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Vinchon M, Noulé N, Karnoub MA. The legal challenges to the diagnosis of shaken baby syndrome or how to counter 12 common fake news. Childs Nerv Syst 2022; 38:133-145. [PMID: 34564748 DOI: 10.1007/s00381-021-05357-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Matthieu Vinchon
- Department of Pediatric Neurosurgery, Service de Neurochirurgie Pédiatrique, CHRU de Lille, Lille University Hospital, 59 037, Lille, France.
| | - Nathalie Noulé
- Department of Pediatric Neurosurgery, Service de Neurochirurgie Pédiatrique, CHRU de Lille, Lille University Hospital, 59 037, Lille, France
| | - Melodie-Anne Karnoub
- Department of Pediatric Neurosurgery, Service de Neurochirurgie Pédiatrique, CHRU de Lille, Lille University Hospital, 59 037, Lille, France
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Thau A, Saffren B, Zakrzewski H, Anderst JD, Carpenter SL, Levin A. Retinal hemorrhage and bleeding disorders in children: A review. CHILD ABUSE & NEGLECT 2021; 112:104901. [PMID: 33401159 DOI: 10.1016/j.chiabu.2020.104901] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Retinal hemorrhages (RH) are a common manifestation of abusive head trauma (AHT) resulting from acceleration-deceleration injury with or without blunt impact. Evaluation of a child with RH requires careful consideration of these differential diagnoses. The extent to which coagulopathy alone can cause RH would be useful to understand as coagulopathy may accompany AHT. OBJECTIVE In this systematic review, we sought to identify whether coagulopathies have been reported with RH similar to those of AHT. METHODS We performed a literature search for ocular manifestations of bleeding disorders in children less than 18 years old. We included clotting factor deficiencies, vitamin K deficiency, platelet function abnormalities, thrombocytopenia, disseminated intravascular coagulation (DIC), and trauma induced coagulopathy (TIC). We included only pediatric reports of intraocular bleeding or documented eye examinations that indicated no hemorrhages. We then re-examined cases for ocular and systemic findings that could potentially mimic abuse. RESULTS Our initial search yielded 816 results. Sixty-one articles met our inclusion criteria. Of these, there were 32 children within the AHT age range (less than 5 years old) who had RH and concomitant coagulopathy. Only 5 cases might potentially be confused for abuse. Of these, no classic characteristics of RH from abuse such as retinoschisis or retinal folds were found. Systemic features were inconsistent with AHT. CONCLUSIONS The presence of coagulopathy alone does not rule out the possibility that the child has been abused. Coagulopathy alone has not been reported as an etiology of RH that are consistent with AHT, especially when other findings are present.
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Affiliation(s)
- Avrey Thau
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Brooke Saffren
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Helena Zakrzewski
- Department of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shannon L Carpenter
- Department of Hematology, Oncology, and Bone Marrow Transplantation, Children's Mercy Hospital, Kansas City, MO, USA
| | - Alex Levin
- Flaum Eye Institute and Golisano Children's Hospital, University of Rochester, New York, USA.
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Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, Engström I, Erlandsson BE. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018; 107 Suppl 472:3-23. [PMID: 30146789 PMCID: PMC6585638 DOI: 10.1111/apa.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
The Swedish Agency for Health Technology Assessment and Assesment of Social Services (SBU) is an independent national authority, tasked by the government with assessing methods used in health, medical and dental services and social service interventions from a broad perspective, covering medical, economic, ethical and social aspects. The language in SBU's reports are adjusted to a wide audience. SBU's Board of Directors has approved the conclusions in this report. The systematic review showed the following graded results: There is limited scientific evidence that the triad (Three components of a whole. The triad associated with SBS usually comprises subdural haematoma, retinal haemorrhages and encephalopathy.) and therefore, its components can be associated with traumatic shaking (low-quality evidence). There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). Limited scientific evidence (low-quality evidence) represents a combined assessment of studies of high or moderate quality which disclose factors that markedly weaken the evidence. It is important to note that limited scientific evidence for the reliability of a method or an effect does not imply complete lack of scientific support. Insufficient scientific evidence (very low-quality evidence) represents either a lack of studies or situations when available studies are of low quality or show contradictory results. Evaluation of the evidence was not based on formal grading of the evidence according to GRADE but on an evaluation of the total scientific basis.
