Probably the most commonly missed method of homicide in infants and young children is smothering. Based on the authors' experiences, smothering is, after impulse homicides, the second most common type of homicide in infants. In infants, smothering is very easily accomplished. One closes off the child's nose with two fingers, at the same time pushing up on the lower jaw with the palm to occlude the airway. Other methods have involved placing a pillow or towel over the child's face and pressing down; pushing the face down into bed clothing, or just covering the nose and mouth with one's hand. These descriptions are based on either confessions or witnessed homicides. In a few cases, attempted homicides have been videotaped.
The true number of smotherings in infants is not known and can never be known until there is some scientific test to determine whether an individual has been smothered. The amount of force necessary to produce smothering is so minor in this age group that there is virtually never evidence of trauma. Autopsy findings are essentially unremarkable, the same as those found in SIDS deaths (Figure 12.7). Undoubtedly, a small percentage of SIDS deaths are due to smothering. This has been estimated as high as 10%. It has been the authors' opinion, that this percentage was too high and smotherings disguised as SIDS probably accounted for only a few percent of alleged SIDS cases. If the campaign to reduce SIDS deaths by placing infants on their backs
is truly successful in reducing SIDS deaths, then the percentage of SIDS-attributed deaths that are really caused by smothering will increase and approach, if not exceed, the previously cited 10%.
The amount of time necessary to smother an infant, such that their electroencephalogram is flat and there is no spontaneous respiration, has been documented at 70-90s.12,13 Deaths caused by smothering tend to be missed in large urban communities with high crime rates, where both the medical examiner's office and police agencies are overworked and cannot afford to expend the time on detailed investigations of all cases.
While most homicidal suffocation of infants is sporadic, a small number of individuals, virtually all of whom are mothers, practice a lethal form of Munchausen's syndrome by proxy, a form of child abuse in which children are brought to physicians and hospitals for induced signs and symptoms of illnesses in conjunction with a fictitious history.14 The child is usually subjected to multiple hospital admissions and extensive medical evaluations, treatments and procedures for these nonexistent medical conditions. Thus, a child might be brought into the hospital with hypoglycemia because the mother is administering insulin or there may be blood in the urine because the mother pricks her own finger and adds blood to the child's urine.
With the more common forms of Munchausen's, the diagnosis is usually made after a number of admissions because the symptoms and signs usually do not make sense clinically and appear bizarre. Male and female children are affected equally and, in virtually every instance, the perpetrator is the mother. The father is usually supportive of the mother, is unaware of what she is doing, and usually stands by her after she is accused. Initially, multiple and varied tentative diagnoses are considered. The mother and child seem to be extremely close and it is difficult for the physician or social worker to realize what the mother is doing.
Forensic pathologists are familiar with a much more lethal version of this entity in which the individual, again virtually always the mother, repeatedly smothers the child into unconsciousness. Children are then either resuscitated by the parent or brought to an emergency room in a semi-moribund state, with a history of apnea, cyanosis, and losing consciousness. This continues to recur until the children are admitted to the hospital. After admission, the children are worked up extensively, with no abnormal findings. Usually, these children never have these episodes of apnea and cyanosis while in the hospital. If they do, a careful history reveals that the parents who have witnessed these attacks outside the hospital are alone with the children in the hospital room at the time the attack occurs. After discharge from the hospital, the "attacks" continue until either the diagnosis is made or the children killed.
The more lethal variant of Munchausen's syndrome by proxy was long unrecognized by pediatricians, though it was described in the forensic pathology literature, without resort to this terminology, by Di Maio and Bernstein in 1974.15 Rosen et al. were the first to describe two siblings with recurrent cardiorespiratory arrest caused by smothering by the mother, in which the act was documented on videotape.12 The first child was a 5-month-old girl admitted for cardiorespiratory arrest. Her 4-year-old brother had had a similar medical history. The mother gave a history of almost daily episodes of apnea, cyanosis, bradycardia, and loss of consciousness since 1 week of age. The attacks were very common, with the longest period between attacks only 72 h. These attacks occurred whether the child was asleep or awake. The child had been extensively worked up by computerized tomography, ECG, and EEG and had been given multiple anticonvulsive medications. She had had multiple apneic episodes in the hospital and was found apneic, cyanotic, bradycardic, and unresponsive. Ventilation with oxygen and closed chest massage always resuscitated the child. On this admission, however, the physicians became suspicious and, using video equipment, were able to document the mother smothering the child by placing the palm of her right hand over the baby's face. She kept the hand in position for 90 s. The heart rate began to fall 30 s after the obstruction of the airway. The EEG slowed and flattened at 90 s.
