Infant Deaths

According to the Infanticide Act of England ( 1938), infanticide means the unlawful destruction of a child under the age of one year. Only the mother can be charged with the offence when the circumstances justify it, such as when the infant is killed by its mother while suffering from disease of the mind due to the effect of stress associated with her pregnancy, delivery, puerperium, or lactation. In such cases, the mother may not be held wholly responsible for killing the infant. In India, there is no such special Act, and as such there is no distinction between the murder of newborn infant and that of any other individual. Foeticide is the killing of the foetus at any time prior to birth. Filicide is the killing of a child by its parents. Neonaticide is the deliberate killing of a child within 24 hours of its birth. Infanticide does not include the death of foetus during labour, when it is destroyed by craniotomy or decapitation. Infanticide is rare and usually committed by a young unmarried woman or widow. Infanticide is usually committed at the time of, or within a few minutes or hours after the birth. The alleged mother should be examined for signs of recent delivery and her mental condition should be noted. In case of the child, the points to be decided are:

1. whether the child was stillborn or dead born?
2. Whether the infant has attained viability or not?
3. Whether the child was born alive?
4. If born alive, how long did the child live?
5. What was the cause of death?

STILL BIRTH: A stillborn child is one, which is born after twenty-eighth week of pregnancy, and which did not breathe or show any other signs of life, at any time after being completely born. The child was alive in utero, but dies during the process of birth. Stillbirths occur more frequently among illegitimate and immature male children in primiparae. The incidence is about five percent. It is born in sterile condition, and as such, putrefaction occurs from without inwards, whereas in case of newborn child which lived for some time, the bacteria inside the body may cause putrefaction to start in the abdomen. Signs of prolonged labour, i.e., oedema and bleeding into the scalp, a caput succedaneum, and severe molding of the head indicate stillbirth or death from natural causes shortly after birth.

Common causes of stillbirth are: prematurity, anoxia of various types, birth trauma especially intracranial hemorrhage due to excessive moulding, placental abnormalities, toxemias of pregnancy, erythroblastosis foetalis, and many types of congenital defects.

DEADBIRTH: A dead born child is one which has died in utero, and shows one of the following signs after it is completely born.

1. Rigor mortis at delivery.
2. Maceration: Maceration is a process or aseptic autolysis, and is the usual change. This occurs when the dead child remains in the uterus for about three or four days surrounded with liquor amnii but the exclusion of air. Signs of maceration are not seen, if the child is born within 24 hours after death. If air enters the liquor amnii after death of the foetus, putrefaction occurs instead or maceration.

The earliest sign of maceration is skin slippage, which can be seen in 12 hours after the death of the child in  utero. The body of a macerated foetus is soft, flaccid and flattens out when placed on a level surface. It has a sweetish, disagreeable odour. The skin is red or purple. Large blebs are present which contain a red  serous or serosanguineous fluid. The epidermis detaches easily and leaves moist and greasy areas. The tissues are reddish and oedematous. The abdomen is distended. The serous cavities may contain a turbid reddish fluid. The bones are flexible and readily detached from the soft parts. The joints become abnormally mobile. The skull bones are separated and  the brain has a grayish – red pulpy appearance. All the viscera become soft and oedematous and lose their morphology, but lungs and uterus remain unchanged for a long time. The umbilical cord is red, smooth, thickened and soft.

Spalding’s Sign: Loss of alignment and overriding of the bones of the cranial vault occurs due to shrinkage of the cerebrum after death of the foetus. In the early stage, there is only loss of the alignment without overriding. The sign will develop earlier with a vertex presentation than with a breech. It may be detected within a few days of death of the foetus, but often takes much longer time, some times even two nto three weeks.

Mummification: Mummification occurs when the foetus dies from deficient supply of blood, when liquor amnii is scanty, and when no air enters uterus.

Viability of the Infant: Viability means the physical ability of a foetus 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.

Live birth: It 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. The causing of death of such a child is regarded as homicide.

 

In civil cases, any sign of life after complete birth of the child is accepted as proof of live birth, e.g., hearing `` cry, seeing movement of the body or limbs, muscle contractions, etc. The muscles may twitch for some time after death, and therefore is not safe to assume that twitching of muscles indicates life. A child may cry either in the uterus or in the vagina, which may be heard by bystanders or even outside the room of delivery. This occurs only when the membranes have ruptured and air has entered the uterus. The law presumes that every newborn child found dead was born dead until the contrary is proved. In criminal cases, signs of live birth have to be demonstrated by post-mortem examination of the child. Internal examination may provide strong, but not definite evidence of a live birth.

