Lewis Thomas, in his essayOn Matters of Doubt wrote: “What we have been learning in our time is that we really do not understand this place or how it works, and we comprehend ourselves least of all. And the more we learn, the more we are—or ought to be—dumbfounded.”1For centuries, physicians have tried to explain those phenomena that confronted them every day, knowing that each mystery unlocked often led to more questions. Sometimes we put labels on things we observed but did not completely understand. “the battered child syndrome,” “sudden infant death syndrome (SIDS),” and apparent life-threatening events (ALTEs) are examples of labels we affixed to tragic situations that confronted us often. Physician and societal recognition of these syndromes has expanded rapidly over the last several decades. Billions of dollars have been spent on building an investigative child protection system to deal with battered children, and millions more were contributed to research on SIDS and ALTE as well as support for families whose children died of SIDS.
It is not difficult to imagine, given the random nature of ALTE, that a parent or other caretaker might, by chance, walk in to an infant's room just as (or after) the precipitating event occurred. Given the trusting nature of most health professionals, it is also not difficult to understand our propensity to assume that the child brought to the emergency room after an ALTE must have an organic cause. Given enough money and enough time, we can diagnose nearly anything. Two decades ago, Meadow brought “Münchausen syndrome by proxy” (MSBP) to our lexicon.2 More recently, he and his colleagues pointed out the striking differences in the medical, social, and family histories between children dying of SIDS and those dying of MSBP. Looking posthumously at children with these conditions (and their associated premortem ALTE), however, is too late. The challenge for pediatricians is to recognize the children whose caretakers have the potential to kill them, and prevent a fatal outcome.
Southall and his colleagues3 present data in this issue of Pediatrics that should help pediatricians and pathologists do a better job in paring away the layers of ignorance that have confounded the differential diagnosis of SIDS and fatal child abuse for years. Using covert video surveillance, the authors studied the parent-child interaction in 39 children hospitalized for either suspected child abuse or ALTEs. The videos showed clearly that 30 of the 39 children suspected of being abused who had histories of ALTEs were being suffocated by a parent! Three others were poisoned or physically abused on tape. The transcripts of the tapes are compelling reading, and shatter one's ability to minimize or explain away the calculated nature of the attempted murder of these children. There were two findings that could help in early diagnosis of inflicted ALTEs: the presence of oral and/or nasal bleeding in association with the ALTE, and a positive family history of other sibling deaths.
Southall properly separates the typical cases of physical abuse in which parents are more amenable to treatment from these cases in which the parents are seriously disturbed (although not entirely untreatable). Unless there is acknowledgment by the parent of his or her actions (often denied, even when they see themselves on tape), psychiatric intervention is unlikely to be successful, and court-ordered separation will be required to assure the safety of the child.
What are the lessons to be learned from this work? The first, and perhaps most obvious, is that we must overcome our professional and societal denial of the existence of abuse and neglect not just in this, its most morbid form, but in all its forms. For health professionals who find abuse and murder of children unimaginable, the transcripts of the tapes in the appendix of Southall's paper should be required reading! These tapes are chilling! But their value in diagnosis is compelling.
Second, there are several straightforward clues that appear in these cases that should alert us to the true etiology of some children with ALTE. The finding of nasal and/or oral bleeding after the episode, and the finding that other siblings have died unexpectedly should be a warning sign to us. One wonders how many clinicians actually examine the nares when children are brought to emergency rooms for apnea. And if we haven't been doing so, how many of these cases have we missed?
Third, although the abusers in this study should be dealt with by law enforcement and the judicial system, unless we begin to look at these cases from a public health and a medical perspective, we will have intervention after the fact by the child welfare and judicial systems—both of which have demonstrated their inability to deal with the problem effectively. There is recent evidence that neglectful behavior in mice—specifically a defect in the nurturance of newborns4—is related to a single gene (the immediate early gene fosB), which acts in the preoptic area of the hypothalamus. With the gene, new mother mice (and other males and young females) nest, retrieve, and suckle the newborns (mothers only). Without the gene, none of those behaviors are present, and the pups die. Suppose there was a genetic basis to the problem of abuse and neglect?5 Would we still deny it? Or would we raise millions of dollars for research and treatment programs?
Finally, it is striking, that more than a third of a century after Kempe's paper,6 that we have so little public discussion about what we should be doing to protect children from child abuse and neglect. The public discussion we have is stuck at the recognition phase—child abuse exists—but, other than focusing on the lurid details of the occasional high-profile case (Lisa Steinberg and Elissa Esquivel in New York, Jon-Benet Ramsey in Colorado, Eli Creekmore in Washington), we hear nothing from our elected or appointed public officials. Whether abuse and neglect turns out to be a true medical problem or not, averting our gaze from the issue year after year will only add to the toll taken on infants and children. It is not incumbent on all pediatricians to be able to treat cases such as those presented in the Southall paper, but it is incumbent on us all to be as assiduous in diagnosis as we are in the rest of our practice that tries to avert life-threatening illnesses. Seeing or reading the transcripts of these tapes is believing!
- Received September 2, 1997.
- Accepted September 2, 1997.
Reprint requests to (R.D.K.) University of Colorado School of Medicine, 4200 East 9th Ave, C-290, Denver, CO 80262.
- SIDS =
- sudden infant death syndrome •
- ALTE =
- apparent life-threatening event •
- MSBP =
- Münchausen syndrome by proxy
- ↵Thomas L. On Matters of Doubt in Late Night Thoughts on Listening to Mahler's Ninth Symphony. New York, NY: New York Viking Press; 1983
- Southall DP,
- Plunkett MCB,
- Banks MW,
- et al.
- Kempe CH,
- Silverman FH,
- Steele BF,
- Droegemuller W,
- Silver HK
- Copyright © 1997 American Academy of Pediatrics