Death and Injury in Infancy

8/11/2019 Death and Injury in Infancy

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DEATH AND INJURY

IN INFANCY

Prof. Dr Slobodan Savić



In infancy, there are specific features

concerning both natural and violent death

natural death

- st i l lb ir th

- SIDS

violent death

- in fant ic ide- ch i ld abuse (SCAN)



Syndrome of Child Abuse and Neglect

S C A N ???Q



a dead infant found in a container



Medicolegal task for forensic pathologist is

to assess:

1. if it is a newborn or an older child

2. maturity of a newborn baby or fetus

(gestational age)

3. infant's viability

4. whether the child was born alive /

duration of life

5. the cause of death / the time of death

6. identity of an unknown mother



1. Estimation if an infant is a newborn

or an older child

newborn period immediately after delivery

- WHO definition - the first four weeks

- some pediatricians and forensic pathologist

- the first week

signs of recent delivery

external:

- skin - cyanotic, blood, maeconium, vernix

- umbilical cord - soft, wet

- falls of after 5 to 7 days

Q





SKIN is cyanotic,

covered with blood,maeconium, and

vernix







UMBILICAL CORD - soft, wet







umbilical cord - falls of after 5 to 7 days



dried and shrunken remnant of the umbilical

cord – just before falling of



uncompletely healed umbilical area

after falling of the umbilical cord

THE BABY IS NOT A NEWBORN ANY MORE



completely healed umbilical area

after falling of the umbilical cord



1. Estimation if an infant is a newborn or an

older child

signs of recent delivery

internal:

- caput succedaneum - if the head excelled- cefalhaematoma - if the head excelled

- maeconium in the intestines





CAPUT SUCCEDANEUM

gelatinous edema of the scalp tissue on the partof the head which was prominent during delivery



usually occipital region













CAPUT SUCCEDANEUMgelatinous edema of

the scalp tissue

yellowish, sometimes

dark-red due to the

extravasation of blood



CEFALHAEMATOMA

subperiostal hematoma on the part of the skull

which was prominent during the deliveryusually occipital region

limited by skull sutures



MAECONIUMdark-green intestinal contents - in mature

children present in the terminal part of the

rectum









appearance of the intestinal

contents after feeding

with milk



2. Estimation of maturity

of a newborn baby or a fetus

estimation of gestational age

normal duration of pregnancy

10 months x 4 weeks = 40 weeks





2. Estimation of maturity

of a newborn baby or a fetus

estimation of gestational age

traditional formulae – the Haase rule

the first 5 months (20 weeks) of gestation

the length of the body in cm equals thesquare of the age in months

in the 3 rd month the length is 3 2 = 9 cm

the last 5 months (21 to 40 weeks) of gestation the length of the body in cm equals five

times the age in months

in the 7 th month the leng th is 7 x 5 = 35 cm

Q



2nd month







Put the proper number (only one) which

indicates the expected length of the fetal body,

on the line with corresponding gestational age(according to the Haase Rule):

(1) 6 cm

(2) 16 cm _____ the end of the 7th month


(4) 28 cm(5) 35 cm






(1) 6 cm

(2) 16 cm __5__ the end of the 7th month


(4) 28 cm(5) 35 cm






(1) 6 cm



(4) 28 cm(5) 35 cm



Changes in body weight are not so regular,

and depend much more on life conditionsin utero – “small for date baby”





Other signs of gestational age:

external: diameters of the head, head hair, alveolarsockets in mandible, finger- and toe-

nails, lanugo, vernix, genitals (palpabletesticles)

internal:

diameter of fontanelles, ossificationcentres (lower end of femur in thegestational age of 9 months)



in a mature baby

length of the

head hair is 2cm



in a mature

baby

ear lobe

and nose

cartilages are well

developed

andpalpable



in a mature baby

finger- and toe-nails

reach the tips of fingers and toes



in an immature

baby(26th gestational week)

finger- and toe-

nails

do not reach the

tips of fingers

and toes



in a prolonged

pregnancy

finger- and toe-nails exceed

the tips of fingers

and toes



in a mature baby lanugo hairs are present only

on the shoulders and in the scapular region







5th th vernix caseosa



5th month vernix caseosais absent

vernix caseosa



26th weekvernix caseosa

is absentskin is redish



8th month

large amount of

vernix caseosa

th



10th month – vernix caseosa is present

only in body folds



genitals – in mature male babiestesticles are palpable in scrotum





genitals – in immature male babiestesticles are not palpable in scrotum

(26th gestational week)

in immature female babies labiaj d t l bi i



majora do not cover labia minora

in mature female babies

labia majora cover labia minora



large fontanelle small fontanelle



in a mature baby

diameter of the

large fontanelle

is 2cm

ossification centre in calcaneum is present in the



pgestational age of 5 months – its diameter in amature baby is 10 mm









3 Estimation of an infant’s viability



3. Estimation of an infant s viability

the potential ability of an infant

to survive after birth

3 main factors:

1. maturity of an infant

2. absence of life-threatening diseases

3. absence of anomalies incompatible with life

Q



3. Estimation of an infant’s viability

termination of pregnancy

up to 28 weeks – abortion or miscarriage

from 29 to 38 weeks - premature birthfrom 39 to 40 weeks - mature birth

- up to 28 weeks – abortion or miscarriage - fetus



up to 28 weeks abortion or miscarriage fetus

is not viable due to the immaturity of the body

- owing to the modern medicine, a fetus of even

24 weeks can potentially survive given intensivehospital care

- the age of viability in English law was taken as

28 weeks' gestation, though this has now been

reduced to 24 weeks



The remains of a fetus recovered from asewage farm – the result of an abortion. Thereis considerable maceration of the body. The

gestational age was 16 weeks – the baby wasnot viable, so that no further action wasrequired.

Death occurs due to the baby’s immaturity – fatal



S-1320/06 female praematurus – born in 26/27 week of

pregnancy, body weight at delivery 800g - died 4 months

after delivery

y youtcome may be delayed, and it is immediatelycaused by some complications (pneumonia, brainedema, brain hemorrhage, sepsis)

female praematurus – born in the gestationalage of 25/26 weeks body weight 650g



age of 25/26 weeks, body weight 650g,

died 7 days after delivery



pink-stained hyaline membranes lining alveoliin the lung - Respiratory Distress Syndrome

(RDS) of the newly born, particularly if the

child survives for some time



pulmonary atelectasis and hyaline membranes

Respiratory Distress Syndrome (RDS)









brain in an

immature baby(26th gestational week)

flattened

surface without

gyri and sulci



brain in an

immature baby(35th gestational week)

no visible gray

matter





female praematurus



female praematurus



ventricular hemorrhage






3. Estimation of an infant s viability

from 29 to 38 weeks - premature birth

- an organism of a prematurely born child is

immature, primarily regarding state of the

lung and respiration, with possible

development of respiratory distress

syndrome

- the prematurely born child may stay aliveonly under the special medical conditions

and care - conditional capability of life




3 st at o o a a t s ab ty

from 39 to 40 weeks - mature birth

- If the child is born between 38 and 40 weeks

of pregnancy, its organism is mature and

viable

- the child may survive, if there are no life-

threatening diseases or anomalies which areincompatible with life



S-725/06 Mature male infant – normal course ofpregnancy and spontaneous delivery – APGAR score 9



p eg a cy a d spo ta eous de e y G sco e 9

The baby started to cry immediately after normal

delivery, but only one minute later he suddenly

manifested severe respiratory crisis, became cyanoticand rapidly died





Autopsy findingscomplete

transposition

of the big heart

vessels – aortaexits from the

right ventricle

the right ventricle was consequentlyextremely hypertrophic



y yp p

(6mm thick wall instead of normally 2mm)

pulmonary trunk exitsfrom the left ventricle



Foramen ovale was closed during the pregnancy,and ductus Botalli was not identified



and ductus Botalli was not identified

this anomaly was

incompatible with lifeimmediately fatal











unrespired lungs – collapsed in the thoracic

cavity , dark, heavy, sharp margins



respired lungs

expanded,

overlapping themediastinum,

rounded edges



respired lungs

pink or mottled,rounded edges,

spongy tissue,

when rubbed

between the

fingers -

crepitation

FLOTATION TEST - lungs and

t i t ti l t t t i t t



gastrointestinal tract are put into water

positive test – the tissue is on the water

surface

indicates that specific weight of lung tissueis less than specific weight of water – it is

not a certain sign of breathing



positive flotation test



negative test

the neck andthoracic

organs sink

on the bottom



negative test

the lung

tissue sinks

on the bottom





negative flotation test



the test is of limited value - only as a



y

suggestive pointer

false positive results - tissue floats in water

even from the dead body (putrefaction

gases, artificial ventilation)

false negative - lung tissue from

indisputably alive infant sink in water

Q

infant born in intact amniotic sac aspiration of amniotic fluid instead of air



p

false negative flotation test



microscopical examination of the lung is inevitable

f ll i d l ti



fully respired lung tissue

non-respired lung tissue

pulmonary atelectasis



pulmonary atelectasis

air in the gastrointestinal tract - estimation of

duration of life - stomach filled with air after 3



duration of life - stomach filled with air after 3

minutes of breathing

the presence of air only in the stomach, whileintestines sink – indicates a short period of life (up



