Pathology of Death in Childhood Flashcards by Sarah-Louise Watson

How many live births are there in children

Live births: > 600, 000 per annum

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what are the total deaths in the country

Total deaths: 541, 589

- 3390 are children aged 0-16

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What is neonatal death

this is death before the age of 1 year old

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what makes up a large portion of childhood deaths

neonatal death

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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

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what is it called when a baby dies outside of hospital

sudden unexpected death

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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

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what is the definition of childhood death

childhood death is death greater than 1 year of age

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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

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what is the leading cause of death in 1-4 years

Congenital malformations, deformations, chromosomal abnormalities

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what are the leading cause of death in 5-19 year olds

Suicide, injury/poisoning – leading CoD in 5-19 years

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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

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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

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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

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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

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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

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what are the parts that make up the post mortem examination

CLINICAL HISTORY & CIRCUMSTANCES OF DEATH

RADIOLOGY

External examination

Microbiology

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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 1. 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