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Squier W. Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence. Dev Med Child Neurol 2024; 66:290-297. [PMID: 37353945 DOI: 10.1111/dmcn.15676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 06/25/2023]
Abstract
The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine.
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Affiliation(s)
- Waney Squier
- Department of Neuropathology, John Radcliffe Hospital, Oxford, UK
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2
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Frasier L. Retinodural haemorrhage of infancy: Support for continuing current terminology and approaches. Dev Med Child Neurol 2024; 66:273-274. [PMID: 37691477 DOI: 10.1111/dmcn.15754] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/12/2023]
Abstract
This commentary is on the invited review by Squier on pages 290–297 of this issue.
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Affiliation(s)
- Lori Frasier
- Penn State Hershey College of Medicine - Pediatrics, Hershey, PA, USA
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Hutchinson K, van Zandwijk JP, Vester MEM, Seth A, Bilo RAC, van Rijn RR, Loeve AJ. Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Update to parts I&II: A systematic review of animal, mathematical and physical models. Forensic Sci Med Pathol 2024:10.1007/s12024-023-00765-5. [PMID: 38236351 DOI: 10.1007/s12024-023-00765-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/19/2024]
Abstract
Inflicted shaking trauma can cause injury in infants, but exact injury mechanisms remain unclear. Controversy exists, particularly in courts, whether additional causes such as impact are required to produce injuries found in cases of (suspected) shaking. Publication rates of studies on animal and biomechanical models of inflicted head injury by shaking trauma (IHI-ST) in infants continue rising. Dissention on the topic, combined with its legal relevance, makes maintaining an up-to-date, clear and accessible overview of the current knowledge-base on IHI-ST essential. The current work reviews recent (2017-2023) studies using models of IHI-ST, serving as an update to two previously published reviews. A systematic review was conducted in Scopus and PubMed for articles using animal, physical and mathematical models for IHI-ST. Using the PRISMA methodology, two researchers independently screened the publications. Two, five, and ten publications were included on animal, physical, and mathematical models of IHI-ST, respectively. Both animal model studies used rodents. It is unknown to what degree these can accurately represent IHI-ST. Physical models were used mostly to investigate gross head-kinematics during shaking. Most mathematical models were used to study local effects on the eye and the head's internal structures. All injury thresholds and material properties used were based on scaled adult or animal data. Shaking motions used as inputs for animal, physical and mathematical models were mostly greatly simplified. Future research should focus on using more accurate shaking inputs for models, and on developing or and validating accurate injury thresholds applicable for shaking.
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Affiliation(s)
- Kim Hutchinson
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands
| | - Jan Peter van Zandwijk
- Division of Digital and Biometric Traces, Netherlands Forensic Institute, Laan Van Ypenburg 6, 2497, The Hague, GB, Netherlands
| | - Marloes E M Vester
- Care Needs Assessment Centre CIZ, Orteliuslaan 1000, 3500 GR, Utrecht, Netherlands
| | - Ajay Seth
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands
| | - Rob A C Bilo
- Veilig Thuis Rotterdam Rijnmond (Center for the Reporting of Child Abuse, Domestic Violence and Elder Abuse), Paul Krugerstraat 181, 3072 GJ, Rotterdam, Netherlands
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Academic Medical Center Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, Netherlands
- Department of Forensic Medicine, Netherlands Forensic Institute, Laan Van Ypenburg 6, 2497, The Hague, GB, Netherlands
| | - Arjo J Loeve
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands.
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Doswell A, Killough E, Zinkus TP, Sherman A, Anderst J. Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury. CHILD ABUSE & NEGLECT 2023; 144:106371. [PMID: 37536244 DOI: 10.1016/j.chiabu.2023.106371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists. OBJECTIVES To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs). PARTICIPANTS AND SETTING Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career. METHODS This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons. RESULTS There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example. CONCLUSIONS Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.
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Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - Emily Killough
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Timothy P Zinkus
- Division of Pediatric Radiology, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, University of Kansas School of Medicine, Saint Louis University School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Ashley Sherman
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
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5
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Comparative study of brain damage and oxidative stress using two animal models of the shaken baby syndrome. Exp Gerontol 2022; 166:111874. [PMID: 35779807 DOI: 10.1016/j.exger.2022.111874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/26/2022] [Accepted: 06/21/2022] [Indexed: 11/21/2022]
Abstract
The objective was compare the morphological damages in brain and to evaluate the participation of oxidative stress, using two animal models of shaken baby syndrome (SBS). Five-day-old Wistar rats were used to develop two models of SBS as follows: Gyrotwister (GT) group was subjected to low intensity, high duration rotating movements and Ratshaker (RS) group made to undergo high intensity, low duration anteroposterior movements. Both groups presented respiratory distress, weight loss and shorter stature compared with the control group. In addition, involuntary movements occurred in both experimental models. Hemorrhage was observed in 10 % of the GT group and in 40 % of the RS group. This last group experienced lesser weight gain at 30 days. Glutathione decreased by 25.7 % (GT) and 59.96 (RT). Cell data analysis revealed the presence of crenate and pyknotic cells, characterized by apparent absence of nucleus and nucleolus as well as vacuolation in the GT group. In the RS group, there were a high number of angular, pyknotic and shrunken cells, and a lot of vacuolization. The severity of the brain damage can be related to the magnitude of biochemical modifications, specifically, those related to the production of reactive oxygen or nitrogen species, oxidative stress, oxidative damage.
