Infant deaths and female feticide

DR. ARIF MASOOD
PRINCIPAL
ANANYA COLLEGE OF HOMOEOPATHY
KALOL, GANDHINAGAR
M.D.(HOM)

 Introduction
All infants are susceptible, like adults to
natural disease from which they could die.
They may also die as a result of congenital
anomalies or by application of violence or
may present as case of sudden death.

Infanticide
Definitions
1. Infanticide: It means unlawful destruction of
a newly born child and is regarded as murder
in law. It is punishable under Sec 302 of IPC.
2. Feticide: It means killing of fetus prior to
birth.
3. Neonaticide: It means killing of neonate.
4. Filicide: It is defined as killing of a child or a
step-child, aged between 0 and 18 years, by
his or her parents.Filicide is broad term and
includes neonaticide infanticide and pedicide

Causes
Death due to application of violence and may be caused
either by:
1. Acts of commission or
2. Acts of omission
1. Acts of Commission: These are the willful acts done to
cause the death of infant. It includes:
1. Suffocation
2. Strangulation
3. Drowning
4. Head injury
5. Fracture-dislocation of cervical spine
6. Concealed puncture marks (pithing)
7. Poisoning

Causes
Acts of Omission: Acts of omission refer to
failure to take care of child or negligent
towards the child during or after birth. It
includes:
1. Failure to provide assistance during labor.
2. Failure to clear the air passage after birth.
3. Failure to cut and ligate the umbilical cord.
4. Failure to feed the child.
5. Failure to protect the child from heat or
cold.

Medicolegal Questions
Following questions are raised while doing
autopsy in infanticide case:
1. Was the child still-born or dead born?
2. Was the child born alive (i.e. live born)?
3. If born alive, how long did the child survive
the birth?
4. What was the cause of death?

Still-Born (Still Birth) Child
• Definition: “The child which has issued forth
from the mother after the 28th week of
pregnancy and did not any time, after being
completely expelled, breathes, or shows any
other signs of life”.
• Thus, a still-born child is alive in uterus up to the
initiation of birth process and died during the
process (i.e. delivery) but did not show any sign
of life after being completely born. In other
words, after birth, the child was still (immobile)
and therefore the term still born child.

 Dead-born Child (Dead Birth)
• Definition: A dead-born child is one, which had
died in uterus before the birth process begins
and may show rigor mortis, maceration or
mummification at birth.
• Fetal death has been defined by World Health
Organization (WHO) as “death before complete
expulsion or extraction from its mother of a
product of conception, irrespective of the
duration of pregnancy”.
Rigor Mortis
• Rgor mortis may set in early stages of death.
• Presence of rigor mortis may cause difficulty in
delivery.

Maceration
• Definition: It is a process of aseptic autolysis occurringin fetus
that remains dead in the uterus surrounded byliquor amnii.
• Maceration in fetus is sign of death.
• Mechanism: The cells of fetus break down after death and due to
enzymatic action (autolysis) body becomes soft and flaccid.
Unlike putrefaction or decomposition, there is no bacterial action
in maceration.
• Duration required: If fetus remains in uterus after death,then the
earliest sign of maceration is seen at about 6 to 12hours in form
of areas of desquamation and appearanceof brown-red
discolouration of umbilical cord stump
• The macerated fetus is soft and flabby and flattens when kept on
table.
• Emits sweetish disagreeable smell
• The earliest sign of maceration is skin slippage (seen at 6-12
hours)

Maceration
• Definition: It is a process of aseptic autolysis
occurringin fetus that remains dead in the uterus
surrounded by liquor amnii.
• Maceration in fetus is sign of death.
• Mechanism: The cells of fetus break down after death
and due to enzymatic action (autolysis) body
becomes soft and flaccid. Unlike putrefaction or
decomposition, there is no bacterial action in
maceration.
• Duration required: If fetus remains in uterus after
death,then the earliest sign of maceration is seen at
about 6 to 12hours in form of areas of desquamation
and appearance of brown-red discolouration of
umbilical cord stump

Maceration
• The macerated fetus is soft and flabby and flattens
when kept on table.
• Emits sweetish disagreeable smell
• The earliest sign of maceration is skin slippage (seen
at 6-12 hours)
Mummification
• It is drying and shriveling of fetus occurring in uterus
after death
• It results when liquor amnii is scanty and no air enters
the uterus.
Putrefaction
If the membranes are ruptured early and air enters the
uterus, then the dead fetus shows signs of
putrefaction instead of maceration

