Caffeine toxicity: a case of child abuse by drug ingestion

The case of a 14-month-old child who died of caffeine toxicity is presented. The evidence for prolonged toxicity associated with inappropriate delay in the seeking of medical care and the presence of various recent and healing injuries are diagnostic of child abuse. Fatal caffeine toxicity and child abuse by drug/substance administration are uncommonly reported. Relevant medical literature is reviewed.     

Laceration of the stomach by blunt trauma in a child: a case of child abuse

A case of perforation of the stomach following blunt abdominal trauma is described in a two-year-old boy. The abdominal trauma was the result of a blow to the abdomen by the stepfather. The child had ingested a large meal in the hour preceding the injury. The child died from peritonitis and shock 12 h following the injury. The literature on gastric perforation by blunt trauma is reviewed. Injuries to the stomach from nonpenetrating trauma are quite rare and are most often related to vehicular accidents. Gastric injury in a child presenting with a history of a minor home or play injury should arouse suspicion of more significant and perhaps intentional trauma.     

虐待儿童致死1例报告

虐待损伤具有病变的多样性、广泛性及新旧不一性等特点,与其它损伤有较大区别,现报告一例.     

Burn injuries caused by a hair-dryer--an unusual case of child abuse

About 1.4-26% burn injuries in children appear to be abusive in origin. A 2.5-year-old girl was referred to our institute because of suspected child abuse. Clinical examination and later interrogation of the mother revealed non-recent deep second degree burn injuries on both gluteal regions, caused by the partner of the mother by pressing a hand-held hair-dryer against the skin. The authors present the findings of this unusual method of child abuse.     

Oral abuse of fentanyl patches (Duragesic): seven case reports

In order to increase the understanding regarding the oral abuse and potential toxicity of fentanyl patches seven cases were identified over a 3-year period where fentanyl, either alone or in combination with other factors, contributed to death following the oral abuse of Duragesic patches. The decedents comprised three females and four males with ages ranging from 20 to 51 years. Postmortem blood fentanyl concentrations were determined in all cases and ranged from 7 to 97 ng/mL. Two deaths were classified as a fentanyl overdose, three deaths were classified as a fentanyl and ethanol overdose, one death was considered a mixed drug intoxication and the remaining death was determined to be a combination of fentanyl and medical causes. These cases represent the largest reported series of deaths following the oral administration of transdermal fentanyl patches and provide detailed information on the potential for the abuse of transdermal Duragesic patches via this route. The postmortem blood fentanyl concentrations detected for each of the decedents demonstrate the potentially fatal blood concentrations that can arise after this relatively rare route of administration.     

A case of panhypogammaglobulinemia masquerading as child abuse

A case of panhypogammaglobulinemia in a 15-month old boy is presented. The child was followed at a local university teaching hospital for pneumonia, failure to thrive, and possible child abuse/neglect. Following minor trauma to the face, massive sepsis developed in the child. The mother was afraid to seek medical care because she was fearful of legal action against her. Upon the child's demise at home, police and medical examiner involvement ensued. The correct diagnosis was established at autopsy.     

An unusual case of child abuse homicide/suicide

This case report examines a child abuse homicide in which the perpetrator committed suicide a few hours after the infant's death. At the time of the perpetrator's suicide he was not under investigation, nor was he a suspect in the death of the child. Although the literature does not contain reports of similar cases, we are sure they exist. This report raises the question of the degree of social stigma attached to the accusation of child abuse. It also serves as a warning to those who must deal with the potentially suicidal child abuser.     

