Original Article

Autopsy Study of Pediatric Deaths S.R. D a l a l , M.V. J a d h a v a n d S . D . D e s h m u k h

Department of Pathology, B.J. Medical College, Sassoon General Hospitals, Pune, India

Abstract. Objective : Childhood autopsies occurring dudng January 1997 to December 1999 were reviewed. ~ : Of the total 1,445 deaths autopsied, 441 (30.5%) were of pediatric patients. Result : Of these deaths, 70.3% occurred during neonatal period, 8.6% in infancy, and 21.1% in childhood. Birth asphyxia (57.7%) was the most frequent mode of death in the neonatal period. Infections (67.2%) predominantly accounted for infant and childhood mortality, those of respiratory tract (46.1%) being most frequent in infancy, early and mid childhood, and enteric fever in late childhood (33.3%). Descrepancy between ante-mortem and post-mortem diagnosis occurred in 29 cases (6.6%) Conclusion: Autopsy is an important clinical tool providing useful information to the physician. Few published reports are available on pediatric autopsies. This study aims to help in a better understanding of causes of deaths in neonates, infants and children. [indian J Pedlatr 2002; 69 (1) : 23-25] Key words : Autopsy; Pediatrics

To improve maternal and child with health services, it is w o r t h w h i l e to find the etiopathogenesis of pediatric deaths occurring in a government hospital that caters to the general population. We report an analysis of 441 pediatric autopsies of the total 1,445 autopsies performed over a period of 3 years. The data provide a complete clinical record alongwith investigations and pathology of organs. This allows clinico-pathological correlation of the disease process, which has cost the child's life. MATERIALS AND METHODS Records of 441 pediatric autopsies from January 1997 through December 1999 were reviewed. Special emphasis was laid on clinical and post-morten findings including external, in-situ and systemic examination of the body. The histopathological slides were reviewed from cases of childhood autopsies. Clinico-pathological correlation was done to arrive at the cause of death.

c o m p l e t e l y i m m u n i z e d , w h i l e 6 were i m m u n i z e d partially. Congenital malformations were present in 36 (8.4%) n e o n a t e s , of w h i c h 26 were lethal. The c o m m o n l y occurring lethal malformations were diaphragmatic hernia with associated congenital anomalies TM,congenital h e a r t diseasse 7, m e n i n g o c o e l e 2, m i c r o c e p h a l y w i t h associated anomalies 1, t r a c h o - o e s o p h a g e a l fistula 1, harlequin fetus 1, choledochal cysfl, Juene's syndrome ~, renal agenesis ~and congenital adrenal hyperplasiaL In 10 neonates with non-lethal congenital malformations the cause of death was birth asphyxia s, p n e u m o n i a 1 and septicaemia 1. Congenital malformation responsible for mortality in infants and children were-congenital heart diseases 7, biliary atresia ~and Zellwegger syndromeL Death in n e o n a t e s d u e to metabolic causes was u n c o n g u g a t e d hyberbilirubinaemia 7, galactosemia 1, glycine e n z y m e deficiency *, acute renal failure ~ a n d TABLE1. Causes of~eonatal Deaths. (N=310)

RESULTS

Total numbers of autopsies occurring during the threeyear study period were 1,445, of which 441 (30.5%) were childhood autopsies. There were 310 (70.3%) neonatal deaths (Table 1), 38 (8.6%) infant deaths and 93 (21.1%) childhood deaths (Table 2). The sex distribution was 230 males, 207 females, a n d 4 h a d a m b i g u o u s sex. Immunization status was available of 11 out of the total 38 infants. They were completely immunized. 21 out of 93 childhood deaths were immunized out of which 15 were Reprint requests :Dr. Shefali R. Dalal, 108/B, Poonam Apts, Ideal Colony,Paud Road, Kothrud, Pune-411029. E-mail - [email protected] Indian Journal of Pediatdcs, Volume 69--January, 2002