to 3 minutes of air swallowing)



the whole small intestine is filled withair after 6 hours



air after 6 hours

indisputable but late sign ofliving - milk in the stomach





indisputable but late sign of living - shriveled

umbilical cord or with inflammatory ring

rarely useful since most infants die within hours

or even minutes of birth

5. Estimation of the cause of deathand time of death



the most important medicolegal problem -

detailed analysis

Medicolegal investigation of a dead infant

special autopsy technique (flotation test,dissection of bones for ossification centres)

detailed microscopic examination

other investigations depending on actual

case history(radiological, toxicological, biochemical,serological, bacteriological, virological)



Examination extremely difficult - many dead newbornshave not been discovered until decomposition has

begun or been in an advanced stage impossible to

estimate viability, stillbirth or live birth, the cause and

time of death, and identity of an unknown mother

6. Identification of an unknown mother



When a dead infant is found in clandestinecircumstances (in ditches, rivers, rubbish

dumps, etc.) - unknown identity - important

to identify the mother (especially ininfanticide)

- artifacts discovered with the body (bags,

blankets, clothing, newspapers)

6. Identification of an unknown mother



- autopsy – apparent ethnic group, bloodgrouping, DNA profiling, ligation of the

umbilical cord (medical or amateur)

Most abandoned newborn corpses fail to be

linked to the mother (delayed discovery

advanced putrefaction)

The child was

recently born, but



had been washed

and dressed. The

lungs were fully

expanded, but no

injuries or any

cause of death

was found atautopsy. The

mother was never

traced, which is

common in thistype of case.

concealment

of birth

THE CAUSES OF DEATH IN INFANCY



natural violent

NATURAL DEATH IN INFANCY

death during the pregnancy - in utero (bacterial and viral infections, metabolicdisorders, congenital anomalies, placental

disturbances) - the child will be born dead

"STILLBIRTH"



If the dead body isnot expelled from

the uterus more

than a few days

missed abortion

maceration

Q



macerationautolysis, without

bacteria - the body

is red, blistered and

desquamated skin,softened tissues,

loosen head and

joints

maceration clearly indicates that

death occurred before parturition



death occurred before parturition

death during the delivery



g y

- prolonged and hindered birth - early

attempt of breathing aspiration of

amniotic fluid (suffocative asphyxia)



Alveoli containing squamous cells from the vernix

caseosa of the fetal skin. When these are abundant

and lying free in the alveoli it suggests that the child

has not breathed.

In this case of meconium aspiration, small rounded balls of meconium are

seen in an alveolus, along with flattened "squames" or desquamated fetal

skin cells that are found in the amnionic fluid. Meconium is an irritant that



leads to respiratory distress. At birth, tracheal suction and lung lavage may

be useful to help remove the meconium.

excessive head compression craniocerebralinjuries (tear in the tentorium - subdural hemorrhage)





A positive finding in a baby whose body was

abandoned after death. Respiration had occurred,

but on examination of cranium, a tear in thetentorium was found with an adjacent meningeal

hemorrhage, presumably caused by excessive

moulding of the head during delivery.

examination of falx cerebri



examination of tentorium



Definition of stillbirth (British) - a child ofmore than 28 weeks (until recently 24 weeks)



o e t a 8 ee s (u t ece t y ee s)gestational age, which after being

completely expelled from the mother, did notbreathe or show any signs of life (movement,crying, pulsation of the umbilical cord)

Until a separate existence is gained, itcannot be the victim of murder or infanticide

In practice, the proof of a separate existenceis the proof of live birth

death during the newborn period and

infancy - various congenital or acquired



infancy - various congenital or acquired

diseases and anomalies

Sudden Infant Death Syndrome (SIDS)

"cot death" "crib death"

Sudden death of infants, which is unexpected

by history, and in which the cause and mode

of death remain unclear after detailed post-

mortem examination including autopsy,microscopical, toxicological, serological,

bacteriological, biochemical and all other

analyses.

Q

- Age between 2 weeks and 2 years - majority

between 1 and 7 months - peak at 2-3 months



between 1 and 7 months peak at 2 3 months

- Incidence - higher in premature and lowbirth-weight infants colder and wetter

months and regions disadvantages families

(poor housing)

- In developed Western countries - 1 case in 500

live births a noteworthy decrease since 1991

(campaign encouraging mothers to sleep thebaby on its back, refrain from smoking in

pregnancy and near the baby, not overheating

the baby)

- SIDS still forms the most common cause of

death in the postperinatal period in the



death in the postperinatal period in the

developed countries !

