Sudden Unexpected Infant Death: A Compassionate Forensic Approach to Care

Swedish child homicide investigations: A population-based study 1998 to 2017

BACKGROUND

Child homicide investigations are intricate, and the forensic examinations are of paramount importance in such cases. Despite this, the forensic profile of child homicides remains unexplored.

OBJECTIVE

Our objective was to provide an overview of the forensic aspects and investigational challenges in Swedish child homicide cases spanning from 1998 to 2017, with a specific focus on enhancing investigative methods.

PARTICIPANTS AND SETTING

70 cases with 82 victims (41 girls, 41 boys) aged between 0 and 14 were included.

METHOD

Police, crime scene and autopsy reports of solved Swedish child homicides were retrospectively reviewed.

RESULTS

On average, 3.5 cases (4.1 victims) occurred annually, primarily within families (79 %). Notably, the number of cases increased by 10 % during the latter half of the study period (2008-2017) compared to the initial decade (1998-2007). In nearly 29 % of instances, the perpetrators followed the homicides with their own suicides. A majority of child deaths (89 %) resulted from concentrated acts of violence, most frequently involving blunt or sharp force. Furthermore, 66 % of the homicides took place within the parental home. Adequate crime scene processing, including documentation and evidence collection, occurred in 74 % of cases. The investigation unveiled several complicating factors: 22 % of victims and 47 % of crime scenes displayed no obvious signs of violence. Moreover, offenders often made physical (27 %) and verbal (26 %) attempts to mislead investigators.

CONCLUSIONS

In conclusion, most child homicides are familial in nature and associated with investigational complexities that can lead to misdirection. This research may inform procedural recommendations for child homicide investigations, but further exploration is needed to better understand the forensic characteristics of suspicious child deaths.

Postmortem computed tomography plus forensic autopsy for determining the cause of death in child fatalities

BACKGROUND

Postmortem computed tomography (CT) and magnetic resonance imaging have been gradually introduced to forensic pathology centres over the past two decades, with varying results in comparison to autopsy.

OBJECTIVE

The purpose of this study was to determine the accuracy of postmortem CT in determining a cause of death in children who died of unnatural causes.

MATERIALS AND METHODS

This was a prospective recruitment of 30 children (< 18 years) who underwent postmortem CT and a forensic autopsy. A cause of death was independently assigned by two experienced paediatric radiologists and compared to that of the forensic autopsy.

RESULTS

A correct cause of death was assigned by reviewers 1 and 2 in 70% (n = 21/30) and 67% (n = 20/30) of cases, respectively. For gunshot injuries and blunt force head injuries, there was 91% (n = 10/11) and 100% (n = 6/6) agreement between forensic autopsy and both reviewers, respectively. No cause of death could be assigned by reviewers 1 and 2 in 27% (n = 8) and 30% (n = 9) of cases, respectively. An incorrect cause of death was assigned by both reviewers in one case (3%). The Cohen Kappa level of agreement between the forensic autopsy and reviewers 1 and 2 was k = 0.624 (95% confidence interval [CI]: 0.45-0.80, P = 0) and k = 0.582 (95% CI 0.41-0.76, P = 0), respectively. There was near perfect agreement between reviewers 1 and 2 (k = 0.905) (95% CI 0.78-1.00, P = 0).

CONCLUSION

Postmortem CT has good diagnostic accuracy for identifying a cause of death related to trauma, but it has poor accuracy for children dying from causes not associated with apparent physical injury.

Sudden Unexpected Death in Infancy [SUDI]: What the clinician, pathologist, coroner and researchers want to know

The loss of an apparently healthy infant is confronting for any family, puzzling for a clinician and challenging for the pathologist charged with the task of demonstrating a cause for death. The term "cot death" evolved to "sudden infant death syndrome" [SIDS] and now "sudden unexpected death in infancy [SUDI]" as the epidemiology and pathology of infant death changed. Community interventions were successful in changing sleep practices for young babies. The current research focus is on understanding genetic predispositions to unexpected death in early childhood. Whilst much has been achieved in reducing the infant mortality rate from SUDI by between 50%, and 80% in some countries, over the last 30 years, there remain challenges for improving rates of accurate diagnosis and reaching out to more vulnerable families with clearly modifiable risk factors for SUDI. These challenges directly involve the clinician through taking a systematic and detailed history and better standardised death scene evaluations with specifically accredited assessors. Better knowledge regarding circumstances of SUDI cases will help Coroners and researchers provide answers for grieving families now, and in the future contribute to further reductions in the rate of SUDI in communities across the world.

Feasibility of analysis of the SCN5A gene in paraffin embedded samples in sudden infant death cases at the Pretoria Medico-Legal Laboratory, South Africa

To determine variations in the SCN5A gene linked to inherited cardiac arrhythmogenic disorders in sudden, unexplained infant death (SUID) cases examined at the Pretoria Medico-Legal Laboratory, South Africa. A retrospective study was conducted on SUID cases and controls, analyzing DNA extracted from archived formalin-fixed, paraffin-embedded (FFPE) myocardial tissue samples as well as blood samples. A total of 48 FFPE tissue samples (cases), 10 control FFPE tissue samples and nine control blood samples were included. DNA extracted from all samples was used to test for variations in the SCN5A gene by using high resolution melt (HRM) real-time PCR and sequencing. Genetic analysis showed 31 different single nucleotide variants in the entire study population (n = 67). Five previously reported variants of known pathogenic significance, and 14 variants of benign clinical significance, were identified. The study found 12 different variants in the cases that were not published in any database or literature and were considered novel. Of these novel variants, two were predicted as "probably damaging" with a high level of certainty (found in four case samples), one (identified in another case sample) was predicted to be "possibly damaging" with a 50% chance of being disease-causing, and nine were predicted to be benign. This study shows the significant added value of using genetic testing in determining the cause of death in South African SUID cases. Considering the high heritability of these arrhythmic disorders, post mortem genetic testing could play an important role in the understanding of the pathogenesis thereof and could also aid in the diagnosis and treatment of family members at risk, ultimately preventing similar future cases.

Long QT syndrome and sudden unexpected infant death

Long QT syndrome (LQTS) is an inheritable primary electric disease of the heart characterised by abnormally long QT intervals and a propensity to develop atrial and ventricular tachyarrhythmias. It is caused by an inherited channelopathy responsible for sudden cardiac death in individuals with structurally normal hearts. Long QT syndrome can present early in life, and some studies suggest that it may be associated with up to 20% of sudden unexplained infant death (SUID), particularly when associated with external stressors such as asphyxia, which is commonly seen in many infant death scenes. With an understanding of the genetic defects, it has now been possible to retrospectively analyse samples from infants who have presented to forensic pathology services with a history of unexplained sudden death, which may, in turn, enable the implementation of preventative treatment for siblings previously not known to have pathogenic genetic variations. In this viewpoint article, we will discuss SUID, LQTS and postmortem genetic analysis.