FORENSIC MEDICINE

LECTURE ON INFANTICIDE, BATTERED BABY SYNDROME, SUDDEN INFANT DEATH SYNDROME

LEARNING OBJECTIVES

At the end of this lecture the students will be knowing definitions of-InfanticideFeticideStill born babyDead born bodyMacerationFoetal age estimationSigns of Live birthPrecipitate Labor/ Unconscious DeliveryCriminal causes of death of new born babiesAutopsy on bodies of new born dead bodiesChild Abuse i.e. Battered Baby SyndromeSudden Infant Death Syndrome and its medicolegal aspects.

INFANTICIDE

It means unlawful destruction of a newly born full term viable infant up to one year of age after birth. It is punishable under SEC 302 PPC. Although most of the new born babies are destroyed with hours after birth but for Legal purposes newly born infant under this Act is defined as one who is in the first year of its life.

FOETICIDE is the destruction of the foetus at any time prior to birth. NEONATICIDE is the destruction of the child in the first month FILICIDE (Latin filius means son and filia means daughter, is deliberate act of killing of

a child by the parents. Punishment for infanticide is death, life imprisonment and also fine. Infanticide differs from ordinary murder. It is necessary for prosecution to prove that

child was alive and viable at the time of birth and criminal violence was applied to foetus after birth.

According to English Infanticide Act of 1938 the mother may not be held responsible for killing her child when her mental balance is disturbed by experience of labour and

tension and strain of child birth and it’s after effects, she is not charged and punishment is two years imprisonment.

MOTIVE FOR INFANTICIDE:

To get rid of an illegitimate child of a widow or unmarried girl. Married girls killing female child to escape defame of not having a son (as Rajputs in

India). Extreme poverty of parents. Killing of male child by prostitute. In case of infanticide it is necessary to examine woman for signs of recent delivery and

whether time of delivery corresponds with the age of child to prove that child belongs to her.

EXAMINATION OF THE CHILD

Examination is carried out to ascertain that. Was the child born dead if so was it still born or dead born? Was the child viable, mature or immature? Was the child born alive? if so has he breathed and extend of breathing. For how long did the child survived after birth? What was the cause of death whether natural, accidental or homicidal?

DOES THE CHILD BELONG TO THE ACCUSED WOMAN?

The proof is established by: Signs of recent delivery or was the delivery compatible with age of child (i.e. changes

in breasts and genital tract.) Evidence from people with whom the suspected woman has been intimately related

in work or social life Careful examination by police and doctor of the wrapping in which the child was

thrown e.g. particular newspaper used can lead to the accused. By sweepers who collect discharges from houses e.g., pads which show stains of blood

or discharges from the vagina and uterus i.e. Lochia because of recent delivery.

MEDICOLEGAL ASPECTS.

WAS THE CHILD BORN DEAD, IF SO WAS STILLBORN OR DEAD BORN.

It is necessary to distinguish between stillborn and dead born. STILL BORN OR SILENT CHILD Child, who has issued from its mother after 28th week or after viability and it did not

at any time after being expelled, breathed or showed any other signs of life. Still births are frequent being 1:7 births, Proportion in primiparas being 1:11 and are

due o many causes both before and during birth. Still births occur commonly among

illiterate and immature male children, when labour is usually unassisted. If the putrefaction has started it may occur within the uterus or from outside, when foetus inhales bacteria then putrefaction starts from within outwards.

DEAD BORN CHILD:

Child who died within the uterus. Age should be above 28th weeks according to some but some say that age does not count. Dead born child shows signs of.

Rigor mortis before birth making labour and delivery difficult. Maceration. Adipocere formation. Mummification. Putrefaction. When foetus dies in uterus aseptic autolysis of foetus commence, although the body is

sterilized and no bacteria are there, even then also autolysis occurs. If dead foetus is in uterus surrounded by liquor amnii and remains there for at least 24

hours, then signs of maceration occur. Process is aseptic because the child enclosed in membranes is in aseptic sterile condition, when membranes rupture, air enters in and then signs of putrefaction appear

FINDINGS OF MACERATION:

Body is softened, flaccid and when placed on table flattens out. Emits out unpleasant, disagreeable odour which differs from putrefaction. Skin is brown or black, not greenish as in putrefaction. Cuticle is raised in blisters containing red serous fluid, epidermis peels easily leaving

moist and greasy patches. Bony junctions in the skull and joints are abnormally mobile. Skull bone sutures are

separated and over-ride each other ( this maybe mistaken for crush injury of skull) Internal tissues are soft and edematous, turbid red fluid collects in serous cavities. Important radiological sign known as Spaulding’s sign which confirms over riding, even

when foetus is in uterus the +ve sign shows that the foetus is dead. Brain is grayish red, pulpy mass. Umbilical cord is soft, smooth, thickened and is easily lacerated. Do histological examination if in doubt. Degeneration of nuclear structure and

disintegration of cells of muscular tissue and internal organs.

