A prospective study of paediatric autopsies conducted at Bapuji Hospital and Research Centre, Davangere

Pediatrics is the branch of medicine dealing with children and their diseases. Injury & Violence are major killers of children and adolescents under the age of 18 years throughout the world, and are responsible for about 950000 deaths each year. Unnatural childhood deaths are not only associated with intense trauma and separation distress, but also relate to a sense of self neglect to protect children from harm. Out of 532 autopsies performed during the study period from January 2010 to December 2013, 87 victims belongs to the pediatric age group, were autopsied at the Department of Forensic Medicine & Toxicology at J.J.M.Medical College's, Bapuji hospital and Research center, Davangere. The purposes of this study were to report the autopsy findings of unnatural child deaths, and to identify the prevalence of specific factors such as age, sex, postmortem findings, cause of death and manner of death. The adolescent age group (12-18 years) were most commonly affected, with a significant male preponderance. Many of the cases were accidental in nature with road traffic accident being the greatest cause. Other causes were assaults, burns, drowning, falls, snakebite, stings, There was much coexistence of the parameters typical of both industrialization and population explosion in developing countries, indicating the epidemiological transition. It is important to find out the origin and causes of childhood deaths to guide health policies in preventing the unnatural deaths. Besides, different legal approaches are also needed for different causes. KEYWORDS: Pediatric autopsy; Unnatural childhood deaths; Cause of death; Manner of death Language: en

IJBAR (2014) 05 (02) www.ssjournals.com   16(18.39%) were in the age group of 1-3 years, 12(13.79%) were in the age group of 3-6 years, 13(14.94%) were in the age group of 6-12 years and 43(49.42%) were in the age group of 12-19 years (Table 3).  In our study, among 87 paediatric deaths, 23 deaths were due to road traffic accidents, 22 deaths were due to poisoning, 18 deaths were due to burns/scalds, 5 deaths were due to snake bite/scorpion sting, 8 deaths were due to fall from height, 7 deaths were due to hanging, 1 died due to drowning, 1 case of assault and 2 deaths which were classified as others were due to gore injury by goat, fall of slab. (Table-5) Among 62 accidental child hood deaths, 23 deaths were due to road traffic accidents, 16 deaths were due to burns/ Scalds, 8 deaths were due to fall from height, 5 deaths were due to snakebite/ scorpion sting, 5 deaths were due to poisoning, 2 deaths were due to hanging, 1 death was due to drowning, 1 death was due to gore by goat and another one death was due to due to fall of slab.
Among 20 suicidal child hood deaths, 15 deaths were due to poisoning, 5 deaths were due to hanging. (Table-5)

