Paediatric Forensic Medicine and Pathology 2nd Edition by Anthony Busuttil, Jean Keeling ISBN 1040054471 9781040054475

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ISBN 10: 1040054471 
ISBN 13: 9781040054475
Author: Anthony Busuttil, Jean Keeling

Child abuse and suspicious child deaths are very complicated matters for clinicians, pathologists, law enforcement officials and legal professionals to investigate. Meanwhile, the evidence base for forensic pathology, especially in paediatrics, is steadily growing.

Paediatric Forensic Medicine and Pathology 2nd Table of contents:

1 Clinical assessment in suspected child abuse
Introduction
Historical Background
Definition
Prevalence
Alerting Signs
Types of Abuse
The Need For Comprehensive Assessment
Significant Harm
The Interagency Context (Flow Chart of Process)
Joint Working and the Complementary Skills of Paediatricians and Forensic Specialists
Legislation
Consent and Confidentiality
The Process – Joint Paediatric/Forensic Examination
Presenting History
Social History
Presenting History Taken from the Parent
Information from the Child
Examination
Investigations
Assessment of Growth and Development
Emotional Abuse
Documentation and Report Writing
Interpretation of the Findings
Formulating an Opinion
Ongoing Health Care
Involvement in Ongoing Legal and Child-Care Processes
References
2 Investigation of suspected sexual abuse
Introduction
The Medical Evaluation
History
Technique of the Examination
Examination of Boys
The Colposcope in the Medical Examination
Forensic Evidence
Skills and Experience Required
Consistent Vocabulary
Normal Female Genital Anatomy
Labial, Posterior Fourchette and Vestibular Findings
Hymenal Configuration
Hymenal Ridges, Bumps, Tags and Bands
Hymenal Notches, Clefts and Transections
Gaping/Narrowing/Attenuation of the Hymen
Hymenal Measurements
Perianal Findings
Acute, Healing and Healed Anogenital Trauma
Female Genital Findings in Sexual Abuse
Signs of Anal Abuse
Conditions that Mimic Abuse
Screening for Sexually Transmitted Infections
Interpretation of Clinical and Laboratory Findings
Summary
References
3 Radiology of child abuse
Role of the Radiologist
Radiological Investigations
Skeletal Survey
Follow-up Skeletal Survey
Post-mortem Skeletal Survey
Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Scintigraphy
Skeletal Injuries
Periosteal New Bone
Long-bone Fractures
Metaphyseal Fractures
Epiphyseal Plate Injury
Rib Fractures
Spinal Trauma
Digital Injuries
Other Bony Injuries
Dating of Injuries
Head Injury
Skull Fractures
Dating of Skull Fractures
Extradural Haematoma
Subdural Haematoma
Subarachnoid Haemorrhage
Parenchymal Brain Injury
Sequelae of Head Injury
Spinal Cord Injury
Cerebrospinal Fluid Spaces
Visceral Injuries
Liver, Spleen, Kidneys and Adrenals
Pancreas
Bowel Injury
Visceral Chest Trauma
Penetrating Trauma
Soft-Tissue Injury
Differential Diagnosis
Head Injury
Subdural Haematoma
Physiological Periosteal Reaction
Accidential Injury
Normal Variants
Birth Trauma
Osteomyelitis
Metabolic Bone Disease
Osteogenesis Imperfecta
Temporary Brittle Bone Disease
Conclusion
References
4 Haematological abnormalities that can simulate abuse
Introduction
Primary Haemostasis
Platelet Adhesion
Platelet Activation
Platelet Aggregation
Platelet Secretion
Platelet Enhancement of Coagulation
Von Willebrand Factor
Secondary Haemostasis
