INFANT DEATHS Infanticide It is defined as the unlawful destruction of a child under the age of one year. In India there is no distinction between the murder of a newborn infant and that of any other individual. Other terms used are: – Foeticide: the killing of the fetus at any time prior to birth. – Filicide: the killing of a child by its parents. – Neonaticide: the killing of a child within 24hrs of birth. Questions to be answered: Whether the child has attained viability or not? Whether the child was stillborn or dead born? Whether the child was born alive? If born alive, how long did the child live? What was the cause of death? Still Birth A stillborn child is one, which is born after 28th week of pregnancy, and which did not breath or show any other signs of life, at any time after being completely born. In this, the child was alive in utero, but dies during the process of birth. Incidence is about 5% and is seen more frequently in illegitimate and immature male children. In these cases, the body is sterile and putrefaction occurs from without inwards, but in those which has shown some form of life, this starts from within. Prolonged labour, which is shown by presence of caput succedaneum, and severe moulding of head, indicates still birth or death from natural causes shortly after death. Common causes of stillbirth are: – – – – – – – Prematurity. Anoxia of various causes. Birth trauma, specially ICH. Placental abnormalities. Toxemia of pregnancy. Erythroblastosis fetalis. Congenital defects of fetus. Dead Birth This is a child, which has died in utero and shows one of the following signs after it is completely born: – Rigor mortis at birth. – Maceration: • This is aseptic autolysis and occurs when the child remains in the uterus for about 3 – 4 days immersed in liquor amni but devoid of air. • Earliest sign of maceration is skin slippage and is seen in 12 hrs of death in utero. Gas in aorta of fetus indicates fetal death. • Other changes seen are red/purple skin, blebs, distended abdomen, flexible joints and bones, soft viscera, etc. • Spalding sign: loss of alignment and overriding of skull bones of the cranial vault. – Mummification. – Putrefaction Viability of Fetus Viability means the physical ability of a fetus to lead a separate existence after birth apart from its mother, by virtue of a certain degree of development. A child is viable after 210 days of intrauterine life and in some cases after 180 days. Livebirth means that the child showed signs of life when only part of the child was out of mother, though the child may not have breathed or completely born. Causing of death of such a child is regarded as homicide. Signs of Livebirth In Civil cases, any sign of life after complete birth of the child is accepted as proof of livebirth. They may be hearing a cry, movement of limbs, etc. The law presumes that every newborn child found dead was born dead till the contrary is proved. In Criminal cases, livebirth has to be demonstrated by Postmortem examination of the child. Postmortem Examination Shape of chest: – Before respiration, the chest is flat and its circumference is 1 – 2 cm less than the abdomen at the level of umbilicus. – After respiration, the chest expands and becomes arched or drum shaped. Position of diaphragm: – Highest point of diaphragm is found at the level of 4 – 5 ribs if respiration has not taken place, but if breathing has taken place, it lies opposite 6 – 7 ribs. May be affected by decomposition gases. Lungs: – Volume: Fully respired lungs fill the pleural cavities, whereas in unrespired cases the lungs appear collapsed on to the hilum. – Margins: Usually sharp before respiration, but becomes rounded even if feeble respiration has taken place. Bullae, if seen suggests some form of obstruction. – Consistency: Lungs are dense, firm and non – crepitant like liver before respiration, but becomes soft, spongy, elastic and crepitant if respiration takes place. This should be differentiated from crepitation following putrefaction or artificial respiration. – Color and Expansion of Air vesicles: Before respiration, lungs are uniformly reddish-brown, bluish or deep violet according to the degree of anoxia. On section, there is little froth-less blood coming out. After respiration, air cells becomes expanded and raised above the surface. The color becomes pink and whole lung have mottled or marbled appearance. On section, frothy blood exudes out. – Blood in Lungs field: Amount of blood after respiration increases to twice that in circulation to that of still born. – Weight: • Static Test / Fodere’s Test: Lungs are ligated at hilum and separated and weighed. Before respiration, it is 30 – 