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Majority of unnatural deaths among children occur at home: Local study

28 Oct 2021

  • Notes inadequate/improper parental supervision; recommends public health education and child protection legislation
BY Ruwan Laknath Jayakody The majority of unnatural deaths among children taking place at home, indicates the lack of adequate and proper parental supervision, a local study noted. This finding was made in an original article on “Child victims in medico-legal autopsy” which was authored by I.D.G. Kitulwatte, P.A.S. Edirisinghe, and T. Ratnayake (all attached to the University of Kelaniya Medical Faculty’s Forensic Medicine Department) and published in the Medico-Legal Journal of Sri Lanka 1 (1) in August 2014. According to R.E. Black, S.S. Morris, and J. Bryce’s “Where and why are 10 million children dying every year”, over 10 million children below the age of five years die every year. Even the death of a single child can result in calls for, per P.J. Fleming, P.S. Blair, P.D. Sidebotham, and T. Hayler’s “Investigating sudden unexpected child deaths in infancy and childhood and caring for bereaved families: An integrated multi agency approach” and H. Ferguson’s “Protecting children in time: Child abuse, child protection, and the consequences of modernity”, extensive child welfare reform. In this regard, N. Canturk, B.E. Iyok, E. Ozkara, G. Canturk, A.B. Ozata, and M.F. Yavuz’s “Medico-legal child deaths in Istanbul: Data from the Morgue Department” and S. Asnaes and F. Paaske’s “The significance of medico-legal autopsy in determining the mode and cause of death” noted that the medico-legal autopsy is an important solution in addressing many unanswered questions that arise after death. Also, information revealed after reviews of children’s deaths which address a wider context, is obligatory per M. Connolly and M. Doolan’s “Responding to the deaths of children known to child protection agencies”, in order to improve child survival and to strengthen child welfare services. Hence, Kitulwatte et al. conducted a retrospective, descriptive study based on reports of post-mortems/medico-legal autopsies performed on 98 children, between the ages of one day to 18 years, during three consecutive years, of those referred to a tertiary care teaching hospital. Neonatal deaths associated with complications arising from birth asphyxia and birth-related reasons were excluded. The alleged circumstances of death that were considered were accidental, suicidal, homicidal, and natural. The alleged causes of death that were seen under accidental deaths were drowning, aspiration, other asphyxia, blunt head injury, poisoning, burns, snake bites, blunt chest injury, and sharp force injury. The alleged causes of death that were seen under suicidal deaths were hanging and poisoning. The alleged causes of death that were seen under homicidal deaths were drowning, sharp force injury, and blunt head injury. The alleged causes of death that were seen under natural deaths were respiratory pathology, congenital heart disease, other congenital conditions, and other infections. The majority (39 – 40%) were infants of the age group of less than one year, while there were 34 (35%) between 11 to 18 years, and 25 (25%) between the ages of one to 10 years. A total of 50 (51%) of the circumstances of death were natural, while there were 39 (40%) accidents, six (6%) deaths by suicide, and three (3%) homicides (two infants and one between the age of one to 10 years). Of the accidents, 15 (38%) were drowning, while there were nine (23%) accidental blunt head injuries, and seven (18%) accidental aspirations seen among the infants. Of the deaths by suicide, five (83%) were due to hanging. The causes of death in homicides were drowning, blunt head injury, and sharp force trauma. In terms of the natural deaths, 30 (60%) were due to respiratory and other infections. There was a significant difference in the circumstances of death between infants, and children between one to 10 years along with those between 11 and 18 years. Death due to natural conditions was predominant among infants (30 – 75%), while 17% of infants died due to accidental aspiration, and 14 (58%) children between one to 10 years and 56% between 11 to 18 years died of accidental causes. In the 11 to 18 years age group, six (16%) deaths were by suicide. There were no deaths by suicide among the younger age groups. Once natural deaths were excluded, there was a significant difference in the circumstances of death among the age groups of zero to 10 years and 11 to 18 years. Of the unnatural deaths among the 11 to 18 years group, six (25%) were deaths by suicide.  The commonest mechanism of death once natural deaths were excluded was asphyxia (30 – 63%) with 16 (53%) of them caused by mechanical asphyxia due to drowning. There were seven (23%) aspiration-related deaths, and two other asphyxial deaths which included a case of traumatic asphyxia and a case of choking. In terms of the location of the deaths, a little over half of the unnatural deaths had occurred at home (54%) followed by 23% on the road and at other places. Out of the 16 children who died of drowning, seven (44%) incidents had occurred at home while nine (56%) had occurred outside, in lakes, rivers, ponds, and wells. As explained by C. Onwuachi-Saunders, S.N. Forjuoh, P. West, and C. Brooks in “Child death reviews: A gold mine for injury prevention and control”, child mortality review is important in the prevention of deaths among children. According to J. Pearson and D.H. Stone’s “Pattern of injury mortality by age group in children aged zero to 14 years in Scotland, 2002-2006, and its implications for prevention” and S.M. Rabson’s “Sudden and unexpected natural death in infants and young children”, sudden unexpected natural deaths occur throughout childhood but most commonly in infants and toddlers between the ages of one to four years. The majority of such sudden deaths among infants are, per C.E. Hunt’s “Sudden Infant Death Syndrome and other causes of infant mortality diagnosis, mechanisms, and risk for recurrence in siblings”, natural. Rabson also found that respiratory diseases have been identified to cause 80% of the unexpected deaths in infants. Accidents are, Kitulwatte et al. pointed out, the major cause of child morbidity and mortality worldwide. In “Facts about childhood drowning”, Safe Kids Worldwide noted that drowning is the second leading cause of accidental injury-related death among children between the ages of one to 14 years, and is second only to motor vehicle-related accidents, and is also the leading cause of accidental injury-related death among children between the ages of one to four years across the world. Regarding the higher proportion of drowning in the present study group, Kitulwatte et al. explained that such indicates the lack of supervision of children when they are in water.  Studies (H. Saha and V.J.R. Rao’s “Accidental deaths among children”, R.G. Rice, G.W. Starbuck, and R.B. Reed’s “Accidental injuries to children”, S. Lalwani, G.A.S.K. Sharma, S.K. Kabra, S. Girdhar, and T.D. Dogra’s “Suicide among children and adolescents in South Delhi”, and M. Arslan, R. Akcan, A. Hilal, H. Batuk, and N. Cekin’s “Suicide among children and adolescents: Data from Cukuroiva, Turkey”) showed an increase in the number of accidents with age, due in part to the increasing independence of children with age and teenagers having more freedom due to maturity. The fact that once the natural deaths were excluded, there was a significant difference in the circumstances of death between the ages of zero to 10 years, and 11 to 18 years, was explained by Kitulwatte et al., as being due to the presence of deaths by suicide being seen only among the older children and being absent in younger children. As Saha and Rao observed, death by suicide has become a common cause of death among adolescents and young children worldwide. However, Kitulwatte et al., elaborated that even if deaths by suicide were present among the younger children, they may have been labelled as accidents. Analysing the findings further, Kitulwatte et al., while noting that the results clearly show the lack of proper supervision of children even in their own homes, emphasized the need therefore to target the home environment, in order to prevent such deaths as sudden deaths associated with injuries and violence. Since comprehending the nature and circumstances of childhood accidents can in turn assist in accident prevention strategies and programmes, Kitulwatte et al. recommended effective health education programmes for the public whilst calling for the enactment and implementation of suitable legislations for child protection in order to effectively improve child survival.

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