INFANTICIDE

&

Child Abuse

Infanticide

• Infant + cide (an act of killing)
• It means unlawful destruction of a newly born child and is regarded as murder in law
• The practice in some societies of killing unwanted children soon after birth
• A person who kills an infant, especially their own child
• The crime of a mother killing her own child within a year of birth treated under a separate law in some countries

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Infanticide

• By the Infanticide Act of 1938 in England a woman who kills her newly born child under certain circumstances is regarded as guilty of infanticide and is punishable as for manslaughter
• Provisions of the act:
• An infant is any child within 12 months of its birth
• Applies only to mother who it is presumed that because of the effect of giving birth or because of the effect of lactational stress, the balance of her mind was disturbed
• The law presumes that the child was born dead

Medico-legal aspects

• In India killing of an infant is no different from killing of an adult and the same law applies.
• In U.K. if infanticide is done by the mother herself then a different law applies covered under Infanticide Act(1938)
• This act was considered progressive measure as killing by mother and some one else can not be equated. A mother can not kill her own child and if she does then because of stress of pregnancy, delivery or lactation she must have lost her mind

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Medico-Legal Questions in Infanticide Cases

• Viability of the foetus
• Still born
• Dead born
• Live birth of a child
• How long after birth the baby died
• Causes of death
• Natural
• Accidental
• By acts of omission or commission

Viability of Foetus

• A foetus or unborn child is capable to survive after birth if gestational period was 210 days or more
• It is the capacity to survive outside mother’s womb and be able lead a separate existence and grow with proper nursing
• Foetus of 210 days
• Length 37cms (14.6 inch), wt. 1.5 kg, scalp hair more than 2 cm long, Umbilicus at mid point of body, nails reach almost tips of fingers, Lt testicle in scrotum and Rt. at the external inguinal ring, Gall bladder contains bile, Ossification centre for talus and all sacral vertebrae appeared. Wt of placenta about 400gm

Still Birth

• A foetus born after 28^th week of gestation after being completely expelled did not at any time breathe or show any other sign of life
• The child was alive in uterus and dies during the process of birth
• 5% of total birth is still born
• Causes of still birth
• In majority no cause found
• Primarily anoxia, prematurity, birth trauma, placental abnormality, toxaemias of pregnancy, congenital defects, Rh incompatibility

Dead Born

• A child which died in utero and shows signs of such death after it is completely born
• Rigor mortis present when delivered death 2-3 hrs earlier
• Maceration: This is an aseptic autolytic decomposition of the dead foetus surrounded by liquor amnii and absence of air, in the aseptic environment in the uterus, when the dead foetus remains inside the uterus for at least 2-3 days after death. No bacterial invasion present

Maceration/ Mummification

• Signs of maceration: Foetus flat, flaccid, with sweetish disagreeable smell. Colour of skin reddish purple with blebs containing serosanguinous fluid
• Spalding sign overriding of bones(sagital suture) of cranial vault after death of foetus due to shrinkage of brain
• Mummification : -
• Foetus may be born Mummified following death in uterus, due to scanty or absent liquor amnii, deficient blood supply and when air does not inter the uterus.

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Live Birth

• According to the English Law
• A living child completely born external to the mother irrespective of attachment or severance of umbilical cord
• As per Indian law
• Live birth if any part of a living child is born even if the child may not have respired or be completely born

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Signs of Live Birth

• In the living:-
• Cry of neonate: The first cry of the neonate is a strong evidence of live birth. It indicates setting in of respiration
• Vagitus vaginalis
• Vagitus uterinus
• Presence of respiration, heartbeat, response to pain sensation and muscle tone
• In dead:-
• External signs of live birth
• Internal findings of live birth

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External signs of live birth

• Dead Born
• Chest flat anteroposteriorly
• Circumference of chest 2-3 cms less than abdomen
• Other evidences of dead born /still birth
• Post-mortem state of body and umbilical cord same

• Live born
• Chest barrel shaped
• Circumference of Chest 2-3 cms more than abdomen
• Cleaning of Vernix caseosa is done after live birth
• Changes in Umblical cord like drying, shrinkage, application of gentian violet

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Internal Findings

• Dead Born
• Level of diaphragm
• Level of 3-4 rib
• Lungs
• Small, upper part of Para vertebral gutter, looks like liver with sharp margin, no air