As awareness of this syndrome spread among pediatrians, and because of the availability of video cameras, other cases have been discovered and documented. Thus, Southall et al. reported two cases of apneic episodes induced by smothering that were documented by video cameras.13 In one instance, the mother placed a T-shirt over the nose and mouth of a 22-month-old child and forced his head onto the mattress. In the second child, 6 months of age, the mother also placed a garment over the face of the child and forced its head onto the mattress. In a prior episode, which was not videotaped, but during which monitoring was being conducted, the child was found unconscious and cyanotic apparently after 2 min of smothering.
The videotapes showed that both the children struggled violently until they lost consciousness. Thus, the term "gentle" homicide is a misnomer. It took at least 70 s before electroencephalographic changes, probably associated with loss of consciousness, occurred. No marks were seen on the lips or nose. Southall et al. describe a series of physiological changes observed by their recording during the smothering.13 Initially, there was the sudden onset of large body movements, apparently the child's violent struggling against the smothering. At 1 min, there was the appearance of a series of deep breaths occurring at a relatively slow rate with a prolonged expiratory phase, in other words, a "gasping" respiratory pattern. About this time, the electroencephalogram showed large slow waves progressing to an isoelectric baseline indicative of cerebral hypoxemia.
The authors have encountered a number of fatal cases of Munchausen's syndrome by proxy, such as the previously mentioned case described by Di Maio and Bernstein, where a woman was convicted of smothering her adopted child after repeated episodes of admission to the hospital for cyanosis and apnea.15 She was also linked to six other deaths. Other cases encountered by the authors have involved anywhere from one to three deaths. In one instance, a mother was indicted by the grand jury for smothering two children, though she was never tried for either death, because the district attorney refused to try the case. He was advised by a pediatrician that the two deaths were examples of hereditary SIDS and was quoted the work of Steinschneider (see next section). One of the authors was also consulted in a case occurring in Houston, in which a child, who was repeatedly admitted for cyanotic episodes with essentially negative workups, subsequently died and was felt to represent a variant of SIDS. When a second sibling presented with the same history of multiple episodes of cyanosis, a video camera recorded the mother smothering the child (M. Munier, personal communication). The mother subsequently confessed to having smothered the first child as well.
Probably the most bizarre case of Munchausen's syndrome by proxy one of the authors (VJMD) has encountered involved a nurse in a pediatric intensive care unit. She was suspected of administering heparin, potassium chloride, and succiny1choline (alone and in various combinations) to infants and young children to precipitate a medical crisis (massive bleeding, cardiac and pulmonary arrest) so that she could resuscitate them and be viewed as a heroine. Unfortunately, she was not always able to resuscitate them. She was convicted of killing one child with succinylcholine and injuring another with heparin. Attorneys involved in the case suspected her of causing the deaths of from 15 to 30 other children.
Deaths from the lethal form of Munchausen's Syndrome by Proxy may be diagnosed as cases of near-miss SIDS (an entity which may not exist). Thus, Berger presented two cases of child abuse by suffocation presenting as near-miss SIDS.16 Fortunately, both children survived. The perpetrator was the mother in both instances. She apparently put her hand over her child's nose and mouth. Minford also reported child abuse presenting as apparent near-miss SIDS.17 Again, the child did not die. The mother admitted holding his nose, causing the child to become cyanotic and apneic.
The existence of cases of near-miss SIDS is debatable. Whether such cases actually represent potential cases of SIDS aborted due to the intervention of another or whether they are a misinterpretation of a normal apneic episode of an infant by an inexperienced observer is not clear. The importance of near-miss SIDS is that Munchausen's syndrome by proxy can be confused with it or some obscure apneic disorder. The presentation of the lethal variant of Munchausen's cases, however, is usually the same. Repeated apneic episodes in the presence of one individual (usually a parent), with the child's becoming cyanotic and limp; resuscitation, and repeated presentation in an emergency room or hospital with numerous admissions to a hospital, at which time the child has no problems unless left alone with the parent. Unfortunately, if suspicion is not aroused, there is a possibility that this will lead to the death of the child.
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