Deaths and Injury in Infancy

• Infant- <1 year
• Infanticide means the unlawful destruction of a child under the age of 1 year.
• Stillbirth and sudden infant death syndrome, which have important medico-legal aspects.

Still birth

• It is the child (born after 28 weeks)which did not breathe or show any sign of life at any time after being expelled from the mother.
• Common causes are prematurity, anoxia, birth trauma especially intracranial hemorrhage due to excess moulding, placental abnormality.

Dead birth:

• Is a child which has died in the utero and shows one of the following signs after complete birth:
• Rigor mortis at delivery
• Maceration (aseptic autolysis after 3-4 days in uterus filled with amniotic fluid and no air). The earliest sign of maceration is skin slippage, which can be seen in 12 hours after death in utero. The body of the macerated fetus is soft, flaccid, and flattens out when placed on a level surface. It has a sweetish disagreeable odor. Spalding’s sign is the loss of alignment and overriding of the bones of the cranial vault.
• Mummification: is the condition in which the fetus dries up, shriveled in the uterus. It occurs when fetus dies from deficient supply of blood, when the liqor amni is scanty and when no air enters the uterus.

A newborn infant showing marked maceration due to an intrauterine death. The cord around the neck is significant, but a full autopsy is required to establish the cause of death.

Signs of live birth:

Shape of chest- flat, circumference

The position of diaphragm- found at the level of 4th or 5th rib if no respiration, 6th or 7th rib after breathing.

Lungs- After respiration, volume is increased, margins become rounded, consistency becomes soft, spongy, elastic and crepitant. The hydrostatic test by placing the lung tied at bronchi into water- if floats suggests respiration but an unexpanded lung may float from putrifaction and the expanded lung may sink from disease like acute edema, pneumonia.

Stomach- air is swallowed into the stomach during respiration.

Other signs of live birth- caput succedaneum, cephalhematoma, air in GI tract, clothed body, vernix caseosa washed.

How long did the child survive?

• Caput succedaneum disappears within 7 days.
• Changes in umbilical cord:

1)Clotting at cut end- 2hours

2)Shrinks and dries- 1st day

3)Cord mummified- 3 to 4 days

4)Cord falls- 5 to 6 days

5)Ulcers heals by scar- 10 to 12 days

Skin changes:

1)Vernix caseosa- persists for a day or 2

2)Color bright red at birth, becomes dark at 2nd or 3rd day

3)Original color 7 to 10 days.

Cause of death:

• Natural- Immaturity; malformation; disease of heart, lungs or brain; meconium aspiration; Rh incompatibility.
• Accidental- cord prolapse; prolonged labor; cord round the neck; placenta previa; death of mother; aspiration of blood or liquor; precipitate labor.
• Criminal- suffocation, strangulation with cord, drowning in milk or water, throttling, failure to tie the cord, removal of child from mother’s charge, omission to feed.

Abrasion of the neck of a baby. These marks were said to have been caused by traction of the neck of the baby by the mother during self-delivery. Similar marks could be caused by strangulation.

Battered baby syndrome/ child abuse syndrome

Also called maltreatment syndrome in children

A child who has received repetitive physical injuries as a result of non-accidental violence produced by a parent or a guardian.

In addition to physical injuries, there may be deprivation of nutrition, care and affection.

The classical discrepancy between the nature of the injuries and explanation offered by parents, and delay between the injury and medication is clear.

Constant repetition of injuries at different dates.

Munchausen’s syndrome by proxy

Is feigning illness or injury and going from hospital to hospital for unnecessary investigations and treatment.

Children are brought to doctors for induced or fabricated signs or symptoms of illness.

Child is frequently admitted to hospital for illness, non existing in real.

These patients appear to be compulsively driven to make the complaints. The parent is aware that he is acting an illness but he can not stop the act.

Method of production of illness- mother pricks her finger and adds blood to the urine sample of her child, a pillow or towel is put over the face of the child and the face is pushed down into bed clothing, mother gives insulin to the child and takes to hospital with hypoglycemia, drugs for diarrhea, vomiting given to the child.