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• Wt of lung-30-40 g

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• Pulmonary vasoconstriction, minimal lung circulation, no air sac, lungs filled with fluid Alveoli lined by cubical or columnar epithelium

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• Live Born
• Level of diaphragm
• Level of 6-7 rib
• Lungs
• Size greatly increased, margins rounded, mottled red appearance, crepitates on pressure, exudes frothy blood

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• Wt of lung-60-70 g

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• Pulmonary vasodilatation, alveolar expansion, air present, Alveoli lined by flat squamous epithelium

Lungs and Respiration

• Static test-
• Increase in wt. Of lung after respiration from 30-40g to 60-70g
• Ploucquet’s test
• Change in relationship of body wt. And lung depending on respiration.
• Lungs are 1/70^th of body wt. In unrespired state.
• After respiration it becomes 1/35^th

Hydrostatic Test

• Unrespired lung sinks in water where as respired lung floats.
• Sp.gravity of unrespired lung- 1.04 to 1.05
• Sp.gravity of respired lung- 0.94
• Fallacies of the test
• Unrespired lung may float due to
• Gases of decomposition
• Due to efforts to artificially induce respiration
• Respired lung may sink due to
• Due to atelectasis
• Oedema lungs
• Feeble respiration

Hydrostatic Test Need Not Be Performed

• If
• Foetus had not attained viability
• Foetus shows signs of intrauterine death
• Congenital anomalies incompatible with life
• Stomach contains milk
• Umblical cord cicatrised

Breslau's Second Life Test

• Demonstration of presence of air in gastro-intestinal tract in dead body of an infant is indicative of live birth
• Air swallowed during the effort at respiration
• In such condition the gastrointestinal tract floats in water.
• Air bubbles come out if dissected under water

How long the baby survived after birth

• Changes in Umbilical cord
• Clotting at cut end- 2hrs
• Dries and shrinks- 12 to 24 hrs
• Inflammatory ring at base- 36 to 48 hrs
• Falls off on the 5-6^th day leaving an ulcer
• Ulcer heals & cicatrises within 10-12 days
• Presence of caput succedaneum
• Disappears from 24 hrs to 2-3 days
• Changes in skin
• Vernix caseosa in axillae,groin,and folds of neck - 1-2day
• Changes in circulation

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1.Ductus Venosus- Bypass liver.2 Foramen Ovale between two atria 3.Ductus Arteriosus between pulmonary artery and descend. aorta

Other findings

• Obliteration of blood vessels
• Ductus arteriosus functional closure immediate obliteration in about 10 days
• Umbilical arteries within 12 hrs complete by 4^th day
• Umbilical vein and ductus venosus by 5^th day
• Foramen ovale: Functional closure- immediate Complete Within 3 months
• Large intestine free of meconium within 24 hrs after birth

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Causes of death of Infants

• Neonatal death:-
• Of the total number of death in 1^st year 90% die in 1^st month,
• Of total no. of death in 1^st month 90% die in 1^st week,
• And of total no. of death in 1^st week 90 % die in first 24 hours

Natural causes of Death of Infants

• Leading causes
• Premature birth-
• X ray examination of body will establish Low birth Wt.-Weak,
• Congenital Malformations-
• Monster, abnormalities of blood vessels, heart,& gastro-intestinal tract
• SIDS

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Natural Causes of Death of Infants

• Other causes
• Congenital diseases-syphilis, hyaline membrane disease
• Haemolytic diseases including Rh incompatibility,
• Haemorrhages- from umbilical cord, stomach, rectum, genitals
• Placenta- Diseases & Early separation of placenta,
• Placenta Praevia or abnormal gestation
• Asphyxia-Atlectasis due to spasm of larynx, mucus, meconium, pressure of thymus gland

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Accidental Causes of Death

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• During Birth:-
• Prolonged labour –Bleeding in meninges & Brain substance. It may be associated with slight fissure of parietal bone or a spoon shaped depression. Marked caput succedaneum or cephalhaematoma is present
• Exhaustion and foetal distress,
• Injury to mother, death of mother (Baby dies unless removed within 25 mts from womb)
• Prolapse of cord, twisting of cord round the neck of foetus,
• Meconium, Liquor amnii, or Vernix in bronchial tubes