1. Shape of the Chest: Before respiration, the chest is flat and its circumference is one to two cm. less than the abdomen at the level of the umbilicus. After respiration, the chest expands and becomes arched or drum-shaped..
2. The Position of the Diaphragm : The abdomen should be opened before the thorax, and the highest point of the diaphragm is noted, which is found about the level of fourth or fifth rib if respiration has not taken place, and at the level of the sixth or seventh rib after breathing. The position is affected by gases of decomposition.
3. Lungs: Breathing causes important and permanent changes in the lungs, the extent of which depends on the physical strength and period of respiration.
4. Volume: Unrespired lungs appear smaller, being collapsed on to the hilum when the thorax is opened. Fully respired lungs fill the plural cavities, and the medial e edges overlap the mediastinum and part of the pericardium.
5. Margins: Before respiration the margins are sharp, which become rounded even when the breathing is feeble. Glistening bullae appear along the margins when there has been a struggle to breathe due to some mechanical obstruction.
6. Consistency: Before respiration, the lungs are dense, firm, and non-creoitant like liver. After respiration they are soft, spongy, elastic and crepitant. The lungs are also crepitant in prtrefaction and after artificial inflation.
7. Colour and Expansion of the Air Vesicles: Before respiration, lungs are uniformly reddish-brown, bluish or deep-violet, according to the degree nof anoxia. The surface of the lobules is marked with shallow furrows. On section, interior of the lung is uniform in colour and texture, and little forthless blood exudes on pressure. After respiration, the air cells become distended with air, usually about the anterior surfaces and margins, and then on the remaining portions of the lungs. As the air vesicles expand, they become raised slightly above the surface, and may be observed as polygonal or angular areas on the surface of the lung, giving it a fine mosaic appearance. As the blood becomes aerated in the expanded area, the colour becomes a light-red, and the whole lung has a mottled or marbled appearance, with rose-coloured patches of expansion and aeration alternating with the cosllapedsed dark bluish-red areas. If there is complete expansion of the lungs, they usually float and support the heart on the surface of the water. On section, frothy blood exudes from the cut surfaces on slight pressure. Exposure to air will brighten the colour of the fortal lungs, but the air cells are not distended. Mottling is absent  in  artificially inflated lungs, and on section the exposed surface will exude little blood but no froth.

Sl. No	Trait	Before respiration	After respiration
(1)	volume	Normal or small.	Larger, and cover the heart.
(2)	Consistency :	Dense, firm, mom-crepitant.	Soft, spongy, elastic, crepitant.
(3)	Margins	Sharp.	Rounded.
(4)	Colour :	Uniformly reddish-brown or dark red	Mottled or marbled appearance.
(5)	Air vesicles:	No inflated.	Inflated.
(6)	Section :	Little frothless blood exudes on pressure.	Abundant frothy blood exudes on section.
(7)	Weight :	1/70 of body weight.	1/35 of body weight.
(8)	Floatation :	Whole and parts sink in water.	Expanded areas or whole  float in water.

1. Gas: In putrefaction, bubbles of gas are seen under the pleura which can be moved from place to place by stroking with the finger. Interstitial blebbing indicates decomposition.
2. Blood in the Lung Beds: The amount of blood in the lungs after respiration is about twice that in circulation in the stillborn.
3. Weight: (1) Static Test or Fodere’s Test: The lungs are ligated across their hila and separated. The average weight of both lungs before respiration varies from 30 to 40g. and after respiration from 60  to 66g. The increase in weight is due to the increased flow of blood.
4. Ploucquet’s Test: The blood flow in the lung beds is so increased after breathin that their weight is almost doubled from 1/70 of the body weight before respiration to 1/35 after respiration. The increase in weight is not constant and is not a reliable indication of breathing.
5. The Hydrostatic Test: It is based on the fact that on breathing, the volume of the lungs is increased, which more than compensates the weight of the additional blood, due to which their specific gravity is diminished. The specific gravity of the lungs before respiration baries from 1040 to 1050, and after respiration about 940. A ligature is tied on the bronchi, and lungs separated. Each lung individually is placed in water. If they float, each lung is cut into twelve to twenty pieces and floated in water. A small piece of liver may serve as control. If the liver floats, the test is of no value. If these pieces float, they are each squeezed in between thumb and index finger under the surface of water, to see if any bubbles of air escape, and if they still persist to float, or they are taken out of water, wrapped in a piece of cloth and  squeezed by putting a weight to remove the tidal air. The pieces are again placed in water, and if they continue to float, due to the presence of residual air, it indicates that respiration has taken place. If the pieces sink after pressure, respiration has not taken place. If some pieces float while others sink, it shows feeble respiration. A piece of lung is rolled gently between the finger and thumb very near to the ear. A crackling crepitant noise indicates a significant degree of respiratory activity. The hydrostatic test is not of much value, because the lungs of the live born who have lived for few days may sink, and the lungs of the stillborn may float.