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Affiliation(s)
- Göran Elinder
- Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, Umeå, Sweden
- The National Board of Forensic Medicine, Sweden
| | - Boubou Hallberg
- Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niels Lynøe
- Medical Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Maly Sundgren
- Diagnostic Radiology, Lund University, Lund, Sweden
- Department of Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Måns Rosén
- Health Technology Assessment, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Engström
- Child and Adolecent Psychiatry, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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The Swedish Agency for health technology-report about traumatic shaking: much ado about nothing? Forensic Sci Med Pathol 2018; 14:541-544. [DOI: 10.1007/s12024-018-0006-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
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Ledoyen A, Bresson V, Dubus JC, Tardieu S, Petit P, Chabrol B, Bosdure E. [Complementary exams in child abuse: A French national study in 2015]. Arch Pediatr 2016; 23:1028-1039. [PMID: 27642147 DOI: 10.1016/j.arcped.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 06/22/2016] [Accepted: 07/04/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Even if there are HAS (French National Health Authority) guidelines on shaken baby syndrome, many other child abuse situations are not included in these recommendations. The aim of this study was to invent the complementary exams in cases of child abuse in France and compare the practice to existing guidelines. MATERIAL AND METHODS This was a multicenter study by email to 128 French hospitals (35 university hospitals and 93 general hospitals) that receives children in emergency and hospitalization settings. Three child abuse clinical situations were included in a clinical case multiple-choice format concerning the further explorations. We described the main results and evaluated their adherence to the HAS protocol for case 1. RESULTS Of 128 hospitals surveyed, 104 responded, for an 81 % response rate, which corresponded to 274 doctors. Analysis of the results showed great heterogeneity in practices. The majority of physicians (99 %) performed systematic explorations in the situation of physical abuse, while only 27 % undertook such exams in situations of serious neglect. The situation of sexual abuse was the most consensual in terms of diagnostic tests for the detection of sexually transmitted diseases, but other types of associated abuse were not sought. In the first case, the HAS guidelines were respected in less than half of the cases for all complementary exams except the eye fundus exam. Abdominal imaging was insufficiently performed (40 % of cases). Examinations that were not indicated were still prescribed. Moreover, siblings under 2 years of age were examined in only one-third of cases (n=88/274; 32 %). Practices were not influenced by the age of the child. CONCLUSION This study illustrates the heterogeneity in the use of complementary exams in cases of child abuse in France. Common protocols throughout the country would be useful, standardizing the most relevant exams for potential medical-legal issues, and facilitating exchanges concerning practices between different centers.
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Affiliation(s)
- A Ledoyen
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - V Bresson
- Urgences pédiatriques, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - J-C Dubus
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France; Service de médecine infantile, hôpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
| | - S Tardieu
- Pôle Santé publique, service d'évaluation médicale, CHU Conception, 147, boulevard Baille, 13005 Marseille, France
| | - P Petit
- Service de radiologie pédiatrique, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - B Chabrol
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - E Bosdure
- Service de spécialités pédiatriques et médecine infantile, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
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Abstract
Shaken Baby Syndrome occurs in infants as a result of the brain pushing against the skull due to severe acceleration-deceleration forces. Symptoms of Shaken Baby Syndrome include subdural, subarachnoid, and retinal hemorrhages. MRI and ocular examinations are used to determine the extent of mental and visual damage and β-amyloid precursor protein immunohistochemical staining is used to detect axonal injuries. Surgeries such as Subdural hemorrhage (SDH) evacuation surgery and the Burr hole craniotomy are used to treat Shaken Baby Syndrome; however, the prognosis is poor in many cases. Because of the severity of Shaken Baby Syndrome and its traumatic and sometimes fatal effects, it is important to educate new parents, nurses, and doctors on the syndrome in order to prevent incidents.
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Affiliation(s)
- Maha Mian
- 1SUNY Stony Brook, Physiology and Biophysics, Stony Brook , New York , USA
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Abstract
Bleeding symptoms are common in healthy children but occasionally may indicate an underlying congenital or acquired bleeding diathesis. The rare bleeding disorders (RBDs) comprise inherited deficiencies of coagulation factors I (congenital fibrinogen deficiencies), II, V, VII, X, XI, and XIII and combined factor deficiencies, most notably of factors V and VIII and of vitamin K-dependent factors. These disorders often manifest during childhood and may present with recurrent or even serious or life-threatening bleeding episodes, particularly during the neonatal period. Accordingly, primary care and other nonhematologist pediatric providers should be familiar with the clinical presentation and initial evaluation of these rare disorders. Bleeding manifestations generally vary within the same RBD and may be indistinguishable from 1 RBD to another or from other more common bleeding disorders. Serious bleeding events such as intracranial hemorrhage may be heralded by less serious bleeding symptoms. The results of initial coagulation studies, especially prothrombin time and activated partial thromboplastin time, are often helpful in narrowing down the potential factor deficiency, with factor XIII deficiency being an exception. Consultation with a hematologist is advised to facilitate accurate diagnosis and to ensure proper management and follow-up. The approach to bleeding episodes and invasive procedures is individualized and depends on the severity, frequency, and, in the case of procedures, likelihood of bleeding. Prophylaxis may be appropriate in children with recurrent serious bleeding and specifically after life-threatening bleeding episodes. When available, specific purified plasma-derived or recombinant factor concentrates, rather than fresh frozen plasma or cryoprecipitate, are the treatment of choice.
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Affiliation(s)
- Suchitra S Acharya
- Bleeding Disorders and Thrombosis Program, Cohen Children's Medical Center of New York, 269-01 76th Ave, Suite 255, New Hyde Park, NY 11040.
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