Live-born Child (Live-birth)
• A child showing a sign of life, even when only
part of the child is out of mother, though the
child has not breathed or completely born, is
considered as live-born child.
• Causing death of such child is treated in the
same manner as homicide.
Viability of Child
• Viability means the ability of fetus to lead a
separate existence after birth by virtue of
certain degree of development.
• A child is viable after 210 days or 7 months or 30
weeks of intrauterine life

Evidence of Live Birth (Signs of Live Birth)
The law in India presumes that every child
found dead was born dead unless the
contrary is proved. Proof of live birth is
required in civil or criminal cases.
In Civil Cases
Following are considered as signs of live birth.
1. Crying of baby
2. Movement of body or hand or foot
3. Muscle twitching or twitching of eyelid

Evidence of Live Birth (Signs of Live Birth)
In Criminal Cases
In criminal cases, signs of live birth have to be demonstratedby autopsy
examination of the child. Following are the external and internal autopsy
findings in live birth.
External changes
1. Changes in chest
2. Changes in skin
3. Changes in umbilicus
Internal changes
1. Changes in lung
2. Position of diaphragm
3. Changes in heart and circulation
4. Changes in gastrointestinal tract
5. Changes in middle ear
6. Changes in kidneys
7. Changes in blood

External Findings at Autopsy
1. Changes in Chest:
A live birth child will respire and due to act of
respiration, certain changes are induced.(Next
Slide)
2. Changes in Skin
• After live birth, color of skin is pinkish red and
darkens after 2 to 3 days. The permanent
complexion ofskin comes by seven days after
birth.
• Desquamation of skin is seen by 2nd day onwards
• Physiologic jaundice manifests by 2nd day.

3. Changes in Umbilicus and Umbilical Cord
The changes occurring in umbilicus and umbilical cord are
summarized in Table

INTERNAL CHANGES
Signs of live birth observed in internal examination are as follows
I. Changes in Lungs: Due to respiration, following changes occur in
lungs of live birth child. Differences between respired and
unrespired lungs are summarized in Table below.
A) Gross and microscopic examination
1. Volume: non-respired lungs appear small, collapsed, lie in the
back part of chest on side of vertebral column whereas respired
lungs appear voluminous; filling the whole pleural cavities and
medial margin overlaps the mediastinum and pericardium.
2. Colour, consistency and appearance: Before respiration, the lungs
are uniformly reddish-brown and hard in consistency like that of
liver, non-crepitant. The pleurae over lungs are loose and
wrinkled. After respiration, air cells (alveoli) are distended with
respired air. The distended alveoli are raised above the surface

INTERNAL CHANGES
I. Changes in Lungs
A) Gross and microscopic examination
However, lungs may be crepitant in dead fetus if the fetus is
showing:
• Signs of decomposition (putrefaction) or
• If fetus is given artificial respiration.
3. On cut section: In non-respired lungs, the cut surfaces are
uniform, hard and exude little froth-less fluid. In respired
lungs, the cut surfaces are spongy and exude frothy blood.

INTERNAL CHANGES
I. Changes in Lungs
B). TESTS
1. Static test or Fodere’s test
• Before respiration – average weight of lung (both) varies from 30 to 40
gm
• After respiration – the average weight of both lungs increases and
varies from 60 to 70 gm. The increase in weight is due to increase in
circulation.
2. Ploucquet’s test
• Before respiration – the weight of both lungs is about 1/70th of the
weight of whole fetus.
• After respiration – the weight of both lungs is about 1/35th of the
weight of whole fetus.
3. Specific gravity
• Non-respired lung – specific gravity is 1040 to 1050
• Respired lung – specific gravity is 0.940 to 0.950

INTERNAL CHANGES
I. Changes in Lungs
B). TESTS
4. Hydrostatic test
• Also called as floatation test
• The test is used to differentiate between respiredand non-
respired lungs and is based on following principle:
• Principle: If an infant breaths after birth, air will enter in lungs
and makes them lighter and floats in water.
• Procedure: Ligate the bronchi at hilum and placed individual lung
in water. If the lung floats in water, remove lung and cut into
many pieces and then squeeze or press the pieces between
sponges and again place the individual pieces into water. A piece
of liver may be used that will serve as control.