The expanded luings may sink from :
1. Disease, e.g. acute oedema, pneumonia, congenital syphilis, etc.
2. Atelectasis (non-expansion) of the lungs due to:

1. Air not entering the lungs due to feeble respiration but aeration of lungs may occur through the mucosa of trachea and bronchi.
2. Complete absorption of air from the lungs by the blood, if circulation continued after stoppage of respiration.
3. More air being expelled from the lungs during expiration than what is inhaled during inspiration, if the respiratory movements are very feeble.
4. Obstruction by an alvelolarduct membrane.

The unexpanded lungs may float from:

1. Putrefactive gases the putrefied lungs are soft and greenish. Signs of decomposition of the body will be seen.
2. Artificial inflation: The foetal lungs may be artificially inflated by blowing air through a tube, catheter or cannula passed into the trachea or by the mouth-to-mouth method. In such cases, the lungs can be inflated only partially and the stomach contains air.

Hydrastaic test is not necessary when:

1. The foetus is born before 180 days of gestation.
2. The foetus is a monster.
3. The foetus is macerated or mummified.
4. The umbilical cord has separated and a scar has formed.
5. The stomach contains milk.

Signs of the struggle to breath:
The victims of the “struggle to breathe” may be stillborn or they die shortly after delivery. The gross changes in both the groups are similar. The sequence of changes, as the struggle to breathe develops is as follows:

1. Dark fluid blood (due to raised CO), haemo-concentration. “Pseudo-clots”.
2. Cyanosed, expanded lungs. expansion due to (a) inhaled liquor amnii or vernix, (b) obstructive emphysema, (c) oedema with or without air or liquor amnii.
3. Tardieu’s spots on pericardium, pleura and thymus.
4. Liver swelling due to congestion of whole lobule.
5. Distension of large bowel with meconium.
6. ascites.
7. Retroperitoneal oedema.

Respiration Before and During Birth: A child may breathe:

1. while it is in the womb, after the rupture of the membranes (vagitus uterinus),
2. while its head is in vagina (vagitus vaginalis),
3. while its head is protruding from the outlet. A child who has breathed in the womb or vagina may die from natural causes, befre it is completely born. Therefore, proof of breathing is not proof of livebirth. In the newborn child, the respirations may not be strong or deep enough to expand the air cells, but may not be sufficient to distend the fibrous tissue. The air may be subsequently absorbed by the blood, or may be lost. The child may live for many hours or even one or two days with only small portion of its lung tissue expanded. When the air cells have been distended once, they never return to the foetal condition. For the above reasons, the hydroststic test fails in a small percentage of cases.

Microscopic Examination of the Lungs: Microscopic examination is of value in determining the extent of respiration, and also in providing evidence of pulmonary disease or abnormality, which may have caused or contributed to the death. The thoracic contents are removed intact by cuts with a scalpel by “no touch” technique of Osborn (1953), to eliminate artifacts. They are fixed for 48 hours and sections are taken of the whole lung in cross-sections. At four months pregnancy, the parenchyma of the lung has gland-like structure with a cuboidal or columnar cell lining. After fifth month, the air sacs are filled with amniotic fluid. The thin-walled adult type of alveolus is formed before full term. The normal foetal lung at full term is almost completely atelectatic but many of its terminal bronchioles and vesicles are partly expelled through the bronchi and partly absorbed back into the pulmonary circulation. It was thought that if respiration has not taken place, the alveoli appear as hollow gland-like structures lined by cuboidal or columnar epithelium. This is not correct, for the change in the type of cell which lines the air sacs does not occur with the onset of respiration. If the child has lived only for a few minutes, microscopy cannot always provide clear evidence of extrauterine respiration. Obstruction of the lower bronchial tree by hyaline duct membrane causes respiratory failure. Its development and clinical features are obscure, but its presence is evidence that death is due to natural cause. The struggle to breathe may result in: (1) incomplete lung expansion, (2) suboxia and cyanosis, (3) petechial haemorrhages mainly subpleural, (4) oedema of the mediastinum and often of the lung.

Livebirth is probable when:

1. All the lobes of the lungs are fully expanded with or without obstructive emphysema.
2. There is oedema of the lungs, especially gross.
3. An alveolar duct membrane is present and has widespread distribution in the lungs.
4. Pulmonary atelectasis due to obstruction by an alveolar duct membrane is present.
5. Contusions of the lungs are present.

A gland-like appearance of the alveoli does not exclude live birth but only indicates prematurity. Tardieu’s spots may be present both in stillbirth and livebirth and also in bronchopneumonia.

