Zainab Alalyat

Mohammad Abed
Dr. Rayyan Al-Ali
 Neonaticide
Definition: the deliberate killing of a child within 24h of its birth.

The perpetrator is usually the mother; young and unmarried.

Her Goal:
1. Conceal the fact that she gave birth to a child.
2. Dispose of an unwanted child.
 Neonaticide
Where dead infants are found?

- In sewers, trash dumps, and public bathrooms.

- Usually abandoned by the mother.
-If the mother is apprehended, her defense:
the child was stillborn, she panicked and disposed of the body.
 Neonaticide
Establish if neonaticide or stillbirth?

1. Intrauterine maceration  intrauterine demise.

2. Presence of milk or food in the stomach  was alive.
Limitation: killing usually occurs immediately after birth.
 Neonaticide
Establish if neonaticide or stillbirth?

3. Hydrostatic test (the standard test): if a child has breathed.

Both whole lungs, then sections of the lungs are immersed in water,
If All float  the child most likely breathed.
If sink  did not breathe.
Limitations:
1. If putrefaction has taken place, the lungs might float even
if stillborn.
Solution: the liver is a marker of putrefaction
If liver floats putrefaction started.
2. Some children delivered alive do not aerate their lungs
enough to float.
 Neonaticide
Establish if neonaticide or stillbirth?

4. Microscopic examination of the lungs (check alveoli):

If the alveoli collapsed  the child had not breathed.
If the alveoli completely and uniformly distended (presumably by air)
 the child had breathed.

Limitation: if there has been attempted resuscitation, there may be distension of

air passages and alveoli by air.
 Neonaticide
Establish if neonaticide or stillbirth?

5. Petechiae of the lungs or heart.

Limitation: can occur from intrauterine stress.

6. Air in the stomach on imaging.

Limitation: can be due to labored respiratory efforts as the infant transit through
the birth canal.

* Neither of these criteria is valid.

 Neonaticide
Determine how the child was killed:

1. Suffocation (Simplest, most convenient):

1. Hand over the face.
2. Obstructing the nose and mouth with an object such as a pillow.
3. Placing the child in a plastic bag.
leaves no physical signs; diagnosis is made if: mother leaves the baby in a plastic bag,
leaves toilet tissue in the mouth, or confesses.
2. Strangulation.
3. Drowning the child in a toilet or bathtub.
4. Throwing the child off a building.
6. Abandonment.
 Neonaticide
Determine how the child was killed:

6. Abandonment:
Deaths may be unintentional: child not found, environmental
conditions.

- In moderate temp., newborns can survive 7-10 days without food or

water.
-If the newborn is placed in a warm dry atmosphere (in attics or
beneath floorboards) mummification
Due to the bacteria-free condition of a newborn.
 Infanticide
- Definition: Homicide of the baby after the first few days of life.
- Suspected perpetrators: the mother, joined by the husband,
boyfriend, or babysitter.
- Mostly occur in the first 2 years of life (majority in the first year).
 Infanticide
Causes of death:
1. Blunt trauma (most common).
2. stabbing.
3. Shooting.
4. Poisoning.
 Infanticide
Blunt trauma:
Shows:
1. Contusions and abrasions: recent and healing.
2. Lacerations, burns and patterned injuries.

Mongolian spots
 Infanticide
Blunt trauma:
- If contusions difficult to see (dark-skinned)  long cuts down the
back, buttocks, and extremities to look for soft tissue hemorrhage.
- Always check the interior of the mouth for lacerations and contusions
indicates blows to the mouth.
- Perpetrators may try to explain the injuries found as a result from CPR!
 Infanticide
Categories of young children murders:
1. Battered child, with its variant the neglected or starved child.
2. “impulse” or “angry” homicide, with its variant the “punished”
child (often scalded skin).
3. “gentle” homicide.
4. Miscellaneous.
 Infanticide
Battered child syndrome:

- Definition: Repeated intentional acts of trauma to a young child

inflicted at the slightest or most trivial provocation.
The child presents to a physician or ER with an acute trauma.
 Infanticide
Battered child syndrome:

Presentation Parents Explanation

Late presentation They did not realize that the child was so ill.
Multiple bruises The child bruises easily or always falling down.
(recent and healing)
Head injuries The child fell from arms, from chair, table or bed.
Burns The child put hands in hot water, spelled boiling water on
themselves, or turned on the hot water in a tub
Starved and dehydrated The child is a fussy eater, and spits everything up
Diaper rash The child has tender skin, and allergic to everything
 Infanticide
Battered child syndrome:

