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Unexplained deaths in infancy
COMMENTARY
CORRESPONDENCE
Unexplained deaths in infancy Sir—Roy Meadow1 evoked strong reactions from the public by asserting that the proportion of babies dying from infanticide among those attributed to sudden infant death syndrome (SIDS) in Leeds, UK, cannot be established, and that about half of the 81 cases of unexplained infant death ascribed to parental homicide were initially certified as SIDS. In response, your Jan 16 editorial2 on unexplained deaths in infancy draws attention to the professional responsibilities with respect to exploration of the causes of sudden death. The notion of child death used in these circumstances can lead the physician to make inadvertent decisions on whether to conduct a thorough case investigation. However, there is a cultural side. Infanticide is a taboo in our society and elsewhere. In the Andean highlands of southern Peru, infanticide is practised in Amerindian families.3 In some villages early neonatal mortality is very high (but remains under-reported), and has an uneven ethnic and sex distribution.4 In one village (altitude 3820 m above sea level), the civil register recorded 25 births of infants, all of whom survived the first months of life. In the same year, the village baptist who was allowed by the church to baptise stillbirths but not live infants who had died, reported ten stillbirths brought to him to receive the sacrament, which entitled the parents to bury their child as “an angel of the light”. In a retrospective anthropological survey, the village households reported 35 live births over the same period, of whom ten had died within the first few days. The inconsistencies can be explained by under-reporting in the civil registry, and by the definition of the task endowed by the religious authorities on their indigenous servicemen. Natural causes of early child death are common in the Peruvian Andes, and include premature birth and infection. The social definition of infant death can be ambiguous in such cases. An Aymara mother told me that her baby “almost did not live before it died”, leaving me
THE LANCET • Vol 353 • February 27, 1999
to define it as a late fetal death (stillbirth) or early neonatal death. As Meadow1 and your editorial2 emphasise, although application of the complete definition of SIDS is necessary, the diagnosis of SIDS in cases of infant death is not sufficiently covered by the application of strict criteria. Diagnosis is also a social process in which parents, when they give indifferent or ambiguous answers, communicate meanings that the medical profession (or civil registry) may prefer to apply. Children are highly valued in Amerindian and European cultures, but the estimated high frequency of repeated infanticide in both cultures1,3,4 shows that this is not true in all families. Parental neglect and homicide require attention from medical professionals who are aware of the social context of infant death. The anthropologist’s view on societal emotions and individual (parent and physician) conduct in their cultural context is also needed. Kees de Meer Boter Str. 12, 3511 LZ Utrecht, Netherlands 1
Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7–14. 2 Editorial. Unexplained deaths in infancy. Lancet 1999; 353: 161. 3 de Meer K. Mortality in children among the Aymara indians of Southern Peru. Soc Sci Med 1988; 26: 253–58. 4 de Meer K, Bergman R, Kusner JS. Sociocultural determinants of child mortality in Southern Peru: including some methodological considerations. Soc Sci Med 1993; 36: 317–31.
Sir—Not so long ago, women found guilty of infanticide were executed by drowning them in a sack in company with sundry fauna according to the code of Justinian. Innocent mothers falsely accused might prefer this fate to the lifetime’s stigma and gossip that can result. There cannot be many working in the paediatric field who are not by now well aware that a not negligible proportion of unexplained deaths are brought about by gentle smothering, as you discuss in your but few paediatric e d i t o r i a l ,1 pathologists would claim to be able to distinguish the post-mortem findings
in such cases from others due to a tragic accident. In these circumstances the principle of primum non nocere is usually applied—ie, more harm is done by wrecking the lives of innocent parents than by failing to track down the guilty and so, problematically, prevent later children from suffering the same fate only to land them in “care” with all that it implies. There is something to be said for letting ill alone lest worse befall; and anger is surely an emotion out of place in those professionally concerned. Where Roy Meadow2 does have a point is the need for an adequate corpus of paediatric pathologists—not just to help sort out instances of sudden death but to add to our inadequate knowledge of infant pathology. It is said that when the UK’s Medical Research Council was considering setting up a Chair in Paediatric Pathology to ensure an adequate supply of trained specialists in this field, it was advised against doing so by their own college. Fortunately, the Foundation for the Study of Infant Deaths stepped into the breach, but recruitment is still a problem not helped by the conversion of the British Paediatric Association— of which pathologists were honoured members—into a College of Paediatric Physicians. One of the late Princess Diana’s imaginative acts of charity was to arrange to meet a representative set of bereaved families when years ago now it was stated by a Home Office pathologist that most cot deaths were murder—a statement belied by the halving of the incidence as a result of mothers being advised to nurse their young infants supine rather than prone. It would be a pity if her good work were to be undone by the media as a result of a misreading of Meadow’s message. John A Davis 1 Cambridge Road, Great Shelford, Cambridge, CB2 5JE, UK 1 2
Editorial. Unexplained deaths in infancy. Lancet 1999; 353: 161. Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7–14.