Stillbirth is probable in the presence of: 1) Maceration of the infant. 2)Flooding of the lungs with liquor amnii, and especially evidence of phagcytosis of meconium by the cells lining the air sacs. 3)Desquamation of bronchial epithelium. 4)Distention of large bowel with meconium indicating a struggle to breathe.

1. Changes in the Stomach and Intestines: Air is swallowed into the stomach during respiration.The stomach and intestines are removed after tying double ligatures at each end. They float in water if respiration has taken [lace, otherwise they sink. This is known as Breslau’s second life test, or stomach bowel test. This is not of much value because air may be swallowed by the child in attempting to free the air-passages of fluid obstructions in cases of stillbirth. It is useless when there is decomposition.

In a stillborn child or one dying shortly after birth, the stomach will contain grey-white gastric mucin mixed with swallowed amniotic fluid. Sometimes, the infant may swallow maternal blood during delivery. When dissected under water, the stomach shows mucus, saliva and air bubbles if respiration has taken place and only mucus if breathing has not occurred. Blood, meconium or liquor amnii in the stomach indicate that the child was alive at or shortly before birth. If milk is present in the stomach, it is positive evidence that the child has lived for some time after birth.

1. Changes in the Middle Ear: (Wredin’s Test). 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 gelatinous substances in few hours to five weeks. This is not at all reliable.

If a placenta is found with the body, it should be examined. If placenta is absent, the length of the remaining umbilical cord should be measured. Examine the cord to see whether a ligature has been applied and to know whether it has been cut or torn. A torn cord is usually ragged.

1. Other Signs of Livebirth: Several changes occur in the child after birth, which are helpful in estimating the length of time the child lived after birth.
   1. Blood: Nucleated red cells usually disappear from the blood within 24 hours. Foetal haemoglobin which is about eight percent before birth rapidly decreases to 7 to8% at third month.
   2. Meconium: It is the green viscid substance consisting of thickened  bile and mucus. The meconium is completely excreted from the large intestine in the first 24 to 48 hours after birth, but in a breech presentation and also in severe anoxia, the meconium may be excreted completely before birth.. Meconium stains are brownish-green and stiffen the cloth. The reaction is acid.
   3. Caput Succedaneum: This is an area of soft swelling that forms in the scalp over the presenting part of the head in vertex presentations. The elevated rounded area of the caput succedaneum corresponds to the portion of the scalp surface that is exposed within the opening of the dilated vervixduring labour. The scalp in the area of the caput is swollen to three to four times its normal thickness. The localized area of oedema and congestion is due to local interference with venous return produced by the pressure of the rigid cervical ring. Most commonly, the caput occurs asymmetrically over the crown of the head, in the parietal region. With breech presentations, similar swellings occur over the buttocks and scrotum or labia. The caput succedaneum gradually diminishes often disappearing during the first day (within a week) after birth.

Cephalhaematoma: This is a localisedaccumulation of blood deep to the scalp, between the periosteum and bone surface. The haematoma is limited to the periosteal sheath of single bone, commonly the right parietal bone, and never crosses a suture line. Cephalhaematoma is raer, occurring in less than one percent of newborns, and varies in size from a centimeter to golf ball proportions. The haematoma swelling often tends to increase during the first day or two after birth, as more and more blood accumulated, but gradually decreases in subsequent weeks as the blood is absorbed. Neonatal jaundice may be increased because of the extra load of blood pigment.

1. Skin: At first skin is bright red, which becomes darker on second or third day, then brick-red, yellow and normal in about a week. Physiological jaundice is seen by third day due to relative insufficiency of enzymes required for conjugation and excretion of bilirubin. Vernix caseosa covers the skin, mostly in the axilla, inguinal region and folds of the neck, buttocks and persists for one or two days. Sometimes it may be absent at birth and it is removed by washing. The skin of the abdomen exfoliates during the first three days after birth.
2. Air in G.I. Tract: Air moves along the gastrointestinal tract at the same speed in full term infants as in premature ones. The air reaches stomach after fifteen minutes; the small intestine after one or two hours; the colon after five to six hours; and the rectum after twelve hours. Bacterial gas formation and resuscitation attempts may be a source of error.
3. Umbilical Cord: The blood clots in the cut end two hours after birth, and the vessels begin to be obliterated ib about 24 gours. The cord attached to the shrinks and dries in 12 to 24 hours but this appearance is also seen in the body of a stillborn infant, and an inflammatory ring forms at its base in 36 to 48 hours. It mummifies on second or third day. Mummification of the cord also occurs after death if exposed to air. The cord falls off on the fifth or sixth day and leaves an ulcer, which heals and forms a scar in 10 to 12 days.
4. Circulation: Contraction of the umbilical arteries starts in about ten hours and are completely closed by third day. The umbilical vein and ductus venosus are closed on the fourth day. The ductus arteriosus closes by tenth day and doramen ovale by second or third month.

