words, please describe the events leading up to your child’s death. Please take as much time as you need and be as detailed as you can.” 6 The VA tool modified for use in this study was the IHME-modified version of the verbal autopsy tool created and validated by the Population Health Metrics Research Consortium (PHMRC) ( PHMRC: Shortened verbal autopsy instrument ) 9 , 10 . Data collectors were notified if an eligible BID decedent presented at the UTH Morgue. Informed consent was sought from respondents and those who gave consent were interviewed. In addition to the VA tool, demographic information such as maternal and paternal education, occupation, and household census was collected. We also collected data on the closest clinic where the infant usually received care as a proxy for the location of the residence. In total, 809 verbal autopsies (VAs) were conducted between August 2017 and August 2020 as part of ZPRIME. Please see the underlying data 11 . Coding and statistical analysis To estimate the proportion of infants who died suddenly and unexpectedly, we focused our analysis on the open response narrative in the VA tool. We did this in two steps. Firstly, we qualitatively coded the free text narratives in Microsoft Excel 2021 (RRID:SCR_016137) and classified the responses into symptomatic and asymptomatic (suspected SUIDs) deaths based on reports of danger signs of ill health within the week immediately preceding death. Any narrative with reports of fever, difficulty breathing, cough, hospital admissions or other symptoms within the week immediately preceding death were classified as symptomatic deaths and assigned a score of 0. Any narrative that described an infant who was otherwise healthy with no antecedent illness prior to death or reported to have no symptoms or hospital admissions in the week prior to death and reported to be found dead in bed after a sleep episode were classified as asymptomatic deaths or suspected SUID and assigned a score of 1. We further classified the asymptomatic deaths into unexplained (possible SIDS) and explained deaths (possible suffocation/smothering (ASSB)). A SUID death was explained if the narrative suggested suffocation or smothering as the likely cause of death based on: finding of blood or vomitus/milk from the nose/mouth after bed sharing with parents with or without a compressed abdomen descriptions of mothers or fathers rolling on the baby after a night of drinking or finding of baby in a prone position with a cloth in the mouth or muffled by blankets In the second step, the coded data was then uploaded into SAS software v9.4 (SAS Institute Inc., Cary, NC, USA) (RRID:SCR_008567) and quantitatively analyzed (The analysis can also be performed using R Statistical Software (v4.2.1; R Core Team 2022) (RRID:SCR_001905)). We calculated frequencies and percentages for dichotomous and categorical data and estimated mean and standard deviation for continuous data. We used logistic regression for univariate and multivariate analysis to test statistical differences between symptomatic and asymptomatic deaths on key infant, maternal and other demographic risk factors of SUIDs. All statistical analysis were conducted at a 0.05 significance level. We calculated odds ratios (OR), and 95% confidence intervals (95% CI) to show statistical differences in univariate and multivariate analysis. Included are sample narratives for SUID cases to show our coding decisions. Results Population characteristics There were slightly more females than males in the sample (44% vs 43.8%). Most of the BIDs occurred in infants younger than two months old with a mean age of 2.3 months (SD = 1.7 months). The majority had normal birth weight (mean = 2,629 kg, std = 643 kg) and lived in households with siblings (79.4%, 642/809). The mothers of these infants were mostly unemployed (78.4%, 634/809) and seldom had education beyond secondary school. Only 2.9% (24/809) of mothers reported completing post-secondary school. Educational attainment for fathers was also low. A total of 6.1% (49/809) of fathers had some or completed post-secondary school. However, the majority of fathers were reported to be self-employed or salaried employees (79.4%, 642/809). Almost all the infants lived with their mother at the time of death (99.4%). Nearly a quarter of infants did not live with both parents with fathers present in 77.1% (624/809) of households. Household sizes tended to be larger with a mean of 5.6 persons and standard deviation 2.4 persons. The majority of these households had greater than four children in the household (34.2%, 277/809). Demographic characteristics of these BIDs are presented in Table 1 . Table 1. Population characteristics of brought in dead (BID) deaths. Characteristic N = 809 Infant characteristics Age at death in months, mean (sd.) 2.3 (1.7) Birth weight in grams, mean (sd.) 2,629 (643) Birth weight in grams, n (%) <1500 10 (1.2) 1500 – =2500 92 (11.4) Unknown 671 (82.9) Sex, n (%) Male 354 (43.8) Female 356 (44.0) Unknown 99 (12.2) Maternal characteristics Mother’s education, n (%) None 33 (4.1) Some primary/completed primary 