Prosecuting child sexual abuse in rural Kentucky: Factors influencing case acceptance by prosecuting attorneys

This study examined the relationship between felony prosecutors’ discretion and the legal and social factors present in cases of child sexual abuse. Prosecuting attorneys from 20 rural circuits in Kentucky were targeted for semistructured interviews in order to determine what influences them to accept or not accept a case for prosecution. Findings show a relationship between rural Kentucky prosecutors’ decision to accept a case and the availability of physical evidence, victims’ age and competence, potential trauma inflicted upon the victim, and the situation in which the allegation of sexual abuse originated. The relationship between prosecutors’ discretion and various factors is discussed regarding the impact on other criminal justice officials in their pursuit to combat child sexual abuse in Kentucky and in other rural communities as well. Winner of 1997 Outstanding Graduate Paper Award, Southern Criminal Justice Association     

Family and social factors associated with substantiation of child abuse and neglect reports

One hundred fifty-nine families who were reported for child abuse or neglect to a country social services agency in a single fiscal year were studied empirically to test the ecological model of child abuse and neglect. Several family and social factors were studied. Only two, size of family and stage in family developmental cycle, were significantly associated with an increased risk of substantiation of the report. Two potential sources of social support, the use of regular child care and the presence of an extended family member, were tested for their effect on substantiation in those cases where risk factors such as the two mentioned above and combinations of risk factors such as single parenthood and unemployed head of household were associated with higher rates of substantiation. In every case, these two examples of social support reduced the substantiation rate. The influence of the use of regular child care was especially strong in mitigating the effect of the family and social risk factors.     

Death of a 6-year-old boy with mental retardation: accident versus child abuse

This case study involved death of a 6-year-old child with a history of mental retardation secondary to meningitis at 11 months, spastic quadriplegia, seizure disorder, and hydrocephaly with a remote ventriculoperitoneal shunt placement and gastric tube feedings. Reportedly, the child was co-sleeping with his mother when she awoke and discovered him lying prone and not breathing on the carpeted floor next to the bed. He was transported to the hospital and died in the emergency room of unknown causes. The medical examiner assumed jurisdiction of the body. The external examination revealed petechial hemorrhages on the neck and face, with patterned linear pressure abrasions on the chest, arms, and face. X-rays revealed leg fractures of different ages. This case emphasizes the importance of coordination of death scene investigation, medical history review, and autopsy results through a forensic team approach to determine the accurate cause and manner of death.     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.     

Scald burns complicated by isopropyl alcohol intoxication. A case of fatal child abuse

Scald burns are the most common type of thermal injury in child abuse. Death associated with nonaccidental burns, however, is uncommon. We recently investigated the case of a 4-year-old child who died from extensive body burns due to scalding. A contributory cause of death was isopropyl alcohol intoxication resulting from application of this chemical to the burns.     

Biomechanical and morphologic reconstruction of a questionable case of child abuse

A 3-month-old baby died 8 days after admission to the hospital as a result of injuries received under unknown circumstances. The forensic autopsy revealed a fracture of the scull and a severe blunt injury to the head and brain. Histological investigation of the reactive changes at and around the edges of the fracture showed that the trauma could not possibly have been congenital. According to the defendant, the baby boy had been lying on the table used for changing his nappy and almost fell off it. The defendant moved "instinctively" to catch him, and this "reflex movement" caused the injuries observed. The event was then reconstructed by the criminal investigators and this reconstruction, coupled with the authors' biomechanical experiments using stroboscopic recording, revealed that the defendant's statement could not be true, as the force necessary to inflict the injuries was much greater than could be explained by an attempt to catch the baby.     

A case of traumatic osteomyelitis in a victim of child abuse

A premature black female infant born at 31 weeks gestation with history of 4 weeks in the newborn intensive care unit was discharged healthy to the care of her mother and was lost to follow-up. At age 4 months the infant was found dead in bed. There was no history of trauma and no external injuries were noted. There was no attempt at resuscitation. Coroner's autopsy showed acute bronchopneumonia, 3 partially healed skull fractures, a chronic subdural hematoma, chronic intracerebral hemorrhage, retinal hemorrhages, multiple healing rib fractures, a fractured fibula, and a partially healed fracture of the distal right radius. The fracture of the right radius showed a medullary abscess of the bone surrounded by scar tissue and containing pus and granulation tissue. We believe this inflicted fracture became secondarily infected by a hematogenous route. The final diagnosis of the cause of death was pneumonia secondary to multiple blunt force trauma, and the manner of death was diagnosed as homicidal. This is believed to be the first reported case of osteomyelitis in a context of child abuse.     

