Letter from the Guest Editor

Child abuse is one of the most polarizing and contested topics in forensic pathology. Few other types of cases will be challenged as frequently and as vigorously as an autopsy on an abused child. Therefore, it is imperative for forensic pathologists to be well-versed in the current as well as the historical literature on pediatric nonaccidental trauma. The unique physical and developmental characteristics of infants and children and the inability to test proposed injury mechanisms have led to many different published theories on inflicted trauma in infants, creating division amongst experts involved in the cases. Special dissections and techniques have been developed to assist the pathologist with identifying trauma in areas previously unseen, providing new information that may help elucidate the cause and manner of death. Utilization of neuropathology and anthropology consultants has become standard practice in these difficult cases.

Recognition and prosecution of child abuse had an interesting origin in America. Because no child protection agency existed at the time, the first documented case was investigated by the American Society for the Prevention of Cruelty to Animals in 1874 (1). This spawned the creation of the New York Society for the Prevention of Cruelty to Children, the first entity devoted to the protection of children in the world, which is still in operation today. Hundreds of other agencies have been created since then, all relying on physicians to properly recognize and document inflicted trauma.

Medical training in the recognition and documentation of inflicted trauma in children didn't make much headway until the 1960s, following the classic articles by pediatric radiologist John Caffey in 1946 and Henry Kempe et al. in 1962 (2, 3). Very little published material existed on the topic of child abuse at that time. Today, all pediatricians are trained to recognize and report abuse and forensic pathology fellows and anthropologists are trained in specific techniques to identify injuries.

Child abuse autopsies can be physically and emotionally draining, often taking four to five times as long as an adult autopsy. It is important that appropriate time is devoted to these cases to allow for the additional special dissections and consultations required. Once an injury is found, it must be correctly interpreted, considering the medical history of the child, the circumstances of the death, scene findings, and investigative information. These autopsies cannot and should not be performed in a vacuum.

The ramifications of a child abuse case span beyond a criminal trial. The health and safety of other children exposed to the potential suspect(s) must be considered by investigating agencies. Forensic pathologists may find themselves testifying about their autopsy findings in family courts litigating cases regarding the custody of living children from the same household. Testimony in both criminal and custody cases may be lengthy and require repeated and extensive explanations of what was found. It is not uncommon for personal criticisms and attacks against the testifying pathologist to find their way into the courtroom. Preparation and review of relevant literature before the trial, such as the articles found in this issue of AFP, will enhance our testimony.

Child abuse autopsies are the hardest cases I encounter, with each one presenting a new or different challenge. It is an honor and a privilege to be entrusted with such a complex topic. Many thanks to Editor-in-Chief Keith Pinckard for providing me with this opportunity and for his support and help throughout the process. It was challenging and stressful, but immensely rewarding! Finally, my profound gratitude goes to all the authors that gave their already limited time to share their knowledge and expertise with us. I hope that readers find these articles interesting and can use the information and techniques presented when faced with a potential child abuse case.