Accidental Causes of Death

• After Birth
• Suffocation in mother’s discharge,
• Precipitate labour, causing fracture skull and intracranial haemorrhage or baby is drown in lavatory pan or death results due to haemorrhage from the torn end of cord
• Neonatal infection,
• SIDS

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Criminal causes of death of Infants

• Acts of commission
• Suffocation
• Pressure over mouth or chest,
• Putting foreign matter in throat
• Strangulation- Umbilical cord
• Drowning- Dudh Pita Karna
• Fracture of cranium- By blunt weapon or dashing the head against wall or floor
• Fracture dislocation of cervical vertebrae- Neck twisted
• Wounds- Mark of injury in fontanelle, base of brain or heart
• Poisoning

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Criminal causes of death of infants

• Acts of omission
• The law presumes that a woman who is about to be confined should take ordinary precautions to save her child after it is born. She is guilty of criminal negligence if she fails to do so
• Omission to take help from midwife or doctor
• Informing friends/ relations when labour starts
• Failure to ligate cord
• Omission to remove the child from mother’s discharge, clean mouth, nose, & throat
• Omission to protect the child from cold or heat
• Omission to supply the infant with proper food

Concealment of Birth

• Where charge of Infanticide not proved the Police charge the woman & others with concealment of birth
• Intentional concealment of birth is a punishable criminal offence in India u/s 318 of IPC with imprisonment of two years
• Sec 318 IPC
• Whoever, by secretly burying or otherwise disposing of the dead body of a child, whether such a child die before or after or during its birth, intentionally conceals or endeavours to conceal the birth of such child, shall be punished with imprisonment of either description for a term, which may extend to two years or with fine or with both

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Child Abuse

• Child abuse is the physical, sexual or emotional maltreatment or neglect of a child or children.
• Child maltreatment is any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.
• Any recent act or failure to act, on the part of a parent or caretaker, which results in death, serious physical or emotional injury, sexual abuse or exploitation, or poses an imminent risk of such serious harm

Abuse And Neglect of Children

• 140 per 1000 (14%) of age group 3- 18 yrs were kicked, bitten, punched, hit with object, beaten up or threatened with knife or a gun in one year
• 85 % younger than 5 years
• 45% were infants ( under 1 year)
• About 10 % of injuries in emergency were due to abuse among under 5 yrs
• 15% admitted for burn due to abuse
• And 50% of fractures in under 1 year due to abuse
• Death rate 6% due to abuse
• In 55% immediate family members were perpetrators. Father(21%), mother(21%), Boyfriend of mother(9%), Baby sitter(8%), step father (5%). Average age of abuser was 25 years

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Types of Abuse

• Physical abuse
• Emotional & Psychological abuse,
• Neglect
• And sexual abuse.

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Abuse And Neglect of Children

• Abusers belong to all ethnic, religious, educational, occupational and socio-economic groups
• More among poor due to
• Increased number of crises in life
• No economic & social resources for support in stress
• Increased violence in neighbourhood
• Teenage and single parenthood
• Substance abuse

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Child Abuse

• Increased incidence in military bases
• Spouse abuse increases the likelihood of Child abuse
• Substance abuse a common finding
• More than 90% of abusing parents have neither psychotic nor criminal personality
• They are lonely, unhappy, angry, young, and single parents, unplanned pregnancy, little knowledge of child development
• Unrealistic expectation from the child

Abuse And Neglect of Children

• 10 to 40% of abusing parents were themselves abused as children
• Physical abuse most likely-
• High risk children-
• Premature infants, infants with chronic medical conditions, colicky babies, children with behavioural problems ( including Mentally retarded)
• High risk parent is responsible for care
• low self-esteem, poor impulse control, antisocial behavior, anxiety, depression, marital conflict, domestic violence, single parenthood, and social isolation

Physical Neglect

• Nutritional Neglect is the commonest cause of failure to thrive
• Medical neglect by failure to provide appropriate medical care
• Failure to provide schooling, adequate clothing, and protection from environmental hazards- heat, cold
• Omissions due to religious beliefs
• Refuse to allow recommended medical treatment
• Neglect of appropriate precautions
• To ensure a child’s safety
• Neglect is roughly 50% of the total cases and accounts for more deaths than physical abuse

Acts of Omission & Commission

• Emotional abuse
• Intentional verbal and behavioural acts that result in to adverse emotional consequences
• Rejection, scapegoat assignment, isolation, criticism or terrorising by the care taker
• Emotional neglect
• A caretaker intentionally does not provide nurturing verbal behavioural actions necessary for healthy development
• By mother may have devastating consequences.