Initiation and Amplification of Coagulation
Classical Coagulation Pathway
Laboratory Tests
Measurements of Primary Haemostasis
Evaluation of a Bleeding Patient
Clinical History and Presentation
Examination of the Child
Haematological Investigation
First-Line Investigations
Patterns of Abnormal Results
Isolated and Prolonged aPTT (PT Normal, TT Normal, Fibrinogen Normal, Platelets Normal)
Isolated and Prolonged PT (aPTT Normal, TT Normal, Fibrinogen Normal, Platelets Normal)
Prolonged PT and aPTT (TT Normal, Fibrinogen Normal, Platelets Normal)
Prolonged PT and aPTT, Long TT with Low Fibrinogen (Platelets Normal)
Prolonged PT and aPTT, Long TT with Low Fibrinogen and Platelets
Prolonged PT and aPTT, Platelets Low (TT Normal, Fibrinogen Normal)
Normal Coagulation Screen With a Normal Platelet Count
Von Willebrand Disease
Platelet Storage Pool Disorders
Factor XIII Deficiency
Antiplasmin Deficiency
Plasminogen Activator Inhibitor-1 Deficiency
Glanzmann’s Thrombasthenia
Henoch–Schonlein Purpura
Vitamin C Deficiency
Abnormalities of Platelet Number or Morphology
Congenital
Wiskott-Aldrich Syndrome
Bernard–Soulier Syndrome
Hermansky–Pudlak Syndrome
Chediak–Higashi Syndrome
May–Hegglin Anomaly
Other Macrocytopathies
Grey Platelet Syndrome
Acquired
Immune Thrombocytopenia
Myelodysplasia
Coagulation Defects
Haemophilia A and B
Haemophilia C
Rare Coagulation Deficiencies
Deficiencies of Factor XII, High-Molecular-Weight Kininogen and Prekallikrein
The Neonate
Thrombocytopenia in the Neonate
Neonatal Alloimmune Thrombocytopenia
Vitamin K Deficiency
Drugs Associated with Bleeding
Warfarin
Heparin
Platelet Dysfunction Secondary to Drugs
Sodium Valproate
Non-Steroidal Anti-Inflammatory Drugs
Anti-Platelet Drugs
Bone Marrow Failure Syndromes
Inherited Bone Marrow Failure Syndromes
Aplastic Anaemia
Leukaemia
Myelodysplasia
Bone Marrow Infiltration
Systemic Disease Associated with a Bleeding Tendency
Renal Failure
Liver Failure
Malabsorption Syndromes
Activation of Coagulation
Disseminated Intravascular Coagulation
Head Injury
Cyanotic Congenital Heart Disease
Conclusion
References
5 Biochemical investigations on post-mortem specimens
Introduction
General Evaluation
Nutritional Status
Recent Nutritional Intake
Long-Term Nutritional Status
Hypoxia
Inflammation
Anaphylaxis
Infection
Dehydration and Electrolytes
Time of Death (Post-Mortem Interval)
Endocrine Disorders
Diabetes Mellitus
Glucose
Ketones
Addison’s Disease: Adrenal Insufficiency
Renal Failure
Genetic Metabolic Disorders Presenting as Sudden Unexpected Death
Fatty Acid Oxidation Defects
Other Genetic Metabolic Disorders
Technical Considerations at the Time of Autopsy
Vitreous Humour
Blood Collection
Urine Collection
Fibroblast Culture for Enzyme Analysis
Tissue for DNA Analysis
The ‘Acute’ Metabolic Autopsy
Cerebrospinal Fluid
References
6 Ocular involvement in non-accidental injury
Introduction
Scope of Ocular and Adnexal Injury
Eyelids
External Eye
Anterior Segment
Posterior Segment
Visual Pathways
Ocular Motor Control
Fundus Haemorrhages
Types
Nerve Fibre
Deep Retina
Subretina
Pre-Retina
Posterior Hyaloid
Mechanisms
Forces Required to Cause Bleeding
Associated Neurological Injury
Differential Diagnosis of Fundus Haemorrhages
Accidental Injury
Cardiopulmonary Resuscitation
Epileptic Seizures
Arousal Shaking
Bleeding Disorders
Bleeding Secondary to Infection
Genetic Metabolic Disorders
