Friday, April 1, 2011

How Do We Track Kidney Failure and Kidney Damage in Children Who Are Trained Using the Pearl Method?

I corresponded with someone earlier this week who was completely unaware of the death of Lydia Schatz. I also spoke with a friend of mine who followed the Pearl Method of “child training” with her children, and when I told her of the tragedy, it became so stressful and threatening, we declared a moratorium on the topic so that we could remain friends. This is a difficult matter that I believe needs to be revisited.

I would like to state from the outset that I think that there are some limited, reasonable applications for spanking of toddlers under certain circumstances, and I am not decrying the practice, nor am I to be confused with a zealous advocate. I wish to point out the potential for harm that the Pearl Method poses, something different than spanking to keep a child from running into the street or putting their hand on a hot burner, preventing greater pain and potential injury.

For those who are unaware, Michael Pearl is an Evangelical minister of No Greater Joy Ministries who for about the past 25 years or so has advocated spanking of infants and children. He boasts teaching approximately 1 million couples his particular view of “child training.” His developed his model based upon way the Amish train horses by “breaking their spirits.” He teaches that from infancy, a “liberal totalitarian” child struggles to dominate the parent in a war that continues and resurfaces throughout their childhood, and they must be “chastized” until their will “breaks.” Sparing the rod is spoiling the child, and Pearl's first choice for a “rod” is ¼ inch Teflon reinforced plumbing supply line which should be kept in every room in the house, something that can be worn around the parent's neck for easy access. More can be read about the practice on other critical websites (critical of Pearl's methods) such as Why Not Train a Child? And Tulip Girl.

On February 6, 2010, an eight year old child who was adopted from Liberia collapsed in her Paradise, California home after a spanking with plumbing line, reportedly for mispronouncing a spelling word. She died from the complications of acute kidney failure due to rhabdomyolosis (which I intend to explain in this post). Her eleven year old sibling Zariah (also adopted from Liberia) was hospitalized for renal failure but survived. The other children in the family were removed from the home and placed in the foster system. Their parents, Kevin and Elizabeth Schatz, face charges of torture, cruelty to a child resulting in harm, and murder in Butte County Superior Court on April 11.

From the initial news report about the Schatz Family from February 2011 2010:

My concern: If the Pearl Method of child discipline is followed in approximately 1 million homes, and we have seen cases of muscle cell destruction from parents that were described as mild, kind and gentle who have followed the method, I am concerned that other children have suffered some degree of significant kidney damage that will remain undiagnosed until later in life. Other cases of kidney failure may have not been reported within the Church. With the rising incidence of diabetes which is very damaging to the kidney, I believe that this population of children will be at even greater risk for kidney disease in their later years. A dose of the wrong antibiotic or too many NSAIDS could pose a clinical problem for these children. Are some parents causing kidney damage, not severe enough to produce in their children at the time of “child training,” a level of compromise that could only be detected by a physician who notes these changes in the blood work of these children? How will these people know until it is too late?

What is Rhabdomyolosis?

Rhabdomyolosis describes the condition which follows massive skeletal muscle deterioration, liberating large amounts of muscle cell waste into the bloodstream. As a nurse in critical care, working in critical care for more than ten years and in nursing for twenty-five, I've cared for about four patients in active and severe rhabdomyolosis, two of which were related to metabolic/medical processes and two were trauma related. The trauma cases were patients that had major muscles that were torn apart in car crashes, and the damage was extensive and very visible. Some marathon runners and people in or training for triathlons can develop clinically significant rhabdomyolosis because of extreme and abnormal muscle cell rupture, showing high levels of muscle cells in their bloodstream after these types of events. My salient point here: moderate to severe rhabdomyolosis is not a common occurrence. It certainly should not be a consequence of spanking or discipline.

I want to refocus here and explain exactly what happens in the kidney when so much muscle tissue breakdown product is released into the bloodstream. If parents regularly discipline some of their more “problematic” children with this method, I am concerned that cumulative damage can occur over time and that more acute damage (rapid onset of symptoms) may also occur in other children in the future. I'm also concerned that the church may never find out about most of these cases and cannot really get the information needed to truly evaluate the safety of Pearl's method.

“Rhabdo” refers to skeletal muscles. “Myo” means muscle. “Lysis” means rupture, creating the word “rhhabdomyolysis.” Rhabdomyolosis is the condition that results from rhabdomyolysis (the process). When muscle tissue breaks down, if it is in small quantities as happens naturally, the cells themselves contain enzymes (a natural digestive substance) which digest the tissue into very tiny particles. When exceptionally large numbers of muscle cells break down or are broken open due to great stress or trauma from beating, the muscle cells enter the bloodstream because there are so many and muscles have lots of blood vessels in them. When the blood becomes overloaded with these broken muscle cells (called myoglobin), they travel through the body. When they get to the kidney, these big broken cell pieces get pushed into the kidney and clog it.

Within each kidney, there are one million tiny, very fragile structures called nephrons, tiny little special tubes which not only remove fluid and protein waste products but also absorb nutrients, acids, and bicarbonate back into the body. Each of the yellow tube-like structures (we each were given two million of them) regulates what remains in the tube, eventually becoming urine.

