Sudden Unexpected Death in Infancy: Two European Models, One Diagnostic Imperative

The study by Ducloyer and colleagues in Acta Paediatrica offers an overview of contemporary post-mortem investigations in sudden unexpected death in infancy (SUDI), based on 1934 French cases collected between 2015 and 2024. Its main message is not merely epidemiological: it highlights a persistent problem in paediatric forensic practice, namely the incomplete implementation of standardised diagnostic pathways even where national recommendations, dedicated centres and registries exist [1]. For an Italian readership, the French experience is particularly useful because it allows comparison with the diagnostic model developed in Italy. The French system is strongly oriented towards centralised referral, multidisciplinary coordination, epidemiological surveillance and early recognition of possible non-natural deaths. The growing emphasis on post-mortem imaging, skeletal survey, ophthalmological examination and toxicology reflects an approach increasingly linked to forensic radiology and child protection [2]. The Italian model developed along partly different lines. Law No. 31 of 2 February 2006 introduced a specific framework for infants dying suddenly within the first year of life without an apparent cause and for foetuses dying unexpectedly after the twenty-fifth week of gestation [3]. It provides for diagnostic post-mortem examination in authorised centres, collection of clinical, familial and environmental information, regional reference centres, a national database, prevention campaigns, multidisciplinary research, continuing professional education and psychological support for affected families. This framework was made operational by the Ministerial Decree of 7 October 2014, published in the Italian Official Gazette on 22 November 2014, which approved two distinct diagnostic protocols: the “Protocollo di indagini e di riscontro diagnostico nella morte improvvisa infantile” and the protocol for unexpected foetal death after the 25th gestational week [4]. The decree is important because it explicitly recognises that SUID/SIDS and SIUD are distinct conditions requiring separate diagnostic pathways, and because it strengthens the role of medico-legal investigation, autopsy, infectious molecular diagnosis, toxicology, genetic assessment, genetic counselling and cytogenetic investigations. Thus, the Italian model should not be reduced to autopsy alone. Its specificity lies in the fact that a broader public-health framework is built around a strong anatomical-pathological and medico-legal core. This is reflected in the Lombardy protocol developed by the University of Milan and the “Lino Rossi” Research Centre, which emphasises the detailed study of the central and peripheral autonomic nervous system, brainstem, cervico-thoracic spinal cord, cardiac conduction system, pulmonary maturation, genetic-molecular investigations and toxicological analyses [5]. The contrast between France and Italy should therefore be interpreted as a difference of emphasis rather than as an opposition. France appears to be moving towards an integrated paediatric-radiological-forensic model, oriented towards standardisation and child protection. Italy preserves a specialised medico-legal and neuropathological tradition, embedded in a normative framework that also includes prevention, data collection and family support. Ultimately, both models converge on the same principle: the sudden and unexpected death of an infant cannot be responsibly classified without a rigorous, multidisciplinary and standardised post-mortem investigation. Fortunato Pititto: conceptualization. Maricla Marrone: supervision. Roberto Bellacicco: writing – original draft. Elisa Paladini: writing – review and editing. Giuseppe Pulin: investigation. The authors declare no conflicts of interest. This article is linked to Ducloyer et al. paper. To view this article, visit https://doi.org/10.1111/apa.70587. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.