Birth-Associated Retinal Haemorrhage
Examining the Child With Fundus Haemorrhages
Long-Term Visual Sequelae
Additional Observations
References
7 The death scene following the sudden death of a child
Introduction
Scene Management
The Crime Scene Manager
Sequence of Events at the Death Scene
Unclothing the Body
A Good Look Around
Sudden Infant Death Syndrome or Non-Sudden Infant Death Syndrome
External Petechiae
Bruising
Abandoned Neonates
Deaths From Trauma
Deaths in Fires
Dyadic and Multiple Deaths
Sudden Deaths of Older Children
Sensitivity and Stress of the Investigation
Inquests and Inquiries
References
8 Post-mortem examination in babies and children
Introduction
Death Scene Investigation
Rectal Temperature
Medical and Family History
Other Important Information
Radiological Examination
Photography
Microbiological Samples
Toxicological Investigations
Biochemical and Metabolic Investigations
Weights and Measurements
External Examination
Estimating Blood Loss
Dissection (Infants and Older Children)
Examination of the Brain, Spinal Cord and Eye
Examination of the Newly Born
Radiography
External Findings
Examination of The Scalp and Cranium
External
Internal
Cranial Cavity
Spinal Cord
Body Cavities
Placenta
Recognized Birth Injuries
Histological Samples
Demonstration of Bony Injury
Retention of Organs
Exchange of Information and Multidisciplinary Review
References
9 Pathology of neurological abnormality in early life
Introduction
Clinical Manifestations of Early Brain Damage: Cerebral Palsy
Timing of Injuries by Histology
Cerebral Oedema
Cell Death
Macrophage Response
Gliosis
Capillary Reaction
Haemosiderin
Cyst Formation
Mineralization
Axonal Damage
Acquired Intra-Uterine Damage
Early
Agenesis of the Corpus Callosum
Neuronal Migration Disorders
Porencephaly
Schizencephaly/Polymicrogyria
Late
White Matter Damage
Hypoxic–Ischaemic Injury at Term
Predominantly Brainstem Damage (Cardiac Arrest Encephalopathy)
Basal Ganglia/Thalamus
Cortical and Watershed Damage
Germinal Matrix Haemorrhage
Parenchymal Venous Infarction
Birth-Related Injury
Birth Trauma
Scalp and Skull
Intracranial Haemorrhage
Intradural Haemorrhage
Subdural Haemorrhage
Method of Delivery
Location
Natural History of Infant Subdural Haemorrhage
Extradural Haemorrhage
Subarachnoid Haemorrhage
Posterior Fossa Damage
Spinal Cord and Nerve Roots
Stroke in the Developing Brain
Cerebral Sinovenous Thrombosis
Metabolic Disorders
Hypoglycaemia
Mitochondrial Diseases
Lipid Storage Diseases
Infections
References
10 Fetal and perinatal death
Introduction
Definitions
The Law
The Offence of Procurement of Abortion
Child Destruction
Concealment of Birth
Infanticide
Background Information
Concealed Pregnancy
Unattended Delivery
Delivery into Toilets
Was the Baby Born Alive?
Is the Baby of Sufficient Maturity to Survive?
Is There Evidence of Prolonged or Difficult Labour?
Are there any Significant Injuries?
Fetal Death Following Maternal Injury
Fetal Injuries and Cause of Fetal Death
Is There a Natural Cause for Death?
Can I Give a Cause of Death?
Should the Intrapartum Still Birth Be A Medicolegal Autopsy?
References
11 Sudden Unexpected Death in Infancy: Sudden Infant Death Syndrome or Something Else?
Introduction
The Definition of Sids
How Sudden?
How Old?
Unexpected by Whom?
Which Historical Events are Significant?
What is a Thorough Necropsy Examination?
What is an Adequate Cause of Death?
