FORENSIC PATHOLOGY

1. FORENSIC PATHOLOGY SUDDEN INFANT DEATH SYNDROME

2. SIDS • Incidences of SIDS cases have been falling steadily since 1992 • Less than 1 per 1000 live births

3. SIDS • SIDS occurs prior to 10 months of age • Most frequently during first 6 months • Males outnumber females • Socioeconomic status • Low temperature may increase incidence

4. SIDS • Non-Hereditary • 1st death may be SIDS • 2nd death “Undetermined” • 3rd death “Homicide”

5. SIDS • What is SIDS? • Unknown etiology • Diagnosis is one of exclusion • Examine organs, microscopy and toxicology • Autopsy fails to reveal cause of death or substantial disease • No unusual circumstances surrounding death

6. SIDS • Myths about disease • Produced by DPT vaccine • Hereditary idiopathic apnea

7. SIDS • Investigation of Death • Be careful accusing family of child abuse • May confuse postmortem lividity for bruising • Child may have blood-tinged froth in mouth and nose • Diaper rash may or not be due to trauma

8. Neonaticide, Infanticide, Child Homicide • Neonaticide = Within 24 hours of birth • Infanticide = 1st year of life • Child Homicide = What is a child? • Media can distort these figures

9. Neonaticide, Infanticide, Child Homicide • Child Murders by Age (1999) • Infants (under 1 year) = 205 • 1 to 4 years = 208 • 5 to 8 years = 95 • 9 to 12 years = 79

10. Neonaticide Most murders occur in the first two years of life. Filicide The killing of a child by its parent Most killings by parents are done using “personal weapons”

11. Neonaticide • Usually done by mother • Young and unmarried • Didn’t know she was pregnant???

12. Neonaticide • Was child born alive? • Hydrostatic Test of Lungs • Petechiae of lungs can occur during labor • Gas in stomach can be due to labored respiratory efforts • Microscopic exam of Lungs

13. Infanticide • May be done by mother, husband, boyfriend, babysitter? • Common weapons are • Hands, feet, fists, blunt objects, firearms, strangulation, smothering, knives, etc.

14. Infanticide • Quite often: • “impulse” or “angry” homicide • “punished child” • “gentle” homicide • Munchhausen’s Syndrome by Proxy

15. Infanticide • The majority of deaths are due to: • 1st – Head injuries • Subdural or subarachnoid hematomas usually with accompanying skull fractures • 2nd – Abdominal injuries • Lacerations of the liver, spleen, pancreas and bowels • May lead to peritonitis

16. Infanticide • Battered Baby Syndrome • Repeated intentional trauma • Deprivation of food and water and • Locking baby in closet or leave alone for prolonged periods are variants of this syndrome

17. Infanticide • Battered Baby Syndrome • Old and recent bruises • Unusual fractures • Burns • Odd marks • Linear or odd shaped contusions • Interior of mouth cut or split open

18. Infanticide • Battered Baby Syndrome • Excuses • Fell out of High Chair • Rolled off of table or bed • Put hands in boiling water or pulled a pot off of stove • Sibling turned hot water on in tub

19. Infanticide • Battered Baby Syndrome • Most die due to head trauma • Starved or neglected child • Left in feces and urine • Sunken feature of face • Sunken abdomen • Prominent ribs and other bones • Ulcerating diaper rash

20. Infanticide • Battered Baby Syndrome • Impulse or Anger Homicide • Usually husband or boyfriend • May be burn injuries • Parent can get quite creative with punishment • Pick child up and throw or slam into an object • Head injuries #1 • Abdominal injuries #2

21. Infanticide • Gentle Homicides • Smothering • Death occurs in 70 – 90 seconds • SIDS ??? • Little to no struggle • No defense wounds on perpetrator or victim

22. Infanticide • Munchausen’s Syndrome by Proxy • Can be Lethal or not??? • Virtually always mother who’s perpetrator • Mentally unstable • Looking for sympathy • Induced signs and symptoms of illness • Fictitious medical history

23. Child Homicide • Child Deaths caused by: • Poisoning • Stabbing • Clubbing • Drowning • Shooting • Burning • Use your imagination

24. Child Homicide • Assailants • 1 – Psychotic Parent • No attempt to conceal actions • 2 – Sane Individual • Tries to make death appear as an accident • Tries to make self appear insane • 3 – Sibling • Jealousy

25. Child Homicide • Fractures • Epiphyseal injuries • Probably not accidental • Spiral • Twisting of an extremity • Transverse • Direct blow to bone • Bending of bone • Skull • Rib

26. Shaken Baby Syndrome • Does this truly exist? • Symptoms may include • Retinal hemorrhages • Intracranial bleeding • Subarachnoid and subdural hematomas • May also experience contusions and fractures due to hitting head with hard surface

27. Shaken Baby Syndrome • Or is it Shaken Impact Syndrome (SIS)? • Angular acceleration and velocity associated with SBS is not enough to cause symptoms • Must have impact to cause damage • Concussion, subdural hematoma, diffuse axonal injury

28. Case Study • The janitor of a university dormitory went into a women’s restroom and discovered a baby in the toilet. He immediately called the police and they in turn called the medical examiner. The medical examiner observed a newborn, approximately third trimester, infant with an attached placenta. There was blood within the toilet and on the floor of the stall.

29. Case Study • Later in the day a young coed living on the fifth floor admitted she gave birth to the baby shortly after midnight. She became scared, stayed in her room and did not tell anyone what happened. • The police asked the girl what she specifically did to the baby while it was being born. The girl replied that she did not remember the exact sequence of events but she did feel the baby was not alive when it was delivered

30. Case Study • Because the baby was not moving. She assumed the baby was born dead, but did not know for sure. • The pathologist did not see any internal or external injuries, except for some subscapular hemorrhages which he attributed to the birthing process. There was approximately 10 ml of water in the stomach but no water in the lungs. He placed the lungs in both water and formalin and they sank.

31. Case Study • He concluded the baby had never taken a breath and was stillborn. Was this an accurate diagnosis and examination of this case? Explain why or why not. Please add specific details to verify your explanation.

32. Case Study • The determination of a live birth versus a stillborn is difficult, particularly when a child may have died within a few minutes after birth. The question in this case is whether or not the baby drowned in the toilet or was born dead. X-rays should have been taken to determine if air was present in the lungs in addition to the gastrointestinal tract. If a baby is born alive, there should be some indication of air in the lungs.

33. Case Study • An obsolete test was performed to determine if the lungs would float in water. If they floated, presumably air had been inhaled. This test has been shown to be meaningless. The gross appearance of the lungs can provide some indication of whether they have been aerated. Areas of aeration will appear pink as opposed to a dark purple-red color of those areas which never expand after birth. The presence or absence of air within the

34. Case Study • Gastrointestinal tract is helpful because babies will swallow air, even if they live a short time, and it will travel into the small bowel. Unfortunately, if cardiopulmonary resuscitation is attempted, air may be forced into both the small bowel and lungs, negating this finding.

35. Case Study • The pathologist in this case made assumptions based on unreliable techniques. The baby should have been x-rayed to check for the presence of air. Even if x-rays had been taken, however, the diagnosis of stillbirth may not have been made with certainty. In the absence of evidence of trauma, however, stillbirth is clearly the most reasonable conclusion.