Causes of death:
1. Head trauma (most common): subdural, and subarachnoid
hemorrhage, with or without skull fractures.
Note: the absence of external head trauma does not rule out trauma.
 Infanticide
Battered child syndrome:

Causes of death:
2. Injuries to the abdomen: (punching, kicking)
At autopsy  liver laceration,
spleen rupture,
mesentery tears,
or bowel rupture.
 Infanticide
The Neglected or Starved Child:

- Definition: The child is fed insufficiently, left to lie in its own feces and
urine.
- Presentation: Sunken, wizened features, sunken abdomen, prominent
ribs, wrinkled loose skin, loss of turgor.
 Infanticide
The Neglected or Starved Child:

Explanations:
1. Criminal neglect.
2. Parental ignorance of the care and feeding ( when the mother is
young, poor, uneducated, or intellectually challenged).
3. Congenital disease (malformation of GI tract).

Mostly hospitalized once before they die. If rapidly gain weight in the
hospital and discharged healthy, then found starved dead homicide.
 Infanticide
The “Impulse” or “Angry” Homicide:

- Definition: Sudden violent act brought on by a slight or trivial

provocation (children crying or dirtying their diapers)
- The perpetrator is often the husband, boyfriend, or less often the
mother.
Causes of injuries and death:
1. The child is thrown or slammed against an object  head injury.
2. Blow or kick in the abdomen abdominal trauma.
3. Immersion in hot water “to teach” scalding burns.
 Infanticide
The “Impulse” or “Angry” Homicide:

Characteristic distribution of immersion burns:

- Water is not very deep: 6-12in.
- Position of the child: in squatting.
- Sparing: popliteal fossa, inguinal region.
 The Gentle Homicide
The most commonly missed method of homicide in infants and young
children is smothering

The second most common type of homicide in infants.

HOW? closes off the child’s nose with two fingers, at the same time
pushing up on the lower jaw with the palm to occlude the airway
OR cover the child’s face by pillow, towel or one’s hand
The Gentle Homicide
 The Gentle Homicide
Perpetrator: Mother , which is suffering from Munchausen’s syndrome by
proxy , now known as Factitious Disorder Imposed on Another

How to distinguish?

Multiple hospital admissions ,Extensive medical evaluations for these

nonexistent medical conditions.

The father ?? supportive of the mother WHY?

Unaware,
The mother and child seem to be extremely close
 The Gentle Homicide
• Amount of force necessary is so minor = NO evidence of trauma

