The pathology of fatal child abuse

It is a sad indictment of human society that the abuse of children is such a prevalent and widespread problem. The acknowledgement that physical, emotional and sexual injury as well as intentional neglect can be inflicted upon the young by any person but especially by caregivers has been increasingly realised by the community. As a result, many professionals, especially in the medical sciences, are involved in the study and management of such cases with the ultimate goals of recognising children at risk, diagnosing those cases that have occurred, preventing initial or subsequent injury and bringing perpetrators to justice. The aim of this paper is to review recent published work on the pathology of abuse leading to death of the child. Particular reference is made to the patterns of observed physical damage as well as to the interpretation of those observations. Clearly many more children are abused than die directly as a result of that abuse, but pathologists are infrequently involved in the management of clinical abuse cases. Exceptions to this rule, of course, include assessment of biochemical changes in cases of Munchausen syndrome by proxy, diagnosis of infective lesions resulting from sexual assault as well as the interpretation of unexplained cutaneous lesions subsequently shown to be caused by physical assault (such as burns and bite marks). Cases of physical abuse are usually managed by pediatric specialists with assistance from radiologists, neurosurgeons and ophthalmologists, and it is important that effective communication be maintained by pathologists with these practitioners when investigating a case that has unfortunately culminated in death.