Pathology of Death in Childhood Flashcards
How many live births are there in children
Live births: > 600, 000 per annum
what are the total deaths in the country
Total deaths: 541, 589
- 3390 are children aged 0-16
What is neonatal death
this is death before the age of 1 year old
what makes up a large portion of childhood deaths
neonatal death
name the 3 ways that neonates tend to die
- baby dies before leaving hospital
- baby die after admission to hospital for recognised illness
- baby may die outside of hospital = sudden unexpected death
what is it called when a baby dies outside of hospital
- sudden unexpected death
what are the causes of neonatal and infant death
- Complications of prematurity
- Complications of delivery – e.g. birth asphyxia
- Congenital malformations, chromosomal abnormalities – known (antenatal diagnosis), unknown
- Infection
- Accidents – e.g. drowning, suffocation, foreign body aspiration
- Trauma – RTA
- Non-accidental injury (NAI) – inflicted injury
- Unexplained deaths - SIDS
what is the definition of childhood death
- childhood death is death greater than 1 year of age
what can cause childhood deaths
- malignancy, neurological disease, complications of prematurity
- congenial malformation, chromosomal abnormality
- admission to hospital with recognised illness
- accidents, trauma, sucidie
- non accidental injury
what is the leading cause of death in 1-4 years
Congenital malformations, deformations, chromosomal abnormalities
what are the leading cause of death in 5-19 year olds
Suicide, injury/poisoning – leading CoD in 5-19 years
what is the difference between sudden unexpected death in infancy (SUDI) and sudden unexpected death in childhood (SUDC)
Sudden unexpected death in infancy (SUDI) < 1-year-old
Sudden unexpected death in childhood (SUDC) >1-year-old
What is a sudden unexpected death
Death not anticipated as a significant possibility 24 hours earlier
- Any cause – natural or unnatural - no symptoms - ‘minor’ illness - death within 24 hours of acute symptoms
what is the circumstance of death in sudden unexpected death
Baby or child is found dead in cot/bed
Sudden collapse during normal daily activityschool, sport
Baby dies in parents/carers arms (instantaneous death)
During a recognised illnesshospital, GP surgery, home
Accidents and trauma
how do you investigate sudden unexpected death
designated paediatrician co-ordinates response
- police informed
- coroner informed
- social services
- preliminary examination of the body - any evidence of inflicted injury
- detailed history from family/carers and witnesses
- death scene investigation
- Coroner - all deaths where medical practitioner is unable to issue MCCD plus other circumstances
- post mortem examination - paediatric pathologist
- inquest - who died, how and where
- if NAI is suspected then the death becomes responsibility of the police
- forensic autopsy = home office pathologist and paediatric pathologist
- child death overview
why do we do a post mortem examination
To elucidate the cause of deathprovides basis for counsellingidentify other family members at riskprevention of future deaths
Accurate certification of death for epidemiological and research purposes
what are the parts that make up the post mortem examination
CLINICAL HISTORY & CIRCUMSTANCES OF DEATH
RADIOLOGY
External examination
Microbiology
what makes up clinical history and circumstances of death in a post mortem examination
birth development vaccinations previous illness family history
what makes up the radially section of the post mortem examination
Skeletal survey – exclude NAI, skeletal dysplasias reported by 2 paediatric radiologists before commencing autopsy
what does the external examination of the post mortem examination effect
- child identification
- body weight and measurements
external signs of injury
- Skin - lacerations, bruises, petechiae, conjunctival petechiae(seen in asyphication), torn frenulum (if this is torn this suggests that a bottle has been forced in the babies mouth), perineum and anus
= stop post mortem examination and refer back to coroner
External signs of disease
- dysmorphism and deformities, rashes, oedema, jaundice
what does the microbiology part of the post mortem examination include
Bacteriology – aseptic technique
- Nasopharyngeal swabs
- CSF- lumbar puncture or base of skull
- Blood cultures (take from the heart)
- Lung swab
- Stool (parasites)
Virology
- Swabs
- Tissue: lung, liver, heart, spleenBlood, CSF
- Stool
Toxicology
- femoral blood
- stomach content
- urine
metabolic studies
- vitreous
- Guthrie card; blood and bile spots
- skin for fibroblast culture
- frozen tissue: muscle, heart, liver, kidney for oil-red-O, to assess for abnormal fat accumulation
How do you do genetic testing
Requires consent
- Offence to analyse DNA without consent
Exceptions
- Coroner for identification of the deceased and determining the cause of death
PM practice:
- Store frozen tissue: muscle, heart, Kidney, liver, spleen, cartilage
If PM findings suggest a genetic disorder, recommendation in PM report that family are referred to Clinical geneticist
what does the internal examination include
sampling
- Blood - micro, toxicology, metabolic studies
- fluids - pericardial, pleura
- tissue samples/swabs - micro
organ examination
- remove and weight and examination all organs
- tissue samples from all organs
open the skull
- remove and weigh the brain
- fix in foramen for 1-2 week proper to dissection and sampling
describe how tissue samples are made
Tissue blocks are chemically treated to remove water, embedded in paraffin and cut in 4 u.