Multidisciplinary Case Review
Epidemiology
Epidemiology of SUDI and SIDS
Predicting SIDS – and What Else?
Recent Medical History in SUDI and SIDS
Adverse Historical Factors
Sleeping Environment
Good practice
Suboptimal sleeping environments
Inappropriate sleep surfaces for infants
Other unsafe sleeping environments
Co-sleeping
Pathological Findings In SUDI
The Pathology of Explained Natural Death
Instantaneous Death
Rapid Death During Recognized Illness
Found Dead In Cot
Sudden Death In Neonates
Which Post-mortem Findings are Compatible With the Conclusion of SIDS?
Macroscopic
Histological
Changes Induced by Attempted Resuscitation
Pathological Findings which Raise Concern About the Possibility of Non-Accidental Injury (NAI)
External Findings
Fractures
Visceral Pathology
Pulmonary Haemorrhage/Siderophages
Aspiration Of Foreign Material
Hepatic Siderophages
Findings of Questionable Significance
External
Internal
Microscopic
Death Certification
References
12 Sudden natural death in infants and children
Introduction
Cardiovascular Causes of Sudden Death
Cardiac Malformation
Myocarditis
Cardiomyopathy
Hypertrophic Cardiomyopathy and Variants
Dilated Cardiomyopathy
Endocardial Fibroelastosis
Arrhythmogenic Right Ventricular Dysplasia (Right Ventricular Cardiomyopathy)
Histiocytoid Cardiomyopathy
Anomalous Coronary Arteries
Kawasaki’s Disease
Abnormalities of Cardiac Conduction
Occlusive Disease of the Coronary Arteries
Tumours of Cardiac Muscle
Endodermal Heterotopia of the Atrioventricular Node
Rhabdomyoma
Fibroma
Myxoma
Other Cardiac Tumours
Thromboembolism
Marfan’s Syndrome
X-Linked Hypohidrotic (Anhidrotic) Ectodermal Dysplasia
Achondroplasia
Tuberous Sclerosis Complex
Intracranial Haemorrhage, Neoplasms and Malformations
Encephalitis and Leucodystrophies
Adrenal Hypoplasia/Insufficiency
Haemorrhagic Shock Encephalopathy Syndrome
Reye’s Syndrome
Gastrointestinal Causes
Fatal Anaphylaxis
Sickle Cell Disease
Haemorrhage as a Cause of Sudden Death
Respiratory Causes of Sudden Death
Abnormalities of the Trachea
Acute Epiglottitis
Retropharyngeal Abscess
Bacterial Tracheitis
Acute Bronchiolitis
Pulmonary Veno-Occlusive Disease
Pulmonary Arterial Hypertension
Epilepsy and Sudden Death
Deaths From Acute Asthma
Diabetes Mellitus
Genetic Metabolic Disorders
Mitochondrial Abnormalities
Fatty Acid Oxidation Defects
Disorders of Oxidative Phosphorylation
Other Bacterial Infections
Deaths Related to Obstetric Events and Premature Birth
Miscellaneous Causes of Sudden Natural Death
Sudden Unexplained Death in Older Children
Sudden Natural Death in the Early Neonatal Period
Sudden Death Associated with ‘Intermediate’ Pathology
References
13 Recent advances in paediatric toxicology
Scope of the Problem
Specificity of Paediatric Toxicology
Techniques Used in Drug Testing
Drug Screening
Immunoassay Techniques
Sample Preparation
High-Performance Liquid Chromatography
Gas Chromatography
Capillary Electrophoresis
Drug Confirmation
Method Validation
Special Techniques for Analysis of Volatile Substances
Alternative Specimens for Drug Testing
Urine
Blood
Hair
Specimen Collection
Sample Preparation
Drug Identification
Cut-Off Values
Oral Fluid
Sweat
Meconium and Amniotic Fluid
Pitfalls and Limitations of Drug Screens
Causes of False-positive Drug Screens
Causes of False-negative Drug Screens
Technological Shortcomings
Pharmacokinetic Characteristics
Intentional Specimen Alteration or Adulteration
