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The American Journal of Forensic Medicine and Pathology 22(2):200–202, 2001. ©2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Many children do not survive after presentation in ex-tremis. Some survive varying intervals and are found tohave bronchopneumonia at death. The question is raisedwhether bronchopneumonia is a consequence of survivalrather than the initiating disease leading to collapse. A

prospective study of the deaths of 156 children dividedthem into two groups: 80 children with head injury and76 with causes of death other than sudden infant deathsyndrome. In 43 of the total group of children, bron-chopneumonia was found. In the total group, 76 survivedmore than a day. Of these 39 had bronchopneumonia, 32died of head injury, and 7 had other causes of death. Of the children surviving less than a day, 4 had broncho-pneumonia at death—only 1 with head injury. If bron-chopneumonia is present, it is more likely to have devel-oped after the collapse than to have caused it in thispopulation.Key Words: Bronchopneumonia—Head injury—Childabuse.

The consequences of cardiorespiratory collapse,

especially when caused by head injury, can include

aspiration of gastric contents leading to broncho-

pneumonia. Even without recognized aspiration,

bronchopneumonia is often found following col-lapse. 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 broncho-

pneumonia at autopsy. Such information could be

compared with the cause of death and would pro-

vide 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 conse-quence of the cause of death. This study was un-

dertaken 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).

Sample Selection

One hundred seventy-five of nearly 400 deaths of

young children investigated at the Dallas CountyMedical 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 appar-

ent natural death. History, autopsy findings, and oc-

Frequency of Bronchopneumonia in Children With Survival

Interval Before Death

M. G. F. Gilliland, M.D.

Manuscript received May 3, 2000; revised October 9, 2000;accepted October 15, 2000.

From the Department of Pathology and Laboratory Medi-cine, Brody School of Medicine at East Carolina University,Greenville, North Carolina, U.S.A.

Presented at the National Association of Medical Examiner’sMeeting, September 15, 1997, Baltimore, Maryland, U.S.A.

Supported by departmental funding.Address correspondence and reprint requests to M. G. F.

Gilliland, Brody School of Medicine at East Carolina Univer-sity, 600 Moye Blvd., Department of Pathology and Labora-tory Medicine, Greenville, NC 27834, U.S.A.



Am J Forensic Med Pathol, Vol. 22, No. 2, June 2001

BRONCHOPNEUMONIA WITH BRIEF SURVIVAL 201

ular findings were gathered and reviewed for the

more general study.

Subgroup Selection

The immediate rather than the underlying cause

of death was chosen to select the subgroup. Chil-dren whose immediate cause of death was head in-

jury were selected for comparison with the remain-

der of the group. Head injury included both abusive

and nonabusive head injury. Three children whose

underlying cause of death was head injury were in-

cluded in “other causes.” In these children, the im-

mediate cause of death was a consequence of the

head injury but death came by a different mecha-

nism than in the remainder of the head-injured

group.

The interval between presentation and death was

known for all the children. Microscopic examina-

tions identified the presence or absence of bron-chopneumonia. 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.

RESULTS

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. An-

cestry distribution was 86 white, 50 black, 16Latino 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 res-

piratory 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 com-

pared with 28% of those with other causes of death.

Table 2 shows the distribution of bronchopneumo-

nia in the two subgroups. Most (97%) of the head-

injured children with bronchopneumonia had sur-

vived more than a day, although the percent

surviving was also quite high (70%) of those with

other causes of death.

DISCUSSION

Bronchopneumonia was identified at autopsy in

43 of this group of children. Head injury ac-

counted 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 abu-

sive injuries, which would not have been immedi-

ately 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 bron-

chopneumonia at autopsy did not die of head in-

jury. The causes of death of 7 children of these chil-

dren surviving more than a day included respiratory

disease, 3; nontraumatic brain disease, 2; delayed

death after an asphyxial event, 1; and gastrointesti-

nal disease, 1. The other 3 of the 10 children were

found dead or did not survive attempts at resuscita-

tion. The deaths of 2 of them were attributed to res-

piratory 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 of-

fered 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 con-

sequence of the head injury that caused collapse,

not the cause of the collapse.

TABLE 1. Subdivision of group by cause of death and by survival interval after presentation for

medical attention

Head injury Other causes Total

Two subgroups 80 76 156Did not survive 1 day 26 55 81Survived 1 day 54 21 75

TABLE 2. Bronchopneumonia (BPN) in groups subdivided by cause of death and by survival

interval after presentation for medical attention

Head injury Other causes Total

BPN in the two subgroups 33 10 43BPN in survivors 32 7 39BPN in nonsurvivors 1 3 4



Am J Forensic Med Pathol, Vol. 22, No. 2, June 2001

202 M. G. F. GILLILAND

REFERENCES

1. Gilliland MGF, Luckenbach MW, Chenier TC. Systemicand ocular findings in 169 prospectively studied childdeaths: retinal hemorrhages usually mean child abuse.Forensic Sci Int 1994;68:117–32.

2. Gilliland MGF. Interval duration between injury and severe

symptoms in nonaccidental head trauma in infants andyoung children. J Forensic Sci 1998;43:723–5.

3. Gilliland MGF, Folberg R. Shaken babies: some have noimpact injuries. J Forensic Sci 1996;41:114–6.

4. Gilliland MGF, Luckenbach MW. Are retinal hemorrhagesfound after resuscitation attempts? Am J Forensic Med Pathol 1993;14:187–92.

frequency of broncho pneumonia in children with.19

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