Causes of Death:
I. Natural Causes:

1. Immaturity.
2. Debility due to lack of general development.
3. Congenital diseases, e.g. syphilis and specific fevers, such as small pox, plague, etc. affecting the mother, or disease of the child’s internal organs, such as lungs, heart, brain, etc.
4. Malformations.
5. Haemorrhage from the umbilical cord, genital organs, stomach, rectum, etc.
6. Post-maturity.
7. Pre-eclamptic toxaemia.
8. Disease of the placenta or its accidental separation from the uterine wall
9. Placenta praevia or abmormal pregnancy.
10. Neonatal infection.
11. Intrapartum or ante-partum anoxia.
12. Cerebral birth trauma.
13. Erthroblastosis.

(II) Unnatural Causes: These may be: (1) Accidental and (2) Criminal

 

Accidental Causes:
(A) During birth:

1. Prolonged labour: Severe compression of the head against contracted or deformed pelvis may cause intracranial haemorrhage and death with or without fissured fracture of the parietal bones of the skull. Extradural haemorrhage is rare. Subdural haemorrhages are common and usually bilateral. They are usually caused by ruptures of the bridging veins, but may also occur less commonly from tears of the falx cerebri. Rarely, haemorrhages occur from ruptures of the internal or great cerebral veins. Tentorial tears may be bilateral and haemorrhage occurs into the subdural space, the head of the child shows evidence of well-developed moulding and caput succedaneum. Fractures and dislocations of the limb bones and clavicles may be found.
2. Prolapse of the cord or pressure on the cord: They produce death by asphyxia. The cord is liable to be compressed by the fortal head, especially in breech presentations. On post-mortem examination, blood, meconium, liquor amnii or vernix caseosa may be found in the bronchial tubes.
3. Twisting of the cord round the neck of the cord: It causes compression but no abrasions or ecchymoses and cause death by strangulation.
4. Injuries to the mother: Heavy blows or kicks on the mother’s abdomen or falls from a height may cause concussion of the brain of the child with or without fracture of skull or rupture of blood vessels or organs. Rarely, powerful uterine contractions may fracture the cranial bones of the foetus.

Table (19-2). Difference between head injury due to labour and blint force.

Sl. No	Trait	Head injury due to labour	Head injury due to blunt force
(1)	Bruises :	May be present on the presenting parts of the scalp.	Found any where on the scalp.
(2)	Lacerations :	Not present on the scalp.	Present on the scalp.
(3)	Fractures :	Fractures are fissured; usually of parietal bones and run downwards at right angles to the sagittal suture.	Extensive comminuted and depressed fractures of the skull bones affecting vault or base.
(4)	Brain :	Usually not injured.	Contsions, lacerations and haemorrhage.

Death of the mother: The child can be saved if it can be delivered within five to ten minutes of the mother’s death.

(B) After birth: 1. Suffocation : It may result when the membranes cover the head during birth, or if the face is pressed accidentally in the cloth pr submerged in the discharges, such as blood, liquor amnii or mecoium. A child can survive in the membranes for 20 to 30 minutes.
Precipitate Labour: Labour terminating in a very short time than that taken on the average, either in a primipara or multipara is called precipitate labour. In this delivery occurs suddenly and rapidly without the knowledge of the mother. All the three stages of labour are merged into one. The foetus is normal or premature. It is possible in multiparae with large roomy pelves, but is extremely rare in primiparae. A woman may be delivered unconsciously during fits or periods of coma, hysteria, hypnosis, under the influence of narcotic drugs, anaesthetics, and even deep drunkenness. It is highly improbable that any primiparous woman would be delivered during ordinary sleep without being aroused. Sometimes, a woman may not be able to distinguish the sense of fullness produced by the descent of a child from the feeling of bulky evacuation.

The child may die from

1. suffocation by falling into a lavatory pan,
2. head injury and fracture of the skull with subdural haemorrhage often bilateral, by a fall on a hard floor, if the woman was standing, and
3. haemorrhage from the torn end of the cord.

If the birth occurs in the toilet bowl or into a bucket containing liquid, the infant will inhale the liquid and blood, and meconium and vaginal mucus are found in the air-passages. Microscopic examination of the lungs will show the foreign particles contained in the drowning dluid. In accidental falls, the haemorrhages are usually sibdural and often bilateral. The average length of the cord is fifty cm. which is not sufficient to allow the child to fall to the ground, and is sufficiently strong to withstand the weight of the foetus without breaking. The cord is torn most commonly at the foetal end than the placental end, but is-not torn in its middle. Caput succedaneum and moulding of the head are absent. Foreign materials, such as mud, sand, gravel may be found in the hair or injured scalp of child. The fractures of the skull are usually fissured and limited to parietal bones, but may extend to frontal and squamous part of temporal bones. Fractures due to forceps lie at points normally gripped by the instrument and are usually “gutter” or “pond” type.

