Babies Can't Wait: A Judicial Response

During my career as a Family Court Judge over the past 12 years, I was faced daily with the difficult task of deciding whether or not to remove a newborn infant from the care of her mother and place the child in foster care upon discharge from the hospital. In the huge majority of cases, removal was ordered based upon the mother's history of substance abuse and the subsequent positive toxicology of the infant at birth. I could not risk the health and safety of this often premature and vulnerable infant to a mother with such an addiction to drugs that she would expose her child in utero to these toxic substances. Such a mother was incapable of caring for the basic needs of this vulnerable infant, and therefore removal was ordered. This decision saddened me because, as a mother myself, I knew of the critical bond existing between infant and mother during those critical first days and weeks of a child's life. That bond must be nurtured and strengthened and is crucial to a child's development.     

The epidemiology of sudden infant death syndrome in Finland in 1969-1980

SIDS cases were defined by examining all death certificates, in which sudden deaths were expected to be found from the years 1969-80 from the Central Statistical Office of Finland. The age limits were 28-364 days. If the death certificate did not give enough information as to whether the cause of death was explained or unexplained, autopsy records and microscopic specimens were examined. If the death was sudden, but no autopsy was done, no microscopic specimens were taken, or there were some slight findings which could have partly explained the death were classified as borderline cases. The mean annual incidence of SIDS in Finland was 0.41/1000 livebirths in 1969-80. In 1969-74 and 1975-80 the incidences were 0.31 and 0.51, respectively. The increasing tendency of SIDS was partly due to more borderline cases in the first period and partly due to more twins, and infants with small birth weight, dying of SIDS in the second period. Deaths at weekends and sleeping with parents in the second period were more common than in the first study period. In the SIDs group the young maternal age, low social class, family type unmarried couple or single mother, maternal anemia during pregnancy were more common than in the control group. Mothers of SIDS infants had more previous children and fewer visits and later first visit to prenatal clinics than control mothers. The duration of gestation was shorter and the mean birth weight and length were smaller in the SIDS case than in the control group. Twins were more common among SIDS infants than in the common population. The most important risk factor of SIDS was maternal smoking during pregnancy. The epidemiological results conform with the hypoxia hypotheses.     

Infant Death Following Home Birth: A Case Report of Fatal Neonatal Hypoglycemia

Infants born to diabetic mothers are at increased risk for symptomatic hypoglycemia and death after birth. A 36-year-old G4P3 mother with a history of gestational diabetes and newly diagnosed type II insulin-dependent diabetes gave birth at home, in the care of a midwife, to a macrosomic infant girl (10 lbs.). Several hours after birth, the infant became lethargic and was found to be hypoglycemic (blood sugar: 28 mg/dL). Glucose and sugar water were administered by the midwife; however, the infant continued to decompensate. Emergency medical services were called, and the infant was transported to the hospital where, despite resuscitative efforts, she died. An autopsy and review of the literature was performed. At autopsy, characteristic features of maternal–fetal glucose dysregulation were identified, including fetal macrosomia, cardiomegaly, hepatomegaly, and severe pancreatic islet cell hypertrophy/hyperplasia. Developmental abnormalities and other potential causes of death were not identified. Although deaths due to hypoglycemia cannot be reliably diagnosed postmortem using vitreous glucose levels, a clinical history of maternal glucose dysregulation in combination with certain gross and histologic findings should prompt a pathologist to consider maternal–fetal glucose dysregulation as a diagnosis of exclusion and cause of death.     

Sudden infant death syndrome: a subject of medicolegal research

During the last decade, much attention has been paid to the risk factors of sudden infant death syndrome (SIDS). Many researchers have demonstrated that infant-care practices are linked to the risk of SIDS. Prone sleeping, bed sharing, maternal substance abuse, and cigarette smoking have been reported to be significant potentially modifiable risk factors for SIDS. Despite the reports that the incidence of SIDS has decreased by 38% in the United States, it remains the leading cause of death in the first year of life. Deaths resulting from child abuse or neglect inflicted or permitted by their caretakers being second only to SIDS in infant mortalities and some recommendations regarding the differentiation of SIDS and child abuse have generated speculation that some cases of infanticide were misdiagnosed as SIDS. To reach a proper conclusion as to the cause and manner of death of an infant who died suddenly and unexpectedly, investigation must be thorough and professional.     