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Song HH, Thoreson WB, Dong P, Shokrollahi Y, Gu L, Suh DW. Exploring the Vitreoretinal Interface: a Key Instigator of Unique Retinal Hemorrhage Patterns in Pediatric Head Trauma. KOREAN JOURNAL OF OPHTHALMOLOGY 2022; 36:253-263. [PMID: 35527527 PMCID: PMC9194735 DOI: 10.3341/kjo.2021.0133] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/18/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Various types of trauma can cause retinal hemorrhages in children, including accidental and nonaccidental head trauma. We used animal eyes and a finite element model of the eye to examine stress patterns produced during purely linear and angular accelerations, along with stresses attained during simulated repetitive shaking of an infant. Methods Using sheep and primate eyes, sclerotomy windows were created by removing the sclera, choroid, and retinal pigment epithelium to expose the retina. A nanofiber square was glued to a 5 mm2 area of retina. The square was pulled and separated from vitreous while force was measured. A finite element model of the pediatric eye was used to computationally measure tension stresses during shaking. Results In both sheep and primate eyes, tension stress required for separation of retina from vitreous range from 1 to 5 kPa. Tension stress generated at the vitreoretinal interface predicted by the computer simulation ranged from 3 to 16 kPa during a cycle of shaking. Linear acceleration generated lower tension stress than angular acceleration. Angular acceleration generated maximal tension stress along the retinal vasculature. Linear acceleration produced more diffuse force distribution centered at the poster pole. Conclusions The finite element model predicted that tension stress attained at the retina during forcible shaking of an eye can exceed the minimum threshold needed to produce vitreoretinal separation as measured in animal eyes. Furthermore, the results show that movements that involve significant angular acceleration produce strong stresses localized along the vasculature, whereas linear acceleration produces weaker, more diffuse stress centered towards the posterior pole of the eye.
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Affiliation(s)
- Helen H Song
- University of Nebraska Medical Center, Truhlsen Eye Institute, Omaha, NE
| | - Wallace B Thoreson
- University of Nebraska Medical Center, Truhlsen Eye Institute, Omaha, NE
| | - Pengfei Dong
- Florida Institute of Technology, Department of Biomedical & Chemical Engineering, Melbourne, FL
| | - Yasin Shokrollahi
- Florida Institute of Technology, Department of Biomedical & Chemical Engineering, Melbourne, FL
| | - Linxia Gu
- Florida Institute of Technology, Department of Biomedical & Chemical Engineering, Melbourne, FL
| | - Donny W Suh
- University of Nebraska Medical Center, Truhlsen Eye Institute, Omaha, NE.,Children's Hospital and Medical Center, Omaha, NE
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7
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Park YS. Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants. J Korean Neurosurg Soc 2022; 65:385-396. [PMID: 35468708 PMCID: PMC9082116 DOI: 10.3340/jkns.2021.0289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.
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Affiliation(s)
- Young Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University, Kashihara, Japan
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8
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Abstract
Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury. An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries. Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.
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9
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Narang SK, Sachdev KK, Bertocci K, Pierre-Wright MJ, Kaczor K, Bertocci G, Pierce MC. Overturned abusive head trauma and shaken baby syndrome convictions in the United States: Prevalence, legal basis, and medical evidence. CHILD ABUSE & NEGLECT 2021; 122:105380. [PMID: 34743053 DOI: 10.1016/j.chiabu.2021.105380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Media reports and the Innocence Network assert that wrongful Abusive Head Trauma (AHT)/Shaken Baby Syndrome (SBS) convictions pervade the United States (U.S.) criminal justice system. Yet, no empirical evaluation of overturned AHT/SBS convictions has been conducted. OBJECTIVE To evaluate the prevalence, legal basis, and characteristics of appellate rulings of AHT/SBS convictions. PARTICIPANTS AND SETTING U.S. appellate cases in a legal database, Westlaw. METHODS Retrospective review of AHT/SBS convictions that had appellate rulings from January 2008 through December 2018. Multiple search terms ensured all potential AHT/SBS cases were included. A mixed-methods analysis was conducted on overturned AHT/SBS convictions. RESULTS We identified a total of 1431 unique AHT/SBS criminal convictions that had appellate rulings since 2008. Of those, 49 convictions (3%) were overturned, and 1382 (97%) were affirmed/upheld. Of those overturned, 20 cases (1% overall) were overturned on medical evidence-related grounds. The most common themes from the medical evidence-related reversals were controversy over the AHT/SBS diagnosis (n = 12) and accidental injury mechanism (n = 11). After being overturned on appeal, upon retrial, 42% of defendants either re-plead guilty to or were convicted again of the same offense. CONCLUSION(S) AHT/SBS convictions are rarely overturned on medical evidence-related grounds. When overturned, medical evidence-related themes seldom reflect new scientific or clinical discoveries, but rather are alternative or differing medical opinions from those offered at the original trial. Our data tends to support the concerns of other authors regarding irresponsible communication of medical information in AHT/SBS cases.