The muscle cell breakdown products look something like the broken muscle fragments that appear in the figure displayed above. The kidney is designed to handle only tiny particles that are dissolved in fluid, not cells or tissue breakdown products. These cellular byproducts get squeezed into the tiny tubes and clog them. During treatment in the hospital, patients are administered huge amounts of IV fluids to keep the pressure high, pumping constant fluid through the tubes so that debris does not lodge in them.

What happens when the tubes get blocked so much that fluids cannot open them? Each one of those affected tiny tubes dies, a condition called acute tubular necrosis. Necrosis means that something is dead and rotting. Those tiny little marvelous and fragile structures die. They die, turn black and rot. They don't grow back. These patients will be compromised for the rest of their lives. If too many of those tiny tubes die, the body cannot process nutrients and wastes, it cannot balance acids in the body, and the kidney failure causes anemia, because another part of what the kidney does involves telling the bone marrow to make red blood cells.

For those who have rhabdomyolosis which produced acute kidney failure, as many as 20% of these people die. (This is sometimes what happens to marathon runners who die the day after a race.) The lack of function of the kidney creates a metabolic state in the body that can be inconsistent with life. Sometimes, treatment of these conditions that result are not enough to save a person's life. Such was the case with Lydia Schatz.

Zariah Schatz will live with compromised kidneys for the rest of her life because a part of her kidneys died. She may have enough function after treatment, but she will be compromised somewhat. As she ages, this will be a health concern for her.

Are the Dangers Worth the Risks?

Considering all of these factors, I am concerned that there are numbers of children who actually suffer some degree of rhabdomyolosis that results from the use of the Pearl method. If enough muscle damage occurs in a short period of time, a part of the kidney could clog and die, but not enough to produce symptoms. If the children are aggressively spanked on a chronic basis, considering Lydia and Zariah, it is possible that chronic damage could occur in children that is not bad enough to cause kidney failure but bad enough to cause damage. Unless a child undergoes blood tests at some point, “renal insufficiency” (inefficient kidney function that is lower than a normal, healthy level) could be present and no one would be the wiser. It is conceivable that at least some children have experienced some damage, but not enough to produce symptoms of kidney failure.

My other concern involves the unreliable or absent reporting of cases of children who have suffered renal failure as a consequence of the use of the Pearl method. Individual states may keep records of children who have suffered renal failure because of these spankings and were removed from the home, but they may not be identified and tracked (as associated with the Pearl Method). State Child Protection Agencies also do not typically share information with other states unless trends have been recognized on larger scales. Healthcare agencies will not be aware of these discipline methods, and it is my guess that families that used the Pearl method will seek to keep the specifics a secret. The cases may not occur often enough for those intervening doctors and nurses (and CPS agents) to notice and capture/track what may be trends on a broader scale. Even if parents are prosecuted in Family Court, these individual cases may not be easy to identify. They may not result in prosecution in some cases.  We only know about Lydia and Zariah because Lydia died.

Have there been several cases of renal failure in children whose families utilized the Pearl method?  [2Apr11 Update: There probably are. ]  I don't think that there would be a way to know on a broad scale. Child protective services and healthcare providers cannot report individual cases to the press because of privacy laws and concerns. Families, church members, and individual pastors would have to report such occurrences to the Church, and given the embarrassment factor, I do not believe that many if any would be forthcoming.

Have there been undiagnosed cases of rhabdomyolosis and has it occurred on a chronic basis producing renal insufficiency in some children? Many of the communities of people who rely on the Pearl method eschew traditional healthcare. Some children are never issued birth certificates, born with the assistance of lay midwives. What else goes unnoticed?

I think that it would be wise for the church to take notice of these matters before one more child suffers. You only get 2 million nephrons in life (those tiny little wonderful miracle tubes in the kidney), and they don't grow back if they get damaged. Could the plumbing line be ironically destroying a child's own metaphorical plumbing?

I don't think that those low protein, low potassium diets are a whole lot of fun, and dialysis is no picnic. Renal insufficiency and failure limits the treatment of arthritis pain, as NSAIDS strongly affect the pressure of blood in the kidney and cannot be used in patients with damage. Certain antibiotics and other medications cannot be used in people with weak kidney function, and others medicines must be used sparingly and monitored. Is it really worth this divine right of spanking with plumbing line if it puts little ones at risk?

What is the church going to do about it, 
or will we ignore it until Caesar does something for us?


A list of symptoms and management of early and chronic renal insufficiency:

  • Usually few or no physical symptoms that you can feel. 
  • Blood work results will show abnormalities - mainly a slightly elevated serum creatinine. Note that there is often a time lag between elevations of serum creatinine. By the time serum creatinine is elevated, the person may already have lost 50% of kidney function.
  •  Urine may show abnormalities, and urine amounts in this stage do not indicate whether compromise is present. Urine can be checked by dipstick in the doctor's office (as an initial check), and followed up with a more complete urinalysis that is sent out to a lab. 
  • High blood pressure can occur early in renal insufficiency. 
  • Anemia may rarely occur at this stage. 
  • Treatment may include a low protein diet and blood pressure medicines even though high blood pressure may not be present. 

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