Post-mortem Changes
Post-Mortem Redistribution of Drugs
Post-Mortem Degradation of Drugs
Post-Mortem Formation of Drugs
Specific Applications
Drug Screening for Doping Agents
Forensic Applications of Hair Analysis in Children and Teenagers
Determination of Fetal Exposure to Drugs of Abuse
The Importance of Paediatric Toxicology in Specific Cases
Deliberate Poisoning by Health Professionals
Toxicology and Sudden Infant Death Syndrome
Conclusions and Future Considerations in Forensic Paediatric Toxicology
References
14 Head and neck injuries
Definition
Epidemiology
Accidental Head Injury
Non-accidental Head Injury
Traumatic Birth Injury
Mild Accidental Head Injury
Physiological Monitoring in the Neurointensive Care Unit
Electrophysiological Monitoring
Cerebral Blood Flow
Microdialysis
Imaging of Accidental Head Injury
Epidural Haematomas
Subdural Haematomas
Contusions
Skull Fractures
Non-Accidental Head Injury
Traumatic Birth Injury
Primary Mechanisms of Injury to the Brain
Secondary Mechanisms of Brain Injury
Injury to the Cervical Spinal Cord
Genetic Influence on Recovery From Traumatic Brain Injury
References
15 Heat-induced injury or death
Introduction
House Fire Deaths
The Pathologist’S Role
Smoke Inhalation
Effects of Smoke Inhalation
Interpretation of Results
Burns
Pathological Changes
Non-Accidental Burns and Scalds
Burns Caused by Electricity
References
16 Asphyxial deaths in children
Petechiae
Scene of Death
Traumatic Asphyxia in Children
Entrapment Asphyxia
Foreign Body Inhalation
Plastic Bag Asphyxia
Overlaying and Wedging
Strangulation
Hanging by a Ligature
Drowning and Near Drowning
Imposed Airways Obstruction
Abuse of Inhalants (Solvent Abuse)
Reverse Suspension
Chemical Asphyxia
Prevention
References
17 Accidental injuries in children
Overview of Paediatric Trauma
Accident Proneness In Children
Causes and Mechanisms of Injuries
Consequences
Bicycle Helmets
Falls
Playground Injuries
Sports Injuries on Snow and Ice
Riding Injuries
Agricultural Injuries
Prevention
Older Children and Substance Abuse
Accidental Poisoning
Hypersensitivity
References
18 Drowning and near drowning
Introduction
The Causes of Childhood Drowning: a Perspective
The Drowning Medium
Fresh Water
Sea Water
‘Dry’ Drowning
Water Temperature
Immersion Asphyxia Occurring Other than in Water
The Pathophysiology of Drowning
The Diving Reflex
Lung Pathology
Peripheral Airway Resistance Increases
Laryngeal Spasm
Reflex Pulmonary Vascular Vasoconstriction
Fluid Shifts Across Alveolar Membranes
Surfactant Changes
Froth Formation
Hypoxic Cascade
Forensic Immersion Syndromes
Classification of Drowning in Children
Child-killing Immersion Syndromes
Neonaticide
Infanticide
Filicide
Site-specific Immersion Syndromes
Bucket or Pail
Bath Tub Drownings
Accidental Child Drowning in Bath Tubs
Bath Tub Drownings and Child Abuse
Bath Tub Drowning and Child Homicide
Childhood Bath Tub Immersion in Epilepsy
Bath Tub Drowning and Euthanasia
Bath Tub Drowning and Organic Pathology
Swimming Pool Drownings
Public Swimming Pool Drownings
Rivers, Creeks and Lakes
Drains, Trenches and Sewers
Sea Drowning
Aftermath
Acknowledgement
References
19 Sudden death of children in hospital
Introduction
Definition and Frequency
Deaths Due to Natural Disease
Fatal Haemorrhage
Septic Shock
Fatal Embolism in Childhood
Cerebral Oedema
Cardiac Dysrhythmia
Deaths Due to Failure to Monitor
Therapeutic Misadventures