• Inference: Depending on floatation or sinking of lung/ pieces
following inference can be drawn
• If lung pieces floats – respired lung
• If lung pieces sinks – unrespired lung
• If liver piece floats – inconclusive
Reason: Floating of lung and pieces can be explained as
• In first part – lung floats because – after respiration is established,
air will expand the collapsed alveoli. The specific gravity of lung
before respiration varies from 1040 to 1050. However, after
respiration, the specific gravity is about 0.940- 0.950, which is
less than that of water. Thus the floatation of lung in water
indicates the act of respiration and lung is respired one.
• In second part – the pieces of lungs float because – after
respiration, residual air is present in respired lung. The residual
air cannot be squeezed out by pressing. Thus due to presence of
air in lung pieces, the pieces will float. It indicates that child has
respired after birth.

Drawbacks or fallacies of hydrostatic test
1. Respired lung may sink in following conditions:
• Pulmonary edema
• Pneumonia
• Atelectasis – non-expansion of lung
• Obstruction by alveolar duct membrane
• Due to feeble respiration.
2. Non-respired lung may float in following conditions:
• Putrefaction – presence of gases of decompositionmay
cause floatation of unrespired lung
• Artificial respiration

Hydrostatic Test is Not Necessary or Indicated in:
1. Fetus is dead born with signs of
maceration/mummification.
2. Born before 180 days of gestation (non-viable).
3. The stomach contains milk.
4. Umbilical cord separated and scar formed at
umbilicus.
5. When fetus has gross congenital anomalies
incompatible with life, for example,
anencephaly, monster etc.

II. Position of Diaphragm
• In fetal autopsy, abdomen is opened first to note
the position of diaphragm. The features of
diaphragm in respired infant are mentioned in
Table below.
• The position of diaphragm may be affected by
presence of gases of decomposition developing
within the chest and abdominal cavity.

III. Changes in Heart and Circulation
The changes occurring in heart and circulation of
live birth child are mentioned in Table below.

IV. Changes in Gastrointestinal Tract
1. Radiological evidence: Presence of air,
demonstrated on X-ray, in gastrointestinal tract
is a strong evidence of respiration. It is
suggested that during the act of respiration,
some air is swallowed in stomach and due to
peristaltic movement; the air gradually descends
in small and large intestine that can be
demonstrated on X-rays. The presence of air in
GIT may be confused with

2. Breslau’s second life test or stomach-bowel test
• The test is based on following principle
Principle: Air is swallowed in stomach during respiration. Stomach and
intestine will float in water if air is present.
Procedure: Stomach and intestine are removed after tying ligature at each
end. Then they are placed in water.
Result and interpretation: The results and inferences are as follows:
• If stomach and intestine floats – it indicates presence of air in GIT and
suggest child has respired after birth.
• If stomach and intestine sinks in water – it indicates absence of air and
suggest non-establishment of respiration in a child after birth.
• The test has less utility and act as corroborative evidence rather than
conclusive evidence
• Drawbacks: The test may be positive (i.e. float in water):
• If air or gases is present in GIT due to decomposition • If air or gases is
present in GIT due to artificial respiration
Advantages: The test is useful when air is prevented from entering into
lungs by:•Foreign body or • Due to occlusion of bronchi or • Due to
presence of tracheo-bronchial fistula

2. Breslau’s second life test or stomach-bowel test
• Drawbacks: The test may be positive (i.e. float in
water):
• If air or gases is present in GIT due to decomposition • If
air or gases is present in GIT due to artificial respiration
 Advantages: The test is useful when air is prevented
from entering into lungs by:•Foreign body or • Due to
occlusion of bronchi or • Due to presence of tracheo-
bronchial fistula
3. Demonstration of air under water: if stomach is
dissected under water, air bubbles will be released from
stomach if the child has respired.
4. Presence of milk or liquid food in stomach is a definitive
evidence of live birth of child and establishes that child had
lived for some time.

Sudden infant death syndrome (SIDS)
Also Called as Cot Death, Crib Death or SIDS In international
conference held in 1969, Beckwith proposed following definition
“the sudden death of any infant or young child which is
unexpected by history and in whom a thorough necropsy fails to
demonstrate an adequate cause of death”. A more
comprehensive definition was proposed in 1989 by the National
Institute of Child Health and Human Development stressing the
need of examination of scene of death. It defines infant deaths
to be classified as SIDS if:
1. The death of infant occurs up to the age of 1 year of age
2. A thorough postmortem examination fails to demonstrate an
adequate cause of death.
3. A death scene investigation is conducted and yields no evidence
of unnatural cause of death and
4. A review of the infant and the mother’s medical records reveal no
history of medical condition that might have caused death.

