Child Abuse & Infanticide PDF

Child Abuse Dr. Isam Ahmed Ali Specialist of Forensic Medicine and Clinical Toxicology  Child Abuse Child Abuse Physical Sexual Emotional (Psychological) Negligence  Child Abuse MCQ: Hydrostatic test is not necessary in: A- F...

Child Abuse Dr. Isam Ahmed Ali Specialist of Forensic Medicine and Clinical Toxicology  Child Abuse Child Abuse Physical Sexual Emotional (Psychological) Negligence  Child Abuse MCQ: Hydrostatic test is not necessary in: A- Foetus is a monster H B- Macerated C- The umbilical cord has separated and a scar has formed D- All of the above  Child Physical Abuse (CPA) Definition: It is the crime of repeated willful injury of a child by inadequate parents or guardian or watcher.  Child Physical Abuse (CPA) General features: 1- Repeated injuries; (different ages, sites and patterns) 2- Delay in seeking medical assistance; 3- Child has been taken to different hospitals or doctors for treatment of the different injuries; 4- The explanation(s) does not correlate with the type or the extent of the injuries  Child Physical Abuse (CPA) Injuries: External Internal 1- multiple bruising with different colors from rough handling, punching, kicking, etc.; 2- Burn (stubbing by cigarette ends upon the skin, hot water- trickle-like burns where the water has run down the body.) 3- multiple fractures in limbs, ribs or skull 4- Subdural hemorrhages, cerebral trauma and axonal damage 5- retinal and vitreous hemorrhages 6- torn frenulum 7- visceral injuries NB Negative external findings do not exclude child Physical abuse  Child Physical Abuse (CPA) NB: Head injuries are the most frequent cause of death in child abuse, they are caused either by; direct trauma to the head or shaking (shaken baby syndrome).  Fatal Child Abuse Infanticide and Child Murder Infanticide  Infanticide Definition: It is a deliberate killing of a newly born, live born and viable infant.  Infanticide It should be noted that:  Only the mother can benefit from this alternative to murder.  The child has to be less than one year old, though the majority of cases occur within hours or even minutes of birth (newly born= infant within the first 15 days after delivery).  It has to be a child with separate existence (viable = the end of the 7th intrauterine month.)  child death must have by a willful act of omission or commission.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 1- Assist in identifying the child & his mother (unknown or suspected) 2- Estimate the maturity & viability of the child 3- Estimate whether born alive or stillborn 4- Estimation of the period of survival 5- Determine causes of death of a newly born infant  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 1- Assist in identifying the child & his mother (unknown or suspected) depending on:  The date and place where the body should be noted (Crime Scene)  Description of anything with the body e.g. clothes, newspapers, blankets, wrappings, & bags should be done carefully.  The appearance of cut end of the cord and any ligation or clamping.  The apparent ethnic group of the child as well as any congenital anomaly or birth mark.  Blood grouping.  DNA fingerprinting.  Estimation of age during the intra-uterine life  However, despite these clues, identification of the mother remains unattainable.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 2-Estimate the maturity & viability of the child Any neonate born before37 completed weeks regardless the weight is considered premature. On the other hand, the age of viability is 28 weeks’ gestation i.e. 7 months, below this age there is a strong presumption that child could not long survive a birth away from medical attention.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn * Non medical evidence of live-birth e.g. witness stating that the infant moved a limb, cried, sneezed or opened its eyes. * Medical evidence of live-birth Changes at Cord base Desquamation of Resp. skin Ext. Signs Int. Signs A.M. injury Feeding Well formed stool CV Absence of maceration  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn External signs of alive born  Changes around the base of the umbilical cord 1 day after birth ----- a ring of hyperemia appears. 2 days after birth ---- ulceration starts in this ring. 1 week after birth ----- fall of umbilical stump. 2 weeks after birth ----- formation of umbilicus.  Desquamation of the skin Starts 2 days after birth, and is completed after 2 weeks  A.M. injury Denotes the live-birth of the newborn, and it may be due to: - The application of forceps. - The actual cause of death e.g. cut throat.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn External signs of alive born  Well-formed stools May be present in the infant wrappings. These are yellow, stools which must be differentiated from the dark green meconium that are expelled by still-birth infants squeezed during difficult labor.  Absence of Maceration Maceration denotes death in utero (IUFD) before delivery; and a macerated child is characterized by a brown red discoloration of skin , a rancid smell, flaccidity of the body, and undue mobility of skull bones.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of respiration A- Naked-eye appearance of the lungs B- Microscopical appearance of the lungs C- Static test D- Hydrostatic test (Floatation test) E- Stomach-bowel test  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of respiration A- Naked-eye appearance of the lungs The changes in a respired lungs are due to the expansion of the lung alveoli. Respired lungs are characterized by being: Voluminous filling the chest cavity and cover the heart & thymus. With rounded edges. With mosaic or mottled appearance. Crepitate under the fingers. B- Microscopical appearance of the lungs The alveoli of a non- respired lungs are collapsed, lined with columnar epithelium. On the other hand, respired lungs show distended air vesicles lined with flattened epithelium.