SIDS and the Munchausen Syndrome by Proxy

Over the years, a number of causes have been proposed for SIDS. One suggestion was that the episodes of prolonged apnea seen in premature infants are a form frustre of SIDS. This concept was proposed by Steinschneider in an article in Pediatrics in 1972.18 He studied five infants, three of whom were referred to him at about 1 month of age because of cyanotic episodes of undetermined etiology. Two subsequently died of what was called the sudden infant death syndrome; three survived. One of the two was a 29-day-old female seen because of recurrent cyanotic episodes. The first occurred at the 8th to 9th days of life; the second 5 days later. She was admitted to the hospital at the time and discharged at the age of 25 days without a diagnosis. She was then re-admitted following another severe cyanotic episode. This pattern of admission, discharge and readmission occurred until her death at home at 79 days of age. During her workup by Steinschneider, the child allegedly suffered multiple episodes of apparent prolonged apnea.

The second child, a male, was studied from age 5 days to 33 days. The morning following discharge, he had an alleged episode of prolonged apnea and cyanosis. A similar alleged episode occurred 15 to 20 min later. The child was hospitalized for 34 days and then discharged. He was re-admitted the following day for a period of 6 days because of apparent aspiration during feeding. He was discharged and, on the morning following, had an apneic episode, became cyanotic, and died.

The two deaths reported by Steinschneider that form the basis for the contention that apneic episodes are associated with SIDS cases involved a brother and sister. In addition to these two deaths, mention is made in the article that three other children in the family had also died. The first male developed recurrent cyanotic spells and died suddenly at 102 days of age; the second, a female, turned blue and died at 48 days of age. Neither of the two children was autopsied. The third cried out and died suddenly at 28 months of age. An autopsy was negative, except for the fact that the adrenal glands were "considered to be of small size."

The Steinschneider article became one of the most quoted articles in the field of SIDS.18 It led to the introduction of apnea monitors to "prevent" SIDS. In addition, the article indicated that there was hereditary basis for SIDS. Following its publication, a number of articles appeared in the medical literature describing multiple cases of SIDS in families, thus appearing to confirm that SIDS was indeed hereditary.

Forensic pathologists were immediately skeptical about the article, strongly suspecting serial homicide. In the first edition of this book, the authors stated that the deaths in the article were homicide and that Steinschneider's article was describing a lethal variant of Munchausen's syndrome by proxy. In March 1994, the mother of the two dead children in Steinschneider's article confessed to smothering all five children because she couldn't stand their crying. She was subsequently tried and convicted of homicide.19

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