Factors Influencing the Risk of SIDS
1. Age: Death is common between 2 weeks to 2 years
with peak incidence occurs at around three month.
2. Sex: The incidence is more with male baby and most
surveys show the ratio of 1:1
3. Twins: The incidence is more in a member of a twin
pair as opposed to singletons.
Etiology and Theories of Causation of SIDS
Many theories are proposed for the causation of SIDS
but all remain speculative. Following are the
proposed theories:
1. Allergy to cow’s milk
2. Allergy to house-mite
3. Spinal hemorrhages.

 Battered baby syndrome
• Also called as Caffey’s syndrome, child abuse
syndrome, maltreatment syndrome, non-accidental
injury of childhood
• Definition: A battered child is one that suffers
repetitive physical injuries inflicted by parent or
guardian, which are non-accidental in nature.
• Caffey (1946) first reported the unusual
combination of recurrent subdural hematoma with
fracture of long bones but thought that the
phenomenon could be due to metabolic abnormality.
Silverman (1953) was the first to point out that
both, subdural hematoma and bone fracture were the
result of severe recurrent trauma. Kempe et al
(1962) coined the term “battered child syndrome”
now frequently called the “battered baby syndrome

Features of Battered Baby Syndrome10
• Age is usually less than 2 years
• Seen slightly more in male sexes
• There is general condition of neglect in child
• Disproportionate amount of soft tissue injury and
history is inconsistent with pattern of injury
• Occurrence of injuries at different times
• History given by parents are incompatible with
clinical findings
• There may be history of multiple admission to
hospital
• Such children usually belong to broken families, low
socioeconomic strata or the child may be result of
unwanted pregnancy or as a result of illegitimate
sexual relationship.

Diagnosis
• Nature of injuries inconsistent with history
provided by parents
• Recurrent injuries and injuries of different age
with different stage of healing
• Purposeful delay in seeking medical aid by
parents.
Medicolegal Implications
1. In India, the incidence of battered baby
syndrome is less.
2. If death of child occurs, a charge of homicide
may be labeled against offending parent.

Cinderella syndrome
• This syndrome was first described by Peter
Lewin13 in 1976.
• In some family, a single child, particularly female
child, is chosen for battering. The child is usually
the youngest or eldest child in the family. The
child is repeatedly abused while other children
(i.e. brother or sisters) of same family are
spared.
• The child may develop inattention disorder,
temper tantrums, failing grades and may leave
the home.13
• In other variety of syndrome, few adopted
female child accuse their step-parents of
maltreatment

Shaken baby syndrome
• Shaken baby syndrome was first described by
Guthkelch in 1971.
• Shaken baby syndrome is violent act of abuse
that can cause myriad neurological, cognitive
and other functional deficits. In the most
serious cases, deaths can result.
• It is a form of child abuse characterized by
retinal, subdural and/or subarachnoid
hemorrhage caused by severe shaking

Preconception and prenatal Diagnostic
Techniques Act 2003 (PCPNDT) prohibits sex
selection before or after conception and the
use of pre-natal diagnostic techniques to
determine sex of fetus.
Sex can be Determined By:
1. Amniocentesis
2. Chorionic villous biopsy
3. Ultrasonography scan and imaging
techniques

Features of PCPNDT Act
• Act prohibits sex selection before or after conception
• Regulates the use of prenatal diagnostic techniques
• Gynecologist or RMP have to conduct pre-natal diagnostic techniques at
recognized place
• Nursing home or RMP or hospital where ultrasonography is used have to
display the board stating “hospital does not do sex determination test”.
• Prenatal diagnostic techniques can be conducted for purpose of
determination of chromosomal or genetic or congenital abnormalities.
• Written consent of pregnant woman is must to undergo PC and PND
technique
• Doctor contravening the provisions of Act shall be punished for 3 years
imprisonment and fine of Rs. 10,000.
• Any person seeking help for sex selection shall also be held guilty and a
provision of punishment for 3 years
and fine of Rs. 50,000 is made under the Act.
• Doing sex determination test amounts to misconduct by Medical Council of
India

Pre-Requisite for Doing PCPNDT
PCPNDT should not be carried out unless any
one or more conditions, mentioned below,
are fulfilled:
1. History of two or more spontaneous
abortion.
2. Age of two pregnant female is above 35
years.
3. History of exposure to teratogenic drug,
radiation or infections.
4. History of mental or physical deformities or
genetic disease in family.

Indications
PCPNDT is carried out only to detect:
1. Chromosomal abnormalities
2. Genetic or metabolic abnormalities
3. Hemoglobinopathies
4. Sex-linked genetic diseases
5. Congenital anomalies

Infant deaths and female feticide

Infant deaths and female feticide

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