DEATH AND INJ URY

IN INFANCY
Prof. Dr Slobodan Savi
In infancy, there are specific features
concerning both natural and violent death

natural death
- stillbirth
- SIDS
violent death
- infanticide
- child 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 part
of the head which was prominent during delivery

usually occipital region
CAPUT SUCCEDANEUM
gelatinous 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 delivery
usually occipital region
limited by skull sutures
MAECONIUM
dark-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 the
square 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 length is 7 x 5 = 35 cm
Q
2
nd
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
(3) 30 cm _____ the end of the 4th month
(4) 28 cm
(5) 35 cm
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 __5__ the end of the 7th month
(3) 30 cm _____ the end of the 4th month
(4) 28 cm
(5) 35 cm
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 __5__ the end of the 7th month
(3) 30 cm __2__ the end of the 4th month
(4) 28 cm
(5) 35 cm
Changes in body weight are not so regular,
and depend much more on life conditions
in utero small for date baby

Other signs of gestational age:

external:
diameters of the head, head hair, alveolar
sockets in mandible, finger- and toe-
nails, lanugo, vernix, genitals (palpable
testicles)

internal:
diameter of fontanelles, ossification
centres (lower end of femur in the
gestational 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
and
palpable
in a mature baby
finger- and toe-nails
reach the tips of fingers and toes
in an immature
baby
(26
th
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
5
th
month
vernix caseosa
is absent
26
th
week
vernix caseosa
is absent
skin is redish
8
th
month
large amount of
vernix caseosa
10
th
month vernix caseosa is present
only in body folds
genitals in mature male babies
testicles are palpable in scrotum
genitals in immature male babies
testicles are not palpable in scrotum
(26
th
gestational week)
in immature female babies labia
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
gestational age of 5 months its diameter in a
mature baby is 10 mm
ossification centre in the lower end of femur is
present in the gestational age of 9 months its
diameter in a mature baby is 5 mm
3. Estimation of an infants 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 infants viability
termination of pregnancy

up to 28 weeks abortion or miscarriage
from 29 to 38 weeks - premature birth
from 39 to 40 weeks - mature birth

- 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 intensive
hospital 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 a
sewage farm the result of an abortion. There
is considerable maceration of the body. The
gestational age was 16 weeks the baby was
not viable, so that no further action was
required.
S-1320/06 female praematurus born in 26/27 week of
pregnancy, body weight at delivery 800g - died 4 months
after delivery
Death occurs due to the babys immaturity fatal
outcome may be delayed, and it is immediately
caused by some complications (pneumonia, brain
edema, brain hemorrhage, sepsis)
female praematurus born in the gestational
age of 25/26 weeks, body weight 650g,
died 7 days after delivery
pink-stained hyaline membranes lining alveoli
in 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
(26
th
gestational week)
flattened
surface without
gyri and sulci
brain in an
immature baby
(35
th
gestational week)
no visible gray
matter
ventricular hemorrhage
usual complication
and immediate
cause of death
in immature infants
female praematurus
female praematurus
ventricular hemorrhage
3. Estimation of an infants 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 alive
only under the special medical conditions
and care - conditional capability of life
3. Estimation of an infants viability
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 are
incompatible with life
S-725/06 Mature male infant normal course of
pregnancy and spontaneous delivery APGAR score 9
The baby started to cry immediately after normal
delivery, but only one minute later he suddenly
manifested severe respiratory crisis, became cyanotic
and rapidly died
Autopsy findings
complete
transposition
of the big heart
vessels aorta
exits from the
right ventricle
the right ventricle was consequently
extremely hypertrophic
(6mm thick wall instead of normally 2mm)
pulmonary trunk exits
from the left ventricle
Foramen ovale was closed during the pregnancy,
and ductus Botalli was not identified
this anomaly was
incompatible with life
immediately fatal
4. Estimation if the child was born alive,
duration of life
- proving of presence of air in the lung and
intestines - due to breathing and swallowing
indisputably vital phenomena

the most difficult pathologist's task

- the best estimation - appearance of lungs
at autopsy

unrespired lungs collapsed in the thoracic
cavity , dark, heavy, sharp margins
respired lungs
expanded,
overlapping the
mediastinum,
rounded edges
respired lungs
pink or mottled,
rounded edges,
spongy tissue,
when rubbed
between the
fingers -
crepitation
FLOTATION TEST - lungs and
gastrointestinal tract are put into water

positive test the tissue is on the water
surface

indicates that specific weight of lung tissue
is less than specific weight of water it is
not a certain sign of breathing

positive flotation test
negative test
the neck and
thoracic
organs sink
on the bottom
negative test
the lung
tissue sinks
on the bottom
positive flotation test
negative flotation test

the test is of limited value - only as a
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
false negative flotation test
microscopical examination of the lung is inevitable
fully respired lung tissue
non-respired lung tissue
pulmonary atelectasis
air in the gastrointestinal tract - estimation of
duration of life - stomach filled with air after 3
minutes of breathing
the presence of air only in the stomach, while
intestines sink indicates a short period of life (up
to 3 minutes of air swallowing)
the whole small intestine is filled with
air after 6 hours
indisputable but late sign of
living - 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
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)
5. Estimation of the cause of death
and time of death
Examination extremely difficult - many dead newborns
have 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
When a dead infant is found in clandestine
circumstances (in ditches, rivers, rubbish
dumps, etc.) - unknown identity - important
to identify the mother (especially in
infanticide)