285 (35.2) Some secondary/completed secondary 444 (54.9) Some postsecondary/completed postsecondary 24 (2.9) Unknown 23 (2.8) Mother’s occupation, n (%) Salaried or self-employed 163 (20.2) Unemployed 634 (78.4) Unknown 12 (1.5) Paternal characteristics Father’s education, n (%) None 15 (1.9) Some primary/completed primary 149 (18.4) Some secondary/completed secondary 463 (57.2) Some postsecondary/completed postsecondary 49 (6.1) Unknown 133 (16.4) Father’s occupation, n (%) Salaried/self-employed 642 (79.4) Unemployed 110 (13.6) Unknown 57 (7.1) Domestic composition Household size, mean 5.6 (2.4) Number of children in household, n (%) 1 163 (20.2) 2 202 (24.9) 3 163 (20.2) ≥4 277 (34.2) Father lives in home, n (%) 624 (77.1) Mother lives in home, n (%) 804 (99.4) Both parents live together, n (%) 623 (77.0) Has siblings, n (%) 642 (79.4) Cause of death Most of the BID infants, 92.6% (749/809), presented with symptoms prior to death with 38.2% (309/809) presenting with respiratory symptoms and 54.4% (440/809) with non-respiratory or other symptoms. The proportions of each cause of death identified in the narratives are shown in Table 2 . However, 7.4% (60/809) presented with no preceding symptoms and were classified as suspected SUIDs. Of these, 27% (16/60) had narratives that were suggestive of accidental suffocation or strangulation in bed (ASSB) and 73% (44/60) were classified as suspected SIDS. Table 3 and Table 4 contain a verbatim list of representative narratives for possible SIDS and ASSB to show the coding decisions made in distinguishing between these two causes of SUIDs. A full list of narratives has been included as supplementary tables. Table 2. Narratives assigned to cause of death. Cause of death, n (%) N = 809 Asymptomatic deaths (suspected SUID) 60 (7.4) Unexplained (possible SIDS) 44 (5.4) Explained (possible suffocation/ smothering (ASSB)) 16 (2.0) Symptomatic deaths 749 (92.6) Respiratory causes 309 (38.2) Non-respiratory or other causes 440 (54.4) Abbreviations: SUID = sudden unexpected infant death; SIDS = sudden infant death syndrome; ASSB = accidental suffocation and strangulation in bed Table 3. Representative narratives documenting asymptomatic deaths (suspected sudden infant death syndrome (SIDS)). Narrative Age at death (months) 1 Informant Father: The infant was born at Bauleni clinic. The baby cried after birth. The baby was fine yesterday nothing appeared to be wrong even as we went to sleep. In the early hours of this morning when we wake up to check on the baby, we discovered yellow fluids coming out from the nose. The baby was NOT breathing and was already dead. We then brought the body to UTH BID section for death certification. 0.26 2 Informant the grandfather, according to the parents of the baby this baby was not ill, the day before it happened the baby was very active and feeding well. The baby slept after feeding, the next time the mother went to check on the baby it was not breathing they called me and narrated what happened we went to the police, and we were asked to do a postmortem to ascertain the cause of death, but this is just a baby let it rest in peace. 0.33 3 According to the grandmother yesterday the baby was fine, active, and feeding well. Just in the night the mother woke up to feed the baby afterwards it slept, next time the mother went to check on the baby, she observed some blood and froth coming out of the nostrils and the mouth tried to shake the baby it was already dead. That is how we went to the police. 2.60 4 We were at the funeral gathering for one of our relatives where we had to spend nights. The child has been well all along at the funeral and didn’t show any signs of illness, Fever or cough, and the child was breast feeding very well. I last breast fed the baby at about 05:00 early this morning and after breast feeding the baby, l put him on the mat to sleep while l continued with food preparations for the people at the funeral gathering. After about one hour, l decided to check on the baby where l had left him sleeping and found the baby dead. There was no sign of injury at all. 2.73 5 The child was well yesterday even at bedtime. We went to bed together since we use the same bed me (father), the mother and the child. Without any noticed illness, we noticed the child dead on the bed at about passed midnight. There was no sign of injury noticed either. It was just sudden death without any illness. 