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Affiliation(s)
- S K Narang
- Child Advocacy and Protection Services, Children's Wisconsin, Wauwatosa, WI 53214, United States of America.
| | - K K Sachdev
- University of Illinois College of Medicine at Chicago, Chicago, IL 60612, United States of America
| | - K Bertocci
- University of Louisville, J.B. Speed School of Engineering, Department of Bioengineering, Louisville, KY 40292, United States of America
| | - M J Pierre-Wright
- Northwestern University Feinberg School of Medicine, Chicago, IL 60201, United States of America
| | - K Kaczor
- Mary Ann and J. Milburn Smith Child Health Outreach, Research, and Evaluation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, United States of America
| | - G Bertocci
- University of Louisville, J.B. Speed School of Engineering, Department of Bioengineering, Louisville, KY 40292, United States of America
| | - M C Pierce
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, United States of America; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States of America
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10
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Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:529-540. [PMID: 33908266 DOI: 10.2214/ajr.21.25655] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.
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Bloemen EM, Rosen T, Lindberg DM, Krugman RD. How Experiences of Child Abuse Pediatricians and Lessons Learned May Inform Health Care Providers Focused on Improving Elder Abuse Geriatrics Clinical Practice and Research. JOURNAL OF FAMILY VIOLENCE 2021; 36:389-398. [PMID: 34121804 PMCID: PMC8189565 DOI: 10.1007/s10896-020-00143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The experience of physicians and other health care providers in child abuse pediatrics in the last six decades includes successes and failures, which can offer critical insights to inform the growing field of health care providers focusing on elder abuse clinical practice and research. We identify and describe in detail relevant lessons learned, including balancing an urgent call to action with a need for robust evidence to support clinical conclusions. We discuss solutions to research challenges, including the lack of a uniform gold standard for abuse diagnosis and how to ethically recruit subjects who may have cognitive impairment and also be crime victims. We offer recommendations on recruiting and training a specialized health care workforce. We make suggestions for health care providers about how to navigate the legal world including issues with expert testimony and also how to participate in policymaking and development of rational systems. We emphasize the importance of developing and supporting partnerships within the field, with allied fields inside and outside medicine, and internationally. We also highlight the value of connecting researchers and clinicians focused on different types of family violence.
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Affiliation(s)
- Elizabeth M. Bloemen
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, New York, NY 10065, USA
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, 525 E. 68 St., Room M130, New York, NY 10065, USA
| | - Daniel M. Lindberg
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, USA
| | - Richard D. Krugman
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, USA
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12
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Suh DW, Song HH, Mozafari H, Thoreson WB. Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma. Am J Ophthalmol 2021; 223:396-404. [PMID: 32663454 DOI: 10.1016/j.ajo.2020.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of infant death and long-term morbidity from injury. The ocular consequences of AHT are controversial, and the pathophysiology of retinal research findings is still not clearly understood. It has been postulated that vitreoretinal traction plays a major role in the retinal findings. A computer simulation model was developed to evaluate the vitreoretinal traction and determine whether the distribution of forces in different layers and locations of the retina can explain the patterns of retinal hemorrhage (RH) seen in AHT. DESIGN Computer simulation model study. METHODS A computer simulation model of the pediatric eye was developed to evaluate preretinal, intraretinal, and subretinal stresses during repetitive shaking. This model was also used to examine the forces applied to various segments along blood vessels. RESULTS Calculated stress values from the computer simulation ranged from 3-16 kPa at the vitreoretinal interface through a cycle of shaking. Maximal stress was observed at the periphery of the retina, corresponding to areas of multiple vessel bifurcations, followed by the posterior pole of the retina. Stress values were similar throughout all 3 layers of the retina (preretinal, intraretinal, and subretinal layers). CONCLUSIONS Ocular manifestations from AHT revealed unique retinal characteristics. The model predicted stress patterns consistent with the diffuse retinal hemorrhages (RH) typically found in the posterior pole and around the peripheral retina in AHT. This computer model demonstrated that similar stress forces were produced in different layers of the retina, consistent with the finding that retinal hemorrhages are often found in multiple layers of the retina. These data can help explain the RH patterns commonly found in AHT.
