Post-mortem fundus examination after sudden unexpected death in infancy (SUDI): can we do better? a study based on the French SUDI registry.

Background: Fundus examination is crucial to assess retinal haemorrhages after sudden unexpected death in infancy (SUDI), to rule out fatal abusive head trauma.

Objective: To determine how many SUDI cases in France underwent a fundus examination, and to identify factors associated with its completion.

Method: Children who died from SUDI included in the French SUDI registry were analysed. It was determined whether a fundus examination had been performed and, if so, whether the results showed the presence of retinal haemorrhages. Groups having undergone or not fundus examinations were compared in terms of age at death, gender, perinatal history, need for resuscitation, post-mortem investigations (brain imaging, autopsy), potential prosecutor's intervention, and presence of traumatic injuries. A survey was sent to referral centres to determine whether and how they performed fundus examinations.

Results: Our study included 1,326 cases of SUDI occurring between 2015 and 2022, of which 252 (19%) underwent fundus examinations, with a significant increase from 10 (9.3%) in 2015 to 57 (31.8%) in 2022 (p < 0.001). Significant differences were observed between the groups with and without fundus examination in the number of autopsies (217 [86.8%] vs. 845 [79%]; p = 0.004), and the presence of traumatic injuries (15 [6.4%] vs. 23 [2.3%]; p = 0.003). Retinal haemorrhages were detected in 26 children, and were significantly associated with higher rates of prosecutor's interventions after hospital admission (12 [57.1%] vs. 32 [16.2%]; p < 0.001), cardiac activity resumption (9 [40.9%] vs. 17 [7.9%]; p < 0.001) and traumatic injuries (14 [53.8%] vs. 1 [0.5%]; p < 0.001). Of the 34 centres surveyed, 15 completed the questionnaire, and only 5 reported regularly performing fundus examinations.

Conclusion: A fundus examination is performed in only 19% of SUDI cases in France. Efforts should be made to generalize this examination to avoid missing out fatal abusive head trauma.