Infanticide or SIDS? That is the Question
Infanticide or SIDS? That is the Question
ABSTRACT & COMMENTARY
Synopsis: Records of 81 children who were judged by British courts to have been killed by their parents were reviewed. Initially, 42 of these children had been certified as dying of sudden infant death syndrome and another 29 were assigned another cause of natural death.
Source: Meadow R. Unnatural sudden infant death. Arch Dis Child 1999;80:7-14.
Eighty-one cases of unexpected deaths of children from all over the United Kingdom over an 18-year period were ultimately judged by criminal and family courts to have been caused by their parents. Half of these children were initially diagnosed as having sudden infant death syndrome (SIDS) and another one-third were attributed to another natural cause. Twenty-four families had at least one previous death in infancy; 58 children were younger than 6 months of age; and most died in the afternoon or evening. Seventy percent of these children had experienced unexplained illnesses. Half had been admitted to a hospital in the preceding month and 15 had been discharged within 24 hours of death. Mothers were responsible in most cases. Most families were economically deprived. Half of the perpetrators had a history of a factitious disorder. Death was usually caused by smothering and nearly half of the children had bruises, petechiae, or blood on their face when discovered.
COMMENT BY JOHN LEVENTHAL, MD, FAAP
When a child younger than 1 year of age dies unexpectedly and suddenly, a clinician’s first "diagnosis" is often SIDS. Over the last several years, however, physicians have paid increasing attention to other diagnostic possibilities, ranging from metabolic causes to homicide. In this article, Roy Meadow, Professor of Pediatrics at St. James’s Hospital in Leeds, England, an expert in child abuse, first described Munchausen syndrome by proxy. Meadow presents the clinical features of 81 children who were evaluated by him over a period of 18 years and who were determined by criminal and/or family courts to have been killed by their parents. The 81 children came from 50 families; in 24 families, more than one child had died (2 children in 18 families, 3 in 5, and 4 in 1). In 19 families, a parent confessed to smothering or choking the child.
Although it is difficult for physicians to consider the possibility of homicide when an infant dies suddenly, Meadow’s experience, which is probably the largest in the world in these kinds of cases, offers several clues to point clinicians toward the unspeakable diagnosis of homicide.
The first clue that something was "not right" was repeated, unexplained deaths in a family. In this series, 24 families had more than one infant who died. Some of these children were older than the age of 12 months. The label of "SIDS" should never be used in an unexplained death in a child older than the age of 12 months.
The second clue was that 30 of 70 children had suspicious external signs at the time of death. Twenty-seven had blood in the mouth or nose or on the face, and 10 had either unusual bruises or petechiae on the face or neck. Meadow warns that blood should be distinguished from the common serosanguineous froth that can be present when attempts are made at resuscitation.
A third clue was that, of the 42 infants classified as SIDS, five were older than 12 months of age, two had fractured ribs (think abuse), and two younger than 6 months of age had "balls of paper" in the stomach. Of the 29 who had a specific pathological diagnosis, two had lacerations of the throat and three had foreign bodies in the airway or stomach.
A fourth set of clues came from information about the parents. Of 44 perpetrating parents, Meadow found evidence of Munchausen syndrome in 10 (7 mothers and 3 fathers) and somatizing disorders (including factitious illness) in 11.
Other important information was provided by Meadow, but this seemed less helpful in trying to distinguish a true SIDS from a homicide. Of note, 43 of the perpetrators were mothers, five were fathers, and two were both. All the perpetrators were white Europeans and the majority, but certainly not all, were from the lower social classes. Almost all of the infants had had an unusual or unexplained event prior to dying. Many of these events included descriptions of the infant stopping breathing, looking blue, appearing dazed, twitching, or seizing, and many of the events would be described as "acute life-threatening events." It was also interesting that many of the children (55/72) were found dead between 11:00 and 22:00, and 15 died within 24 hours of being discharged from the hospital for observation.
So what should a clinician do when evaluating an infant’s death before 1 year of age? Look for some of the worrisome features highlighted by Meadow, review the medical record for previous unexplained or suspicious injuries, make sure that a death scene investigation is done (documenting where the child was found and the child’s condition, who was present in the home, and any unusual circumstances), and review the results of the autopsy (which should include a roentgenographic skeletal survey). To consider a diagnosis of homicide when an infant dies is always difficult for both family and physicians. Not to consider such a diagnosis may place other children at substantial jeopardy of dying.
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