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13
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Cartocci G, Fineschi V, Padovano M, Scopetti M, Rossi-Espagnet MC, Giannì C. Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma. Brain Sci 2021; 11:179. [PMID: 33535601 PMCID: PMC7912837 DOI: 10.3390/brainsci11020179] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/10/2023] Open
Abstract
In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration-deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.
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Affiliation(s)
- Gaia Cartocci
- Emergency Radiology Unit, Department of Radiological, Oncological and Pathological Sciences, Umberto I University Hospital, Sapienza University of Rome, 00198 Rome, Italy;
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00198 Rome, Italy; (M.P.); (M.S.)
| | - Maria Camilla Rossi-Espagnet
- Neuroradiology Unit, NESMOS Department, Sapienza University, 00185 Rome, Italy;
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Costanza Giannì
- Department of Human Neurosciences, Sapienza University of Rome, 00198 Rome, Italy;
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14
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Zhao D, Wang Q, Cao Z. Forensic examination of abusive head trauma in child abuse cases. JOURNAL OF FORENSIC SCIENCE AND MEDICINE 2021. [DOI: 10.4103/jfsm.jfsm_44_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Ksiaa I, Ghachem M, Besbes H, Khochtali S, Chouchane S, Khairallah M. Swept-source OCT findings in shaken baby syndrome: case report. BMC Ophthalmol 2020; 20:396. [PMID: 33028244 PMCID: PMC7541327 DOI: 10.1186/s12886-020-01666-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background Our purpose was to document the swept source optical coherence tomography (SSOCT) findings in a patient with Shaken baby syndrome (SBS). Case presentation SSOCT was obtained without sedation in a six-month-old girl with bilateral multilayered retinal hemorrhages due to SBS. It documented vitreoretinal interface abnormalities, including internal limiting membrane (ILM) detachment with retinal traction, in association with other specific changes in the inner and outer retinal layers. Six weeks later, retinal hemorrhages had substantially resolved, and there was optic disc pallor. OCT showed ILM reattachment with release of retinal traction and the development of severe diffuse retinal atrophy involving the fovea. Conclusions SS OCT can provide useful information in SBS, revealing a wide variety of vitreoretinal interface, inner, and outer retinal changes not detected by clinical examination. It also may have a prognostic value over follow-up.
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Affiliation(s)
- Imen Ksiaa
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Mohamed Ghachem
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Habib Besbes
- Department of Pediatrics, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Sana Khochtali
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Slaheddine Chouchane
- Department of Pediatrics, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Moncef Khairallah
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia.
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Miller AJ, Narang S, Scribano P, Greeley C, Berkowitz C, Leventhal JM, Frasier L, Lindberg DM. Ethical Testimony in Cases of Suspected Child Maltreatment: The Ray E. Helfer Society Guidelines. Acad Pediatr 2020; 20:742-745. [PMID: 32068125 DOI: 10.1016/j.acap.2020.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/03/2020] [Accepted: 02/08/2020] [Indexed: 11/26/2022]
Abstract
New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.
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Affiliation(s)
- Aaron J Miller
- Office of Ambulatory Care (AJ Miller), New York City Health + Hospitals, New York, NY.
| | - Sandeep Narang
- Department of Pediatrics (S Narang), Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Philip Scribano
- Department of Pediatrics (P Scribano), Safe Place Center for Child Protection and Health, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher Greeley
- Department of Pediatrics (C Greeley), Baylor College of Medicine, Houston, Tex
| | - Carol Berkowitz
- Department of Pediatrics (C Berkowitz), Harbor-UCLA Medical Center, Torrance, Calif
| | - John M Leventhal
- Department of Pediatrics (JM Leventhal), Yale School of Medicine, New Haven, Conn
| | - Lori Frasier
- Department of Pediatrics (L Frasier), Penn State Hershey College of Medicine, Hershey, Pa
| | - Daniel M Lindberg
- Department of Emergency Medicine (DM Lindberg), The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, Aurora, Colo
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17
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Iqbal O'Meara AM, Sequeira J, Miller Ferguson N. Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature. Front Neurol 2020; 11:118. [PMID: 32153494 PMCID: PMC7044347 DOI: 10.3389/fneur.2020.00118] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Abstract
Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.
