[The problem of differentiating between sudden infant death syndrome, fatal Munchausen's syndrome by proxy, and infanticide].
BACKGROUND
Sudden infant death syndrome (SIDS) is the most common type of post-neonatal death in infants under 1 year of age. It is defined as the sudden death of an infant that is unexpected on the basis of the child's history and unexplained by a thorough post-mortem examination. The incidence of SIDS in Germany has fallen from 1.7 per 1000 live births in 1990 to 0.62 in 2000. In the U.K. the incidence was 0.56 in 1998. According to the literature, 5 to 11 percent of deaths recorded as SIDS may be disguised homicides. These homicides can be caused by a Munchausen's syndrome by proxy (MSBP). Munchausen's syndrome by proxy is defined as an extreme form of abuse wherein the caregivers produce symptoms of illness in a child by means of internal or by external manipulation. Using case reports, this paper examines some difficulties in differentiating between SIDS, MSBP, and homicide.


METHODS
In a family with three children, the youngest daughter died suddenly of suffocation at the age of 17 months. Before her death, the child had been admitted 11 times to different hospitals for various reasons. The mother reported that her daughter was admitted for epileptic seizures, suffocation attacks, and diarrhoea. No noticeable organic signs or symptoms were found during the child's stays in a hospital. The girl was discharged each time without symptoms and without a clear-cut diagnosis. Toxicological analysis of the blood revealed the presence of caffeine. Clinically, an accidental death appeared to be unlikely.


CONCLUSIONS
When assessing cases of SIDS, a MSBP, or homicide, practitioners should be on the lookout for recurrent symptoms of illness, repeated hospitalisation and/or consultation of physicians, multiple diagnostic procedures without establishment of a clear-cut diagnosis, a certain resistance to therapy, illness or unnatural death of siblings, and repeated signs of poisoning or suffocation. Differentiation between SIDS, MSBP, and homicide should be extensive and done with great care since the legal consequences differ vastly according to the facts of the matter.
Hässler
Frank
F
Klinik für Psychiatrie, Neurologie, Psychosomatik und Psychotherapie im Kindes- und Jugendalter des Universitätsklinikums Rostock. frank.haessler@med.uni-rostock.de
Zamorski
Henryk
H
Weirich
Steffen
S
D001344:Autopsy / Q000331:legislation & jurisprudence; D002110:Caffeine / Q000097:blood / Q000633:toxicity; D003937:Diagnosis, Differential; D005104:Expert Testimony / Q000331:legislation & jurisprudence; D005260:Female; D006801:Humans; D007223:Infant; D007237:Infanticide / Q000331:legislation & jurisprudence*; D008297:Male; D016735:Munchausen Syndrome by Proxy / Q000473:pathology*; D013398:Sudden Infant Death / Q000473:pathology*
D002110:Caffeine