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Editor,—Intentional suffocation is a difficult diagnosis. Children often appear well in between such episodes and cannot tell their paediatrician that they are being intermittently assaulted. The evidence for intentional suffocation is often circumstantial, which means that doctors may have difficulty substantiating the diagnosis in court without evidence from covert video surveillance. We are surprised, therefore, that Daviset al state that a high proportion of suffocation victims were protected effectively without covert video surveillance.1 It may be that these cases were not contested or had evidence of other harm to the child in addition to the suffocation.
Davis et al reinforced the British Paediatric Association working party guidelines that “when there is a very high risk, children should not be exposed to danger simply to achieve a criminal standard of proof.”2 Covert surveillance has been used in our knowledge primarily to confirm the diagnosis and to ensure effective protection for the child and siblings. Even in civil proceedings, which rely on a balance of probabilities, the more serious the allegations of abuse, the higher the level of evidence the court requires. In a number of cases of suspected suffocation, we have seen children inadequately protected because of a lack of firm evidence from surveillance. Medical experts with little experience of suffocation may fail to convince a judge or confound proceedings with clinical controversies. Inadequate evidence may then result in children suffering long term physical or emotional harm.
We suggest that all infants with recurrent apnoeic–cyanotic episodes are investigated within units that can both perform multichannel recordings in hospital or at home, preferably during events for diagnostic purposes, and be open to considering the possibility of abuse. In the latter situation, clinicians should follow appropriate child protection procedures, including the use of confidential multiagency strategy meetings and, if required, covert video surveillance.
An approach that aims to record clinical events may help some children with recurrent events avoid unnecessary medical treatment or surgery. These have often been given as a result of abnormal investigations between episodes (for example, fundoplication for reflux). Searching for the pathophysiology during episodes may mean covert surveillance is used earlier in selected cases to ensure that suffocation is confirmed and not dismissed in the court room.
Dr Davis and colleagues comment:
We agree with much of what Dr Samuels and Professor Southall say. Deliberate suffocation must be considered in the differential diagnosis of apparent life threatening events (ALTE) in infants. All paediatricians managing cases of this type must be aware of this possibility and be prepared to follow their local child protection procedures.
Clearly in these cases, paediatricians need the best quality evidence, and if definitive evidence exists, then this is most helpful. It is our view, however, that fabricated illness should primarily be a clinical diagnosis. There is often a wide range of medical factors in the child’s background as well as ALTE, and there are usually features in the medical histories of siblings. Close examination of this background can usually enable a clear diagnosis on clinical grounds (on the balance of probabilities). Where a clinical diagnosis can be reached it is appropriate to act without subjecting the child to the risk of further harm to obtain definitive evidence.
Covert video surveillance is undoubtedly both ethical and clinically indicated where there is genuine clinical uncertainty about whether the child is suffering “medical” life threatening events, or imposed ones, and where a careful review of the clinical history of the whole family does not support a diagnosis of fabricated illness. However, the fact that covert video surveillance revealed abuse in 33 of 39 suspected cases in Southall’s own report suggests that the clinical criteria used to select children for covert video surveillance were in fact good indicators of abuse in themselves.1-1 This work has been instrumental in bringing deliberate suffocation of children into the public domain and acknowledging that it is an important variety of child abuse. It has also clarified considerably the clinical elements of diagnosis. In light of these reports it is probable that covert video surveillance has become less necessary and a clinical diagnosis without it should now be more acceptable.
Covert video surveillance was used in only a quarter of the cases of non-accidental suffocation we surveyed as part of the British Paediatric Surveillance Unit (BPSU) study. Of the 26 survivors of suffocation abuse followed up, all of them were initially protected by removal from the home or separation from the perpetrator. At follow up approximately two years later, only three of these 28 children had been allowed home without major conditions being applied (usually involving the exclusion of the perpetrator). Most of these children were subject to Care Orders.
Most of these children were, therefore, protected even though there was no evidence from covert video surveillance. Obviously, the follow up duration and the fact that we obtained our information from paediatricians means we can only draw limited conclusions about the risks of further abuse.
It was not our intention to suggest that clinicians were performing covert video surveillance purely to obtain evidence for a prosecution. However, the BPSU study and anecdotal experience suggest that where covert video surveillance evidence is available prosecution is usual. We agree with Professor Southall that prosecution has various benefits, but Children Act proceedings should allow the protection of children perfectly adequately in most cases.
It is, of course, entirely appropriate for diagnoses of child abuse, clinical or otherwise, to be challenged in court. The complexity of cases of fabricated illness is such that only paediatricians with a major research background in this area should be undertaking these expert assessments. Courts seem, quite rightly, to be becoming more selective in this respect.
We agree that covert video surveillance requires specialist facilities and clinicians who are able to consider both organic and abuse diagnoses. However, we feel that many of these children can be diagnosed on clinical grounds and that not all infants suffering recurrent ALTE would need this service.