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Affiliation(s)
- A M Iqbal O'Meara
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Jake Sequeira
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
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18
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Dempsey N, Blau S. Evaluating the evidentiary value of the analysis of skeletal trauma in forensic research: A review of research and practice. Forensic Sci Int 2020; 307:110140. [PMID: 31958760 DOI: 10.1016/j.forsciint.2020.110140] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/05/2019] [Accepted: 12/29/2019] [Indexed: 12/26/2022]
Abstract
Understanding bone trauma characteristics is a fundamental component of forensic investigations that can assist in understanding the nature of blunt trauma related deaths. The variation of each blunt force trauma (BFT) injury is dependent on a magnitude of factors including, age, sex, health, angle of impact, impact mechanism, impact force and clothing, making BFT one of the more difficult area of trauma to interpret solely based on skeletal fractures. A detailed literature review was performed to assess the value and scientific rigour of the current research in forensic anthropology, forensic pathology and biomechanics that attempts to provide an objective framework in which forensic practitioners can assess and interpret BFT injuries. Four areas of research which investigate the analysis of BFT are examined. These included research involving experiments on animal models; experiments on human models (and synthetic models); computer modelling, and research/publications including 'mild', 'moderate' and 'severe' as descriptions of impact force, resulting from trauma. Also briefly discussed is how BFT research is framed within medicolegal contexts. While many published works have contributed to the understanding of the biomechanics of BFT, more research that can provide an objective means to accurately assess and interpret BFT injures is required.
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Affiliation(s)
- Nicholas Dempsey
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia.
| | - Soren Blau
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia.
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19
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Weldy E, Shimoda A, Patnaik J, Jung J, Singh J. Long-term visual outcomes following abusive head trauma with retinal hemorrhage. J AAPOS 2019; 23:329.e1-329.e4. [PMID: 31655114 DOI: 10.1016/j.jaapos.2019.08.276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/21/2019] [Accepted: 08/04/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE To report the rates of vision loss and select ocular findings after abusive head trauma (AHT) with retinal hemorrhages at a single center. METHODS The study cohort was identified by review of billing records for patients presenting simultaneously with retinal hemorrhages and abusive head trauma at the Children's Hospital of Colorado from October 2005 to April 2017. The following data were analyzed: retinal examination at initial admission and visual acuity, other pertinent eye findings, and eye management at follow-up visits. Patients with <1 month of follow-up were excluded. RESULTS Of 96 children, at last follow-up 46% had abnormal vision for the given age in at least one eye. Ocular findings included strabismus (43%), amblyopia (40%), optic disk pallor (13%), and cortical visual impairment (19%). For the 41 patients with strabismus, 20 (49%) required eye muscle surgery. Cortical visual impairment was almost three times higher in patients with strabismus compared with patients without strabismus (P = 0.023) and almost 6 times higher in patients with optic disk pallor than in those without (P < 0.001). Three patients (3%) required retinal surgery. CONCLUSIONS In our study cohort, there was a high rate of long-term vision impairment and ophthalmologic comorbidities in children with AHT and retinal hemorrhage.
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Affiliation(s)
- Eric Weldy
- Department of Ophthalmology, University of Colorado Aurora.
| | | | - Jennifer Patnaik
- Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Jennifer Jung
- Department of Ophthalmology, University of Colorado Aurora; Department of Ophthalmology, Children's Hospital Colorado, Aurora
| | - Jasleen Singh
- Department of Ophthalmology, University of Colorado Aurora; Department of Ophthalmology, Children's Hospital Colorado, Aurora
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20
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Abstract
Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
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21
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Fleury J, Scherdel P, Frampas E, Vabres N, Rey-Salmon C, Blot M, Launay E, Chalumeau M, Gras-Le Guen C. Evaluation of a Temporal Association between Vaccination and Subdural Hematoma in Infants. J Pediatr 2019; 209:134-138.e1. [PMID: 30910470 DOI: 10.1016/j.jpeds.2019.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 01/10/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate a temporal association between vaccination and subdural hematoma, the main feature of abusive head trauma. STUDY DESIGN From a prospective population-based survey carried out in 1 administrative district in France between January 2015 and April 2017, including all infants between 11 and 52 weeks old who underwent a first cerebral imaging (computerized tomography scan or magnetic resonance imaging), we conducted a nested case-control study. Vaccine exposure was compared between cases (infants with subdural hematoma) and 2-3 paired controls, without subdural hematoma or any other imaging findings compatible with abusive head trauma. Cases and controls were matched on chronological (±7 days) and gestational (≤33 vs >33 weeks) ages, respectively. Vaccination status was collected in the personal national pediatric health booklet. RESULTS Among the 228 prospectively surveyed infants, 28 had subdural hematoma including 22 with abusive head trauma. The mean chronological age at imaging was 5.3 months among the 28 cases and the 62 controls, who did not differ significantly in median time since last vaccination (1.4 vs 1.3 months, P = .62) or frequency of at least 1 vaccination since birth (86% vs 89%; matched-pairs OR 0.77, 95% CI 0.17-3.86) or within 7 days (0.94, 0.08-6.96), 14 days (0.70, 0.12-2.92), or 21 days (0.48, 0.08-1.98) before cerebral imaging. CONCLUSIONS We found no significant temporal association between vaccination and subdural hematoma diagnosis, which must continue to be considered a red flag for abusive head trauma and child abuse.