Lethal child neglect

The jurisdiction of the Hannover Institute of Legal Medicine recently experienced an unusually high incidence of lethal child neglect, with three cases in a 5-month period in 1999. Case 1: A girl received an inappropriate and inadequate diet of tea and oatmeal. The child was never breastfed, nor did it ever receive any other formula. The parents report the infant to have been healthy until she suddenly began projectile vomiting at the age of 13 weeks. For the next 3 days the infant was not able to maintain an adequate intake. The mother reports finding the child dead in its bed on the morning of the fourth day. Attempts by medical personnel to revive the child were unsuccessful. Case 2: A mother began spoon-feeding the infant puree on the fourth day of life, which according to the manufacturer's specifications is suitable for children between 4 and 8 months of age. At the age of 5 weeks, the infant was reported to have vomited half the just previously ingested meal, after which she took a nap. Some time later the parents observed the infant to be quite pale, however, assumed this was a result of sleep. When the mother finally did pick her up, the child was lifeless, and the parents brought her to the hospital. Medical personnel could however, only declare the infant dead, documenting a rectal temperature of 30 degrees C. Case 3: A 3.5-year-old girl died after her mother left the locked apartment and did not return for several weeks. The body of the child was found lying dressed on the floor in a state of advanced decay and mummification. Common findings in all three cases include lack of prenatal care, home birth without the help of a midwife, low socioeconomic status or maternal alcohol abuse, body weights below the 3rd percentile, extreme dehydration, fatty hepatic degeneration, thymic atrophy and signs of aspiration.     

Assessment of exposure to opiates and cocaine during pregnancy in a Mediterranean city: preliminary results of the "Meconium Project"

For the first time in Europe, the "Meconium Project" aimed to estimate the prevalence of drug use by pregnant women and the effects of exposure to illicit drugs during pregnancy on the fetus and infant. Between October 2002 and February 2004, 1151 (79%) dyads among the 1439 mother-infant dyads from the Hospital del Mar, Barcelona, Spain, met eligibility criteria and agreed to participate in the study. We present preliminary results on the first 830 meconium samples and 549 mother-infant dyads, for which statistical analysis of socio-economic and demographic characteristics and newborn somatometry was completed. The meconium analysis showed an overall 7.9% positivity for drugs of abuse, with 6-monoacetylmorphine and cocaine being the analytes, most frequently found in samples positive for opiates and cocaine. Structured interview disclosed 1.3, 1.8 and 1.3% of mothers exposed to opiates, cocaine and both drugs, while only one mother declared ecstasy consumption. Meconium analysis showed that prevalence of opiates, cocaine and combined drugs exposure was 8.7, 4.4 and 2.2%, respectively, and confirmed the case of ecstasy use. Arecoline, the main areca nut alkaloid, was found in meconium specimens from four Asiatic newborns, whose mothers declared beetle nut consumption during pregnancy. Parental ethnicity was not associated with drug use, nor was the social class, although a higher tendency toward drug consumption was observed in professional and partly skilled mothers. Drug consuming mothers showed a higher number of previous pregnancies and abortions (p<0.05) when compared to non-consumer mothers (meconium negative test), probably due to a lack of family planning. Consumption of opiates and cocaine during pregnancy was associated with active tobacco smoking, a higher number of smoked cigarettes and cannabis use. Exposure status and smoking behavior correlated with significantly lower birth weight in newborns from mothers exposed only to cocaine and to opiates and cocaine simultaneously. Of the four newborns exposed to arecoline, one showed a low birth weight, low intrauterine growth, hyporeflexia and hypotonia.     

The use of mental status in death certification of suicide

A 5-year study (1982-1986) illustrates the use of mental status in death certification of suicide in 182 consecutive cases from Marion County, Oregon, U.S.A. The presence of specific mental illness was documented in Part II of the filed death certificate whenever sufficient data supported such a diagnosis. This study represents, so far as we are aware, the first use of mental illness in the routine death certification of suicide. The study subjects were described in terms of sex; age group; the presence or absence of a suicide note; the anatomical cause of death (Part I of the death certificate); and the presence of mental illness, severe physical illness, or alcohol abuse (Part II of the death certificate) as contributive to the death. About half (97 of 182 = 53.30%) of the study group was diagnosed as suffering from a major affective disorder. Another portion (18 of 182 = 9.89%) was classified as schizophrenic. A subgroup of 18 men, all of whom were residents of state mental or correctional institutions at the time of death, was also briefly described.     

Evaluation of certifier practices regarding alcohol-related deaths: Fulton County Medical Examiner's Center, Atlanta, Georgia, 2004

CONTEXT: Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation. OBJECTIVE: To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004. MAIN OUTCOME MEASURES: Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death. RESULTS: Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case. CONCLUSIONS: The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.     