40 gm and after respiration, 60 – 66 gm due to increased blood flow. • Ploquet’s Test: After respiration, due to increased blood flow in the lung beds, their weight gets almost doubled from 1/70 of body weight before respiration to 1/35 of body weight after respiration. Not a reliable indicator. – Hydrostatic Test: • Principle: This is based on the fact that on breathing, the volume of lungs is increased and which more than compensates for the increased blood flow. As a result specific gravity of lungs decreases. It varies from 1040 – 1050 before respiration to 940 after respiration. • Procedure: A ligature is tied on the bronchi and lungs separated. Each individual lungs is placed on water. If they float, each lung is cut into 12 – 20 pieces and then placed on water. A small piece of liver is kept as control. If this liver also floats the test if of no value. If the pieces still float, they are each squeezed in between the thumb and index finger under surface of water to see if any bubbles of air escape or not or they are taken out of water, wrapped in piece of cloth and squeezed by putting weight to remove the tidal air. The pieces are again put on water. • If they float because of residual air, respiration has taken place. • If they sink, respiration has not taken place. • If some sinks and some floats, feeble respiration has taken place. • Limitations: – The expanded lungs may sink from Diseases (Acute edema, pneumonia, congenital syphilis), Atelactasis (Air not entering the lungs due to :– a) feeble respiration, – b) complete absorption of air from the tract by blood, – c) more air expelled than inhaled or – d) obstruction by alveolar duct membrane) – Unexpanded lungs may float from Putrefactive gases, Artificial respiration, etc. – Hydrostatic test is not necessary when Fetus is a Monster, Macerated, Mummified, stomach contains Milk, Born before 180 days of gestation, Umbilical cord has separated and a scar has formed. – Vagitus Uterinus: When child breathes after rupture of membrane, while it is still in the womb. – Vagitus Vaginalis: The child breathes while its head is in the vagina. Changes in Stomach & Intestines: – Air gets swallowed into the stomach during respiration. The stomach and intestines are ligated at each end and put into water. If respiration has occurred, they float, otherwise they sink. This is also called as Breslau’s 2nd life test. Changes in the Middle Ear: – Before birth, the middle ear contains gelatinous embryonic connective tissue. With respiration, the sphincter at the pharyngeal end of Eustachian tube relaxes and air replaces the gel like substance within few hours to weeks. This is called as Wredin’s test, but not reliable. Other signs of Live Birth: – Blood: Nucleated RBC usually disappear within 24 hrs and fetal hemoglobin decreases from 80% to 7% by 3rd month. – Meconium: It is a green viscid substance consisting of thick bile and mucus. This is completely excreted in first 24 – 48 hrs after birth. – Caput Succedaneum: This is an area of soft swelling that forms in the scalp over the presenting part of the head in vertex presentation. This is due to local interference with venous return produced by the pressure of the rigid cervical ring. It has to be differentiated from Cephalhematoma. – Skin changes: At first it is bright red, then darker, brick red, yellow and then normal within a week. Yellow color is due to physiological jaundice. Vernix caseosa persists for 1 – 2 days. – Air in GI Tract: Swallowed air gets propelled to Stomach within 15 min, small intestine in 1 – 2 hrs, colon by 5 – 6 hrs and the rectum by 12 hrs. – Umbilical cord: Blood clots within 2 hrs, vessels begin to close by 24 hrs, cord attached to the child shrinks and dries by 12 – 24 hrs, then mummification of the cord occurs on 3rd day and it falls off on 5th or 6th day and scar is formed by 10 – 12 days. – Circulatory changes: Contraction of umbilical artery occurs by 3rd day, umbilical vein and ductus venous gets closed by 4th day, ductus arteriosus closes by 10th day and foramen ovale closes by 2nd or 3rd month. Causes of Death: – Natural causes: like immaturity, debility, congenital diseases, malformations, hemorrhage pre-eclamptic toxemia, placenta previa, neonatal infection, intra-partum or ante-partum anoxia, cerebral birth trauma or erythroblastosis. – Unnatural causes: • Accidental: like prolonged labor, prolapse of the cord, twisting of cord, injuries to mother, death of mother, suffocation, etc. • Criminal: – Acts of commission like suffocation, strangulation, drowning, burning, blunt head injury, fracture of cervical vertebra, wounds, poison, etc. – Acts of omission like neglect (failure of