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of respiration C- Static test The weight of the lungs are doubled on respiration due to closure of the ductus arteriosus. - The weight of non-respired lungs is 40 grams (1/80 of BW.). - The weight of respired lungs is 80 grams (1/40 of B.W.).  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of respiration D- Hydrostatic test (Lung floatation test) Principle : is that respired lungs have Lower specific gravity and tend to float. Procedure: o The chest contents are removed as one block and placed in a basin. o Then each lung and each lobe is tested separately. o Then each lobe is divided into small pieces & placed in water. o finally, some of these pieces are subjected to pressure application either by being firmly squeezed in a towel or pedallic pressure. They are placed in water to see that floatation. Results: All parts of the lungs sinks in non-respired lungs, while all parts of the lungs float in case of full —respiration. The lungs float but some small pieces sinks in partially respired lungs. If the lung pieces float after pedallic pressure, thus floatation is due respiration and not putrefaction.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of respiration E- Stomach-bowel test Principle: on starting breathing, the child having undeveloped reflexes will swallow some air that gradually passes from the stomach to the intestines. Procedure: the stomach, the duodenum, and the upper & lower parts of the intestines are ligated at both ends, and then each of them is placed in a water basin. Results: Floatation of the stomach is an evidence of respiration. Floatation of stomach, duodenum & upper intestines while the lower intestines sinks; is a proof that the infant lived for 3hours. Floatation of all parts denotes that the infant have lived for 6 hours.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of feeding o In the stomach The colostrum corpuscles or digested milk are found on microscopica1 examination of the gastric contents. o In the intestines When yellow well-formed stools are found in the bowels.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 3-Estimate whether born alive or stillborn Internal signs of alive born Signs of CV Umbilical vessels 1 —2 days after birth ----- the vessels are shrunken, and the lumen is filled with red blood clot 1 week after birth starting organization. 2 weeks after birth ----- complete organization of the clot. 4 weeks after birth ---- the vessel changes into fibrous cord. Foramen ovale It closes after 1 week of birth, but sometimes it does not close at all resulting in persistent patent valvular foramen. Ductus arteriorus - After 6 hours functional closure occurs. - After 6 weeks ----- actual obliteration occurs.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 4-Estimation of the period of survival The period the infant lived after its live-birth has to be compared with the time passed since the delivery in a woman suspected to be the mother. The following signs help to estimate the age of the infant after birth: o Desquamation of the skin and its extent. o Floatation of the stomach and intestines. o Changes in the skin at the base of the umbilical cord. o A.M. injuries of the infant and vital reactions (healing & sepsis) occurring in the injuries. o Changes in the umbilical vessels. o Closure of the foramen ovale. o Obliteration of the ductus arteriosus.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 5- Determine the causes of death of a newly born infant  Natural & accidental causes  Negligence (Act of omission)  Violence (Act of commission) NAI  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 5- Determine the causes of death of a newly born infant  Natural & accidental causes - Immaturity of the infant. - Congenital malformations. - Difficult labor mainly due to disproportion between the head of the fetus and the pelvis. - Precipitate labor, means that the child is suddenly expelled without any previous warning whilst the woman was standing in the erect position. - Accidental suffocation of the infant with mucous from the maternal passage. - Accidental strangulation of the infant by its cord. - Congenital syphilis. - Erythroblastosis foetalis.  Infanticide MLI: The role of forensic pathologist in a case of infanticide is to: 5- Determine the causes of death of a newly born infant  Negligence (Act of omission) In this case, death is due to neglect of the mother e.g. omission of feeding of the infant, omission of protect from heat or cold.  Violence (Act of commission) Poisons Cut throat. Are not uncommonly used for the purpose of infanticide Stab wounds Are less common ; and may be caused by needles , or scissors that may penetrate the heart , brain or other organs. Violent asphyxia Such as smothering , throttling , drowning , strangulation especially by the cord , and choking by packing a gauze. Head injury “Cot Death” Sudden Infant Death Syndrome (SIDS) Definition: It is Sudden death of an infant which is unexpected by history and by examination of the scene and in whom a thorough autopsy fails to reveal an adequate cause of death.  Sudden Infant Death Syndrome (SIDS) Etiology The true etiology of SIDS is unknown, but many suggestions have been made: 1. Overlaying and suffocation in the early days. 2. Fulminating viral infections. 3. Allergy to milk proteins. 4. Abnormality of cardiac conducting tissue or malfunctioning respiratory reflexes. 5. Hypernatraemia from incorrectly prepared food. 6. Neurological damage caused by minor birth trauma 7. CO or C02 poisoning. 8. Hypothermia or hyperthermia.  Sudden Infant Death Syndrome (SIDS) Main features of SIDS: 1. Age range between 2 weeks and 2 years, with a peak at 2 to 3 months. 2. Slight preponderance of males. 3. The incidence is greater in one of twin pair whether identical or not (Due to great incidence of premature and low body weight among twins). 4. SIDS more common in colder and wetter months. 5. Higher incidence in poor housing, low occupational status. Autopsy Sudden Infant Death Syndrome (SIDS) N.B. SIDS is a diagnosis of EXCLUSION  Sudden Infant Death Syndrome (SIDS) MLI:  Exclude fatal H child abuse  Counseling of parents