Cocaine and sudden "natural" death

The cardiovascular effects of cocaine may culminate in clinical episodes of angina pectoris, myocardial infarction, arrhythmias, and intracranial hemorrhage. To clarify whether or not cocaine causes fatalities by these mechanisms, we studied 24 cases of sudden, apparently natural deaths as a result of coronary arteriosclerosis (15 cases), hypertensive cardiovascular disease (4 cases), and intracranial hemorrhage (5 cases) associated with cocaine use. In 11 cases, cocaine was found in the blood (average concentration: 0.57 mg/L, range: 0.05 to 1.45 mg/L), whereas in the remainder, cocaine or its major metabolite was found in the urine or other tissues. In the majority of decedents, autopsy disclosed the existence of severe natural disease which could have been exacerbated by the administration of stimulant drugs, including cocaine. These data, and a review of the current medical literature, indicate that cocaine may precipitate the sudden death of an individual with undiagnosed cardiovascular disease. A contributory role of cocaine should be considered in any apparently natural death occurring in a population where cocaine abuse is prevalent.     

Infant mortality and concepts of hygiene. Strategies and consequences in the Kaiserreich and the Weimar Republic: the example of Berlin

The fight against infant mortality followed the guidelines of “hygiene” and their modifications into social, racial, and national hygiene. In Berlin, the campaign to promote infant hygiene began in 1904, when the municipal authorities started to create infant care centers tentatively under the auspices of a charitable association. During and after the First World War, the authorities expanded this campaign to reflect a growing commitment to the principles of social and racial hygiene, which aimed both to improve social conditions that worked against the health of children and to strengthen the constitution of the race. While racial hygienists feared that social measures for the weak would promote degeneration by encouraging their survival, social hygienists argued that it was impossible to distinguish between “fit” and “unfit” in early childhood, and eugenics became increasingly important. Social hygiene as a means of prevention was reduced to a “systematical registration” of the more or less fit individuals. This development and the eugenic background of infant care created a link to the concept of selection in Nazi Germany.     

Infant mortality and concepts of hygiene. Strategies and consequences in the Kaiserreich and the Weimar Republic: the example of Berlin

The fight against infant mortality followed the guidelines of “hygiene” and their modifications into social, racial, and national hygiene. In Berlin, the campaign to promote infant hygiene began in 1904, when the municipal authorities started to create infant care centers tentatively under the auspices of a charitable association. During and after the First World War, the authorities expanded this campaign to reflect a growing commitment to the principles of social and racial hygiene, which aimed both to improve social conditions that worked against the health of children and to strengthen the constitution of the race. While racial hygienists feared that social measures for the weak would promote degeneration by encouraging their survival, social hygienists argued that it was impossible to distinguish between “fit” and “unfit” in early childhood, and eugenics became increasingly important. Social hygiene as a means of prevention was reduced to a “systematical registration” of the more or less fit individuals. This development and the eugenic background of infant care created a link to the concept of selection in Nazi Germany.     

Cocaine and fetal death

Toxicologic screening for cocaine and its metabolites was performed on 103 cases of fetal death autopsied in the Office of Chief Medical Examiner, City of New York. In 64 cases cocaine or its metabolites were found in the blood or in the brain. Some malformations were also found. The study indicates that maternal use of cocaine may lead to abruptio placentae, abortion and fetal death. The importance of toxicologic examination in these deaths is emphasized.     

Cocaine and homicide in Memphis and Shelby county: an epidemic of violence

In Memphis and the surrounding county, there were a record number of homicides (179) in 1986. During the same year, there was a marked increase in medical examiner cases where tests were positive for cocaine or its metabolites. Review of medical examiner and toxicology records from 1980 to 1986 found 87 cocaine related deaths; 46 of these were homicides. In 1986 alone, there were 53 cocaine related deaths, all manners, and 31 cocaine related homicides. In this year, 17.3% of the homicides were positive for cocaine or metabolite. The cocaine related homicides were similar to other homicides in terms of age, race, sex, blood ethanol concentration, and cause of death being due most often to firearms. In homicide cases in which an abuse drug was detected, cocaine accounted for the entire increase in 1986. Police records indicated that cocaine directly contributed to the homicide in 39% of the cases in which the drug was found. In other cases, we speculate that cocaine altered behavior may have contributed to the victim's being murdered either during the drug "high" or during the posteuphoric depression or withdrawal phase.     

Fetal death following maternal trauma: two case reports and a survey of the literature.

When a fetus dies after its mother has suffered trauma, questions often arise about whether the fetal death was linked to the maternal injury. Many state statutes make it a criminal act to cause the death of a fetus by injuring the mother. The authors present two cases in which fetal death resulted from maternal trauma. In addition, we review the pertinent literature on this subject and offer guidelines that may help forensic pathologists evaluate these difficult and often emotionally charged cases.     