Cause of death

No. of deaths

1. Perinatal asphyxia 179 2. Infections 66 - Pneumonia 43 - Septicaemia 17 - Meningitis 4 - Neonatal hepatifis/Enterocolitis I each 3. Congenital malformations 26 4. Prematurity 14 5. Hematologic 12 6. Metablolic 11 7. Neoplasm (Congenital hepatoblastoma) 1 8. Undetermined 1 Total

(%) 57.7 21.3 13.9 5.5 1.3 0.3 8.4 4.5 3.9 3.5 0.3 0.3

310 23

S.R. Dalai et al TABLE2. Causes of Infant and Childhood Deaths. Causes of Death

1. Infections Pneumonia Septicaemia TB bronchopneumonia/Miliary & TB meningitis Acute gastro enteritis Enteric fever Pyogenic meningitis / Encephalitis/Cerebral malaria Hepatitis/Reye's syndrome Diphtheria 2. Hematologic severe nutritional anemia thalassemia 3. Congenital malformations 4. Metabolic 5. Rheumatic Heart Disease 6. Neoplasam/Leukaemia 7. Protein Energy malnutrition 8. Others Total

Infant month-1 year (%)

29 21 3 1

(76.3) (55.3) (7.9) (2.6)

59 14 16 8

(63.4) (15.1) (17.2) (8.6)

3 (7.9)

5 (5.4) 8 (8.6) 6 (6.5)

1 (2.6)

1 1 5 3 2 7 6 6 5 1 4

5 4 1 2 2

(13.2) (10.5) (2.6) (5.3) (5.3)

38

hypoglycemia 1. In infants, death was due to inborn errors of metabolism-galactosemia 1and Niemann Pick diseaseL In children, vitamin D toxicity ~, Wilsons disease 2, and chronic renal failure 3 were the causes of death. Death due to Rh incompatibility 6, ABO incompability 2, bleeding diathesis 3 and congenital hemolytic anaemia ~was seen in neonates. In infants and children, severe nutritional anaemia 7 and thalassemia 3 accounted for hematologic causes of death. Two children died of acute myeloid leukaemia (AML) and acute l y m p h o i d laukaemia (ALL). 3 children were d i a g n o s e d to h a v e h e p a t o b l a s t o m a , h e p a t o c e l l u l a r c a r c i n o m a and e x t r a - a d r e n a l p h e o c h r o m o c y t o m a on a u t o p s y . 21 (22.5%) of the c h i l d h o o d d e a t h s h a d associated protein energy malnutrition. Subdural h e m a t o m a and status epilepticus were included in the "others" category of childhood deaths. Cause of death in two cases could not be ascertained. Discrepancy between ante-mortem and post-mortem diagnosis was found in 29 cases (6.6%). The anti-mortem diagnosis of 15 out of 310 cases of neonatal deaths (48%) was birth asphyxia and death occurred within 1-2 days. The p o s t - m o r t e m diagnosis in these cases was internal c o n g e n i t a l m a l f o r m a t i o n s 9, b l e e d i n g d i a t h e s i s 3 a n d meningitis 3. Similarly in 14 (10.7%) of 131 cases of infant and childhood deaths a n t e - m o r t e m and p o s t - m o r t e m diagnosis did not tally. Three children d i a g n o s e d as having cardiac failure and hypoxic encephalopathy were found to have congenital heart diseases like coarctation of aorta, atrial septal defect and Fallots tetralogy on postm o r t e m e x a m i n a t i o n . T w o p a t i e n t s of h e p a t i c encephalopathy and congenital heart disease in fact had Wilson's disease and N i e m a n n Pick disease. A case of rheumatic heart disease was diagnosed clinically as septic 24

Childhood Deaths 2-18 year (%)

Total no. of deaths (%)

88 35 19 9

(67.1) (26.7) (14.5) (6.8)

8 (6.1) 8 (6.1) 6 (4.6)

(1.1) (1.1) (5.4) (3.2) (2.2) (7.5) (6.5) (6.5) (5.4) (1.1) (4.3)

2 (1.5) 1 (0.7) 10 (7.6) 9 8 6 5 1 4

93

(6.9) (6.1) (4.6) (3.8) (0.8) (3.1)