4.7 6 The aunt stated that, “the mother left the baby sleeping in bed. Healthy baby. She went to attend to some household errands. When she went to the bedroom, she observed the baby was not breathing. Took the baby to the clinic where the baby was confirmed to be dead.” 5.91 Table 4. Representative narratives documenting suspected accidental suffocation and strangulation in bed (ASSB). Obs. Narrative Age at death (months) 1 ……The baby was very well all along. Yesterday Thursday…, around 15:00 hours, the mother breastfed the baby there after the baby slept and she put her on the bed. The mother went to continue with her household errands. After 1 hour, she went to check on the baby only to note that the baby was lying in prone position muffled by the blanket. She turned the baby in supine position. She suddenly noticed that thick mucus mixed with blood were coming from the Nostrils. The baby was not breathing. She summoned the husband who tried to arouse the baby but to no avail. The couple rushed the baby to the Clinic, unfortunately could not make it. The Doctor informed the couple that the baby was brought in already dead. 1.02 2 The child was not known to be sick, was well, breast feeding well. We went to bed in the evening with the child well. We use the same bed the three of us (mother, father, and baby). When we woke up at night to check on the baby and have the baby breast fed by the mother, we noticed the child bleeding from the nose and mouth. We don’t know for how long the child had been bleeding. She was born at 8 months of pregnancy and did not cry soon after birth. The child died at home before we could start off to the clinic. 1.25 3 Baby was fine the past days and also before we went to bed. At night she cried but thought it was normal cry. Around 04 in the morning noticed baby had cloth in the mouth and we went to report to the Police. 5.19 4 What l (grandmother) can say is that the child was not sick as such, it was the mother who was drunk who forgot that she was with a baby on the same bed and rolled over the baby. Yesterday, in celebration of Christmas, the mother decided to go for a drink with friends, but l (grandmother) got the baby from her. But when she came back from drinking, she got the baby in order to breast feed him. Then she went to her home since it was late in the evenings. Knowing that she was drunk last evening and that she has a baby, l decided to check on her in the morning. I found her crying with the baby on the bed. The child was dead with vomitus and blood from the mouth and nose. The abdomen looked compressed. And from that l new that she rolled over the baby at night. 5.72 Population characteristics of asymptomatic (suspected SUID) and symptomatic cases More than half, 51.7% (31/60) of the suspected SUID cases were female with a mean age of 2.1 months (SD = 1.6 months). The majority lived in households with a sibling, 80% (48/60). Educational attainment of SUID mothers was seldom beyond secondary school. Only 1.7% (1/60) were reported to have completed post-secondary school. Most of these mothers were also unemployed, 86.7% (52/60), and lived in larger households with a mean household size of 6.1 persons with more than four children in the household (40%, 24/60). All the suspected SUID cases lived with their mother in the household at the time of death with fathers present in 78.3% (47/60) of these households. Nearly 22% (13/60) of mothers were single mothers. Symptomatic cases were likely to be aged 2.3 months (SD = 1.7months), male (44.6%, 334/749), and with normal birthweight (mean = 2,646 grams, std = 642 grams). Mothers of symptomatic cases were also likely to have had some or completed secondary education (55.3%, 414/809), and were unemployed (77.7%, 582/749). Household sizes of symptomatic cases tended to be smaller (mean = 5.6, std = 2.3), and almost always included the mother (99%, 744/749) or father (77%, 577/809). Demographic characteristics of asymptomatic and symptomatic cases are shown in Table 5 . Table 5. Population characteristics of asymptomatic and symptomatic BIDs in Lusaka, Zambia. Characteristic Asymptomatic or suspected SUID N = 60 Symptomatic N = 749 Infant characteristics Age at death in months, mean (sd.) 2.1 (1.6) 2.3 (1.7) Birth weight in grams, mean (sd.) 2,461 (647) 2,646 (642) Birth weight in grams <1500 1 (1.7) 9 (1.2) 1500 – =2500 7 (11.7) 85 (11.3) Unknown 47 (78.3) 624 (83.3) Sex, n (%) Male 20 (33.3) 334 (44.6) Female 31 (51.7) 325 (43.4) Unknown 9 (15.0) 99 (12.0) Has siblings, n (%) 48 (80.0) 594 (79.3) Maternal characteristics Education, n (%) None 1 (1.7) 32 (4.3) Some or completed primary 24 (40.0) 261 (34.9) Some or completed secondary 30 (50.0) 414 (55.3) Some or completed postsecondary 1 (1.7) 23 (3.1) Unknown 4 (6.7) 19 (2.5) Occupation, n (%) Salaried or self-employed 6 (10.0) 157 (21.0) Unemployed 52 (86.7) 582 (77.7) Unknown 2 (3.3) 10 (1.3) Domestic composition Household size, mean (sd.) 6.1 (3.4) 5.6 (2.3) Number of children in household 1 11 (18.3) 152 (20.3) 2 13 (21.7) 189 (25.2) 3 11 (18.3) 152 (20.3) ≥ 4 24 (40) 253 (33.8) Father lives in home, n (%) 47 (78.3) 577 (77.0) Mother lives in home, n (%) 60 (100.0) 744 (99.3) Both parents live together, n (%) 47 (78.3) 576 (76.9) Single mothers, n (%) 13 (21.7) 166 (22.2) Abbreviations: BID = brought in dead; SUID = sudden unexpected infant death Suspected SUID cases Peak age of SUID. Figure 1 summarizes the distribution of suspected SUID cases by age, time of death, month, and season. The mean age of suspected SUID cases was 2.1 months. Overall, deaths were concentrated in infants younger than two months with a peak age of 1–2 months. More importantly, we found that a quarter, 25% (15/60) of SUID deaths occurred in infants within the first month of life although it has generally been