- artifacts discovered with the body (bags,
blankets, clothing, newspapers)
6. Identification of an unknown mother
- autopsy apparent ethnic group, blood
grouping, 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)
6. Identification of an unknown mother
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 at
autopsy. The
mother was never
traced, which is
common in this
type of case.
concealment
of birth
natural violent

NATURAL DEATH IN INFANCY

death during the pregnancy - in utero
(bacterial and viral infections, metabolic
disorders, congenital anomalies, placental
disturbances) - the child will be born dead
"STILLBIRTH"
THE CAUSES OF DEATH IN INFANCY
If the dead body is
not expelled from
the uterus more
than a few days

missed abortion
maceration
Q
maceration
autolysis, 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 during the delivery
- 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 craniocerebral
injuries (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 the
tentorium 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 of
more than 28 weeks (until recently 24 weeks)
gestational age, which after being
completely expelled from the mother, did not
breathe or show any signs of life (movement,
crying, pulsation of the umbilical cord)

Until a separate existence is gained, it
cannot be the victim of murder or infanticide

In practice, the proof of a separate existence
is the proof of live birth
death during the newborn period and
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

- Incidence - higher in premature and low
birth-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 the
baby 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
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 cot
unexpectedly and
suddenly.
There are pressure
marks 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
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
- Various hypotheses - allergy to cows' milk,
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, active
counselling)
- Usual problem - differential diagnosis to
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 with
some part of the body if an unconscious
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 no
injuries 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 the
head 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
traumatic
separation of the
liver with resultant
exsanguination
traumatic
separation of the
liver with resultant
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
with multiple stab
wounds found
wrapped in
newspapers in a
trash can placed
on the street for
disposal
ligature
strangulation
ligature strangulation
ligature
strangulation
ligature strangulation
throttling
throttling

Important to avoid misinterpretation of some
findings on an infant's body - e.g., scratches
on the neck of a newborn infant following an
unattended birth, are often due to the finger-
nails of the mother trying to assist birth by
pulling on the neck - usually arise suspicion
on throttling
Fingernail marks on
the neck of a
newborn,
suggestive of
manual
strangulation.
The teenaged
mother claimed that
these were inflicted
during her attempts
to deliver the baby
by herself.
Abrasions on the neck due to traction to
assist self-delivery, not strangulation
The body of a newborn infant wired to a
building block recovered from the Baltimore
harbor.
choking
Smothering of a newborn. The bruises and
abrasions are caused by pressure of a hand
against 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 willful act of omission or
commission, causes the death of her child
being under the age of twelve months, but at the
time the balance of her mind was disturbed by
the effects of childbirth or lactation, she may be
dealt with as if she had committed
manslaughter.
Four prerequisites must be fulfilled:

1. The mother is only perpetrator
2. 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 was
disturbed due to the childbirth or lactation
Q
In many countries the infanticide is legally
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, a
medical practitioner must be very careful,
always keeping in mind the possibility that
some deaths caused be injuries due to
infanticide or child abuse may be
deliberately presented as natural by
perpetrators of homicide. In such cases the
usual explanations are presented as a
history of stillbirth or SIDS.
Meadow, R. (1999) Unnatural sudden infant death.
Arch Dis Child, 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 killed
perpetrator mother
method smothering
Because of that, all alleged stillbirths which
were not witnessed by a doctor or midwife,
as wall as all supposed SIDS cases should
be reported for medico-legal investigation.

The only way to positively clear up the real
cause 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.
Thats all for today
thank you for your attention

SLIDES
S-1009/74 Cephalhaematoma
S-286/90 Subperiostal haematoma
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 incisions
L-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 Velj
S-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
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
456/2001
1003/2001
Novoroene - cela specijalna obdukcija - povrede glave (partus
praecipitatus)
spoljanji nalaz je presnimljen sluajem veanja deaka od 14 god. -
specijalna obdukcija vrata (ceo snimak novoroeneta postoji na
prvoj video kaseti)
S.br. TREA TRAKA OD 90 MINUTA
1097/2001 Novoroene iz kontejnera - rono (moda i preneseno) - sa
posteljicom
^
aspect (spekt)
maturity (mtjuriti)
fetus (fits)
gestation (destejn)
gestational
viability (vajbilti)
gelatinous (dltns)
alleged (ledd)
formula (fo:mjul)
diameter (dai mit)
umbilical (^mbilikl)
Incompatible (,inkmptbl)
clandestine (klndestin)
amateur (mt:)
parturition (partjurin)
fluid (flu:id)
Q