original article by Professor Roy Meadow,' rather than the national newspaper reports. For once the newspapers do not seem to have distorted their reports of ...
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Suffocation and sudden infant death syndrome SIR,-I have now had an opportunity to read the original article by Professor Roy Meadow,' rather than the national newspaper reports. For once the newspapers do not seem to have distorted their reports of the article. Let me start by saying that 21 years ago one of my twin sons died in a cot death. I felt then, and I feel now, an enormous guilt as I was the last one to go to him while he was alive. But this sense of guilt is common to every parent in such a death. And because I know this I can live with it. It is this knowledge that got me through those earlier years-and still does; and it is this support that the article you published has partly kicked away. Our loss was 21 years ago, and time does indeed help. Those parents whose loss was more recent could have been devastated by the publicity ensuing from your publication of Roy Meadow's article. I do not hide from the facts of life. I know that Roy Meadow could be right. I have much better reason for thinking so than he does because I have experienced the loss and he produces no evidence for those facts he puts up. That is why I think that his article, and your decision to publish it, is profoundly unprofessional as well as tampering with emotions which neither of you seems to have had the sensitivity to perceive or anticipate. How can you publish a loose, unchecked statement that "between 2 and 10'S) of babies currentlv labelled as dying from sudden infant death syndrome have probably been smothered"? How can you possibly add "by their mothers"? There does not appear from the article to be a shred of statistical, analytical, empirical, or factual evidence for any part of that sentence. Most other evidence is that child abuse is mainly the responsibility of men, so it is perverse to lay this crime mainly at the mother's door. I am not a doctor-although I am a professional man-and I am loathe to bring up the Cleveland syndrome yet again. But I cannot help observing that parents of small babies may have been given yet another reason to avoid taking a worrying symptom anywhere near a pacdiatrician. D S TALION
Lo0ndon N6 4TA Meadow R. Suffocation. BrAMedj 1989;298:1572-3.
}oJite.)
SIR,-We do not understand how you could publish the statement by Professor Roy Meadow that "between 2 and 10% of babies currently labelled as dying from the sudden infant death syndrome have probably been smothered"' without providing appropriate evidence. Most researchers in this subject will accept that a very small proportion of cot deaths is due to undetected
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infanticide (including smothering), but they would not attempt to estimate the proportion involved without substantial data. Unfortunately for readers of this article, including the lay press, the evidence for these figures is not presented. We could summarise the published data linking smothering to cot death as follows. Confidential inquiries, without controls, conducted by Taylor and Emery after postperinatal deaths determined that in 3 of 65 cases there was "a high degree of suspicion of gentle battering."2 As an example they cited a baby who suffered a cot death at 3 months of age. There had been a previous cot death in the family. The mother had a history of psychiatric illness and recurrent back pain. There were marital problems, and different versions of the terminal event were presented by parents. Death was registered as "unexpected death in infancy." In a further article on 12 families in which two or more cot deaths occurred Emery stated that "in five, filicide (infanticide) was probable."' As an example he described an infant who died at 7 months, having been born 8 weeks prematurely. There had been a previous death under suspicious circumstances in that the child had been left for a long while in a closed caravan with the gas fire on. Carbon monoxide poisoning was excluded by blood tests and no cause of death was found. After the second death Emery stated, "the mother seemed to be in an abnormal mental state and we arranged for her to be seen by a psychiatrist. In the meanwhile she attempted suicide. She was found to be in severe depression and had probably had a psychiatric disorder for several years. Filicide was a possible cause of these two deaths." In 1984 Meadow described 32 children from 23 families with seizures induced, or invented, by relatives.4 These included seven children in whom the seizures followed partial suffocation by mothers. There were 33 siblings of these 32 index cases, seven of whom suffered cot death. The family histories of cot death in children with fictitious seizures are important but not quantifiable in terms of cot deaths. Finally, a small number of anecdotal case reports have been published in which mothers have admitted to inducing the death of their babies. A critical examination of one such report' reveals that the diagnosis of filicide by Emery and Taylor relied on circumstantial information. Confessions by mothers may be the truth in some instances but the disturbances of emotions, including guilt, that follow cot deaths make precise interpretation of these admissions extremely difficult. Our own evidence concerning smothering and cot deaths might be inferred from the finding that maternally imposed upper airway obstruction (smothering) is the responsible mechanism in some infants and young children presenting with life threatening episodes of hypoxaemia.' In over 350 patients presenting to our hospital with cyanotic
episodes, in only seven patients were the episodes due to smothering. Although a proportion of these episodes resulted in loss of consciousness, no infants died and all were presented for medical attention by their mothers, conforming with the diagnostic label Munchausen syndrome by proxy.4 Though it cannot be denied that these episodes comprised major child abuse and were dangerous and harmful to the children concerned, there is no proof that they would have resulted in death if the cause had remained undetected. Epidemiological studies have shown that only 8% of infants suffering cot deaths have experienced preceding cyanotic episodes." The pathophysiology leading to Munchausen syndrome by proxy is more likely to present with cyanotic episodes in a living infant. Using the epidemiological findings and accepting wide confidence intervals for our own findings that smothering was responsible for cyanotic episodes in less than 2% of cases, we must conclude that these data do not support the hypothesis that smothering is a major cause of cot death. In conclusion, the evidence linking smothering with cot deaths is uncontrolled, circumstantial, anecdotal, and indirect. It is not possible from published information to quantify the contribution. Most parents losing a baby from cot death live in a state of grief, guilt, and turmoil for many years. Many deaths occur when the father is at work and the mother alone with their baby. The suspicion created by Meadow's unsupported statement introduces into such a setting additional and unnecessary stress. In the words of Meadow himself "the statement that some children dying from cot death have been injured by their mothers must not be exaggerated."4 DAVID P SOUTHALL MARTIN P SAMUELS VALERIE A STEBBENS
Brompton Hospital, London SW3 6HP I Meadow R. Suffocation. Br A 7dj 1989;298:1572-3. (10 June.) 2 Taylor EM, Emer) JI. I wo-year study of the causes of postperinatal deaths classificd in terms of presentability. Arch I)isChtild 1982;57:668-73. 3 Emery JL. Families in which two or more cot deaths have
tccurred. lainta 1986;i:313-5. 4 Meadow R. Fictitious epilepsy. Luncet 1984;ii:25-8. S Southall DP, Stebbens VA, Rees SV, Lang MH, Warner JO, Shinebourne EA. Apnoeic episodes induced by smothering: two cases identified by covert video surveillance. Br Med 3 1987;294: 1637-41. 6 Hoffman HJ, Damus K, Hillmail L, Krottgrad E. Risk factors for SIDS. Rcsults of the National Institute of Child Health and Humani Development SII)S cooperative epidemiological study. Ann NY.Acad Sci 1988;533:13-31).
SIR,-That it is incumbent on all of us to quote accurately from literature would seem a truism, yet how easy it is to fall into the trap of misquotation or rather dysquotation (my neologism for a form of
BMJ VOLUME 299
15 JULY 1989