considered that SUIDs are rare in the neonatal period. Figure 1. Distribution of suspected sudden unexpected infant death (SUID) cases by age, time of day, month, and season of death. A . Age distribution of suspected SUID cases. B . Distribution of suspected SUID cases by time of day. C . Monthly distribution of suspected SUID cases. D . Seasonal* distribution of suspected SUID cases. * Hot and Rainy: Nov, Dec, Jan, Feb, Mar, Apr; Cold and Dry: May, Jun, Jul, Aug; Hot and Dry: Sept, Oct. Time of day of SUID. All the suspected SUID cases occurred during sleep with peak incidence in the night, 37% (22/60), and early morning, 38% (23/60). Very few occurred in the evening, 15% (9/60) with even fewer in the afternoon, 10% (6/60). Month and season of SUID. The majority of the suspected SUID cases occurred in the cold months of May, June, July, and August with peak incidence in August, 15% (9/60). By season, this corresponds to the cold and dry seasons of Lusaka. Half of the suspected SUID deaths occurred in the cold and dry season with almost 40% (24/60) occurring during the rainy season. Fewer deaths occurred in the hot and dry season of September and October. Univariate and multivariate analysis of factors associated with SUID. In univariate analysis, age of death in months and time of death were found to be statistically associated with an asymptomatic presentation. Compared to infants aged less than one month, infants aged between one and two months had 2.6 times increased odds of suspected SUIDs, and this risk was statistically significant (OR: 2.6, 95% CI: 1.31–5.27). The odds of SUID occurring in the night was also 2.64 times higher compared to the afternoon (OR: 2.64, 95% CI: 1.04–6.63). There was an increased odds of SUIDs for female infants, mothers with low education or no employment, larger families with four or more children and the cold/dry season. However, these were not significant with 95% CI which contained the null value as shown in Table 6 . In multivariate analysis, infants aged between one and two months had 2.84 increased odds of suspected SUIDs compared to infants in the first month of life (AOR = 2.84, 95% CI: 1.31, 6.16). Unemployed mothers also had 2.49 increased odds of suspected SUID compared to salaried or self-employed mothers (AOR: 2.49, 95% CI: 1.02, 6.08) Table 6. Unadjusted and adjusted odds ratios (95% confidence interval) of factors associated with sudden unexplained infant deaths (SUIDs). Characteristic Unadjusted OR (95% CI) Adjusted OR † (95% CI) Infant characteristics Age in months <1 1.00 1.00 1–2 2.63 (1.31, 5.27) * 2.93 (1.36, 6.33) * 2–3 1.23 (0.52, 2.89) 1.29 (0.52, 3.21) 3–4 0.68 (0.22, 2.11) 0.82 (0.25, 2.67) 4–5 1.45 (0.57, 3.69) 1.76 (0.66, 4.70) 5–6 0.85 (0.28, 2.64) 0.66 (0.18, 2.46) Sex/gender Male 1.00 1.00 Female 1.59 (0.89, 2.85) 1.51 (0.80, 2.83) Unknown 1.67 (0.74, 3.79) 2.03 (0.81, 5.08) Has siblings No 1.00 1.00 Yes 1.12 (0.57, 2.22) 1.00 (0.45, 2.19) Maternal characteristics Education Secondary/postsecondary 1.00 1.00 Primary/never attended school 1.20 (0.70, 2.08) 1.02 (0.57, 1.82) Occupation Employed 1.00 1.00 Unemployed 2.34 (0.99, 5.54) 2.49 (1.02, 6.08) * Domestic composition Number of children 1–3 1.00 1.00 ≥4 1.34 (0.78, 2.30) 1.62 (0.86, 3.07) Father lives in household No 1.00 1.00 Yes 1.07 (0.56, 2.02) 1.33 (0.65, 2.71) Time of day, and season Time of day Afternoon 1.00 1.00 Night 2.64 (1.04, 6.63) * 2.70 (0.97, 7.51) Morning 1.92 (0.77, 4.83) 2.06 (0.75, 5.68) Evening 2.03 (0.70, 5.87) 2.65 (0.84, 8.37) Season Hot and rainy 1.00 1.00 Cold and dry 1.60 (0.91, 2.79) 1.67 (0.90, 3.12) Hot and dry 0.91 (0.36, 2.29) 1.08 (0.41, 2.83) * Significant at 0.05; † Model was adjusted for infant age, sex/gender, presence of sibling, maternal education and occupation, household composition, presence of father in household, time of day and season of infant death Discussion Our main finding from this analysis is that apparent sudden unexpected infant death accounts for 7.4% of all BIDS in Lusaka, Zambia of which 5.4% were apparent SIDS deaths and 2% were likely due to accidental suffocation. While there is a dearth of data describing the burden of SUID across most of Africa 12 , our findings are similar to estimates of SUID from South Africa, where SIDS/SUID deaths accounted for between 6.2% to 8.7% of all infant deaths in medico legal laboratories 13 , 14 . These findings suggests that SIDS/SUIDs are an important cause of infant death in Zambia; however, it is going unreported. Our analysis revealed three noteworthy findings. Firstly, the peak age of SUID in our analysis was one to two months. Age at death was the only factor that was significant in multivariate analysis with infants aged one to two months at significantly higher odds of SUID compared to infants in the first year of life. Our findings are different from estimates in the U.S. and other high-income countries where the peak age of SUID has been reported as two to four months 15 . However, our findings are similar to findings by Heathfield et al . in South Africa where they reported a peak age of one to two months in SUID cases 16 . In