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A 25-year retrospective review of deaths due to pediatric neglect
Laura D Knight1, Kim A Collins
1Department of Pathology and Laboratory Medicine, Division of Forensic Pathology, Medical University of South Carolina, Charleston, South Carolina 29425, USA. knight1@musc.edu
Insights
Pediatric neglect, particularly malnutrition and dehydration, is a significant cause of child mortality. This study highlights common and less common forms of fatal neglect and challenges in determining manner of death.
Area of Science:
- Forensic Pathology
- Pediatric Mortality
- Child Neglect
Background:
- Child neglect is a critical factor in pediatric mortality, encompassing failures in providing essential care like safety, nutrition, and medical attention.
- This retrospective study examines 16 pediatric deaths attributed to neglect over 25 years at a major forensic pathology office.
Observation:
- Malnutrition/starvation and dehydration were the most frequent causes of death in neglect cases, often classified as homicides.
- Other neglect-related deaths included toxic ingestions, hyper-/hypothermia, unusual drownings/aspirations, electrocution, and delayed medical care.
- Cases involving "gray zones" of neglect, where classification was subjective, were excluded to focus on clearer instances.
Findings:
- Malnutrition/starvation and dehydration remain the predominant forms of lethal pediatric neglect.
- Less common neglect-related fatalities and the complexities in determining the manner of death in ambiguous cases were identified.
- Typical victims include infants deprived of sustenance or older children lacking adequate supervision.
Implications:
- Understanding the patterns of fatal pediatric neglect aids investigators in identifying victims and scenarios.
- Autopsy findings, specimen collection, and ancillary studies are crucial for accurate diagnosis and classification of neglect-related deaths.
- Recognizing potential mimickers of neglect is essential for a thorough forensic investigation.
Abstract:
Neglect, defined as the failure of a caregiver to adequately provide safety, food, clothing, shelter, education, protection, medical/dental care, and supervision for a child in his/her care, is a relatively uncommon but important cause of child mortality. A retrospective review of pediatric deaths (age 18 years or less) referred to the Medical University of South Carolina Forensic Pathology Office for autopsy over the past 25 years revealed 16 deaths due to some type of pediatric neglect. Cases were analyzed as to age, sex, race, cause and manner of death, autopsy findings, ancillary studies, past medical history, social/family history, and caregiver. Six cases of malnutrition/starvation and/or dehydration were identified, composing the most common cause of death in the neglect cases identified and the majority of the homicides due to neglect. Other deaths in which neglect contributed significantly included toxic ingestions (2 cases), hyper-/hypothermia (2 cases), unusual drowning/aspiration (4 cases), electrocution (1 case), and delayed/absent medical therapy (2 cases, including one of the previously mentioned ingestions). Of these additional cases, 7 were certified as accidental manner, 2 as natural, and 1 as a homicide. Cases which fell into a "gray zone" in which the appropriateness of invoking neglect was a matter of opinion or societal convention were excluded from the review; examples included conventional accidental drowning, choking on food or aspiration of foreign body, overlying/wedging during sleep, accidental hanging, and motor-vehicle traffic accidents (pedestrians, unrestrained passengers). The findings of this review reinforce the fact that malnutrition/starvation and dehydration compose the most common form of lethal pediatric neglect while highlighting less common forms of neglect and the difficulty of determining manner of death in cases in which neglect plays a more questionable role than in seemingly clear-cut malnutrition/starvation and dehydration cases. We demonstrate the typical victim and scenario that investigators will encounter in cases of fatal pediatric neglect, often a child under the age of 1 year who has been deprived of food and/or drink for some time, or an older, more independently mobile child who has not been adequately supervised. These children may or may not have a demonstrable prior history of maltreatment or (nonfatal) neglect, and review of medical records is an important part of the investigation. We additionally discuss key gross autopsy findings, appropriate specimen collection, helpful ancillary studies, microscopic findings of significance, potential mimickers of neglect, and other special considerations in cases of pediatric neglect.
