"There will be some die-hards who say they can do everything, adults and children.  But the right thing to do is to have people devote all their attention so that they can see the singularity of paediatric pathology"

Francisco Gonzales-Crussi (Mexico and USA)

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Francisco Gonzáles-Crussí, Miguel Reyes-Múgica, Irene Scheimberg, and Waney Squier are paediatric pathologists, and they discuss in detail the evolution of this branch of pathology from being part of general pathology practice to a specialism in its own right.  

Generally speaking, children were considered to be “just little adults” until a small group of pioneers developed expertise in the pathology of children and began to challenge this assumption in the 1950s and 60s.  

Paediatric pathology was gradually recognised as a specialist subject, but it only got its own board examinations in 1990 in the USA, and 2003 in the UK.  Even today, says Gonzáles-Crussí, "There will be some die-hards who say they can do everything, adults and children.  But the right thing to do is to have people devote all their attention so that they can see the singularity of paediatric pathology."

I think that, compared to adults, it's the overwhelming feeling of sadnessPerinatal pathology, which relates to the few weeks before and after birth, is very different again, says Scheimberg. Whereas paediatric pathology is mostly about living children, and trying to keep them healthy, perinatal pathology is all about death and loss.  "What would have happened in most hospitals 30 years ago is someone would have done a postmortem and said: 'Okay, well there's no malformation; I cannot see any major infection.' And that's it.  They couldn't say any more about what killed the baby.  Nowadays there are very, very few cases in which we cannot say something useful for the next pregnancy."

Scheimberg, Squier, Reyes-Múgica and Paola Domizio talk eloquently about the emotional aspects of working with children. "Children are always worse because you read the histories – often they're lovely little children, they've been ill for quite a long time… I think that, compared to adults, it's the overwhelming feeling of sadness," says Domizio.

They discuss how they achieve professional detachment, particularly when performing autopsies.  It is not always easy:  "I remember doing a postmortem on a child who had died of meningitis…," says Scheimberg.  "I just couldn't stop myself from identifying with the family.  It was the worst postmortem – he was a child more or less the same age as my son, eight years old at that time, had the same build, the same colour of hair."

Interviewees talk about what led them to specialise in paediatrics and what they have found particularly satisfying.  Squier explains: "Much of adult neuropathology has to do with dementia, Alzheimer's disease, strokes, and things that really are on the way downhill, whereas in development every week the brain is different.  It's like putting a puzzle together…"

You're doing this detective work which can really only be done on the developing brainThe conversations focus, too, on childhood diseases and conditions.  Helen Wainwright in South Africa talks about the problems of alcohol and drug abuse in the Western Cape, which result in high incidence of fetal abnormalities and illness, including fetal alcohol syndrome.  HIV infection is also a major threat to newborn babies and children in South Africa.

Gonzáles-Crussí discusses childhood cancers, and teratomas: "fascinating tumours that are composed of all kinds of tissues exotic to the place where they arise." Reyes-Múgica's specialist interest is neural crest disorders such as neurocutaneous melanocytosis, which presents as giant moles or naevi, and Hirschprung disease, a bowel disorder.  


Key intervieweesPaola Domizio, Francisco Gonzáles-CrussíMiguel Reyes-Múgica, Irene Scheimberg, Waney Squier,

See also: Alder Hey, Autopsy



Irene ScheimbergThere are a few places where adult pathologists do the babies, and we're trying to help them by taking that work off them, because we know it's not fair for them.  They are asked to do something that is much more specialised than people often realise…  If they do make a mistake, they don't make it because they are careless; they miss something because we are talking about super-specialisation.
 - Irene Scheimberg (UK)

I did a case of a very sick child who was 11 years old, but he had been ill all his life and really looked much smaller.  He had lots of problems from the disease. It was awful for the family, but for the child dying was probably a kind of liberation and release.  So I don't have difficulty in those sorts of circumstances.  But it's these children who are completely okay and then something happens to them – it's devastating.  But you have to find a way.
 - Irene Scheimberg (UK)

Miguel Reyes-MúgicaWhen you do an autopsy, usually the body has been in the refrigerator for several hours, it’s cold, and it has changed in colour and there are many familiar things. But with this little kid I saw something different.  She was completely dressed as a baby -- in a stroller with all these nice looking clothes.  She was pink and warm.  It is very difficult to open a body like that, and very different.
 - Miguel Reyes-Múgica (Mexico and USA)

Paediatrics is really different from adult medicine, and paediatric pathology is completely different.  You look at a tissue under a microscope, and if it’s from a child that is one day of age it’s different from the tissue of a child one month of age, and that’s different from tissue of a one year old, and that’s different from the tissue of an 18 years old. In Paediatrics the key is development.  When residents take a case to an adult pathologist, the questions the pathologist will ask when looking at a glass slide [of a tumour] are essentially, 'Where is the lesion?  How fast did it grow?  How big is it?'  The first question that a paediatric pathologist will ask is, 'How old is the patient?' 
 - Miguel Reyes-Múgica (Mexico and USA)

Paola DomizioThe first postmortem I ever did on a child was on a four year old girl who'd died after cardiac surgery, and she'd been dressed in her ballet tutu, a pink tutu, which was still on her…  I saw this little girl with blonde curls just lying on the slab and I just wanted to jog her, and say "Little girl, wake up. Wake up and run away, don’t you know what I'm about to do to you?"  And I really had to force myself…
 - Paola Domizio (UK)

Francisco Gonzales-CrussiIn the 40s and 50s…in the United States, there was a woman who was a pioneer.  It was Edith Potter and she was really like the founding mother of paediatric pathology.  [She] was working in Chicago… and she was skilful enough to obtain permission from the authorities of the city that any stillborn child there could be autopsied by her…She did fantastic work.  She was brilliant and so hard working that she really made what became later like the bible of paediatric pathology -- an inventory and a categorization of the different forms of anomalies that can be present.
 - Francisco Gonzáles-Crussí (Mexico and USA)

I think people thought that some of the diseases are so far advanced by the time the child is born that there was no point in wasting time studying them.  Now, with the upsurge in genetics and so on… And not only genetics, there are people who are even doing fetal surgery, right?  They operate on the baby and put it back in the mother's womb!   So now there is interest in all kinds of paediatric pathology.
 - Francisco Gonzáles-Crussí (Mexico and USA)

Irene ScheimbergThe main reason to do a postmortem is for the family.  And that's something you should never lose sight of: you want to tell a family what happened.  I think when a child dies the parents tend to feel guilty. As an adult, a parent, you're supposed to be able to protect your child, and the child's death is like a failure to protect.  So it's very important that there is a professional there to tell parents that this would have happened, no matter what they did, because that guilt is a terrible burden for a parent.
 - Irene Scheimberg (UK)

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