Frequency of Bronchopneumonia in Children With Survival Interval Before Death Many children do not survive after presentation in extremis. Some survive varying intervals and are found to have bronchopneumonia at death. The question is raised whether bronchopneumonia is a consequence of survival rather than the initiating disease leading to collapse. A prospective study of the deaths of 156 children divided them into two groups: 80 children with head injury and 76 with causes of death other than sudden infant death syndrome. In 43 of the total group of children, bronchopneumonia was found. In the total group, 76 survived more than a day. Of these 39 had bronchopneumonia, 32 died of head injury, and 7 had other causes of death. Of the children surviving less than a day, 4 had bronchopneumonia at death—only 1 with head injury. If bronchopneumonia is present, it is more likely to have developed after the collapse than to have caused it in this population.
The consequences of cardiorespiratory collapse, especially when caused by head injury, can include aspiration of gastric contents leading to bronchopneumonia. Even without recognized aspiration, bronchopneumonia is often found following collapse. Severe pneumonia is also a well-recognized cause of collapse. In cases with an accusation of abusive head injury the defense may propose other causes of collapse than head injury. Such issues are raised more often in child deaths.
Review of a large number of child deaths would allow determination of the frequency of bronchopneumonia at autopsy. Such information could be compared with the cause of death and would provide a database. Inclusion of the survival interval after presentation would address the question whether bronchopneumonia found at autopsy was the underlying cause of death or was the consequence of the cause of death. This study was undertaken to provide such information.
MATERIALS AND METHODS
A prospective postmortem study investigated 169 child deaths. (1). Other aspects of these deaths have been reported previously (2–4).
One hundred seventy-five of nearly 400 deaths of young children investigated at the Dallas County Medical Examiner’s Office from 1982 to 1989 were studied prospectively. Case selection depended on random assignment of cases and on the prosector’s willingness to participate in the study. Nineteen pathologists contributed one or more cases each by the end of case collection. All child deaths were equally likely to be included in the study. The deaths included diagnoses of child abuse, suspected child abuse, apparent accidental trauma, and apparent natural death. History, autopsy findings, and ocular findings were gathered and reviewed for the more general study.
The immediate rather than the underlying cause of death was chosen to select the subgroup. Children whose immediate cause of death was head injury were selected for comparison with the remainder of the group. Head injury included both abusive and nonabusive head injury. Three children whose underlying cause of death was head injury were included in “other causes.” In these children, the immediate cause of death was a consequence of the head injury but death came by a different mechanism than in the remainder of the head-injured group.
The interval between presentation and death was known for all the children. Microscopic examinations identified the presence or absence of bronchopneumonia. Thirteen children whose deaths were attributed to sudden infant death syndrome (SIDS) were excluded from the comparison group. By definition, SIDS is a diagnosis of exclusion; bronchopneumonia was excluded in these children.
In the 156 cases (excluding SIDS deaths), the age distribution was as follows: 50% less than 1 year of age, 26.3% 1 to 2 years, 23.7% over 2 years. Ancestry distribution was 86 white, 50 black, 16 Latino origin, 4 other ancestry. There were 92 male and 64 female children.
The percentage of head injury deaths in the group was 51%. The others died of asphyxia, 19; noninjury diseases of the central nervous system, 18; trunk injury, 13; undetermined causes, 10; and other, 21. Those described as “other” included respiratory disease, 11; infections, 5; cardiac disease, 3; gastrointestinal disease, 2.
Those surviving more than one day following presentation for medical attention were 48% of the group. The others were found dead or could not be successfully resuscitated.
Table 1 shows the two subgroups divided fairly evenly by cause of death, but 68% of the children dying of head injury survived more than a day compared with 28% of those with other causes of death. Table 2 shows the distribution of bronchopneumonia in the two subgroups. Most (97%) of the head-injured children with bronchopneumonia had survived more than a day, although the percent surviving was also quite high (70%) of those with other causes of death.
Bronchopneumonia was identified at autopsy in 43 of this group of children. Head injury accounted for 33 of the deaths (77%). Most of these children (32) survived more than a day after the initial presentation. The bronchopneumonia found at autopsy developed after the collapse. One child with abusive head injuries was found dead. This child had bronchopneumonia as well as other abusive injuries, which would not have been immediately fatal. The abusive injuries could well have been associated with aspiration before collapse. The bronchopneumonia was not sufficient to cause death.
The other 10 children (23%) found to have bronchopneumonia at autopsy did not die of head injury. The causes of death of 7 children of these children surviving more than a day included respiratory disease, 3; nontraumatic brain disease, 2; delayed death after an asphyxial event, 1; and gastrointestinal disease, 1. The other 3 of the 10 children were found dead or did not survive attempts at resuscitation. The deaths of 2 of them were attributed to respiratory causes. The third died an asphyxial death while he was recovering from abusive fractures of both legs. The circumstances of this child’s death could have included aspiration.
The prolonged hypoxia after collapse can cause myocardial ischemia, acute renal failure, or liver failure. The latter are rarely proposed as the cause of the collapse. By contrast, pneumonia can be offered as an alternative to head injury as the cause of a child’s collapse and of the child’s death. In this group of children, bronchopneumonia was the consequence of the head injury that caused collapse, not the cause of the collapse.
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