Pediatric forensic pathology: child deaths and injuries.
Children are not small adults. Their anatomy, their diseases and the ways they are injured are different, and so are the mimics of injury. Pediatric forensic pathology is the subspecialty that examines the deaths and injuries of infants and children with that in mind. NAAG’s physicians specialize in it.
Medically reviewed by Evan W. Matshes, MD, FRCPC, D-ABP, Medical Director and Chief Forensic Pathologist · Updated
- Every pediatric case should be examined completely: brain, spinal cord, eyes, bones, heart and genetics, not just the injury in question.
- Many natural diseases, birth-related findings and accidental injuries can mimic abuse. Each must be tested, not assumed.
- Alleged abusive head trauma requires full neuropathology, including the dura, spinal cord and eyes.
- Fractures need skeletal examination and assessment for metabolic bone disease, vitamin D deficiency and inherited bone fragility.
- Sudden unexpected infant deaths deserve genetic and metabolic testing as well as a complete autopsy.
Why is pediatric forensic pathology different?
An infant’s skull, brain, bones and blood vessels respond to force differently from an adult’s. Findings from birth can persist for weeks. Infections, clotting disorders, metabolic disease, inherited conditions and the effects of resuscitation can all produce findings that resemble injury. A pediatric forensic pathologist examines every child with those possibilities in mind, so that the conclusion rests on the whole of the evidence.
Sudden unexpected infant death (SUID) and SUDC
Sudden unexpected infant death describes the sudden death of an infant under one year that is not explained before investigation. Sudden unexplained death in childhood (SUDC) describes the same in children over one. A complete examination includes a full autopsy with neuropathology, a review of the circumstances and sleep environment, microbiology, toxicology, genetic testing for inherited cardiac and metabolic disease, and postmortem metabolic screening. NAAG examines SUID and SUDC brains at no cost to agencies, funded by an internal NAAG grant.
Alleged abusive head trauma
Cases of alleged abusive head trauma, sometimes called shaken baby syndrome, often turn on three findings: bleeding beneath the dura (subdural hemorrhage), bleeding in the retina, and brain swelling. Each has more than one possible cause. A complete examination includes forensic neuropathology of the brain, dura and spinal cord, examination of the eyes, the neck and cervical spine, the skeleton, and testing for clotting disorders, infection and metabolic disease, with the medical history and imaging reviewed in full. Timing studies, such as amyloid precursor protein (APP) staining, can help but have real limits, and should be interpreted by a specialist.
Fractures and the skeleton
Fractures in infants raise questions of mechanism, timing and bone strength. Pediatric forensic anthropology and osteology examine the ribs, long bones and skull directly, with histology of fracture sites and assessment of healing. Metabolic bone disease, vitamin D deficiency and inherited bone fragility, such as osteogenesis imperfecta, must be considered and tested, including with bone histology, vitamin D levels and genetic testing.
Injuries in living children
Many pediatric forensic questions involve living children: in dependency proceedings, in criminal cases and in family-law disputes. The same expertise applies. A pediatric forensic pathologist reviews the medical records, imaging and photographs, interprets the injuries and their possible causes, and explains clearly what the evidence can and cannot establish. Dependency matters move quickly, and NAAG handles them on a rush basis.
What should a complete pediatric examination include?
- Full autopsy with complete photographic documentation.
- Neuropathology of the brain, dura and spinal cord, and examination of the eyes.
- Skeletal examination, with histology of fractures and bone.
- Toxicology, microbiology and metabolic screening.
- Genetic testing where the history or findings suggest inherited disease.
- Review of the birth, medical and investigative history.
- Formal peer review by a second board-certified forensic pathologist.
Where the original examination left gaps, retained tissue can often be re-examined in a Deep Dive.
Frequently asked questions.
Can a second opinion be obtained in an alleged shaken baby case?
Yes. Defense counsel, prosecutors and families can request an independent review of the records, imaging, photographs and slides, and a Deep Dive re-examination of retained brain, eyes and bone.
What conditions can mimic child abuse?
Among others: birth-related findings, clotting disorders, infections, metabolic disease, vitamin D deficiency, inherited bone fragility, accidental injury and the effects of resuscitation. Each must be considered and tested.
Is genetic testing useful after a sudden infant death?
Often. Inherited cardiac arrhythmias, cardiomyopathies and metabolic disorders can cause sudden death, and identifying them may protect siblings and parents.
Does NAAG examine living children?
NAAG interprets injuries in living children from their medical records, imaging and photographs, for criminal, dependency and family-law matters.
Talk to a forensic pathologist
Every case is different. Tell us about yours and we will tell you honestly what an examination or review can answer.
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San Diego, CA 92121
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