A rare case of lethal methadone intoxication of a 3-week-old infant

The authors describe a rare case of lethal methadone intoxication of a 3-week-old infant. Born of a drug-addicted mother who was undergoing methadone substitution therapy, the newborn presented withdrawal symptoms and was immediately admitted to a paediatric ward where it was treated for 3 weeks, without administration of methadone. The infant died during bottle feeding within 24 h following discharge home.A post-mortem examination was performed as well as histopathological, toxicological and genetic tests were carried out in order to establish the cause and mode of death.The autopsy revealed obstruction of the lower air passages by stomach contents along with classical features of asphyxia. Toxicological tests revealed high concentrations of methadone and its metabolite in blood and urine as well as presence of methadone in stomach contents, and the DNA polymorphism analysis of the (sex-specific) amelogenin locus gave a negative result.On the basis of the results of the post-mortem examination, the laboratory tests and the police investigation, it was concluded that the drug was ingested with the bottle milk, and the possibility of administration of methadone at the hospital or its ingestion with the breast milk was precluded. Though both the cause and mode of death were established, the public prosecutor discontinued proceedings in the case due to inability to find the perpetrator.     

Death certificates in Germany, England, The Netherlands, Belgium and the USA

Every country has its own legal system regarding post mortem examinations and death certificates. The authorities want to know the cause and the manner of death of their citizens and especially whether someone is responsible for the death of someone else. In this article a comparison is made between the legal regulations in the Netherlands, Belgium, Germany, England and the USA. Specific attention is given to the following aspects: which official performs the post mortem exam, what is the role of the attending physician by issuing the death certificate and how is the privacy of the deceased protected.     

Incidence of Fetal Drug Exposure in Alabama: 2004–2011

Postmortem toxicological results for neonates and stillborn fetuses were examined to determine the incidence of drug exposure in utero and the relationship to fetal mortality. From 15,600 fatalities with toxicological analyses, 39 subjects were identified; 22 had positive findings (56%). Among the general population, 10,500 had positive findings (67%). Among the subject population, 22 drugs/metabolites were identified; cocaine/benzoylecgonine was most frequent (9 of 22 cases, 41%) then methamphetamine/amphetamine (7 of 22 cases, 32%). Respective incidences among the general positive population were 12% and 6%. Fetal/neonatal concentrations overlap the general population and exceed the mother. Remaining substances, detected largely in fatalities unrelated to drug exposure, were of little toxicological significance. The variety, with exceptions, reflects the general population. That the incidence of cocaine and methamphetamine among fetuses/neonates is three‐ and fivefold greater than the general population is evidence that maternal abuse of these drugs poses greater risk to fetal viability than all other substances identified.     

Evaluation of diagnostic tools applied in the examination of sudden unexpected deaths in infancy and early childhood

During the period between 1984 and 1999, 309 cases of sudden unexpected death in infancy and early childhood (0-3 years) were investigated at the Institute of Forensic Medicine in Oslo. In 73 cases, an explainable cause of death was found. In this non-sudden infant death syndrome (SIDS) group, 42 cases were due to disease, 14 to accidents, 7 to neglect/abuse and 10 cases were due to homicide. In 43 cases, there were pathological findings at the autopsy or suspect features in the history and/or circumstances, which were, however, insufficient to explain death ("borderline" SIDS). In the remaining 193 cases, nothing of significance was detected ("pure" SIDS).The purpose of the present study was to evaluate the importance of the different diagnostic tools used in diagnosing non-SIDS and borderline SIDS cases. The definition of SIDS requires a negative history as well as a negative autopsy result. Thus, the following variables were analysed: circumstances, medical history and autopsy, which included a gross pathological investigation, histology, neuropathology, microbiology, radiology and toxicology. In diagnosing deaths due to disease, histology, neuropathology and microbiology were the most important diagnostic tools. In contrast, information about the circumstances of death and the gross pathological findings at autopsy most often revealed the cause of death in accidents and cases of neglect/abuse and homicide.Following the drop in SIDS rate in Norway after 1989, the share of pure SIDS in proportion to the total population of sudden unexpected deaths in infancy and early childhood has decreased. The increasing proportion of non-SIDS and borderline SIDS cases presents a challenge to improve the quality of the investigation in cases of sudden death in infancy and early childhood.     

Four deaths due to intravenous injection of cocaine

Cocaine is a potent psychotropic drug that alters mood and behavior by stimulating the central nervous system. Deaths from abuse of cocaine are relatively rare. Most such deaths appear to be related to the intravenous injection of the drug. Acute fatal cocaine intoxication is characterized by headache, cold sweats, rapid pulse, tremors and nausea, followed by convulsions, unconsciousness and death. The prime mode of death appears to be respiratory paralysis, secondary to the effects of cocaine on the medullary portion of the brain. This paper presents four deaths due to acute cocaine intoxication following intravenous injection. Blood concentrations of cocaine were 0.11, 0.37, 0.36 and 0.75 mg/dl.