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Pediatric Forensic Pathology: Limits and Controversies Commissioned by The Inquiry into Pediatric Forensic Pathology Ontario, Canada (As amended, 15 February 2008) Authors: Stephen Cordner Jonathon Ehsani Lyndal Bugeja Joseph Ibrahim Victorian Institute of Forensic Medicine November 2007 Paediatric Forensic Pathology: Limits and Controversies i Title Page This paper was written by Stephen Cordner (1), Jonathon Ehsani (2), Lyndal Bugeja (3), and Joseph Ibrahim (4) from the Victorian Institute of Forensic Medicine in Australia for the Inquiry into Pediatric Forensic Pathology in Ontario, Canada. The authors thank Dr Jeffrey Hubbard, Albany, New York for his comments on this paper. Any faults are ours, however. Editorial decisions and the opinions expressed are the responsibility of the first author and do not represent those of the Victorian Institute of Forensic Medicine or Monash University or of the Inquiry into Pediatric Forensic Pathology or the Commissioner. 1—Stephen Cordner AM MA MB BS BMedSc DipCrim DMJ FRCPA FRCPath Professor of Forensic Medicine, Monash University. Director, Victorian Institute of Forensic Medicine, Australia. 2—Jonathon Ehsani BMedSci, MPH (International), MH.Sci (Public Health) PhD Candidate, Monash University Accident Research Centre, Victoria, Australia. Senior Research Officer, Victorian Institute of Forensic Medicine, Victoria, Australia. 3—Lyndal Bugeja BA (Hons - Criminology) PhD Candidate, Monash University Accident Research Centre, Victoria, Australia. Senior Research Officer, Victorian Institute of Forensic Medicine, Victoria, Australia. 4—Joseph Ibrahim MB BS Grad Cert HE PhD MRACMA FAFPHM FRACP Consultant Physician, Victorian Institute of Forensic Medicine, Victoria, Australia. The authors acknowledge with thanks the assistance of Ms Kerry Johannes, Library Manager at the Victorian Institute of Forensic Medicine. Paediatric Forensic Pathology: Limits and Controversies ii Soothsayer: In nature’s infinite book of secrecy A little I can read. —Antony and Cleopatra, Act 1, Scene ii Paediatric Forensic Pathology: Limits and Controversies iii Abbreviations BAPP Beta-amyloid precursor protein CPR Cardio-Pulmonary Resuscitation CSF Cerebro-spinal fluid DAI Diffuse Axonal Injury FII Fabricated or Induced Illness (see also MSbP) HDN Hemorrhagic disease of the newborn IHT Inflicted Head Trauma ILO International Labour Organisation LQTS Long QT Syndrome MSbP Munchausen Syndrome by Proxy (see also FII) NAI Non-accidental injury NAHI Non-accidental head injury NCIS National Coroners Information System NT Northern Territory QAP Quality Assurance Program SA South Australia SDH Subdural hemorrhage SBS Shaken Baby Syndrome SIDS Sudden Infant Death Syndrome SUDI Sudden Unexplained Death in Infancy UK United Kingdom USA United States of America VIFM Victorian Institute of Forensic Medicine WA Western Australia WHO World Health Organization Paediatric Forensic Pathology: Limits and Controversies iv Glossary and Definitions Acute Of recent origin. Anoxia Absence of oxygen in the blood or tissues. Ante-partum Before the beginning of labour. Anterior* Anatomical term: to the front (of). Anthropophagy The generally post-mortem phenomenon of animals, sea creatures or insects consuming human tissue. Artefact (artifact) Artificial product. In relation to autopsy, it is a sign or finding imitating pathology, disease, or injury occurring in life. Asphyxia A complex and confusing term used in varying ways by different authors. It is discussed in detail in this paper. The common notion of asphyxia is a mechanical interference of some sort with breathing. Atrial septal defect “A hole in the heart”; usually small and of little significance. Autopsy The post-mortem examination of a body involving its external and internal examination and incorporating the results of special tests. In a full autopsy, the internal examination involves, but is not limited to, examining the contents of the cranium, chest, and abdomen. Further dissection can and should occur in particular circumstances. Axon A nerve fibre. Bilateral Both sides (of the body). Biochemistry The chemistry of biology, the application of the tools and concepts of chemistry to living systems [1]. Born Complete expulsion of the baby from the mother. Born alive Complete expulsion from the mother and an independent existence from the mother (established breathing and circulation). Brainstem The connection between the brain and the spinal cord; an enlarged extension of the spinal cord attaching to the brain within the skull. Bruise, bruising Bleeding into tissues from damaged blood vessels, usually as a result of external injury. Most commonly understood as bruise in or under the skin, but can occur in any tissue, e.g., muscle, heart, liver, etc. Calvarium