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Fourteen cases of imposed upper airway obstruction
M P Samuels1, W McClaughlin, R R Jacobson
1Department of Paediatrics, Royal Brompton Hospital, London.
Insights
Imposed upper airway obstruction causes severe cyanotic episodes in infants. Covert video surveillance aids diagnosis when physiological recordings are inconclusive, protecting children from harm.
Area of Science:
- Pediatric Medicine
- Child Abuse and Neglect
- Psychosomatic Medicine
Background:
- Recurrent cyanotic episodes in infants can be life-threatening and require accurate diagnosis.
- Distinguishing between organic and non-organic causes of cyanotic episodes is crucial for appropriate management.
- Previous studies have highlighted the challenges in diagnosing non-organic causes of pediatric illness.
Observation:
- A study identified 14 patients with recurrent, severe cyanotic episodes caused by imposed upper airway obstruction.
- Episodes typically began in early infancy (median 1.4 months) and persisted for months.
- Diagnosis was achieved through covert video surveillance, often prompted by specific triggers or inconclusive physiological recordings.
Findings:
- Covert video surveillance revealed parental (primarily maternal) histories of abuse, self-harm, factitious illness, and eating disorders in a significant number of cases.
- Physiological recordings were essential for excluding natural causes, but surveillance was key when these were negative.
- The psychosocial characteristics of parents, particularly those with histories of abuse, were linked to the imposed obstruction.
Implications:
- Imposed upper airway obstruction should be a consideration in infants presenting with recurrent cyanotic episodes.
- Early recognition of parental psychosocial factors may facilitate earlier diagnosis and intervention.
- Covert video surveillance is a vital tool for child protection when natural causes are ruled out, preventing potential fatality or severe injury.
Abstract:
Imposed upper airway obstruction was diagnosed as the cause of recurrent and severe cyanotic episodes in 14 patients. Episodes started between 0.8 and 33 months of age (median 1.4) and occurred over a period of 0.8 to 20 months (median 3.5). Diagnosis was made by covert video surveillance, instituted after either (a) the observation that episodes began only in the presence of one person, or (b) characteristic findings on physiological recordings, lasting between 12 hours and three weeks, performed in hospital or at home. Surveillance was undertaken for between 15 minutes and 12 days (median 24 hours) and resulted in safety for the patient and psychiatric assessment of the parent: mother (n = 12), father (n = 1), and grandmother (n = 1). These revealed histories of sexual, physical, or emotional abuse (n = 11), self harm (n = 9), factitious illness (n = 7), eating disorder (n = 10), and previous involvement with a psychiatrist (n = 7). Management of the abusing parents is complex, but recognition of their psychosocial characteristics may allow earlier diagnosis. Imposed upper airway obstruction should be considered and excluded by physiological recordings in any infant or young child with recurrent cyanotic episodes. If physiological recordings fail to substantiate a natural cause for episodes, covert video surveillance may be essential to protect the child from further injury or death.