addition, we found a quarter of our SUID cases occurred in the first month of life. The triple risk model suggest that SIDS occurs in a vulnerable infant at a critical period of development in the presence of an exogenous stressor 17 . More than half of the SUID cases occurred in families residing in the densely populated peri-urban townships surrounding Lusaka. We hypothesize that these infants are exposed to exogenous stressors at a much earlier age such as infections compared to infants in high-income countries. Moreover, Heathfield et al . hypothesized that infants in overcrowded settlements experience a faster decline in maternal IgG than infants in high-income countries, making them vulnerable to sudden death at an earlier age 16 . Secondly, more than half of our SUID cases were female (51.7% vs 33.3%). This finding is different from what has been reported elsewhere. Most studies report higher rates of SUIDs in males than females 18 . Although not statistically significant, we found females to be at increased odds of SUID compared to males. However, this finding should be interpreted with caution since 12.2% of our cases were missing a gender assignment. We also found the same socio-economic risk factors that have been reported previously including higher SUID cases among unemployed mothers, mothers with lower educational attainment, larger families with more than four children, during the cold season, and in the early morning hours when infants are sleeping 19 – 21 , confirming the presence of some of the risk factors of SIDS in these communities. Policy implications This is the first study to report on the prevalence of SUIDs in Zambia and the first study to describe the burden of SUID in Africa outside of South Africa. Our findings suggest SUID could be accounting for a significant proportion of infant deaths, but this cause of infant mortality is going unrecognized. The risk factors of SUIDs are modifiable with simple interventions. This study shows that there is a large enough burden of disease to merit the implementation of specific interventions or programs targeted at reducing sudden infant death in this population. A sudden infant death can be stressful to the family especially young mothers. Some of the narratives were heart breaking. A common theme in these narratives was a need to understand what caused the death of their child. The response to a SIDS/SUID death has been one of blame and sometimes mothers have been criminalized on suspicion that they intentionally caused the death of their child. We want to shed a light on this important cause of infant mortality and make a case for increased research as well as the implementation of targeted campaigns and programs on SIDS in Zambia. Limitations A key limitation of this study is that we relied on VA narratives to assign a cause of death. We did not conduct a death scene investigation or formal autopsy. For that reason, we consider these to be ‘presumptive’ SUID cases since they lack the gold standard evaluation. With that said, the apparent burden revealed in our analysis is very similar to what has been described in South Africa using that gold standard evaluation and is also consistent with what was described in high-income settings prior to the introduction of SIDS interventions. While there could be some misclassification, the most parsimonious explanation is that most of these are indeed examples of SUID. Another limitation is that we did not collect any information on other key risk factors of SIDS such as maternal smoking or alcohol use and infant sleep practices from the mothers of the deceased infants. However, in a separate analysis recently accepted for publication, we report a high prevalence of SUID risk factors and behaviors from mothers of infants in the same communities as in the current cohort. These included low rates of sleeping in a prone position as recommended, high frequency of bed sharing, bundling of infants with duvets and blankets, and exposure to indoor air pollution and alcohol use 22 . Conclusions/future research Future studies should prospectively characterize SUID deaths with complete diagnostic autopsy and death scene investigation. This is a preliminary study to show if there is enough burden of disease to encourage future research. Consent Written informed consent for publication of the participants’ details was obtained from the parents, guardian or relative of the participant. Data availability Underlying data Figshare: Underlying data for ‘The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies’. https://doi.org/10.6084/m9.figshare.21746375 11 This project contains the following underlying data: Data file 1: Supplementary Tables_SIDS in Zambia_VA.pdf Data file 2: VA_Figshare.xlsx Data file 3: verbal_autopsy_figshare.sas7bdat Data file 4: SASCodeVA_figshare.sas Data file 5: SASCodeVA_figshare.pdf (pdf of SAS Code) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) Acknowledgements We wish to acknowledge the contribution of the data collection team in Zambia who showed a lot of courage in collecting these heartbreaking narratives. We also thank the families of the deceased infants for their willingness to share their stories with us. Without them this work would not have been possible. 