- The usual and uniform case history - a

perfectly well child (or with trivial

respiratory symptoms) being put in the

sleeping place at night, to be found dead in

the morning

A characteristic scene – the child is often lying face

downwards in a carry-cot



The front view of



the child who died

in its cotunexpectedly and

suddenly.

There are pressuremarks due to

bedding. There is

often a little blood-

stained froth at the

nose or mouth.

- No specific autopsy findings - cases with

positive findings (pneumonia congenital



positive findings (pneumonia, congenital

heart disease) are excluded

- The usual autopsy findings - petechiae on

the pleura, epicardium and thymus

(unspecific, diagnosticly useless)

An one-month-old baby – sudden death

suspicious SIDS



p



- Various hypotheses - allergy to cows' milk,

prolonged sleep apnea, hyperthermia,



prolonged sleep apnea, hyperthermia,

hypothermia, viral bronchiolitis, etc.

- The true cause is still unknown - probably

multi-factorial

- The doctor's main concern - to support the

family by explanations (tragedy for the

family, sympathetic handling, activecounselling)

- Usual problem - differential diagnosis to

ll d h i id d t th i b



alleged homicide due to smothering by

willful action of parents - on the basis of

autopsy it is difficult either to confirm or to

negate

SMOTHERING IN INFANTS MAY LEAVE NO

SIGNS AT ALL

VIOLENT DEATH IN INFANCY



accidental homicidal

ACCIDENTAL DEATH IN NEWBORN INFANTS

precipitate (very fast) delivery - in standing or

sitting position - the newborn may fall down on

the ground (head injury) or in a lavatory pan

(drowning)



smothering - covering of an infant's face withsome part of the body if an unconscious

mother



mother

infant born in intact amniotic sac aspiration of

amniotic fluid instead of air

INFANTICIDE (lat. infanticidium)



deliberate killing of a newborn infant

by the mother

may be performed by omission or commission

"omission" - the deliberate failure to provide the

normal care at birth (tying and cutting the cord,

clearing the air passages of mucus, keeping the

baby warm and fed) - abandoned infants

PASSIVE INFANTICIDE

Q

The child was



recently born, but

had been washed

and dressed. The

lungs were fully

expanded, but noinjuries or any

cause of death was

found at autopsy.abandoned infants

"commission" - active manipulations of the

mother in order to terminate the infant's life



ACTIVE INFANTICIDE

Mechanical and asphyxial injuries - blunt

head injuries (child thrown to the floor or

against a wall), stabbing, cutting the throat,

drowning, manual smothering, throttling,

ligature strangulation, drowning (often a way

of disposing of an already dead child)



A midline fracture

of the skull with

blood clot over

the posterior part

of the skull.The mother struck

this child on the

head with a piece

of wood.



A depressed fracture of the skull in a newly born

child caused by a blow across the side of thehead with a rolling pin. There is much

surrounding blood clotted beneath the scalp. A

severe brain injury was inflicted.



Brain injury A contusion of the right lateral

side of the brain with subarachnoid bleeding

in other parts of the brain

homicide of



a newborn

infant

traumaticseparation of theliver with resultant

i ti



exsanguination

traumaticseparation of theliver with resultant

i ti



exsanguination

definite



infanticide

the child having

fully respired

before having this

severe incised

wound of the

neck made with

a kitchen knife

a newborn infant



a newborn infant

with multiple stabwounds found

wrapped in

newspapers in atrash can placed

on the street for

disposal



ligature

strangulation

ligature strangulation





ligature

strangulation

ligature strangulation



throttling



throttling



Important to avoid misinterpretation of some



Important to avoid misinterpretation of some

findings on an infant's body - e.g., scratcheson the neck of a newborn infant following an

unattended birth, are often due to the finger-

nails of the mother trying to assist birth bypulling on the neck - usually arise suspicion

on throttling





Abrasions on the neck due to traction to

assist self-delivery, not strangulation

The body of a newborn infant wired to abuilding block recovered from the Baltimoreharbor.





choking

Smothering of a newborn. The bruises andabrasions are caused by pressure of a handagainst the face.