ROBERT’S SIGN- APPEARANCE OF GAS SHADOW IN CHAMBERS OF HEART AND GREAT BLOOD VESSELS

MAY APPEAR BY 12 HOURS, BUT DIFFICULT TO INTERPRET. HYPERFLEXION OF SPINES IS MORE COMMON. CROWDING OF THE RIBS SHADOW WITH LOSS OF NORMAL PARALLELISM If not examined soon after expulsion superimposed on maceration is putrefaction

which masks the signs of maceration.

If not examined soon after death of foetus, air enters genital tract, liquor amni gets infected and foetus undergoes putrefaction instead of maceration.

FINDING OF PUTREFACTION Nauseating unpleasant odour. Green coloration of skin. Formation of foul smelling gases. Rarely a child who has remained inside the uterus after death undergo ; MUMMIFICATION ADIPOCERE FORMATION

A. FINDINGS OF MUMMIFICATION. Foetus is dried and shriveled results from.

o Deficient blood supply.o Scantly liquor amni.o No air enters uterus.

B. WAS THE CHILD VIABLE? Foetus of less than seven months of intrauterine life is non viable. If foetus is not

mature and chance of being born alive is deprived by mother, charge against the mother is less serious then when the foetus is viable.

C. FOETAL AGE DETERMINATION.

HESS’S RULEFoetal age – Up to 4 months, square of the months is taken and then length of foetus is

measured i.e. 2 months 2 x 2 = 4 cms

For 3 months 3 x 3 = 9 cmsFor 4 months 4 x 4 = 16 cms

After 4th months i.e. from 5th month no of month multiplied by 5 give length of foetus in cms. Say

at 5 months length is 5 x 5 = 25 cmsat 6 months length is 6 x 5 = 30 cmsat 7 months length is 7 x 5 = 35 cmsat 8 months length is 8 x 5 = 40 cmsat 9 months length is 9 x 5 = 45 cms

D. WEIGHT DETERMINATION

Weight of unborn foetus of 20 weeks is up to 400 Gms. From 20th week onwards for every one week there is an increase of 100 Gms, up to 36th weeks or for every 4 weeks rise is 400 Gms. In last months after 36 weeks every week rise of weight is twice i.e. about 200 Gms. In last week increase is 1 kilogram.

F. WHETHER CHILD WAS BORN ALIVE.

Evidence are: Circumstantial By doctor doing post mortem.

CIRCUMSTANTIAL: Circumstantial evidence is taken in civil cases. Witnesses who saw the child having

muscular movements, twitching of eye lids, hearing heart beats and cries. Pulsation of cord after child is born is evidence of live birth, mere cry or muscular movement does not constitute proof of live birth, child may cry in uterus or vagina.

If child cries in uterus ---VAGITUS UTERINALIS. If child cries in vagina --- VAGITUS VAGINALIS Muscular movement or flickering of muscles show child is born. Cellular life continues

after death of the child, muscles may twitch for some time after body is dead and it is therefore not safe to assume that twitching of muscles indicate life.

In criminal cases medical examiner is asked to prove by post mortem that the child was born alive.

FOLLOWING POINTS ARE NOTED. SIGNS OF ESTABLISHMENT OF RESPIRATION.

Before birth lungs receive small amount of blood which is necessary. After birth pulmonary circulation is established. These produce physical changes in form of.

Changes in chest: Flat before birth and arched after birth. Changes in Diaphragm: Arched up at level of 3rd or 4th rib, if respiration has not taken

place. Descend to the level of 6th – 7th Rib after respiration.

CHANGES IN LUNGSUNBREATHED LUNG BREATHED LUNG.

HYDROSTATIC TEST IS NOT NECESSARY IF.Foetus is not viable, less than 180 to 210 days.

Foetus is a monster.Shows signs of intrauterine maceration remaining in uterus till 24 hours after death.When stomach has milk or fruit juices which shows that child did survive after birth.