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Affiliation(s)
- Juliette Fleury
- Unité d'accueil des enfants en danger, University Hospital of Nantes, Nantes, France; Pediatric and Emergency Department, University Hospital of Nantes, Nantes, France
| | - Pauline Scherdel
- Pediatric and Emergency Department, University Hospital of Nantes, Nantes, France; Inserm, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (EPOPé), Paris Descartes University, Paris, France; Epidémiologie Clinique, Centre d'Investigation Clinique (CIC004), University Hospital of Nantes, Nantes, France
| | - Eric Frampas
- Department of Radiology, University Hospital of Nantes, Nantes, France
| | - Nathalie Vabres
- Unité d'accueil des enfants en danger, University Hospital of Nantes, Nantes, France; Pediatric and Emergency Department, University Hospital of Nantes, Nantes, France
| | | | - Marie Blot
- Pediatric and Emergency Department, University Hospital of Nantes, Nantes, France
| | - Elise Launay
- Pediatric and Emergency Department, University Hospital of Nantes, Nantes, France; Inserm, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (EPOPé), Paris Descartes University, Paris, France; Epidémiologie Clinique, Centre d'Investigation Clinique (CIC004), University Hospital of Nantes, Nantes, France
| | - Martin Chalumeau
- Inserm, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (EPOPé), Paris Descartes University, Paris, France; Department of General Pediatrics and Pediatric Infectious Diseases, Hôpital Necker-Enfants malades, AP-HP, Paris Descartes University, Paris, France
| | - Christèle Gras-Le Guen
- Pediatric and Emergency Department, University Hospital of Nantes, Nantes, France; Inserm, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (EPOPé), Paris Descartes University, Paris, France; Epidémiologie Clinique, Centre d'Investigation Clinique (CIC004), University Hospital of Nantes, Nantes, France.
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22
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Weissman J. Vulnerability and Obligation in Science and Medicine. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019. [DOI: 10.1093/jmp/jhz006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Lynøe N, Juth N, Eriksson A. From Child Protection to Paradigm Protection-The Genesis, Development, and Defense of a Scientific Paradigm. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 44:378-390. [PMID: 30184158 PMCID: PMC6525473 DOI: 10.1093/jmp/jhy015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome (SBS) paradigm. The point of departure of the analysis is a recently conducted systematic literature review, which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present (and no other "acceptable" explanations are provided) the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of "groupthink," aggravating the difficulties in considering critics' questioning the criteria established by the teams.
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24
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Lynøe N, Eriksson A. Is the procedure of diagnosing abusive head trauma a purely medical matter? Pediatr Radiol 2019; 49:422-423. [PMID: 30783699 DOI: 10.1007/s00247-019-04344-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/27/2018] [Accepted: 01/10/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation/Forensic Medicine, Umeå, Sweden
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25
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Lynøe N, Eriksson A. A diagnostic test can prove anything if you use incorrect assumptions and circular reasoning. Acta Paediatr 2018; 107:2051-2053. [PMID: 30022518 DOI: 10.1111/apa.14503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/28/2018] [Accepted: 07/16/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University; Umeå Sweden
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26
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Lynøe N, Helgesson G, Juth N. Value-impregnated factual claims may undermine medical decision-making. CLINICAL ETHICS 2018; 13:151-158. [PMID: 30166945 PMCID: PMC6099986 DOI: 10.1177/1477750918765283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical decisions are expected to be based on factual evidence and official values derived from healthcare law and soft laws such as regulations and guidelines. But sometimes personal values instead influence clinical decisions. One way in which personal values may influence medical decision-making is by their affecting factual claims or assumptions made by healthcare providers. Such influence, which we call 'value-impregnation,' may be concealed to all concerned stakeholders. We suggest as a hypothesis that healthcare providers' decision making is sometimes affected by value-impregnated factual claims or assumptions. If such claims influence e.g. doctor-patient encounters, this will likely have a negative impact on the provision of correct information to patients and on patients' influence on decision making regarding their own care. In this paper, we explore the idea that value-impregnated factual claims influence healthcare decisions through a series of medical examples. We suggest that more research is needed to further examine whether healthcare staff's personal values influence clinical decision-making.
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Affiliation(s)
- Niels Lynøe
- Centre for healthcare ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Gert Helgesson
- Centre for healthcare ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Niklas Juth
- Centre for healthcare ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
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27
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Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Room 3-231,Department of Radiology, University of Michigan Health System, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4252, USA.