Childhood panhypopituitarism presenting as child abuse: a case report and review of the literature

Childhood panhypopituitarism may be acquired or congenital. Children with panhypopituitarism can present clinically with diabetes, growth failure, decreased bone density, and morbid obesity. In the forensic setting without the proper history, it can be misdiagnosed as child abuse or neglect. We report a case of a 3-year-old black girl who was admitted to the emergency room with apnea and subsequently died. While at the emergency department, it was discovered that the child had a fractured left hip and was severely growth retarded for age. The coroner wanted to rule out child abuse and/or neglect and requested an autopsy based on the physical findings identified by hospital staff. Significant findings at autopsy included small for age (15th percentile for age), hypoplastic brain/pituitary gland/adrenal gland/thyroid gland, abnormally formed skull with an occipital protuberance, a fractured left hip with decreased bone density, and central adiposity. Subsequent to the autopsy, it was discovered that at 6 weeks of age the child suffered from group B streptococci meningitis that resulted in panhypopituitarism. The panhypopituitarism then resulted in seizure activity, diabetes insipidus, and growth retardation. The authors hope this case report and review of the literature will assist investigators, pathologists, and clinicians in making a distinction between neglect or inflicted injury of child abuse and panhypopituitarism that can present with similar signs and symptoms.     

Mandatory reporting by nurses of child abuse and neglect

Most Australian jurisdictions have mandatory reporting legislation to compel members of selected professional groups, including nurses, to report suspicions that a child has been or is likely to be subjected to abuse or neglect. This article details the legal obligations of nurses in each jurisdiction, and highlights differences between jurisdictions. Problematic features of the laws are identified, including the use of ambiguous concepts like "reasonable" suspicion and "significant" harm. Literature is reviewed to identify what is known about nurses' legal knowledge, actual reporting practice, and the practical problems that arise for nurses in this context. It is concluded that empirical research needs to be conducted, because it is not known if the laws are practically effective, whether nurses have sufficient training in, and knowledge of, their reporting duties, or what factors influence sound reporting. Such research can inform both the development of sound training systems and recommendations for legal reform.     

Case report: Forensic anthropological assessment in a suspected case of child abuse from South Africa

Not many case reports of suspected child abuse as assessed solely on skeletal remains are available. Forensic anthropologists have intimate knowledge of normal skeletal anatomy, bone trauma and processes of healing of bone and may therefore be of help in suspected cases of child abuse. Patterns of trauma in juvenile skeletal remains which are suggestive of abuse include fractures in different phases of healing, multiple fractures, typical fractures on ribs and long bones and severe, complicated cranial fractures. The aim of this paper is to report on the findings of the analysis of the skeletal remains of a 3.5 years old boy. Forensic pathological examination indicated that the boy had died from a massive cranial fracture, with multiple injuries present to the rest of the body. After the body had been buried for some time, it was exhumed and we were requested to look for signs of chronic, long-term abuse. Findings included a massive cranial fracture, another fracture in the roof of the orbit, two areas of non-specific subperiosteal bone growth and several untreated carious teeth. No clear healed fracture could be found, except for a possible healed cranial base fracture which stretched transversely across the petrosal bone. This area showed signs of recent bone activity. The court decided that this was not enough evidence of chronic abuse and found the accused guilty of murder but not of chronic child abuse. This case illustrates the difficulty to obtain clear signs of chronic injury on juvenile remains.     

Female victims of child sexual abuse: Adult adjustment

A questionnaire administered to a University sample of 245 female victims of sexual child abuse and 750 nonvictims attempted to determine whether abuse is related to poor adult social and psychological adjustment. The instrument consisted of three outcome measures of adjustment, variables directly related to abuse, perceived satisfaction with early family life, and demographic data. Only one of the outcome measures — the Texas Social Behavior Inventory — yielded a statistically significant difference between the samples. There was a steady, significant and progressive increase in maladjustment between the nonabused, the nonincestuously abused and the incest victims. When controls were applied for levels of satisfaction with early family life, differences between the abused and nonabused samples disappeared. Those abused as children who reported good treatment by parents exhibited no ill effects as adults on the TSBI.