Diagnostic challenges in infant death associated with maternal cocaine abuse during pregnancy and lactation: a forensic case report and review of the literature.

INTRODUCTION: Maternal cocaine abuse during pregnancy and lactation represents a critical public health crisis. Recent 2024-2025 data indicate approximately 4.3 million users in the United States and 2.7 million young adults in Europe. While epidemiological evidence suggests an independent association between prenatal cocaine exposure and Sudden Infant Death Syndrome (SIDS), forensic interpretation remains complex due to the lack of validated toxicological thresholds for the pediatric population. METHOD: We report the case of a 36-day-old infant who died suddenly and unexpectedly. Post-mortem investigations were performed to differentiate between SIDS and toxicological intoxication. Forensic hair analysis confirmed chronic cocaine exposure, occurring both in utero and via lactation. A systematic review of the literature was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search focused on fetal and infant fatalities associated with maternal cocaine consumption to identify recurrent toxicological patterns. RESULTS: The systematic review identified seven key studies describing neonatal deaths linked to maternal cocaine use. A significant discrepancy was observed between adult post-mortem concentrations, ranging from 900 ng/mL in cardiac-related deaths to over 19,000 ng/mL in acute intoxications, and neonatal levels, which showed mean concentrations of 39 ng/mL, though extreme cases have reached 4.8 mg/dL. This variability underscores the difficulty in establishing a lethal range for infants. CONCLUSION: The findings highlight a critical gap in forensic pathology and toxicology. There is an urgent need for systematic data collection during autopsies to establish standardized reference intervals. Improving these datasets is essential for forensic pathologists to accurately distinguish between incidental exposure and cocaine-induced fatality in pediatric cases.