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Blair PS, Sidebotham P, Berry PJ, et al. : Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK. Lancet. 2006; 367 (9507): 314–319. PubMed Abstract | Publisher Full Text 19. Daltveit AK, Irgens LM, Oyen N, et al. : Sociodemographic risk factors for sudden infant death syndrome: associations with other risk factors. The Nordic Epidemiological SIDS Study. Acta Paediatr. 1998; 87 (3): 284–290. PubMed Abstract | Publisher Full Text 20. Mitchell EA, Clements M, Williams SM, et al. : Seasonal differences in risk factors for sudden infant death syndrome. The New Zealand Cot Death Study Group. Acta Paediatr. 1999; 88 (3): 253–258. PubMed Abstract | Publisher Full Text 21. Blair PS, Platt MW, Smith IJ, et al. : Sudden Infant Death Syndrome and the time of death: factors associated with night-time and day-time deaths. Int J Epidemiol. 2006; 35 (6): 1563–1569. PubMed Abstract | Publisher Full Text 22. Osei-Poku GK, Mwananyanda L, Elliot PA, et al. : Assessing infant sleep practices and other risk factors of SIDS in Zambia: a cross-sectional survey of mothers in Lusaka, Zambia: a cross-sectional survey of mothers in Lusaka, Zambia. BMC Pediatr. 2022; 22 (1): 660. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 15 Feb 2023 ADD YOUR COMMENT Comment Author details Author details 1 Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA 2 Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, 02118, USA 3 Department of Pediatrics, School of Medicine, University of Zambia, Lusaka, Lusaka Province, 00260, Zambia Godwin K. Osei-Poku Roles: Conceptualization, Formal Analysis, Writing – Original Draft Preparation, Writing – Review & Editing Lawrence Mwananyanda Roles: Investigation, Project Administration, Writing – Review & Editing Patricia A. Elliott Roles: Methodology, Supervision, Validation, Writing – Review & Editing William B. MacLeod Roles: Data Curation, Formal Analysis, Methodology, Writing – Review & Editing Somwe Wa Somwe Roles: Methodology, Supervision, Validation, Writing – Review & Editing Rachel C. Pieciak Roles: Project Administration, Writing – Review & Editing Christopher J. Gill Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The ZPRIME study was supported by the Gates Foundation [OPP1163027]. The funder had no role in the development of this manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 15 Feb 2023, 7:46 https://doi.org/10.12688/gatesopenres.14303.1 Copyright © 2023 Osei-Poku GK et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads Gates Open Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Osei-Poku GK, Mwananyanda L, Elliott PA et al. The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.12688/gatesopenres.14303.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 15 Feb 2023 Views 0 Cite How to cite this report: Garstang J. Reviewer Report For: The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.21956/gatesopenres.15614.r33835 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-46/v1#referee-response-33835 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 02 Aug 2023 Joanna Garstang , University of Birmingham, Birmingham, England, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/gatesopenres.15614.r33835 This is a really interesting study and addresses a new area – SIDS in sub-Saharan Africa, of which very little is known. The major limitation is that the diagnosis of SIDS relies on a full post-mortem examination, which of course ... Continue reading READ ALL This is a really interesting study and addresses a new area – SIDS in sub-Saharan Africa, of which very little is known. The major limitation is that the diagnosis of SIDS relies on a full post-mortem examination, which of course has not taken place, verbal autopsy is no substitute. Around 1/3 of unexpected infant deaths have a cause determined at post-mortem, it is likely that a similar proportion of deaths classified as SIDS in this study were due to other causes. The coding used to classify deaths as SIDS or accidental suffocation will introduce further inaccuracies. Minor symptoms of non-specific viral illness are commonly reported in infants who die of SIDS, particularly coryza, reduced feeding and mild cough. By excluding any infant with minor symptoms the number of SIDS cases will be underestimated as these cases will be misclassified as due to disease. The finding of blood or vomitus/milk from the nose/mouth of a baby is very common in all sudden unexpected infant death, including SIDS. It does not support a diagnosis of accidental suffocation. Using this to classify deaths as accidental suffocation will lead to overestimation of deaths from suffocation. By this rationale case 2 in table 4 should not be classified as accidental suffocation. The results are therefore no more than an educated guess – all they can show is that SIDS likely happens in Zambia but the frequency of SIDS remains unclear. Therefore the calculated associations will