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28
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
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Affiliation(s)
- Arabinda Kumar Choudhary
- Department of Radiology, Nemours AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Slovis
- Department of Radiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Gary L Hedlund
- Department of Medical Imaging, Primary Children's Hospital, Intermountain Healthcare, Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Cindy W Christian
- Department of Pediatrics, Child Abuse and Neglect Prevention, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Marvin D Nelson
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Susan Palasis
- Pediatric Neuroradiology, Children's Healthcare of Atlanta, Scottish Rite Campus, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Andrea Rossi
- Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, Western Bank, University of Sheffield, Sheffield, UK
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Andersson J, Thiblin I. It is important not to assume an aetiology for the triad before the outcomes of diagnostic investigations. Acta Paediatr 2018; 107:1308-1309. [PMID: 29450911 DOI: 10.1111/apa.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/12/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Jacob Andersson
- Department of Surgical Sciences, Forensic Medicine, Uppsala University, Uppsala, Sweden
| | - Ingemar Thiblin
- Department of Surgical Sciences, Forensic Medicine, Uppsala University, Uppsala, Sweden
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30
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Andersson J, Thiblin I. National study shows that abusive head trauma mortality in Sweden was at least 10 times lower than in other Western countries. Acta Paediatr 2018; 107:477-483. [PMID: 29105967 DOI: 10.1111/apa.14138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/22/2017] [Accepted: 10/24/2017] [Indexed: 11/29/2022]
Abstract
AIM The validity of the diagnostic criteria for abusive head trauma (AHT) and its attributes has been widely debated. This national study investigated the possibility of false-positive and false-negative cases of fatal AHT in Sweden. METHOD This was a retrospective evaluation of the records of 733 deceased infants up to the age of 365 days who were examined during 1994-2013 at the six forensic medicine departments. All the records were scrutinised for possible cases of AHT. RESULTS We included 12 cases, of which eight had been diagnosed as AHT. Of these 12 infants, eight had a concomitant disease or perinatal illness, five were born prematurely and three were twins. Figures from other Western countries would suggest 6-7 deaths per 100,000 per year in Sweden, but in reality, there was a maximum possible incidence of 0.6 per 100,000 infants per year. CONCLUSION The risk of unreported fatal AHT in Sweden was low, and there may have been cases misdiagnosed as AHT. The at least 10 times lower incidence than has been reported from other Western countries, raises the question if previously reported higher incidences of fatal AHT have been exaggerated.
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Affiliation(s)
- Jacob Andersson
- Department of Surgical Sciences; Forensic Medicine; Uppsala University; Uppsala Sweden
| | - Ingemar Thiblin
- Department of Surgical Sciences; Forensic Medicine; Uppsala University; Uppsala Sweden
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31
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Del Bigio MR, Phillips SM. Retroocular and Subdural Hemorrhage or Hemosiderin Deposits in Pediatric Autopsies. J Neuropathol Exp Neurol 2017; 76:313-322. [PMID: 28340081 DOI: 10.1093/jnen/nlx010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The presence of hemosiderin in the optic nerve sheath and/or retina is sometimes used to estimate the timing of injury in infants or children with suspected non-accidental head trauma. To determine the prevalence of hemosiderin in deaths not associated with trauma, we performed a prospective study of retroocular orbital tissue, cranial convexity, and cervical spinal cord dura mater in infants and children <2.5 years age. In 53 cases of non-traumatic death, approximately 70% had blood or hemosiderin within the orbital fat, ocular muscles, and parasagittal cranial and/or cervical spinal subdural compartment. This bleeding is likely a consequence of the birth process. None had evidence of hemorrhage within the optic nerve sheath. Premature birth was less likely associated with orbital tissue hemorrhage. Caesarean section birth (mainly nonelective) was not associated with lower prevalence. Residual hemosiderin was identifiable up to 36 weeks postnatal age, suggesting gradual disappearance after birth. Cardiopulmonary resuscitation (performed in the majority of cases) was not associated with acute hemorrhage. In 9 traumatic deaths, 6 had blood and/or hemosiderin within the optic nerve sheath. Knowledge of the potential presence and resolution of hemosiderin in these locations is important for medicolegal interpretation of childhood deaths associated with head or brain injury.
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Affiliation(s)
- Marc R Del Bigio
- Department of Pathology, University of Manitoba, Winnipeg, Canada.,Diagnostic Services Manitoba, Manitoba, Winnipeg, Canada.,Children's Hospital Research Institute of Manitoba, Manitoba, Winnipeg, Canada
| | - Susan M Phillips
- Department of Pathology, University of Manitoba, Winnipeg, Canada.,Diagnostic Services Manitoba, Manitoba, Winnipeg, Canada
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Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A. Insufficient evidence for 'shaken baby syndrome' - a systematic review. Acta Paediatr 2017; 106:1021-1027. [PMID: 28130787 DOI: 10.1111/apa.13760] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/24/2017] [Indexed: 01/08/2023]
Abstract
Shaken baby syndrome has typically been associated with findings of subdural haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad. During the last decade, however, the certainty with which the triad can indicate that an infant has been violently shaken has been increasingly questioned. The aim of this study was to determine the diagnostic accuracy of the triad in detecting that an infant had been shaken. The literature search was performed using PubMed, Embase and the Cochrane Library up to October 15, 2015. Relevant publications were assessed for the risk of bias using the QUADAS tool and were classified as having a low, moderate or high risk of bias according to predefined criteria. The reference standards were confessions or witnessed cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed as possibly relevant and read as full texts, and 30 studies were ultimately included. Of these, 28 were assessed as having a high risk of bias, which was associated with methodological shortcomings as well as circular reasoning when classifying shaken baby cases and controls. The two studies with a moderate risk of bias used confessions and convictions when classifying shaken baby cases, but their different designs made a meta-analysis impossible. None of the studies had a low risk of bias. CONCLUSION The systematic review indicates that there is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). It was also demonstrated that there is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).