Medico-legal Importance:(1) The mother or her relatives may be accused of infanticide, while the death of foetus may be due to injury, haemorrhage or asphyxia from precipitate labour. (2) In a case of infanticide, death of the child may be attributed to precipitate labour.

 

1. Criminal Causes: These may be (1) acts of commission, and (2) acts of omission.
   1. Acts of Commission: They are acts done positively to cause the death of the infant. Numerous injuries may be found on the body, especially around the face, head and neck, due to circumferential abrasions around the whole surface on the neck caused due to fingernails. They should not be mistaken for homicide.
   2. Suffocation: The child’s nose is closed with two fingers and the lower jaw is pushed up with the palm to occlude the airway. Other methods are placing a pillow or towel over the child’s face and pressing down, or pushing the face down into debclothing. The amount of force to produce smothering is so minor that there is no evidence of trauma. Overlaying, or forcing mud, rag or cotton-wool into the mouth are other methods.
   3. Strangulation: Throttling or strangulation by ligature is also common, and in the latter case the ligature is frequently left in situ.Sometimes, umbilical cord is used as a ligature to simulate accident. Abrasions on the neck may be caused by the frantic efforts of the mother to deliver herself.
   4. Drowning: It is rare, but the body of a dead foetus may be thrown into a well, tank, etc.
   5. Burning: Infanticide by burning is rare, but it may be used as a mode of disposal.
   6. Blunt head injury: Infanticide by dashing the head against a wall or the floor by holding the feet is rare. In such cases, there may be bruising of the ankles and feet, where they were firmly gripped. Blows on head may be produced with a blunt weapon. Subdural and subarachnoid haemorrhages are common and are usually accompanied by fractures (depressed or comminuted) of the skull and contusions and lacerations of the brain and scalp. In infants, extradural haemorrhages are limited to single bones because of the adherence of the dura to the skull along the suture lines.
   7. Fractures and dislocation of cervical vertebrae : These may be caused by twisting the neck.
   8. Wounds: The child may be killed by stabs, incised wounds, cut-throat, etc.
   9. Poison : Rare
      1. Acts of Omission or Neglect: A woman is guilty of criminal negligence, if she doesnot take ordinary precautions to save her child after birth. The following acts of omission amount to crime. (1) Failure to provide proper assistance during labour may cause death by suffocation or head injury. (2) Failure to clear the air-passages which may be obstructed by amniotic fluid or mucus. (3) Failure to tie the cord after it is cut may cause death by haemorrhage. (4) Failure to protect the child from exposure to heat or cold. (5) Failure to supply the child with proper food.

THE ABANDONING OF INFANTS : If the father or mother of a child under the age of twelve years, or anyone having the care of such child, leaves such a child in any place with the intention of abandoning the child, shall be punished for abandoning of birth as per the laws of the respective state.

CONCEALMENT OF BIRTH: Whoever, secretly buries or otherwise disposes of the dead body of child, whether such child dies before or after or during its birth, intentionally conceals the birth of such child, shall be punished for concealement of birth as per the laws of the respective state.

BATTERED BABY SYNDROME OR NON-ACCIDENTALINJURY OF CHILDHOOD:

It is also known as child abuse syndrome, Caffey’s syndrome, and maltreatment syndrome in children. The typical form of this condition is very rare in India. A battered child is one who has received repetitive physical injuries as a result of non- accidental deprivation of nutrition, care and affection. The classical features of syndrome are obvious discrepancy between the nature of the injuries and explanation offered by the parents, and delay between the injury, and medical attention which cannot be explained. The constant feature is repetition of injuries at different dates, often progressing from minor to more severe.

Features:

1. Age: Usually less than three years old, though it may occur at any age.
2. Sex: Slightly more in males (55 to 63%).
3. Position in family: One child of a family, commonly the eldest or the youngest and often unwanted, such as the result of pregnancy before marriage, failure of contraception or an illegitimate child.
4. Socio-economic factors: Parents tend to be young between 20 to 30 years, and belong to lower social class and lower education. The family is usually isolated. There is often a history of family disharmony, long-standing emotional problems, or financial problems. Many of the fathers have criminal records, or unemployed or socially unstable. Many mothers have multiple social and psychiatric problems with a chaotic and violent home background. The mother is of lower I.Q., often pregnant or in the premenstrual period at the time of battering. Unhappy childhood experiences are common in both parents and many battering parents were “battered children” themselves. Most of the parents suffer guilt-amnesia. (50 History: There is obvious difference between the nature of the injuries and the explanation given by the parents, which may change on several times of repetition, each time the child is taken to a different doctor.
5. Treatment: There is always delay between the injury and medical attention.
6. Precipitating factors: Violence is precipitated by actions of the child itself, e.g., crying, refusal to be quiet, persistent soiling of napkins, etc.