The vault of the skull. Caput succedaneum Diffuse swelling of the scalp in a newborn caused by pressure from the uterus or vaginal wall during a head-first (vertex) delivery. Cardiac To do with the heart. Paediatric Forensic Pathology: Limits and Controversies v Case series A study reporting observations on a series of individuals, usually all receiving the same intervention, with no control group [2]. Cardiopulmonary Compression of the chest and artificial respiration in attempts to restart the beating resuscitation of the heart and spontaneous breathing. Cerebellar tonsillar Protrusion, and consequently compression of, the cerebellum into the foramen herniation magnum as a result of raised pressure inside the skull. This is a very serious and often fatal development when associated also with compression of the brain stem (coning). Cerebral edema Swelling of the brain due to an extracellular accumulation of watery fluid. Cerebral Injury to the substance of the cerebral hemispheres (the largest part) of the brain parenchymal injury Cerebro-spinal fluid The clear fluid circulating around and within the spaces—ventricular system—of (CSF) the brain and spinal cord. Choking Internal obstruction of the larynx, laryngo-pharynx (i.e., the back of the throat), such as by a large piece of food. Sometimes colloquially used to equate with manual strangulation. Clinical Relating to patients. Computerized CT scanning computes multiple X-ray images to generate cross-sectional and other tomography (CT) views of the body’s anatomy. It can identify normal and abnormal structures and be scanner; used to guide procedures [1]. computerized axial tomography (CAT) Congenital Born with. Coning Compression of the brain stem in the foramen magnum because of raised pressure in the skull (or technically, raised intra-cranial pressure). Conjunctiva, -ae, -al The thin membrane lining of the inner aspect of the eyelids and covering the eyes. Contusion Bruise, bruising. Coronary Hardening of the arteries of the heart, heart disease, heart attack, myocardial atherosclerosis infarction. Cutaneous Relating to the skin. Cyanosis A bluish colour of the skin and the mucous membranes reflecting the absolute amount of insufficiently oxygenated blood. For example, the lips may show cyanosis. Cyanosis can be evident at birth, as in a "blue baby" who has a heart malformation that permits blood that is not fully oxygenated to enter the arterial circulation. Its significance as an observation post mortem (as opposed to a clinical observation in life) is minimal [1]. Dermis The leathery part of the skin, covered by the scaly epidermis. Duodenum The first part of the small intestine encountered by food as it leaves the stomach. It Paediatric Forensic Pathology: Limits and Controversies vi connects with the jejunum. Encephalopathy See hypoxic ischemic-encephalopathy Embolus, embolism See Thrombus Epicardium, The outer aspect of the heart. epicardial Epidermis The scaly outer layer of the skin overlying the leathery dermis. Extradural Outside the dura, the membrane lining the inner aspect of the skull, and between it and the skull. Usually used in reference to extradural hemorrhage accompanying head trauma in some circumstances. Extravasation The presence of blood cells in the tissues outside blood vessels; bleeding; hemorrhage. Filicide The killing of a child by a parent. Fontanel The fontanel is a "soft spot" of the skull between the skull bones that has not yet hardened into bone. There are normally two fontanels, both in the midline of the skull: the anterior and posterior fontanel. The posterior fontanel closes by the age of about 8 weeks in a full-term baby. And the anterior fontanel closes at 18 months of age on the average but it can close as early as nine months. If they are sunken or tense, that might indicate a problem [1]. Foramen magnum The hole at the bottom of the skull through which the spinal cord joins the brain stem and, thus, the brain. Forensic Relating to the courts, or more generally, the law. Forensic Medicine The application of the principles and practices of medicine to the needs of the law. The term (and not the practice) encompasses forensic pathology, clinical forensic medicine, forensic psychiatry and, in more recent times, the area of medical law and ethics. Forensic Pathology Part of pathology and is particularly concerned with the investigation of sudden and unexpected deaths from all causes. The discipline of pathology concerned with the investigation of deaths where there are medico-legal implications. Forensic Science The application of science to the needs of the law. Operationally, in the developed world, there are few forensic scientists. Rather, there are forensic biologists, forensic chemists, botanists, toxicologists,
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