Changes in Stomach and intestine, Respiration established, air in stomach and intestine look distended, tie both ends and put in water, if floats in water. This is Breslau’s 2nd life

test +ve.When child was born alive

See diaphragm.See Lungs and Stomach.

See places of indentations of Ribs on surfaces of Lungs.STATIC TEST OR FODER’S TEST.Average weight of foetal lungs is 450 – 500 grams. After respiration is 900 – 1000 grams. (Not

used in practice)

PLOCQUET’S TEST: Before respiration 1/70 and after respiration 1/35 of body weight C. HOW LONG THE CHILD SURVIVED: We see changes in skin. Changes in circulation. (If Lungs are not there other things can proof life birth). Umbilical cord. Caput succedaneum Foetal Hemoglobin.

CHANGES IN SKIN:

The skin of a newly born infant is covered with vernex Caseosa chiefly in the flexures of joints and neck folds. Colour of skin is bright red at birth, becomes darker on 2nd - 3rd day and physiological jaundice appears between 7 to 10 days. Desquamation o skin begins about 2nd day and is complete in a forth night.

CAPUT SUCCEDANEUM

Edematous swelling on presenting part of head during delivery which disappears from 24 hours to 7 days after birth

UMBLICAL CORD:

Clotting occurs in cut end of umbilical cord after 2 hours. Desiccation of umbilical cord on 1st day drying commences at free end.

Inflammatory zone near attached end in 36 hours. Cord mummifies in 3 days and complete in 5-6 days and cord falls off leaving a raw

are. Complete cicatrisation in 3 weeks.

CIRCULATION:

Few hours after birth lumen of umbilical arteries shrink contraction along whole length in 2-3 days.

Ductus arteriosis is obliterated in 7 to10 days. Foramen ovale closes by 2nd or 3rd month

FOETAL HEMOGLOBIN.

At birth 55-58% of Hb is foetal. By about 6 months all Hb is adult type. Foetal Hb is recognized by its isoelectric point, alkali resistance and spectrogram and

fractional crystallization.

+WE ALSO SEE: Degree of maceration, if born alive how long did it survive. Was child mature of immature i.e. full term 9 months or less. If less was it viable or not (least in 180 days, and is 210 days i.e. 7 months. Milk in stomach. Absence of Muconium from large intestine not definite proof . Muconium is not completely separated until several hours after birth. In breech

presentation and severe anoxia Muconium is not completely absent. Absence of urine at birth. Urine may not be passed for some hours after birth or

passed mechanically during birth. Uric acid crystals in Kidney and pelvis but such deposits are even found in still birth. Changes in middle ear-Wreden’s test. Middle ear cavity has gelatinous fluid and

connective tissue at variable interval it is replaced by air entering through Eustachian tube, not reliable sign.

THUS CHILD HAS BEEN BORN ALIVE IF:

Child is able to live independent existence i.e. more that 7 months. Lung fill thoracic cavity. Colour of Lungs is bright red and mottled. Lungs or portions of lungs after squeezing float in water. Blood stained frothy fluid exudes from cut surface of lungs. On application of pressure

fine bubbles escape. Microscopy shows expansion of alveoli and their patency. CHILD HAS SURVIVED BIRTH FOR ENOUGH TIME WHEN: There is evidence of changes in umbilical cord. Food in stomach. Condition of umbilical cord. Jaundice. Desquamation on kin.

CAUSE OF DEATH: Natural causes. Accidental causes. Criminal causes.

1. NATURAL CAUSES Prematurety. Debility Congenital Diseases. (congenital heart diseases). Hemorrhage from umbilical cord. Malformation. Placental disease e.g. placenta previa.

Laryngeal spasm. Abnormal gestation. Erythroblastosis foetalis.

2. ACCIDENTAL CAUSES: During Birth

o Prolonged labouro Prolapse of cord.o Knots or twists in cord.o Premature separation of placenta.o Death of the mother.

AFTER BIRTH Suffocation. Precipitate or Unconscious labour. Precipitate Labour: this occurs in: a). Multipara, never in primigravida. b). Child is small. c). Pelvis is broad It is a condition when child is born without mother’s knowledge, during passing urine

or walking child falls out. Injury to the foetus with fracture of skull. No caput succedaneum. Pelvis is large, child is small. In unconscious delivery the mother may be under influence of narcotics, effect of intoxicating drinks and drugs. In coma, under hysterical fits, then there is unconscious delivery seen in Multipara.