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Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Göran Elinder
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; and Karolinska University Hospital; Stockholm Sweden
| | - Måns Rosén
- Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Pia Sundgren
- Department of Diagnostic Radiology, Clinical Sciences; Lund University; Lund Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University Umeå Sweden
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Lynøe N, Eriksson A. May the fear of being falsely accused of having shaken a baby increase parents' demands for scheduled Caesareans? Acta Paediatr 2017; 106:1052. [PMID: 28543711 DOI: 10.1111/apa.13886] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healtcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University; Umeå Sweden
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Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A. The shaken baby syndrome report was not the result of a conspiracy. Response to Dr. Narang et al. Acta Paediatr 2017; 106:1050-1051. [PMID: 28437569 DOI: 10.1111/apa.13895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Göran Elinder
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Måns Rosén
- Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Pia Sundgren
- Department of Diagnostic Radiology, Clinical Sciences; Lund University; Lund Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University; Umeå Sweden
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The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: A 13-year study in a tertiary hospital. Forensic Sci Int 2017; 276:5-11. [PMID: 28458085 DOI: 10.1016/j.forsciint.2017.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/04/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
Abstract
Fatal abusive head trauma is a major cause of death in children and toddlers who suffer from cruel physical abuse. Postmortem differentiation of fatal abusive head trauma from accidental head trauma can be a complicated process. This consecutive case series study aimed to determine the role of subdural optic nerve sheath hemorrhage (ONSH) in 70 autopsy cases of children ≤3 years old in making this differentiation. The study took place over a 13 year period (between August 1st 2003 and July 31st 2016) at a tertiary hospital in Thailand. Eleven cases were diagnosed with fatal abusive head trauma and 10 were identified as being accidental closed head trauma cases. Bilateral retinal hemorrhage was noted in antemortem medical records in every hospitalized abusive head trauma case (n=10). Upon autopsy, ONSH was observed in all 11 fatal cases of abusive head trauma (bilateral=10 and unilateral=1) but not in any cases of accidental head trauma (0/5). Subdural hemorrhage was found in 10 out of 11 abusive head trauma victims but not in any of the 10 with accidental head trauma. Other postmortem findings in abusive head trauma included subarachnoid hemorrhage (5/11), marked brain swelling (3/11), skull fracture (4/11) and brain contusion (1/11). This study suggests that ONSH, together with subdural hemorrhage, plays an essential role in an accurate postmortem diagnosis of fatal abusive head trauma. Therefore, an ocular investigation should be performed in all autopsy cases where child abuse is suspected and where there is no reliable history/witnesses, confession or antemortem ophthalmologic examination.
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Snyder VS, Hansen LA. A Conceptual Overview of Axonopathy in Infants and Children with Allegedly Inflicted Head Trauma. Acad Forensic Pathol 2016; 6:608-621. [PMID: 31239934 PMCID: PMC6474503 DOI: 10.23907/2016.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/14/2016] [Accepted: 11/12/2016] [Indexed: 11/12/2022]
Abstract
Fatal, allegedly inflicted pediatric head trauma remains a controversial topic in forensic pathology. Recommendations for systematic neuropathologic evaluation of the brains of supposedly injured infants and children usually include the assessment of long white matter tracts in search of axonopathy - specifically, diffuse axonal injury. The ability to recognize, document, and interpret injuries to axons has significant academic and medicolegal implications. For example, more than two decades of inconsistent nosology have resulted in confusion about the definition of diffuse axonal injury between various medical disciplines including radiology, neurosurgery, pediatrics, neuropathology, and forensic pathology. Furthermore, in the pediatric setting, acceptance that "pure" shaking can cause axonal shearing in infants and young children is not widespread. Additionally, controversy abounds whether or not axonal trauma can be identified within regions of white matter ischemia - a debate with very significant implications. Immunohistochemistry is often used not only to document axonal injury, but also to estimate the time since injury. As a result, the estimated post-injury interval may then be used by law enforcement officers and prosecutors to narrow "exclusive opportunity" and thus, identify potential suspects. Fundamental to these highly complicated and controversial topics is a philosophical understanding of the diffuse axonal injury spectrum disorders.
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