Editor,

Two parents, one in the United Kingdom and the other in the United States, are currently serving prison terms of life sentences for the alleged murder of their infants. Both were convicted mainly on the evidence of Forensic Pathologists. In Australia, the slogan “Think Dirty” adopted by some, is what sent Lindy Chamberlain to prison when her baby was taken by a dingo. Unfortunately that slogan has again surfaced is some jurisdictions.

Chief among the findings causing suspicion of violence is the so called “rib fracture”. Pathologists who did the autopsies on the American and British children, on finding a callus on a rib immediately concluded it was a healing fracture – and hence evidence of physical abuse. No thought was given to the possibility that it could be a healing subperiosteal haematoma resulting from a coagulopathy.

Two parents are now victims of this Medical Jurisprudence.

Consider the case of REGINA v SALLY CLARK referred to by Professor Meadow (BMJ 2002;324:41-43). The "injuries" as they were called, which included a callus on the 2nd left rib, were all consistent with the delayed or late form of Haemorrhagic Disease of the Newborn (HDN) notwithstanding the claim of many of the experts that "no natural disease" could account for the lesions observed in and on the child(Harry Clark’s) body.

Any subperiosteal haemorrhage, whether by a blow to the chest, or by a disorder of the coagulation system, such as HDN, will have exactly the same histological features as the healing process progresses. One does not need to "think dirty" in order to explain the dead spicules of bone lying in amongst the other cells as the lesion heals.

For those of your readers unfamiliar with this condition it is a bleeding disorder in the neonatal period due to Vitamin K deficiency. The risk of HDN is highest in the first 13 weeks of life and commoner in exclusively breast fed infants as was Harry.

Prematurity is also a risk factor. Harry was 3 weeks premature .The late or delayed form of HDN usually presents at around 8 weeks of age. Harry Clark was 8 weeks when he died. The essential features of HDN are spontaneous bleeding resulting in a severe haemorrhagic state with bleeding and bruising anywhere in the body [1.2.3].

In an attempt to prevent HDN 1mg of Vitamin K is usually administered at birth but this is not always successful the failure rate in Germany [4] being about 1 in 400000 a rate sufficient to account for about 2 cases a year in England. Incidentally HDN is also known as Vitamin K Deficiency Bleeding (VKDB).

In America a father was charged with the murder of his 10 week old son Alan Yurko. Here again the main lesions found were bleeding into various tissues including callus formation on 4 ribs (5,6,7, and 10 left side). In this instance however, the father, observing the child in respiratory distress rushed the infant to hospital. Blood was taken for various tests including a Prothrombin Time which was prolonged.

The laboratory diagnosis of HDN requires one to demonstrate a prolonged Prothrombin Time as was done in the case of Alan Yurko. Yet surprisingly this evidence was totally ignored by the Medical Experts. One can only conclude that the “Experts” for the prosecution, six in all, were unaware of the existence of HDN. Regrettably the only defence witness must have been innocent of knowledge of the condition because he too, didn’t suggest it.

Ignorance of HDN is widespread. It is time Forensic Pathologists worldwide realized that bleeding and bruising of an infant, and especially rib calluses, are not necessarily due to abuse. Jayawant et al [5] have suggested that a haemorrhagic screen should be mandatory in all suspected cases of child abuse. This should also be mandatory in Australia before we too, start imprisoning innocent parents.

Michael D. Innis FRCPath; FRCPA
Honorary Consultant Haematologist
Princess Alexandra Hospital, Brisbane

References

1.Oxford Textbook of Medicine (1987) Edited by Weatherall DJ. Ledingham JGG. Warrell DA. Oxford Medical Publications 19;230

2. Hematology Fourth Edition Edited by Williams WJ. Beutler E. Erslev AJ. Lichtman MA p 1511

3. A joint position statement of the Fetus and Newborn Committee, Canadian Paediatric Society (CPS), and the Committee on Child and Adolescent Health, College of Family Physicians of Canada

4. von Kries R. Vitamin K prophylaxis – A useful public measure? Paediatr Perinat Epidemiol 1992;6:7 -13

5. Jayawant S. Rawlinson A. Gibbon F et al; Subdural haemorrhages in infants: population based study. BMJ (1998) vol 317:1558-1561