“Shaken baby syndrome” and forensic pathology

The legal challenges to the diagnosis of shaken baby syndrome or how to counter 12 common fake news

BACKGROUND

The shaken baby syndrome (SBS) is a common cause of severe traumatic lesions in infants. Although well established for almost five decades, SBS and its diagnosis are becoming more and more aggressively challenged in courts. These challenges feed on the scientific debate and controversies regarding the pathophysiology and the differential diagnoses, scientific uncertainty being readily exploited by specialized barristers.

MATERIAL AND METHODS

In the present review, we analyze the most common challenges to the concept of SBS and its diagnosis, as well as the scientific evidence available to counter these challenges, the differential diagnoses, and how SBS can be diagnosed with confidence.

RESULTS

We found that the pathophysiology of SBS is well documented, with stereotyped descriptions by perpetrators, in good correlation with experimental studies and computer models. SBS is a well-defined clinico-pathological entity with a characteristic constellation of lesions; with a rigorous evaluation protocol, its diagnosis can be made rapidly and with excellent accuracy beyond a reasonable doubt.

CONCLUSION

It is important that medical experts master an extensive knowledge regarding the pathophysiology of the lesions of SBS, in particular infantile subdural hematomas, as well as other CSF-related conditions. This emphasizes the role that pediatric neurosurgeons should play in the clinical and medicolegal management of these patients.

The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse

In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.

Abusive head trauma: a review of the evidence base

OBJECTIVE

The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma.

CONCLUSION

The evidence base for abusive head trauma encompasses diverse disciplines, including diagnostic imaging, pathology, pediatrics, biomechanics, ophthalmology, epidemiology, and orthopedics. When the varied sources of evidence are pieced together and taken in toto, abusive head trauma is often readily differentiated from alternative explanations of an infant's injuries.