3. CRIMINAL CAUSES:o Acts of commission i.e. use of mechanical violence and poisoningo Act of Omission or neglect.

ACTS OF COMMISSION. Death by violence taking place in infants is seen as in adults. Certain factors predominate. SUFFOCATION (SMOTHERING) STRANGULATION. DROWNING. FRACTURE OF SKULL FRACTURE AND DISLOCATION OF CERVICAL VERTRBRAE OTHER INJURIES AS PITHING POISONS.

II. ACT OF OMISSION: Law presumes that a woman about to deliver should take delivery precautions to save

her child after birth. She is charged with negligence if she does not take care, i.e.

Necessary help of doctor and nurse. Inform her relatives. Failure to tie cord after cutting because it causes fatal haemorrhage.

Omission to remove child from mother’s discharges or sucking of discharges. To save child from heat or cold. Omission to feed child causing starvation. Separation from mother may cause shock. Woman should make provisions for birth of child, should get medical help. If no

provision then this suggests that she had bad intentions unless she was not aware of birth of child e.g. fainting due to sudden pain of labour.

ABANDONING OF CHILDREN:

Section 317 PPC deals with exposure and abandoning of child under 10 years or up to 12 years. Child is left by mother outside the hospitals.

If parents have a child under age of 12 and expose or leave the child with intention of abandonment is punishable with imprisonment for 7 years and fine. Offenders are tried for homicidal e.g. if child dies if left in cold weather.

CONCEALMENT OF BIRTH:

In case where infanticide is not proved, mother is charged with a lesser offence of concealment of birth. According to Section 318 PPC whoever by secretly burying or otherwise disposing off the dead body of the child, whether such child dies before, after or during birth, intentionally conceals the birth of such a child is punishable for the offence.

Still birth may also be charged if it is suspected that child dies at time of concealment. Foetus is a separate existence i.e. after 7 months.

BATTERED BABY OR CAFFEY’S SYNDROME

Term used to define a clinical condition in young children between age of 2-5 years who have received injuries on one or more occasions at hands of adults in a position of trust, generally parents, guardians or foster parents.

In addition to physical injury there is deprivation of nutritional care, affection in circumstances which show that such deprivation is not accidental.

If injuries of different duration are present and child is malnourished then he is battered.

Victim is generally and unwanted child e.g. pregnancy before marriage, illegitimate child or fathers paternity is doubtful, precipitating factor is cry interfering with parents sleep or during television programs.

Result of sudden loss of temper in such circumstances. Involved people have low intelligence quotient (I.Q). Some have family history of discard, long standing financial and emotional problems

while others have a family history of criminal background. Such parents have received similar treatment in their childhood by their parents.

CLINICAL MANIFESTATIONS:

Vary widely in nature and degree, the syndrome must be considered in any child exhibiting fracture of skull or any other bone, injury to abdomen, Subdural hemorrhage soft tissue swelling, skin bruising.

Considered in any child who dies suddenly or where degree of any type of injury is in variance with the history given or there is a purposeful delay in seeking medical attention.

Clinical and radiological evidence shows that injuries have occurred at different occasion’s. a negative X-ray does not exclude the diagnosis. The diagnosis depends on the nature and recurrence of injuries, the time to seek medical attention and a discrepant history.

(Battered wives seen in west and east few cases come to notice of police)

COT DEATH OR CRIB DEATH OR S.I.D.S.

Sudden Infant Death Syndrome is condition in which apparently healthy infants are found dead without any signs and symptoms which would enable such an event to be predicted and on post mortem examination there is in sufficient pathology to explain this death satisfactorily.

Frequently the best that can be done is an investigation so as to eliminate the possibility of foul play and occasionally there may even be difficulty in this incidence.

INCIDENCE:

The death rate is 2-3 / 1000 deaths of live birth. Age: Death usually occurs between the ages of 2 months and 6 months and average

being 2-3 months. Sex: It strikes boys some what more that girls. State of Health: Low birth weight and among weak babies. Income: More among low socio-economic group. Infection: commonly associated with seasonal upper respiratory disease and 60% of

cases have cold prior to death.

In cot death two clinical features are universal i.e. Babies die during sleep. Death is silent. The parents hear no cry or other signs of distress. The role of viral infections obscure. Other possible causes as milk allergy, Parathyroid

inadequacy, Cortisone insufficiency have not been substantiated. Laryngo-spasm and cardiac

Dysarythmias have not worked out. The fact that baby never makes noise indicates that the terminal event is Laryngo-Spasm Gentle nasal obstruction due to respiratory

obstruction leads in some infants but not in others to cessation of respiration with no attempt to breathing through mouth.