Discussion
Injury and violence are major killers of children throughout the world, responsible for about 950000 deaths in children and young people under the age of 18 years each year. In 1990, injuries in the developing countries contributed to 13% of total disability adjusted life years among children. It is expected that by 2020, this share will increase to 22%. Injuries in any form remain the major killer in 44% of the death among children of 1 to 4 years of age and 74% among 15 to 19 years. Motor vehicle accidents (MVAs) are the leading causes of death in children aged 1-19 years, followed by suicide (predominantly by poison & hanging) or homicide. 1 In our study paediatric autopsy constituted 16.35 % of total autopsies conducted. This was almost similar to study done at Manipal south India 3 (10.12 %), Jammu 4 (12.25 %) and Brazil 5 (21 %), Transkei region of South Africa 6 and John R Hall study 7 . Our study is in contrast with the study done at Kuala Lumpur 8 which accounted for only 4.9 % of total autopsies.
In the present study out of 87 unnatural childhood deaths, 49 (56.38 %) were males and 38 (43.67 %) were females and male predominance was obvious. This parameter is in concurrence with studies done at Manipal, south India 3 (55.5% male and 44.5% female) and studies done by John R Hall & coworkers 9 (50.5% male and 49.5% female), Kim A Collins & coworkers 10 (57.5% male and 42.5% female), Jonathan P Wyatt & coworkers 11 (60.5% male and 39.5% female), Frederic P Rivara & coworkers 12 (56.5% male and 43.5% female). The reasons for male preponderance is that, they are more active compare to the female counterpart throughout the childhood days. In contrast to this, female predominance was noted in studies conducted by Pramod Kumar & coworkers 13 (57.4% female and 42.6% male) and Byard RW& coworkers 14 (53.3% female and 46.7% male).
The age wise distribution of unnatural child hood death in our study, shows gradual increase in the number of fatalities from toddler to adolescent age group, and adolescent 49.42 % were predominantly involved. This was in agreement with the study done by Palimar V, Arun M. & Bhagavath Prashantha 5 . The reasons being adolescents are more exposed to external environment and are adventurous, rebellious in nature at this age, more impulsive.
In the present study when the manner of death was taken into consideration, accidental deaths topped the list with 62 (71.26 %) cases followed by 20 (22. Among accidental deaths, 23 fatalities were due to road traffic accidents followed by 16 deaths were due to burns, 8 deaths were due to fall from height, 5 deaths were due to poisoning, 5 deaths were due to snake bite / scorpion sting, 2 deaths were due to hanging, 1 death was due to drowning, 1 gore by goat and 1 slab fall. This is similar to the conclusions drawn by the paediatric Death review Committee report 2010 of the deaths on the province of Ontario 15 . Road traffic accidents were predominated in study done at Manipal 3 and studies done by Palimar 17 . The road traffic accidents being more common could be attributed easy access to two wheelers at an early age and rash driving methods adopted by the children and adolescents. Also reflexes may not act well in a child when a fast approaching vehicle is seen coming towards the child and the road may be a playground for the children resulting in death due to a Road Traffic Accident.
Our study results in consistent with an Indian study; accidental poisoning was common in children below 5 years of age whereas suicidal poisoning was more after 13 years of age 18 . Accidental poisoning predominated in another study done in Boston 19 . In our study, among 20 suicidal deaths, 15 terminated their life by consuming poison which were commonly encountered because of their easy accessibility at their agricultural homes and 5 committed suicide by hanging, which were the second most common cause of death, this was in consistent with the study done at Manipal 3 and Canadian statistics 15 .
The increase in burn fatalities and accidental consumption of Kerosene could be due to use of the kerosene stove or mud stove, where fire wood is used or kerosene or pump stove is used, resulting in easy accessibility of stove & kerosene to children's.
The suicidal victims were predominantly females (15 adolescents), which may be due to the sudden emotional nature of a female, sometimes blamed to the hormonal changes during their menses which is in similarity with the studies done by Baca-Garcia E & coworkers 20 , Magos A & coworkers 21 Fourestie V. & coworkers 22 .
In the present study 5 unnatural childhood deaths were homicidal in nature. Out of the 5 cases, 2 female were victims of burns, 2 female were victims of poisoning and 1 was a male child who died due to assault, this was in consistent with the studies done at Manipal 3 , united states 14 & Virginia 23 . Here there was a female predominance seen, since the female child was disliked by low socio economic, illiterate families because of facing difficulties in providing food, shelter, education and marriage. This may be the reason of female homicidal deaths.

Conclusion
Accidents accounted for the majority of childhood unnatural deaths. The Road Traffic Accidents, accidental burns & scalds are leading causes of death. Adolescent males in the age group of 12-19 years are commonly involved. This indicates that an immense responsibility lies with the parents and caregivers to prevent such childhood deaths. Accurate information on causes and circumstances of such deaths through a process of medico-legal investigations is essential in creating an awareness among the National policy makers and educators/caregivers, to prevent this type of childhood unnatural deaths. A need for further similar studies is stressed & maintenance of Pediatric MLC register to know the pattern of childhood fatalities and legal complications and further reducing the pediatric fatalities in future. To conclude there is a very little information regarding the number of paediatric autopsies in developing country like ours. This suggests that each & every centers conducting autopsies should come up with such studies to reflect the magnitude of occurrence of unnatural childhood deaths.