131

arthritis. Tuberculosis was overdiagnosed in four patients w h e n in fact t h e y w e r e f o u n d to h a v e enteric fever, encephalitis, pyogenic meningitis and Reye's syndrome. Patients w h o died within 24 h o u r s and could not be investigated revealed h e p a t o b l a s t o m a , hepatocellular carcinoma and extra adrenal p h e o c h r o m o c y t o m a and extra adrenal pheochromocytoma on autopsy. DISCUSSION There are innumerable studies on perinatal autopsies, TM but there is hardly any mention of infant or childhood autopsies in the literature. Though autopsy material is not totally representative of childhood mortality, it gives an idea a b o u t its trends. This p r o m p t e d the a u t h o r s to undertake the present composite autopsy study. Neonatal d e a t h s f o r m e d the l a r g e s t g r o u p i.e. 310 (70.3%) of childhood deaths. Most of these deaths occurred due to p e r i n a t a l a s p h y x i a . P e r i n a t a l a s p h y x i a is u s u a l l y a s s o c i a t e d w i t h m a t e r n a l c o m p l i c a t i o n s w h i c h are potentially treatable, thus making it possible to prevent these deaths) ,5,6 38 (8.6%) c h i l d h o o d deaths w e r e r e c o r d e d d u r i n g i n f a n c y , w h i c h m o s t f r e q u e n t l y o c c u r r e d due. to infections. During this period of life the child is m o s t susceptible to infection, as the immunological apparatus is not fully equipped. Maternal antibodies transferred to the offspring are waning and they are being exposed to a variety of antigenic stimuli. 7 The m o s t frequent site of infection in infants was the respiratory tract. 21 (72.4%) of the deaths were due to pneumonia. Three (10.3%) infants had septicemia. As in infancy, the most frequent cause of death during childhood was infection. Respiratory tract infections 8 accounted for most of the deaths in early and Indian Journal of Pediatrics, Volume 69--January, 2002

Autopsy Study of Pediatric Deaths mid-childhod. This fact has been stressed b y p r o g r a m s where c o m m u n i t y health workers are trained to detect r e s p i r a t o r y diseases b y counting the r e s p i r a t o r y rate. 9 Enteric fever w a s the c o m m o n cause of d e a t h in late childhood. A u t o p s y p r e v a l e n c e of tuberculosis in the p r e s e n t series w a s 2.04%. Its prevalence a m o n g infections w a s 6.25%. Surprisingly most of these cases were immunized with BCG. Efficacy of BCG is presently being doubted. 1~" Tuberculous meningitis was present in 3 cases, 2 of which occurred in early childhood. Interestingly one case of diphtheria occurred in late childhood inspire of the child being fully immunized. The importance of knowing about the pattern of deaths in infancy lies in the fact that at least some of these deaths can be p r e v e n t e d , p a r t i c u l a r l y those w i t h infections. Parents can be made aware of this fact during counselling or health education sessions. It is during this period of the child's life that p a r e n t s are m o s t a p p r o a c h a b l e to the healthcare system as they frequently visit the healthcare units during the immunization program. Media can play a great role in this as is exemplified in public interest advertisement on oral rehydration schedule and immunization. T h o u g h a d v a n c e s in m e d i c a l t e c h n o l o g y h a v e revolutionized detection of disease, it has to be brought within the a m b i t of the p e o p l e in rural or inaccessible areas. This assumes importance in antenatal diagnosis of congenital malformations in neonates that were revealed only on autopsy. Autopsies can be used as a feedback for c o n f i r m i n g the clinical diagnosis w h e n the b a b y dies before being investigated or treated. Autopsies play a role in detection of misdiagnosis as occurred in diagnosing

Indian Journal of Pediatrics, Volume 69--January, 2002

some infectious diseases in neonates and children in the present study. It helps the clinicians to gain an insight into the occurrence, features and clinical manifestations of rare diseases. Thus, an autopsy study of childhood deaths can be quite informative. It Can form a baseline information system for future policies of child health. REFERENCES

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