749
CORRESPONDENCE
Unexplained deaths in infancy Sir—Roy Meadow1 evoked strong reactions from the public by asserting that the proportion of babies dying from infanticide among those attributed to sudden infant death syndrome (SIDS) in Leeds, UK, cannot be established, and that about half of the 81 cases of unexplained infant death ascribed to parental homicide were initially certified as SIDS. In response, your Jan 16 editorial2 on unexplained deaths in infancy draws attention to the professional responsibilities with respect to exploration of the causes of sudden death. The notion of child death used in these circumstances can lead the physician to make inadvertent decisions on whether to conduct a thorough case investigation. However, there is a cultural side. Infanticide is a taboo in our society and elsewhere. In the Andean highlands of southern Peru, infanticide is practised in Amerindian families.3 In some villages early neonatal mortality is very high (but remains under-reported), and has an uneven ethnic and sex distribution.4 In one village (altitude 3820 m above sea level), the civil register recorded 25 births of infants, all of whom survived the first months of life. In the same year, the village baptist who was allowed by the church to baptise stillbirths but not live infants who had died, reported ten stillbirths brought to him to receive the sacrament, which entitled the parents to bury their child as “an angel of the light”. In a retrospective anthropological survey, the village households reported 35 live births over the same period, of whom ten had died within the first few days. The inconsistencies can be explained by under-reporting in the civil registry, and by the definition of the task endowed by the religious authorities on their indigenous servicemen. Natural causes of early child death are common in the Peruvian Andes, and include premature birth and infection. The social definition of infant death can be ambiguous in such cases. An Aymara mother told me that her baby “almost did not live before it died”, leaving me
THE LANCET • Vol 353 • February 27, 1999
to define it as a late fetal death (stillbirth) or early neonatal death. As Meadow1 and your editorial2 emphasise, although application of the complete definition of SIDS is necessary, the diagnosis of SIDS in cases of infant death is not sufficiently covered by the application of strict criteria. Diagnosis is also a social process in which parents, when they give indifferent or ambiguous answers, communicate meanings that the medical profession (or civil registry) may prefer to apply. Children are highly valued in Amerindian and European cultures, but the estimated high frequency of repeated infanticide in both cultures1,3,4 shows that this is not true in all families. Parental neglect and homicide require attention from medical professionals who are aware of the social context of infant death. The anthropologist’s view on societal emotions and individual (parent and physician) conduct in their cultural context is also needed. Kees de Meer Boter Str. 12, 3511 LZ Utrecht, Netherlands 1
Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7–14. 2 Editorial. Unexplained deaths in infancy. Lancet 1999; 353: 161. 3 de Meer K. Mortality in children among the Aymara indians of Southern Peru. Soc Sci Med 1988; 26: 253–58. 4 de Meer K, Bergman R, Kusner JS. Sociocultural determinants of child mortality in Southern Peru: including some methodological considerations. Soc Sci Med 1993; 36: 317–31.
Sir—Not so long ago, women found guilty of infanticide were executed by drowning them in a sack in company with sundry fauna according to the code of Justinian. Innocent mothers falsely accused might prefer this fate to the lifetime’s stigma and gossip that can result. There cannot be many working in the paediatric field who are not by now well aware that a not negligible proportion of unexplained deaths are brought about by gentle smothering, as you discuss in your but few paediatric e d i t o r i a l ,1 pathologists would claim to be able to distinguish the post-mortem findings
in such cases from others due to a tragic accident. In these circumstances the principle of primum non nocere is usually applied—ie, more harm is done by wrecking the lives of innocent parents than by failing to track down the guilty and so, problematically, prevent later children from suffering the same fate only to land them in “care” with all that it implies. There is something to be said for letting ill alone lest worse befall; and anger is surely an emotion out of place in those professionally concerned. Where Roy Meadow2 does have a point is the need for an adequate corpus of paediatric pathologists—not just to help sort out instances of sudden death but to add to our inadequate knowledge of infant pathology. It is said that when the UK’s Medical Research Council was considering setting up a Chair in Paediatric Pathology to ensure an adequate supply of trained specialists in this field, it was advised against doing so by their own college. Fortunately, the Foundation for the Study of Infant Deaths stepped into the breach, but recruitment is still a problem not helped by the conversion of the British Paediatric Association— of which pathologists were honoured members—into a College of Paediatric Physicians. One of the late Princess Diana’s imaginative acts of charity was to arrange to meet a representative set of bereaved families when years ago now it was stated by a Home Office pathologist that most cot deaths were murder—a statement belied by the halving of the incidence as a result of mothers being advised to nurse their young infants supine rather than prone. It would be a pity if her good work were to be undone by the media as a result of a misreading of Meadow’s message. John A Davis 1 Cambridge Road, Great Shelford, Cambridge, CB2 5JE, UK 1 2
Editorial. Unexplained deaths in infancy. Lancet 1999; 353: 161. Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7–14.
749