Key Words: Childhood, autopsy, origin of death, medico-legal death, preventable death.

The arrangement of studies on the causes of childhood deaths and recording the findings are very important. Establishing a system that serves to explore all childhood deaths will provide the means of observing these cases. In addition, due to religious beliefs and social reasons cases of suicide are not recorded. With the experiences of countries, that have developed systemic mechanisms have shown that death could be possible in the majority of cases of violence and negligence (1-3).

The Declaration of Children's Rights focuses not only on the basic right to life but also on the contribution of health and training efforts, concerned with the development of the child. At this point establishment of specific mechanisms that will let us explore, record and report all childhood deaths is a requirement. The causes of these deaths are extremely important (4).

The most important characteristic of child injury deaths is the fact that many, if not most, can be prevented (5,6). Saunders et al. (7) have found that 2.7% of natural deaths and 96% of injury deaths are preventable.
The aim of this study is to evaluate the various features of the medico-legal childhood deaths in Istanbul, Turkey; and to contribute to the establishment of a database on childhood deaths.

The records of medico-legal autopsies of the 0-18 age group performed in the Council of Forensic Medicine, Ministry of Justice, Istanbul for the years 1997-2001, were separated into four age groups (0-6, 7-11, 12-15, 16-18). The separation was carried out according to existing age groups specified in child development and legal practice. Our study field, Istanbul, is the largest city of Turkey with a population of 10,018,735.

The cases are grouped as homicides, suicides, accidents, sudden-unexpected deaths (natural deaths and undetermined deaths). Age, sex and causes of deaths of each group were studied.

In this study, childhood deaths according to the causes and origins were evaluated. The records of the autopsies performed in the Council of Forensic Medicine in Istanbul, Turkey between the years 1997-2001 were reviewed. 14,467 medico-legal deaths were investigated in Istanbulover a period of five years. 1,568 (10.8%) of all deaths comprised by our study population were children (0-18 age).

1,047 (66.8%) of those children were male and 521 (33.2%) were female (Figure 1).
The distribution of the years is presented. In a period of five years, 1,568 autopsies were performed on children (Figure 2).

Evaluation of all childhood deaths (n=1,568) revealed that 116 cases (7.4%) were caused by suicides (Figures 3, 4), 609 cases (38.8%) were accidents (Figure 5), 204 cases (13%) were homicides (Figure 6), 188 cases (12%) were natural deaths and 451 cases (28.8%) were unidentified deaths (Table 1).

Of 116 suicides, 78 cases (73.6%) were due to hanging, and 13 cases (12.3%) firearms, 11 cases (10.4%) fall, 3 cases (2.8%) intoxication, and 1 case (0.9%) CO poisoning (Figure 4).

Blunt traumas account for 25% (156 cases) of the 619 cases that were determined as accidents. 22% (137 cases) of accidents were drowning cases (Figure 5).

Of 204 homicides in childhood deaths, 80 cases (39.2%) were associated with stabbing, 76 cases (37.3%) with firearms and 31 cases (15.2%) with strangulation (Figure 6).

Respiratory - cardiovascular diseases (n=119; 63.3 %) are the leading cause of deaths in natural deaths. Infectious diseases with 22.9% (n=43) are the second most common cause of natural deaths (Figure 7).

The term "child" is accepted as the period of 0-18 years of age according to the Declaration of Children Rights. Childhood deaths present various features with respect to age, sex, developmental stage, social and cultural context, geographical location and life styles of the family (1,8). Investigation of childhood autopsies according to the groups is important especially for determining the causes and prevention of childhood injuries and deaths. Accidents and natural deaths are the common causes of the deaths in children like in adults (8,9).

In this study, childhood deaths according to the causes and the origins of deaths were evaluated. The records of the autopsies performed in the National Institute of Forensic Medicine in Turkey between the years 1997-2001 were reviewed and 1,568 of 14,467 deaths were found to be in the childhood age range of 0-18. These cases of 0-18 age group, 1,047 (66.8%) were male and 521 (33.2%) were female.

Deaths caused by accidents, as those in the literature, are the most widespread death origin. The basic cause of this condition is that the persons or institutions taking full responsibility for the 0-6 age group, particularly, don't show enough interest (10). In our study, the ratio of deaths caused by accidents is 70%.

Blunt injuries are the leading causes of deaths in children under 18 years of age (11). In this study; 156 (25%) blunt traumas and 154 (25%) CO poisoning cases were mostly seen due to accident. Drowning (n=137, 22%) was accidentally the second cause of death. Drowning cases usually occurred at sea.

Although suicides are rarely seen in the younger age group and early adolescence, they present a growing risk in older age groups. Preventing suicides in adolescence has become the main concern (12). The autopsy records of the Bonn Institute of Forensic Medicine and the database of the Bonn police authorities from 1989 to 1998 were retrospectively analyzed for this phenomenon. This search revealed 37 respective suicides involving 23 male (62%) and 14 female (38%) victims. The ages ranged from 10 to 21 years with the prevalence sharply increasing in adolescents and young adults (1). For suicides, methods like hanging, intoxication and firearms are mostly used (11). In our study, 71 cases of our 106 suicide cases were in the 16-18 age groups. Hanging (73.6%) was the most common method of suicide among all the deaths. In suicide cases, firearms (12.3%) were the second biggest cause and fall (10.4%) the third cause of deaths.

Homicides were inflicted with stabbing and firearms like other cities of the world (3). Infantile and adolescent patterns of homicides are recognized: Child abuse by parents characterizes the former; gunshots and other assaults by peers characterize the latter (13). During 201 homicides over the five-year period of a study, most of these deaths occurred in adolescents, but there were 36 deaths in children under 13 years old. In young children, the assailant was usually a parent or other family member, including eight children who were murdered by their father and six by their mother. Only three children were murdered by a stranger. Prevention strategies include decreasing children's access to guns and improving parental supervision (14). In our study, of 204 homicides in childhood, 80 (39.2%) cases were associated with stabbing, 76 (37.3%) firearms, 31 (15.2%) strangulation, 15 (7.4%) blunt traumas, and 2 (1%) burns. 117 (57.3%) of 204 homicide cases were in the 16-18 age group.
The commonly encountered origins of childhood deaths were natural causes in early childhood, accidents in the playing age, and homicide and suicide in the adolescents (3). Infections are the most common cause of natural deaths in children in Cyprus. It is common especially in infants and this can be explained with the developing immune system in this period. This emphasizes the importance of preventive medicine (8). Deaths due to infectious diseases took the first place and undetermined deaths came among the whole death causes in the 0-6 age group (11). In our study, respiratory - cardiovascular diseases (n=119; 63.3%) and infections (n=43; 22.9%) are the common causes of natural deaths in children.

Investigation of childhood autopsies according to the origins, is important especially for determining the causes and prevention of childhood injuries and deaths. Accidents are the most common origin of the deaths in children.

Childhood deaths, especially intentional-preventable injury cases, enhance the liability of those who are responsible for the care and supervision of children. So, training programs should be provided for parents, to prevent childhood injuries
In order to prevent childhood deaths, preventive and curative health services should be strengthened, and education within the individual and social level should be a concern of the government bodies and civil society. Meanwhile, starting with the efforts of support and education; all measures must be taken in order to activate the United Nations Child Rights Contract in Turkey.