The pathology of fatal child abuse

Neuropathology and Ophthalmological Pathology of Fatal Central Nervous System Injuries in Young Children: Forensic Neuropathology of Deaths of Children Under Age 2, 2008-2016, in Central Missouri

Nonaccidental head injuries are significant causes of morbidity and mortality among young children. Despite broad agreement among medical experts, controversies remain over diagnostic criteria, including from autopsies, because of opinions expressed by a small group of expert witnesses who testify for defendants in suspected child homicide cases. We reviewed 249 autopsies in children 2 years old and younger from the files of our Medical Examiner office in the University of Missouri School of Medicine done between January 1, 2008 and December, 31, 2016. Because of gradually instituted mandatory examination of spinal cords and retinas, we had 127 autopsies with brain examinations by a neuropathologist plus retinal examinations of which 67 also had spinal cord examinations. Results were correlated with clinical records, police and EMS reports, and imaging. We found that subdural hematomas, cerebral edema, and retinal hemorrhages were mostly limited to autopsy findings in children who suffered from fatal head trauma, whether accidental (3 cases) or inflicted (14); they were not encountered in cases of homicide by other mechanisms or from natural diseases including infections, brain tumors, SIDS/SUID, or SUDC. Two cases with no other evidence of head trauma had focal retinal hemorrhages. We advocate for examination of retinas and spinal cords in all autopsies of children in this age group.

The morphology of cutaneous burn injuries and the type of heat application

The morphology of burn injuries in 120 consecutive patients from the Department of Plastic and Reconstructive Surgery, CHR, Hospital B in Lille was correlated to the etiology and type of heat. Analysis identified five typical patterns of cutaneous burn injuries. Jet of flame-pattern from methylated spirits and gasoline detonations: superficial burn injuries; sparing of skin wrinkles and the submental region; absence or small amounts of soot; preference of exposed body regions, esp. the face and hands. Explosion-pattern from explosions and electrothermal injuries: superficial burn injuries; sparing of skin wrinkles but not of the submental region; soot; preference of exposed body regions. Alveolar soot arrangement and metallisation in electrothermal injuries. Considerable third-degree burns in dust explosions. Flame-pattern from direct flame effects due to burning gasoline or oil, open fires or ignited clothing: nonuniform depth including large third-degree burns; no sparing of the submental region; soot; preference of body regions covered by clothing. Immersion-pattern: superficial (bullous) injuries; blurred junction between scalded and unscalded areas; extremities, buttocks, and back are favourite sites; cave child abuse: waterlines and zebra-burns. Spilling-pattern: superficial injuries; sharp junction between scalded and unscalded areas; head, anterior trunk, and upper extremities are favourite sites; running off and splashing stains. Consideration of these patterns can assist the reconstruction in fire investigations or unclear scaldings. In cases of suspected arson, a typical burn injury pattern or a single finding not compatible with the rest of the pattern can disprove a suspect or raise the level of suspicion.

Retinal hemorrhages in an 8-year-old child: an uncommon presentation of abusive injury

OBJECTIVE

Retinal hemorrhages in pediatric patients have been best described as a component of shaken baby syndrome (SBS), which has been described almost exclusively in the infant/toddler population. We describe the occurrence of retinal hemorrhages in the setting of abusive injury in an older child.

METHODS

Case report.

RESULTS

An 8-year-old boy was transferred to our institution with coma and respiratory arrest. Evaluation demonstrated intracranial hemorrhage, cerebral edema, and severe bilateral retinal hemorrhages. The patient subsequently died of intractable intracranial hypertension. Police investigation confirmed that the injuries were caused by severe abusive injury, including shaking.

CONCLUSIONS

This case emphasizes that the diagnosis of SBS is not limited to babies and that the possibility of abusive shaking injury should also be considered in older children presenting with intracranial pathology and retinal hemorrhages.

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.

Child burn: accident, neglect or abuse. A case report

The authors report a case of a child who has suffered three episodes of burn injuries in a short period of time, probably provoked by neglect or abuse from the parents. This mode of injury is of great importance because of the high mortality, as well as the physical, psychological and social sequelae that it causes. The absence of care and attention from the parents or caretakers contribute to the high frequency of this kind of trauma. In these cases, the admission of the child to the hospital is justifiable, regardless of the size or depth of the burn wound. Aspects concerning the epidemiology are discussed in this article, as are comments based on the literature about infant abuse and neglect.