Injuries: Direct manual violence is the commonest method of injury. Sruface injuries: Soft tissue injuries are very common and may be seen almost anywhere on the child’s body. The head, face and neck show bruises, abrasions and lacerations of different ages. Multiple bruises are seen on brows, checks, mouth and neck. Laceration of the mucosa inside the upper lip, often near the centre line where the frenulum may be torn, is the most characteristic lesion. This may extend laterally and separate the inner surface of the lip from the base of the gums. This injury results from a blow on the mouth or due to other efforts to silence a screaming or crying child. Multiple bruises of various ages all over the body from rough handling, or beating or kicking or throwing the infant are common. Bruises may be seen on either side of the chest, behind the axillae and down the anterior chest wall, where the child has been gripped roughly, between two adult hands and shaken. Caffey (1974) described the effects of shaking a child as a major cause of subdural haematoma and intraocular bleeding in battered babies, the so-called “infantile whiplash syndrome”. In such cases, bruises are produced in areas where the child is held by the hands, but there are no external injuries to the head or fractures of the skull, but there may be traction lesions of the periosteum of the long bones without fracture. Permanent brain damage may be caused due to habitual prolonged shaking. Bite marks may be found on the cheeks, shoulders, chest, abdomen, arms, legs and buttocks. Bruises are usually present around the elbows and knees due to gripping of the child, so as to shake or pull him, or hurl him into cot or against furniture, etc. Slap marks may show clear lines of petechial haemorrhages. Knuckle punches show as rows of three or four roughly round bruises. Bruising caused by belts, straps, canes, pieces of wood, hair brushes may be seen frequently on the buttocks and thighs. Pinch marks may appear as butterfly-shaped bruises with one wing caused by thumb larger than the other. Subgaleal haematoma resulting from vigorous pulling on the scalp is characteristic. Eye: Retinal separation, lens displacement, retinal haemorrhages, vitreous haemorrhages, subconjunctival haemorrhages, subhayaloid haemorrhages, and black eye have been found . Visceral injuries: Subdural haemorrhage is found in about 40% of fatal cases. Crushing or compressing force applied to the abdomen produce either “bursting” injuries of the liver or spleen, or perforations of distended hollow viscera including the stomach, intestine or urinary bladder. The second part of the duodenum and jejunum may be completely teansected. Deceleration or whipping mesentery and can lead to disruption of the small intestine. Extensive internal injuries may be present with minimal external signs of injury. Burns: Small circular, pitted burns may indicate deliberate stubbing of cigarette ends upon the skin. The child may be made to sit upon a hot stove or electric radiator or he may be dipped in very hot fluids.

Skeletal Injuries: Large periosteal haematomas are common because periosteum is readily stripped in infants. Bleeding under the periosteum causes calcification, which is seen on X-ray as an extra line of opacity running alongside the affected length of bone. The violent forces applied to the limbs involve pulling and twisting, both capable of producing epiphyseal separation and periosteal shearing. Transverse and spiral fractures of long bones result from compression, bending and direct forcible blows. Anteroposterior compression of the chest causes fractures of ribs in midaxillary line. Violent squeezing of the chest from side to side causes fractures at the costochondral junctions. Multiple rib fractures also occur along the posterior angles of the ribs. After one to two weels, callus is formed, and on X-ray “a string of beads” appearance is seen in the paravertebral gutter. Avulsion of the metaphyses or epiphysis may occur, with small fragments seen isolated on X-ray. Before autopsy, a whole body X-ray should be taken to detect old fractures and especially metaphyseal and epiphyseal injuries in various stages of healing.

Diagnosis: The diagnosis depends upon (1) nature of injuries, (2) time taken to seek medical advice, and (3) recurrent injuries. Differential diagnosis has to be made from scurvy, congenital stphilis, osteomyelities, leukaemia, rickets, juvenile osteoporosis with stress fractures, and paralytic disease with fractures, infantile cortical hyperostosis and osteogenesis imperfecta. Radiological manifestations of trauma and especially the metaphyseal lesions are specific to the battered baby syndrome.