Injuries usually easily

demonstrable at

autopsy (exception -

suffocation, especially

smothering, may leave

no signs at all - almost

impossible to prove it

or to negate)

SOCIAL AND LEGAL ASPECTS

OF INFANTICIDE



This phenomenon goes back into prehistory -

sacrificial ceremony, method of population

control

Well-recognised medical and psychiatric

phenomenon - different from other types of

homicide

Many countries have introduced legislation of

avoid a criminal charge of murder where a



mother kills her child soon after birth -

Infanticide Acts in England and Wales

Where a woman by a wi l l fu l act o f om iss ion o r

commiss ion , causes the death of her chi ld

being under the age of twelve month s , bu t at the

t ime the balance of her m ind was d isturbed by

the effects of chi ldb irth o r lactat ion, she may be

deal t wi th as i f she had commit ted

manslaughter .

Four prerequisites must be fulfilled:

Q



1. The mother is only perpetrator2. The child has to be less than a year old

(the majority occurs within hours or even

minutes of birth)

3. The victim has to be a living "child"

4. Death has to be caused by a willful act of

omission or commission, at the time the

balance of the mother's mind wasdisturbed due to the childbirth or lactation

Q

In many countries the infanticide is legally

treated as privileged homicide which is less



treated as privileged homicide which is less

severely sentenced comparing to pure

homicide - e.g., in England as manslaughter

- a less serious charge than murder, without

the mandatory penalty of life imprisonment

(sentences are probation or psychiatric

supervision).

MEDICOLEGAL ASPECTS OF UNCLEAR

DEATHS IN INFANCY



In all cases of unclear death in infancy, amedical practitioner must be very careful,

always keeping in mind the possibility that

some deaths caused be injuries due toinfanticide or child abuse may be

deliberately presented as natural by

perpetrators of homicide. In such cases theusual explanations are presented as a

history of stillbirth or SIDS.

Meadow , R. (1999) Unnatural sudden infan t death.

Arch Dis Ch ild , 80(1): 7-14.



81 cases from 50 families (during the 18-year-period) – after medico-legal autopsy and

investigation, a natural manner of death was

determined, under the circumstances typical for

SIDS

By means of further investigation procedure and

detailed medicolegal examination, it was

positively proved that babies were killedperpetrator – mother

method – smothering

Because of that, all alleged stillbirths which

were not witnessed by a doctor or midwife,

ll ll d SIDS h ld



as wall as all supposed SIDS cases should

be reported for medico-legal investigation.

The only way to positively clear up the realcause and manner of death is to perform

thorough medico-legal autopsy and all other

additional investigations (microscopical,

toxicological, microbiological, etc.) in

accordance with each particular case.

That’s all for today thank you for your at tent ion





SLIDES

S-1009/74 Cephalhaematoma

S-286/90 Subperiostal haematoma



p

Aspiration of amniotic fluid – 22 HISTOLOGY COLLECTION

S-319/97 putrefaction

bez broja putrefaction

bez broja maceration

S-150/72 Infanticide – head injury

S-251/86 Infanticide – stab and incised wounds

L-109/67 Infanticide – incisionsL-396/64 Infanticide – incision, cut throat

S-483/82 decapitation (body)

” decapitation (head) S-948/87 drowning, foam

S-329/75 ligature strangulation - take from VeljS-966/81 ligature strangulation, mark - take from Velj

bez broja - sa tekstom throttling - take from Velj

ZA OLU DOKTORAT MOJ I SVEDSKI

UZETI SLIKU SA STUDENTIMA IZ



UZETI SLIKU SA STUDENTIMA IZ

OBDUKCIONE SALE ZA POSLEDNJI SLAJD

Slike – kefalhematom

kaput succedanuem

mekonijum u crevima

otvorena gr. duplja sa disalim plucima

otvorena gr. dup. sa nedisalim plucima

S.br. PRVA TRAKA OD 90 MINUTA



456/20011003/2001

Novorođenče - cela specijalna obdukcija - povrede glave (partus praecipitatus)

spoljašnji nalaz je presnimljen slučajem vešanja dečaka od 14 god. -

specijalna obdukcija vrata (ceo snimak novorođenčeta postoji na prvoj video kaseti)

S.br. TREĆA TRAKA OD 90 MINUTA

1097/2001 Novorođenče iz kontejnera - ročno (možda i preneseno) - sa

posteljicom

æ ə š Ө ∫ З ^

aspect (‘æspekt)

maturity(‘mə‘tjuəriti)

fetus (‘fitəs)

t ti (dЗ ’ t j∫ )Q



gestation (dЗe’stej∫ən)

gestational

viability (vajə’biləti)

gelatinous (dЗə’lætnəs)

alleged (ə’ledЗəd)

formula (‘fo:mjulə) diameter (dai’ æmitə)

umbilical (^m’bilikəl)

Incompatible (,inkəm’pætəbl)

clandestine (klæn’destin)

t (‘ t )

Q

Death and Injury in Infancy

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