have a high degree of error. However, it is still an important study showing that further research in SIDS in sub-Saharan Africa is vital, and safe-sleep campaigns to prevent SIDS have potential to reduce infant mortality. Minor Points: The numbers in the abstract don’t add up correctly – 16 accidental suffocation and 54 SIDS = 70 not 60. The most recent SIDS international consensus on SIDS diagnosis is the 2004 San Diego definition (Krous et al) Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: SIDS, Sudden unexpected death in infancy and childhood, Sudden Unexplained Death in Childhood, Child mortality review, child protection I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Garstang J. Reviewer Report For: The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.21956/gatesopenres.15614.r33835 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-46/v1#referee-response-33835 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Du Toit-Prinsloo L. Reviewer Report For: The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.21956/gatesopenres.15614.r32923 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-46/v1#referee-response-32923 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Feb 2023 Lorraine Du Toit-Prinsloo , School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Sydney, NSW, Australia; New South Wales Health Pathology, Forensic and Analytical Science Service, Newcastle, NSW, Australia Approved with Reservations VIEWS 0 https://doi.org/10.21956/gatesopenres.15614.r32923 Thank you for the opportunity to review this article. I have the following comments for consideration. I am of the opinion that it would be very important to add a paragraph in the introduction where the ... Continue reading READ ALL Thank you for the opportunity to review this article. I have the following comments for consideration. I am of the opinion that it would be very important to add a paragraph in the introduction where the concept of a verbal autopsy is discussed, particularly in the infant population, with up to date references included. The limitations of a verbal autopsy should be addressed. It would be important to described these limitations - specifically pertaining to those cases classified as SIDS. A background on why post-mortems are not done in the country would also be valuable (cultural reasons, infrastructure etc) It would be important to clearly and consistently use the definitions correctly. SUDI or SUID is the sudden and unexpected death in an infant, the larger umbrella term that is used. Upon completion of the investigation, a portion would have an underlying cause of death (explained SUID cases - these could include natural and unnatural deaths) vs. a proportion of deaths where the cause of death is not explained (unascertained deaths - possible SIDS). If the definitions are appropriately applied the cohort should include / can be divided as follows: SUID explained cause of death - natural causes - 749 SUID explained cause of death - unnatural causes (possible asphyxia - see comment below) - 16 SUID unexplained (possible SIDS) - 44 I also have some concern pertaining to the possible suffocation deaths. An unsafe sleeping environment is well reported in a large cohort of SUID deaths, and particularly relating to the comment pertaining to blood/vomitus from the nose/mouth after bed sharing - I would not necessarily agree that the finding in itself would be adequate to indicate an asphyxial cause of death. Consideration could be to change the cohort labelled SIDS as cause of death - to no apparent natural cause of death identified (these infants will resort under the umbrella term Sudden Unexpected Deaths in Infants). The entire cohort of deaths commenced as sudden unexpected infant deaths - not just the ones where no cause of death was apparent. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Sudden Infant Death I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Du Toit-Prinsloo L. Reviewer Report For: The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.21956/gatesopenres.15614.r32923 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-46/v1#referee-response-32923 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 15 Feb 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 15 Feb 23 read read Lorraine Du Toit-Prinsloo , University of Newcastle, Sydney, Australia; Forensic and Analytical Science Service, Newcastle, Australia Joanna Garstang , University of Birmingham, Birmingham, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Garstang J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 02 Aug 2023 | for Version 1 Joanna Garstang , University of Birmingham, Birmingham, England, UK 0 Views copyright © 2023 Garstang J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a really interesting study and addresses a new area – SIDS in sub-Saharan Africa, of which very little is known. The major limitation is that the diagnosis of SIDS relies on a full post-mortem examination, which of course has not taken place, verbal autopsy is no substitute. Around 1/3 of unexpected infant deaths have a cause determined at