Once placed on glass can be examined under the microscope
how can the cause of death be identified by the post-mortem
- macroscopically
- on microscopic examination
- from ancillary investigations
What is Kawaski disease
Medium vessel vasculitis of childhood, <5 years, most reported cases East Asia (Japan).
what are the symptoms of Kawasaki disease
- fever for at least 5 days with 4 or the following
- bilateral conjunctival injection, non-exudative
- cervical lymphadenopathy
- polymorphous rash (not petechial bulls or vesicular)
- oral inflammation and irritation (not discrete lesions or exuate)
- ertherma and oedema of extermetieis progression to desquamination int he second week
what type of inscision do you use
Y incision
what happens if Kawaski disease is not treated
Coronary complications in 15-25% untreated patients: Giant coronary artery aneurysm
what are the most common causes of SUDI
21% infection (pneumonia 22%)
16% non-infectious disease
63% unexplained SUDI
What are the most common causes of SUDC
43% infection (RTI 51%)
28% non-infectious diseases
30% unexplained SUDC
When is a unexplained SUDI diagnosed
Complete post mortem examination with all ancillary investigations, review of the circumstances of death and review of the clinical history
No clear cause of death= ‘Negative autopsy’
No features to suggest unnatural death or inflicted injury
what is sudden infant death syndrome (SIDS)
Sudden unexpected death of an infant under 12 months of age, onset of lethal episode occurring during normal sleep, death remains unexplained after a through investigation
after what investigations is sudden infant death syndrome unexplained
- Complete post mortem examination
- Review of the circumstances of death
- Review of the clinical history.
What is SIDS common
Commonest between 2 and 4 months
Commoner in winter months
Baby found dead in cot or co-sleeping
Death occurs silently during sleep
What are the risk factors
Social class IV or V Unmarried mother Young mother High parity High birth order Short inter pregnancy interval City dweller Co-sleeping Prone sleeping Male baby
Maternal smoking Maternal opiate addiction Maternal infection in pregnancy Low birth weight (<2.5 kg) Preterm IUGR Twins Minor malformations
What are the triple risk for SIDS
- vulnerable ifnant
- cortical developmental period
- external stressor (environment)
what factors make up a vulnerable infant
Prematurity
Male sex
Low birth weight
what can cause SIDS
Developmental immaturity First 6 months, specifically between 2 and 4 monthsRapid neurodevelopmental changes in the brain
- suggest delayed development of arousal, cardio-respiratory control or cardiovascular control and thermal regulation
- Laryngeal spasm with GOR
what are external stressors in the triple risk theory
Prone position Bed-sharing (co-sleeping) Minor illness e.g. URTI Overheating Parental smoking
what are non specific post mortem findings in SIDS
Thymus with petechiae
Petechiae in pleura
Epicardial petechiae
Full expansion of lungs
Liquid heart blood
Empty bladder
Prominent LN & Peyer’s patches
Pulmonary congestion and oedema
Mild inflammation of upper respiratory tract
Persistent haemopoiesis in the liver
what are mimics of abuse that you have have which are not abuse
Fractures
- Sometimes seen in vaginal delivery
- Osteopenia of prematurity
- Vitamin D deficiency especially in breast fed babies
- Osteogenesis imperfecta
- Resuscitation
Shaken baby syndrome
- Triad of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhages
- SDH - 25-46% of asymptomatic newborn babies;
- retinal haemorrhages 34% of newborn babies (clear up to 2 months?)
What is the human tissue act
Coroners post mortem does not require consent
Once investigation is complete consent is required to keep and use tissue for ‘scheduled purposes’:
- keep as part of medical record- education and training
- research
- quality assurance and audit