proper assistance, failure to tie cord, failure to clear air passages, failure to protect from heat or cold, failure to supply proper food). – Abandoning of infants: If the parents abandons a child of <12 yrs should be punished with imprisonment of 7 yrs (Sec 317 IPC). – Concealment of birth: Whoever secretly buries or disposes a dead child with the intention of concealing the birth, will be punished with 2yrs imprisonment (Sec 318 IPC). Battered Baby Syndrome Also called as Child abuse syndrome or Caffey’s syndrome. A battered child is one who has received repetitive physical injuries as a result of nonaccidental violence, produced by a parent or guardian. In addition, there may be deprivation of nutrition, care, affection etc. Classically, this is detected by obvious discrepancy between the nature of injuries and explanation offered by the parents and the delay between the injury and medical attention which cannot be explained. Features: Age: usually < 3ys of age or any age. Sex: Seen more in males. Position in family: Commonly the eldest or the youngest or the unwanted. Socio-economic: Younger parenthood and lower socio-economic status. History: of obvious discrepancies between the injuries and explanations given along with the delay for seeking medical attention. Precipitating factors: by the actions of the child itself. Injuries: Soft tissue injuries like abrasions, bruises, lacerations of different ages seen on cheeks, mouth, tearing of the frenulum of inner mucous membrane of lips, etc. Infant whiplash syndrome: which occurs due to the effects of shaking a child leading to SDH, Intra-occular hemorrhages, retinal detachment etc. Bruises are seen on the arms, hands, with traction lesions of periosteum of long bones. Permanent brain damage may occur due to habitual prolonged shaking of the child. Slap lines showing petechial hemorrhages and butterfly bruises indicating pinching on the skin. Sub-galeal hematoma due to pulling of hairs and traumatic alopecia may be seen. Visceral injuries like bursting injuries of liver or spleen. Cigarette butt burn injuries. Periosteal hematoma, epiphyseal separation, Nobbling fracture (in paravertebral gutter) seen as ‘String of Beads’. Diagnosis: Nature of injuries seen. Time taken to seek medical attention. Injuries of recurrent types. D/d from scurvy, cong. syphilis, rickets, osteomyelitis, osteogenesis imperfecta. Munchausen’s Syndrome by proxy: A type of child abuse involving mother, in which children are brought to doctors for induced signs or symptoms of illness with fictitious history. The child is admitted frequently in the hospitals for non-existing conditions. Methods of Simulation of Illnesses: Mother may prick the child’s finger and adds blood to urine of the child and takes the sample to doctor. Child’s nose is closed with two finger and lower jaw is pushed up with palm to block airways. A pillow may be put on the face of the child and then pushed onto the bed. She may give insulin to the child and take him to doctor for hypoglycemia. She may also give emetics, laxatives, psychotropic drugs, CNS depressants, etc. Sudden Infant Death Syndrome SIDS as it is called is defined as the sudden and unexpected death of seemingly healthy infant, whose death remains unexplained even after thorough investigation. Features includes: – – – – – – – – – Incidence: 0.2 – 0.4 % of all live-births. Age: 1 wk to 1 yr. Sex: Male to female ratio of 3:2. Twins: Increased risk among twins. Geographical: Worldwide incidence. Time of death: During sleep and in early morning. Prematurity: Higher risk. Socio-economic: Lower status. Cigarette smoking: by mother has got higher risk. Autopsy findings: Milk or blood stained froth at mouth and nostrils. Usually negative autopsy findings. In 15% cases, some pathological causes can be seen such as pneumonia, congenital heart diseases, tracheo-bronchitis, etc. The only constant findings are multiple petechial hemorrhages on the visceral surface of the heart, lungs and thymus which are agonal in nature. Hands are clenched to bed sheets. All these changes seen are rarely sufficient to cause death. Theories put forward: – Sleep apnea which is a periodic failure to breathe during sleep. – Respiratory infection leading to nasal edema and mucus secretion. – Laryngeal spasm. – Vomited milk based materials on the mattress may get infected by Staphylococcus aureus and when this gets transmitted to the child, may lead to anaphylactic shock and sudden death. – Other proposed causes are: conduction system anomalies, mechanical upper airway obstruction, adrenal insufficiency, gastro-esophageal reflux leading to bradycardia, hypersensitivity to cows milk, etc.
