A six-week-old premature infant died of unascertained causes while co-sleeping with parents on an adult bed with soft pillows and loose bedding. Baby A had multiple SIDS risk factors including prematurity, low birthweight, co-sleeping arrangements, soft bedding, and prenatal and postnatal smoke exposure. Post-mortem toxicology revealed exposure to multiple illicit drugs (MDMA, methamphetamine, cannabis, tramadol) but no evidence these caused death. An autopsy was not performed due to parental objection. Clinical lessons include the importance of safe sleep practices for infants and the significance of environmental risk factors for sudden infant death. The case highlights challenges in determining cause of death without complete autopsy examination, particularly when natural, accidental, and deliberate causes cannot be excluded.
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