Deaths Due to Drug Treatment
The Wrong Drug or the Wrong Route of Administration
Toxicity Due to the Wrong Dosage
Adverse Reactions to Drugs
Anaphylactic Reactions to Drugs
Deaths Due to Medical Devices and Procedures
Vascular Catheters and Infusions
Nasogastric and Orogastric Tubes
Endotracheal Tubes and Tracheostomies
Lumbar Puncture
Ventriculoperitoneal and Ventriculoatrial Shunts
Other Devices
Deaths Associated with Surgery and Anaesthesia
Deaths Due to Surgery
Complications of Anaesthesia
Deaths in the Dental Chair
Sudden Death in Newborn Babies
Accidents
Suicide
Filicide and Homicide in Hospital
Investigation of Sudden Unexpected Death of Children in Hospital
Acknowledgement
References
20 Road traffic accidents in children
Road Traffic Fatalities
Investigation of a Fatal Road Traffic Collision
The Scene of the Collision
Eyewitness Accounts
Clothing of the Decedent
Inspection of the Vehicles Involved
Information from Others Involved
The Decedent
Vehicular Collisions
Other Supervening Problems in Collisions
Pedestrian Injuries
Child Cyclists
Diffuse Axonal Injury
Whiplash Injuries
Injuries to Children in Utero
Other Vehicular Accidents
References
21 Forensic DNA profiling in cases involving children
Introduction
Inheritance of Genetic Material
Deoxyribonucleic Acid
Genes, Alleles and Genetic Variation
Forensic DNA Analysis: History and Techniques
Restriction Fragment Length Polymorphisms
Short Tandem Repeat Profiling
Principles
Technique
Interpretation
Sample Collection and Processing
DNA Evidence and Child Sexual Offence
Y Chromosome Short Tandem Repeat Typing
Mixed Samples
Additional Sample Problems and Solutions
Mitochondrial Dna
Paternity Testing
Mutation and Anomalous Genotypes
The Use of Mitochondrial DNA and the Y Chromosome in Paternity Cases
Identification of Body Remains and Missing Persons
Identification of the ‘Abandoned Baby’ or Fetal Material and Avenues for Identifying the Source of an Unknown Profile
DNA Databases
References
22 The dentist’s role in child abuse and neglect
Introduction
Dental Neglect
Facial and Oral Pathology
Extraoral Injuries
Intraoral Injuries
The Dentist Accused of Child Abuse
Bite Marks
Types of Bite Marks in Children
Self-inflicted Bites
Animal Bites on Children
Infections in Human and Animal Bites
The Investigation of the Bite Marks
The Bite Marks
The Detail of the Bite
Recording the Bite Mark
Impressions of the Bite
Excision of Skin Samples
The Suspect
Comparison of Evidence from the Bite and the Suspect
References
23 Paediatric dental identification
Introduction
Comparison
Dental Characteristics
Ante-mortem Procedures and Dental Records
Post-mortem Procedures
Facial Reconstruction and Dental Profiling
Facial Reconstruction
Dental Profiling
Age Estimation
Sex Determination
Height
Ethnicity
References
24 The expert witness and expert testimony
Introduction
Mission Statement of the Expert
Claim to Expertise
Professional Witnesses
Opinions
Yes or No?
Admissibility of Expert Evidence
Communications from the Expert Witness
Declaration by the Expert in the Report
In the Witness Stand or Box
Pre-Trial Communication
Conflict of Interest
Rules of Evidence
Conclusion
Recent Developments
References
Appendix A: Child protection examination forms
Form 1: Examination consent form
Form 2: Examination form
Background Information
Account of Circumstances Leading to Referral

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