Poisoning

• Munchausen Disease by proxy (MDP)
• Medications and Toxins may be given intentionally to poison the child
• Other deceptive actions to simulate a disorder
• In 10% of these cases death occurs

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Battered-Baby (Child) Syndrome ( Caffey’s Syndrome)

• Physical Injury:-
• Unexplained, unexplainable or implausible
• The existence of bruises, scars, and fractures at various stages of healing is highly suggestive of abuse
• Bruises most common
• On back, buttocks, genitalia, and back of hands
• Shape may indicate object used
• Colour change will indicate that these are of different Periods or not of the time suggested by guardian

Burns

• 10% of cases out of total cases of abuse.
• Shape & pattern of burn diagnostic as geometric pattern of an object or method of burn
• Cigarette burns cause circular punched out lesion of the same size usually on hands and feet.
• Well demarcated circular immersion burn of buttock & perineum, hands or feet in abused infants & young children

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Trauma of Head

• 95% of serious intracranial injuries in infants due to abuse
• In 29% of cases of abuse there is injury to head, face, or cranial content
• Cases present as coma, convulsion, apnoea, and increased intracranial pressure

Shaken Baby Syndrome (SBS)

• A“triad” of symptoms:
• Bleeding in the retinas of the eyes,
• Subdural hematoma
• And oedema of brain
• All occurring in the absence of a recent car accident or other clear explanation for the injuries.

Intra-abdominal Injuries

• Second commonest cause of death in battered children
• There may be no external injury, but bruises due to fist about 1 cm round three or four in a curve may be present on abdominal wall
• Rupture of liver or spleen is most common internal injury, though there may be tear of duodenum, proximal jejunum, intramural haematoma, chylous ascietis & pseudocyst of pancreas are reported

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Fractures

• Fractures are considered highly specific of child abuse especially:-
• Fractures due to wrenching or pulling
• Chip fracture of metaphysis of long bones with injury to epiphysis & Periosteum
• Spiral fracture of shaft of femur before the age of walking is always due to abuse.
• Fracture of ribs in children
• Fractures should be dated by stage of union, earliest by callous formation in 10 –12 days. Skull fractures not easily dated
• Hairs
• May be pulled causing alopecia- hairs broken at various length
• Area of missing hair on back if left uncared for long times

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Sexual Abuse (15 % of abused)

• Sexual play is viewing or touching of the genitalia, buttocks, or chest of pre-adolescent children separated by not more than 4 years in which there has been no force or coercion
• Sexual abuse is involving a child in any act that is intended for the sexual gratification of an adult
• By family members(incest) acquaintances, or least often by strangers
• Or any activity with a child before the age of legal consent , that is for the sexual gratification of an adult or a significantly older child
• It includes oral-genital, genital-genital, genital-rectal, hand-genital, hand-rectal, or hand-breast contact

Sexual abuse(Cont.)

• Abusers:- Servants, Teachers, drivers, cousins, uncles.
• Sexual abuse by step father is five times higher than natural father.
• Symptoms
• Vaginal, penile, or rectal pain, erythema, discharge or bleeding
• Chronic dysuria, enuresis, constipation, or encopresis.
• Premature puberty in a female
• Behaviour specific of abuse
• Sexualised activity with peers, animals, or objects
• Seductive behaviour
• And age inappropriate sexual knowledge and curiosity

Sexual abuse(Cont.)

• Non-specific behaviours include
• Suicide gestures, fear of an individual or place, nightmares, sleep disorders, withdrawn, stress, poor school performance, running away, self-mutilation,
• Forensic interview
• By experienced interviewer in presence of police
• Preferably videotaped

Examination

• Skin for trauma specially neck & mouth

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• Abdomen
• Examine for pregnancy
• Genitalia
• For injury or scars of healed injury, bite mark of genitalia or Thighs
• Genital molluscum contagiosum

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Sexual Abuse(Cont.)