post-mortem, it is likely that a similar proportion of deaths classified as SIDS in this study were due to other causes. The coding used to classify deaths as SIDS or accidental suffocation will introduce further inaccuracies. Minor symptoms of non-specific viral illness are commonly reported in infants who die of SIDS, particularly coryza, reduced feeding and mild cough. By excluding any infant with minor symptoms the number of SIDS cases will be underestimated as these cases will be misclassified as due to disease. The finding of blood or vomitus/milk from the nose/mouth of a baby is very common in all sudden unexpected infant death, including SIDS. It does not support a diagnosis of accidental suffocation. Using this to classify deaths as accidental suffocation will lead to overestimation of deaths from suffocation. By this rationale case 2 in table 4 should not be classified as accidental suffocation. The results are therefore no more than an educated guess – all they can show is that SIDS likely happens in Zambia but the frequency of SIDS remains unclear. Therefore the calculated associations will have a high degree of error. However, it is still an important study showing that further research in SIDS in sub-Saharan Africa is vital, and safe-sleep campaigns to prevent SIDS have potential to reduce infant mortality. Minor Points: The numbers in the abstract don’t add up correctly – 16 accidental suffocation and 54 SIDS = 70 not 60. The most recent SIDS international consensus on SIDS diagnosis is the 2004 San Diego definition (Krous et al) Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise SIDS, Sudden unexpected death in infancy and childhood, Sudden Unexplained Death in Childhood, Child mortality review, child protection I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Garstang J. Peer Review Report For: The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.21956/gatesopenres.15614.r33835) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-46/v1#referee-response-33835 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Du Toit-Prinsloo L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Feb 2023 | for Version 1 Lorraine Du Toit-Prinsloo , School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Sydney, NSW, Australia; New South Wales Health Pathology, Forensic and Analytical Science Service, Newcastle, NSW, Australia 0 Views copyright © 2023 Du Toit-Prinsloo L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review this article. I have the following comments for consideration. I am of the opinion that it would be very important to add a paragraph in the introduction where the concept of a verbal autopsy is discussed, particularly in the infant population, with up to date references included. The limitations of a verbal autopsy should be addressed. It would be important to described these limitations - specifically pertaining to those cases classified as SIDS. A background on why post-mortems are not done in the country would also be valuable (cultural reasons, infrastructure etc) It would be important to clearly and consistently use the definitions correctly. SUDI or SUID is the sudden and unexpected death in an infant, the larger umbrella term that is used. Upon completion of the investigation, a portion would have an underlying cause of death (explained SUID cases - these could include natural and unnatural deaths) vs. a proportion of deaths where the cause of death is not explained (unascertained deaths - possible SIDS). If the definitions are appropriately applied the cohort should include / can be divided as follows: SUID explained cause of death - natural causes - 749 SUID explained cause of death - unnatural causes (possible asphyxia - see comment below) - 16 SUID unexplained (possible SIDS) - 44 I also have some concern pertaining to the possible suffocation deaths. An unsafe sleeping environment is well reported in a large cohort of SUID deaths, and particularly relating to the comment pertaining to blood/vomitus from the nose/mouth after bed sharing - I would not necessarily agree that the finding in itself would be adequate to indicate an asphyxial cause of death. Consideration could be to change the cohort labelled SIDS as cause of death - to no apparent natural cause of death identified (these infants will resort under the umbrella term Sudden Unexpected Deaths in Infants). The entire cohort of deaths commenced as sudden unexpected infant deaths - not just the ones where no cause of death was apparent. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Sudden Infant Death I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Du Toit-Prinsloo L. Peer Review Report For: The apparent burden of unexplained sudden infant deaths in Lusaka, Zambia: Findings from analysis of verbal autopsies [version 1; peer review: 2 approved with reservations] . Gates Open Res 2023, 7 :46 ( https://doi.org/10.21956/gatesopenres.15614.r32923) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-46/v1#referee-response-32923 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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