Observation leads to belief that even quite trivial respiratory symptoms may trigger off Silent Sudden Infant Death Syndrome.

AT AUTOPSY:

Trachea contains a small amount of oedematous fluid, sometimes this fluid is blood stained.

Lungs are filled with hemorrhagic oedematous fluid. Pleura, Pericardium and Thymus, all have petechial haemorrhages. ON MICROSCOPIC EXAMINATION: Evidence of respiratory infection and poor Expansion of Lungs is found. Napkin rash varying from moderate to severe degree is often found. This Silent

sudden Infant Death is sometimes labeled by police as foul play.

DEVELOPMENT OF THE FOETUS:

AT THE END OF THE FIRST MONTH

The entire ovum is bout the size of a pigeon’s egg the length is about 1 cm. it weight about 2.5 gms. They eyes are seen as two dark spots and the mouth as a cleft. The limbs appears as bud like processes.

AT THE END OF THE SECOND MONTH

The foetus is about 4 cms in length and 15 gms in weight. Eyes and nose are recognizable. The hand and feet are webbed the anus is seen as a dark spot. The umbilical cord begins to

develop. Clavicle, mandible, ribs, and vertebrae show the centre of ossification. The sex is not distinguishable.

AT THE END OF THE THIRD MONTHThe length is about 9 cms. And the weight about 80 Gms. Fingers are well separated Nails begin to appear in the form of thin membranes on the fingers and toes. The sex is not yet

distinguishable, Placenta is formed and differentiated.

AT THE END OF THE FOURTH MONTH The length is about 16 cms and the weight about 200 Gms. Sex is easily recognized Lunago is visible on the body. The papillary membrane is visible. The placenta weight about 90 Gms.

AT THE END OF THE FIFTH MONTH The length is about 25 cms and the weight about 400 Gms. Vernix caseosa appears on the

body. it is supposed to protect the foetal skin from amniotic fluid. Fine hair on the scalp are

visible, Lunago is quite distinct. Muconium is seen at the beginning of the large intestine, Ossification centre in calcaneum appears. The placenta weight about 180 Gms.

AT THE END OF SIXTH MONTHThe length is about 30 cms and the weight about 900 Gms. Hair appears on the head the

eyebrows and eyelashes are beginning to form. The eyelids are adherent and the papillary membrane is still present. The skin is red and pubis, the testicles lie close to the kidneys and the scrotum is empty. Muconium is seen in the upper part of the large intestine. The centers of ossification are seen in the four divisions of the sternum. The placenta weighs about 300

Gms. The child is viable in some cases.

AT THE END OF THE SEVENTH MONTHThe length is about 35 cms and the weight about 1 ½ Kilograms. Subcutaneous fat begins to

be deposited. The nails are thick but do not extend to the tips of fingers and toes. The eyelids are open. The pupillary membrane has almost disappeared. The testicles may be found in the

external inguinal ring. Muconium is seen in the whole of large intestine. Primary centre of ossification of talus has appeared. The child has attained viability the placenta weight about

350 Gms.

AT THE END OF EIGHT MONTHThe length is about 40 cms and the weight about 2 Kilograms. Scalp hair is thicker; the skin is

red, but not winkled, and covered with soft hair Lunago has disappeared from the face. Finger nails nearly reach tips of the fingers and toes. The left testicle but not the right has descended

to the scrotum. The placenta weight about 450 Gms.

AT THE END OF THE NINTH MONTH OR JUST BEFORE BIRTH

The length is about 45 cms and the weight about 3 Kilograms. Scalp is covered with dark hair 3-4 cms in length. Lunago is seen only on the shoulders. Vernix Caseosa is present over the flexures of joints and neck folds. Nails have grown over the tips of the fingers and toes. The umbilicus is midway between symphysis pubis and Xiphisternum. Both the testicles have descended in to the scrotum and the labia have closed the vulva. Muconium is seen at the end of

large intestine. Ossification center appears at the lower end of the femur, and also perhaps in cuboid, and sometimes one in the upper epiphysis of tibia. The ossification center in the femur is about 0.5 cm in diameter. Signs of maturity are present. The placenta is about 22 cms in diameter, 1.5 cms thick at the centre, and weighs about 500 Gms. The umbilical cord is about 50 cms long. 1 cm thick, and has a mild spiral twist.

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