• EEG is flat AND no spontaneous respiration IN 70–90s

• Autopsy findings are essentially unremarkable

 The Gentle Homicide
• How it will come to ER?
• Semi-moribund state, with a history of apnea, cyanosis and losing
consciousness
• After admission, the children are worked up extensively, with no
abnormal findings
• Never have these episodes in the hospital. If they do, do careful
history Parent will be The same in every episodes
• After discharge, Recurrent episodes until either the diagnosis is made
or the children killed.
 The Gentle Homicide
• Physiological changes observed by their recording during the
smothering:
• Initially, there was the sudden onset of large body movements, child’s
violent struggling.
• At 1 min, series of deep breaths occurring at a relatively slow rate
with a prolonged expiratory phase, in other words, a “gasping”
• About this time, the EEG showed large slow waves progressing to an
isoelectric baseline indicative of cerebral hypoxemia.
 The Gentle Homicide
• This case is especially important in the prosecution of child abuse
cases where children, due to age and condition, are unable to give
witness testimony against their abuser.
Shaken Baby Syndrome
 Shaken Baby Syndrome
• Definition : they will grab the victim under the arms, began shaking
violently, “shook backward and forward with all might”
• Clinical pathology : Triad of retinal, subdural or subarachnoid
hemorrhages caused by violent shaking.
• “Shaken impact syndrome.”
• the child is shaken, causing the same clinically and then the head is
impacted against a hard surface, causing contusions and fractures and
presumably additional intracranial hemorrhage.
 Shaken Baby Syndrome
• No evidence of impact on the scalp or skull? Absence of trauma does
not preclude impact.
• HOW?
• Spread over a wide area following contact with a flat surface . NO
evidence but subdural bleeding.
• IS retinal hemorrhages are pathognomonic of the SBS? No
• Why?
• The existence of the SBS is unproven
• occur with other etiologies
 Shaken Baby Syndrome
• Some arguments and hypothesis
• lack of neck and cervical spinal cord injuries?!
• Suppleness (bendability) of the spine in small children prevents injury
to the bony structures; however, this does not explain the lack of
spinal cord injuries.
• SBS occurs due to neck trauma, not head trauma??!
• Does not explain the injuries often ascribed to SBS – namely, the
classic triad
• Shaking are indeed inflicted
Non-Inflicted Causes of Intracranial Hemorrhage
Causes:
1. Accidents, clear-cut and involve significant violence, a motor
vehicle accident or a fall from a great height
2. Natural disease, rupture of a cerebral aneurysm, AND
- (late-form hemorrhagic disease of the newborn).
- Caused by vitamin K deficiency.
- Typically presenting 4–6 weeks after birth.
- It is manifested by intracranial bleeding (subdural, subarachnoid, intra
cerebral) as well as bleeding in the skin, gastrointestinal tract and
urogenital tract.
 Child Homicides
• Causes including : poisoning, stabbing, clubbing, drowning and
shooting.
• Perpetrator:
1- Psychotic assailant, often a parent, for some delusional reason.
(willing to describe in detail what they have done)
2- Individual who commits murder for reasons that might or might not
be apparent.
(claim that the assailant was another individual ,that the child was
kidnapped or an accident)
 Child Homicides
• Occasionally, infants and young children are killed by their siblings.
They may beat them or even smother them.
• Sibling jealousy might be a motive
 Radiologic Evidence of Child Abuse

• Appear in about a third of abused children

• The location, nature and multifocal aspect of the skeletal injuries
• Epiphysealmetaphyseal fractures of the long bones of the arms and
legs and rib fractures exclusive of the newborn period are considered
specific for child abuse
• Multiple repetitive fractures of other areas are only suggestive of
child abuse, but are not specific
 Radiologic Evidence of Child Abuse
• Most frequent sites of injury are the extremities (77%), the skull
(34%) and the rib cage (19%)
• Forces necessary to produce these fractures do not generally occur in
accidental trauma at this age.
• Partial or complete separation or fracture of the epiphysis, the physis
and a thin layer of metaphyseal bone due to violent traction or
torsion of the limb
• Microscopically, there is a transmetaphyseal disruption
(microfractures) in the subepiphyseal area.
 Radiologic Evidence of Child Abuse
• Typical epiphyseal-metaphyseal fractures :
1-fracture-separation of one or both corners of the metaphysis )
“corner fracture”),
2- fracture-separation of an arc of the metaphysis (the “bucket-
handle” fracture)
3-complete separation with displacement of the metaphyseal
fragment.
 Radiologic Evidence of Child Abuse
• Infants and children
• the periosteum can be sheared off by twisting and pulling.
accumulation of blood between the periosteum and the cortex of the
bone. New bone formation takes place
• On X-ray, the subperiosteal calcification appears as a thin line
paralleling the bone
 Radiologic Evidence of Child Abuse
• Diaphyseal injuries are four times as frequent as epiphyseal-
metaphyseal fractures
• Spiral fractures are caused by twisting
• Transverse fractures are produced by either a direct blow to the bone
)more common than spiral fractures in child abusing(
 Radiologic Evidence of Child Abuse
• Rib fractures
• Child without an obvious history of trauma
• Caused by sudden, violent compression of the chest. In battered
children, they are often multiple in number, bilateral and most
frequently posterior adjacent to the costovertebral junction
• On X-ray and at examination, there might be evidence of healing
fractures of different ages
• Posterior rib fractures in child abuse cases are believed to be due to
squeezing or direct trauma to the ribs.
• Lateral fractures of the ribs would be due to violent anterior-posterior
compression of the chest
• Children resuscitated by nonmedical personnel had no fractures.
• Resuscitated fractures they observed were anterior, while most fractures
from abuse are posterior
 Radiologic Evidence of Child Abuse
• Fractures of clavicle are relatively uncommon in child abuse
• Fractures of the distal ends of the clavicle are less common and are
caused by sudden traction on the extremity. These are more
suggestive of child abuse