MUNCHASUSEN’S SYNDLROME BY PROXY: It is a type of child abuse usually involving the mother. It consists of repeated pretentions of illness or the infliction of repeated minor injuries, with the object of gaining admission to hospital or obtaining medical care and attention. The child is brought to hospital for induced signs and symptoms of illness with a fictitious history. The child is admitted frequently in the hospital for medical evaluation for the non-existent conditions. These patients appear to be compulsively driven to make their complaints. The person is aware that he is acting an illness, but he cannot stop the act. There is a continuum, ranging from exaggerated claims of infirmity to actual selfinduced illness. At the extreme end, life-threatening injuries are masqueraded as being legitimately contracted. Some examples are: (1) The mother pricks her finger and adds blood to the urine of the child and takes the sample to the doctor. (2) The child’s nose is closed with two fingers and the lower jaw pushed up with the palm to block the airway. (3) A pillow or towel is put over the face of the child and the face is pushed down into bed clothing. (4) The child is repeatedly smothered into unconsciousness, then resuscitated or taken to the hospital. (5) The mother gives insulin to the child and takes to hospital with hypoglycaemia.

SUDDEN INFANT DEATH SYNDROME: Sudden infant death syndrome (SIDS), or cot death or crib death is defined as the sudden and unexpected death of seemingly healthy infant, whose death remains unexplained even after a complete autopsy.

Features:

1. Incidence: 0.2 to 0.4% of live births.
2. Age: Two weeks to two years. Majority of cases occur between six weeks to six months with a marked peak between two to four months.
3. Sex: Male to female ratio of about 3:2.
4. Twins: There is increased risk (threefold) amongst members of a twin pair. Most twins are premature and of low birth weight.
5. Geographical Time of death: Death always occurs during sleep at all times of night with a moderate increase in the early morning hours.
6. Prematurity has no effect.
7. Socio-economic standard of the family is usually low.
8. Cigarette smoking and drug abuse by pregnant women increase the risk.

The child is either quite well when put to the bed, or may have only a minor upper respiratory tract infection (cold or snuffles), or minor gastro-intestinal disturbance. Cot deaths are major cause of death in infants in the first six months of life.

Autopsy: Milk or a blood-stained froth is sometimes seen on the child’s mouth or bleeding. The post-mortem findings are negative. In about 15% of cases, some pathological condition may be found, such as frank pneumonia, congenital heart disease, Down’s syndrome or a tracheobronchitis. The only constant findings are multiple petechial haemorrhages on the cisceral surfaces of the heart, lungs and thymus which are agonal in nature, perhaps from terminal respiratory efforts against a closed glottis. A small amount of milky vomit in the trachea and main bronchi, and shedding of individual tracheobronchial epithelial cells are commonly found. Many infants show forth in the air-passages and facial pallor. There are no petechial haemorrhages in the face or eyes. The hands are often clenched around fibres from the bed clothes. The lungs show patchy or uniform purplish discolouration of the surface and are firm in consistency with congestion, oedema, patchy alveolar collapse and increase in weight. The alveolar walls are thickened and are infiltrated with lymphocytes and occasional neutrophils and monocytes. Laryngitis, tracheitis, bronchitis, bronchiolitis, Pneumonitis and pleuritis either individually or in various combinations may be found. In the majority of cases, the extent of the pathology present is rarely sufficient to cause death.

Theories: Various theories have been advanced, but there is no single cause of cot death, and death may result from a number of causes which combine fatally while a child is passing through a vulnerable period of development. The commonly accepted hypothesis suggests that some infants have prolonged “sleep apnoea”)s periodic failure to breathe during sleep), which makes them susceptible to hypoxia, which finally leads to bradycardia and cardiac arrest. Respiratory infection may produce a viraemia which adds to the sleep depression of the respiratory centres. Nasal oedema and musus secretion may further narrow the small upper respiratory passages and in some hypotonic babies, a flaccid pharynx and even neck posture may further reduce the airway. An element of laryngeal spasm has also been suggested. Whatever the cause, factors in pregnancy that inhibit foetal circulation could damage the child’s brain, so that it no longer controls breathing properly. An unidentified trigger could affect the airway of a sleeping infant. The brain would not respond correctly and breathing would stop.

Infants may vomit milk after a feed which is absorbed by polyurethane mattress on which infants lie. Staphylococcus aureus are produced in the absorbed vomit in the mattress. Staphylococcus aureus infection of upper respiratory tract is said to cause anaphylactic shock and sudden death.

Other causes of death which have been proposed are conduction system anomalies, mechanical upper airway obstruction due to anatomical abnormalities, adrenal insufficiency, gastro-oesophageal reflux leading to bradycardia.Hypersensitivity to cow’s milk, deficiency of parathyroid, selenium, antibodies, calcium, vitamin D,E,B, magnesium, etc., house-mite allergy, botulism, sodium overload in feeds, hyperthermia’ hypothermia, suffocation by bed clothes and pillows,  bacterial infection, nrurogenic shock, hypogammaglobulinaemia, and metabolic disorders.