Pediatrics International (2005) 47, 206–208
Patient Report
Asymptomatic intracranial sewing needle: An unsuccessful infanticide attempt? NURETTIN UNAL, ARZU BABAYIGIT, SERPIL KARABABA AND SEBNEM YILMAZ Department of Pediatrics, School of Medicine, Dokuz Eylul University, Izmir, Turkey Key words
child abuse, infanticide, intracranial sewing needle.
Infanticide attempts may appear in various clinical scenarios. Although very rarely reported, insertion of foreign objects through the cranial sutures may sometimes be used as a method of infanticide. In the present report, a 10-year-old orphaned girl who was brought to the emergency department because of minor head trauma and diagnosed to have a sewing needle in her brain parenchyma is investigated.
Case report This 10-year-old, previously healthy girl was admitted to the pediatric emergency department complaining of a headache. In addition, she had been vomiting for an hour. From the child’s personal history it was learned that she had been living in an orphanage for 9 years. She had reportedly struck her head against a wall while she was playing with a friend an hour prior to being brought to the hospital. The headache had steadily increased in severity and she had experienced two episodes of projectile vomiting. During a physical examination, her general physical status was found to be very good. She was conscious, alert and cooperative. There were no other pathological findings other than a 2 cm laceration on the right frontal area. She had no other injuries such as skin markings, scars, abrasions, bruises, burns, bites, broken teeth or hair loss due to possible abuse. The patient had no evidence of delayed intellectual development, speech problems, growth and mental retardation which can be seen as a consequence of abusive experiences in early childhood. Cranium radiography detected what appeared to be a sewing needle in the left supraorbital region (Fig. 1). The patient was re-examined for any additional foreign objects
Correspondence: Arzu Babayigit, Dokuz Eylul University Hospital, Department of Pediatrics, Inciralti, 35340, Izmir, Turkey. Email:
[email protected] Received 10 September 2004; revised 2 June 2004; accepted 8 July 2004.
in her hair or scalp. No additional objects were present. Cranial computed tomography (CT) was performed to further evaluate the presence of the foreign object in the cranium. In the CT scan, a 30 mm × 1 mm linear, hyperdense object, judged to be a sewing needle, was reported in the left parietal area. There was no evidence of acute injury such as edema, hematoma or shifting (Fig. 2a,b). The patient was kept under observation in the emergency department for 6 h. Her headache decreased without any medication and vomiting did not reoccur. The needle in her cranium was regarded as an incidental finding. Keeping in mind the social background of the patient, the sewing needle was accepted as an unsuccessful infanticide attempt. The neurosurgery department was consulted regarding the patient. The patient received no surgical intervention, as she was completely asymptomatic and she had no recurring headaches or seizures. The patient is under routine care for any possible complications. The patient is healthy and still living in the orphanage.
Discussion Child abuse and neglect are major causes of childhood morbidity and mortality around the world. The vulnerability of children, from infancy throughout their childhood years of dependency on adults for safety and ongoing nurturing, puts them at risk of neglect and maltreatment in many forms. Approximately 50 years ago, medical professionals became aware of the reality of child abuse. Since then, public and professional awareness of child abuse and infanticide have increased steadily. Each year, 160 000 children suffer severe or life-threatening injury and 1000–2000 children die as a result of abuse in the US. Of these deaths, 80% involve children younger than 5 years of age, and 40% involve children younger than 1 year of age.1–4 One out of every 20 homicide victims is a child. Homicide is the fourth leading cause of death in children from 1 to 4 years of age and the third leading cause of death in children from 5 to 14 years of age.4 It is generally accepted that deaths from maltreatment
Intracranial sewing needle
Fig. 1 Skull radiography of the patient (cranium anterior– posterior radiography) shows linear density in the left supraorbital region.
Fig. 2 Axial cranial computed tomography scan through the (a) bone window and (b) level of basal ganglia, parenchyma window demonstrate linear hyperdense foreign body causing artifacts, penetrating left parietal bone and posterior parietal brain parenchyma. There is no evidence of acute injury such as contusion changes, hematoma, edema or shifting in the brain parenchyma.
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are underreported and that some deaths classified as the result of accident and sudden infant death syndrome might be reclassified as the result of child abuse if comprehensive investigations were more routinely conducted. The child abuse rate for Turkey is not fully reported. Major risk factors for infanticide are young maternal age, a low level of education, previous births, late initiation of prenatal care and low gestational age. The methods of infanticide include throttling, drowning, freezing etc. The insertion of sewing needles through the fontanels is an easy and difficult to detect method of killing an unwanted baby. The victim in this case was an unwanted child who was abandoned and left at the orphanage at the age of 1. Because of this reason, it is not known if it was a single homicide attempt or if it was only one of many attempts. The asymptomatic intracranial location of the sewing needle is thought to be the result of an unsuccessful infanticide attempt, because insertion of a needle into the cranium is practically impossible other than during infancy. There were no fresh needle holes on the skin or calvarium. The cranial tomography scan on the day of admission showed no sign of hemorrhage and/or edema surrounding the needle in the cranial cavity which would have indicated an acute injury. There are only a limited number of publications which present intracranial needle insertions as infanticide attempts.5–10 In the review article by Abbassioun et al., 10 old and three new cases were presented. In these cases needles were inserted before the fontanels closed in infancy. In most cases, the intent appeared to have been infanticide. These cases were mostly diagnosed by skull radiography. Only one parent (mother) admitted to the infanticide. In two cases the needles were found in necropsy.7 Headaches and epilepsy were the
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main symptoms and they appeared after the patients reached adulthood. Our patient reported no headache other than on the day of admission. She has had no further headaches or seizures at any time. The patient is now under regular followup care for possible complications. She may become a candidate for surgery in the future if complications occur. Child abuse can occur in various ways. Inserting a foreign object into the cranium is one of these methods. Physicians and other caregivers should be aware of this potential method of infanticide, which is rare and almost impossible to trace. If the infanticide attempt fails, incidental diagnosis of the foreign object may occur in later years, usually through Xray examinations performed for other purposes. The presence of any intracranial foreign object in an orphaned or abandoned child should especially be regarded as a possible failed infanticide attempt.
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2 MacMillan HL, MacMillan JH, Offord DR, Griffith L, MacMillan A. Primary prevention of child physical abuse and neglect: a critical review. Part I. J. Child Psychol. Psychiatry 1994; 35: 835–56. 3 Wissow LS. Child abuse and neglect. N. Engl. J. Med. 1995; 332: 1425–31. 4 National Center for Health Statistics. Vital Statistics of the United States Vol. II. Mortality. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Hyattsville, Md, 1996. 5 Ameli NO, Alimohammadi A. Attempted infanticide by insertion of sewing needles through fontanels. J. Neurosurg. 1970; 33: 721–3. 6 Askenasy HM. Sewing needle in the brain with delayed neurological manifestation. J. Neurosurg. 1961; 18: 544–6. 7 Abbasioun K, Ameli NO, Morshed AA. Intracranial sewing needles: review of 13 cases. J. Neurol. Neurosurg. Psychiatry 1979; 42: 1046–9. 8 Rahimizadeh A, Sabouri-Daylami M, Tabatabi M, Rabani M, Hadadian K. Intracranial sewing needles. Neurosurgery 1987; 20: 666. 9 Sener RN. Intracranial sewing needles in a 20-year-old patient. J. Neuroradiol. 1997; 24: 212–14. 10 Lukefahr JL, Angel CA, Hendrick EP, Tom SW. Child abuse by percutaneous insertion of sewing needles. Clin. Pediatr. (Phila) 2001; 40: 461–3.