• Diagnostic
• Pregnancy, sperm, semen, syphilis, gonorrhoea, chlamydia, herpes type II (genital) (HSV-2), HIV
• Probably diagnostic
• Condylomata acuminata and Trichomonas vaginalis
• Possibly diagnostic
• Herpes type I(HSV-1)

Protection of Children from Sexual Offences Act, 2012

• The Act Is To Prevent Sexual Exploitation and Sexual Abuse of Children- Like
• (a) the inducement or coercion of a child to engage in any unlawful sexual activity
• (b) the exploitative use of children in prostitution or other unlawful sexual practices
• (c) the exploitative use of children in pornographic performances and materials

Provisions of the Act

• Prescribes punishment for Sexual Offences Against Children for-
• Sexual assault
• Sexual Harassment
• Pornography
• Establishing Special Court for Trial of such Cases

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Terms Used

• Child
• is any person (male/ female/ Intersex) below 18 years of age
• Sexual Assault-
• Touches or makes the child touch with sexual intent vagina, penis, anus, or breast or does any other act which involves physical contact without penetration- 3 to 5 yrs with fine

Penetrative sexual assault

• Penetrates his penis to any extent, in to the vagina, mouth, urethra, or anus of a child or makes the child do so with him or any other person; or
• Inserts to any extent, any object or part of body, not being the penis, in to the vagina, the urethra, or anus of the child or makes the child to do so with him or any other person; or
• Manipulates any part of the body of the child so as to cause penetration…
• Applies his mouth to the penis, vagina, anus, urethra of the child or makes the child do

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Aggravated Sexual ( Penetrative) Assault

• Offence is called aggravated if done by Police/ armed forces personnel; public servants/ staff of hospitals, jail, remand homes/ educational or religious institutions etc at their place of work or in jurisdictional area
• Gang sexual (penetrative) assault, use of deadly weapon, fire, corrosive, causes grievous hurt, injury to sexual organs of the child,

Sexual Harassment

• With sexual intent
• (i) Using word, sound, gesture, or showing object or part of body to be seen or heard by a child
• (ii) Make the child exhibit own body or its part
• (iii) Showing any object in any form or media for pornographic purposes
• (iv) Repeatedly or constantly follows, watches or contacts directly or through electronic, digital or any other means
• (v) Threatens to use, in any form of media, a real or fabricated depiction through electronic, film or digital, or any other mode , of any part of the body of the child or the involvement of the child in a sexual act
• (vi) Entices a child for pornographic purposes or gives gratification there for

Using Child for Pornographic Purposes

• Using child in any form of media- TV, Internet, any other electronic form or printed form either for personal use or distribution for the purposes of sexual gratification including
• Representation of sexual organs of a child
• Uses of child engaged in real or simulated sexual acts (with or without penetration)
• Indecent or obscene representation of a child

Procedure of Recording of Statement

• Statement of child recorded at his residence or any place of his choice in presence of parents or a person in whom the child has trust also by an audio-video device
• By a lady police officer not below sub-inspector
• Police officer shall not be in uniform
• Police officer to ensure that the child does not come in contact with the accused
• No child shall be detained in police station during night
• Police officer to ensure that identity of the child protected from public media

Procedure of Examination & Prosecution

• In case of girl medical examination will be done by a lady doctor.
• Where parents or person of trust is not available the medical examination is conducted in presence of a lady nominated by the head of the health facility
• Guilt of the accused shall be presumed in cases of sexual assault and penetrative sexual assault
• Child is not called repeatedly to testify
• Court will permit the parent or some one in whom the child has trust to be present in court.
• The court shall not permit aggressive questioning or character assassination of the child.

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Other Conditions affecting the Infant

• Cot Death(SIDS)
• Usually between 1 to 6 months, may be below 2 yrs
• Causes could be suffocation,infection, cortisol deficiency hypersensitivity reaction, laryngeal spasm, hyperparathyroidism, irregularity of cardiac rhythm, failure or inhibition of respiration.
• Lower income group and premature more affected
• Abandoning of infant
• Punishable u/s 317 of IPC with 7yrs + Fine or both
• Children below 12 yrs are protected under the law
• It is to be proved that the intension was to wholly abandoning