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Rohrbach JM. [Still room for dispute: on shaken baby syndrome and abusive head trauma (AHT)]. DIE OPHTHALMOLOGIE 2024; 121:328-330. [PMID: 38443493 DOI: 10.1007/s00347-024-01999-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Jens Martin Rohrbach
- Ophthalmopathologisches Labor/Forschungsbereich "Geschichte der Augenheilkunde", Universitäts-Augenklinik Tübingen, Elfriede-Aulhorn-Str. 7, 72076, Tübingen, Deutschland.
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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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Serinelli S, Arunkumar P, Filkins JA, Gitto L. Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office. J Forensic Sci 2016; 62:107-118. [PMID: 27787884 DOI: 10.1111/1556-4029.13219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 02/03/2016] [Accepted: 02/21/2016] [Indexed: 01/07/2023]
Abstract
Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.
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Affiliation(s)
- Serenella Serinelli
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza-University of Rome, Viale Regina Elena 336, 00185, Rome, Italy
| | - Ponni Arunkumar
- Cook County Medical Examiner's Office, 2121 W Harrison Street, Chicago, IL, 60612
| | - James A Filkins
- Cook County Medical Examiner's Office, 2121 W Harrison Street, Chicago, IL, 60612
| | - Lorenzo Gitto
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza-University of Rome, Viale Regina Elena 336, 00185, Rome, Italy
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Cirovic S, Bhola RM, Hose DR, Howard IC, Lawford PV, Parsons MA. Mechanistic hypothesis for eye injury in infant shaking : An experimental and computational study. Forensic Sci Med Pathol 2015; 1:53-9. [PMID: 25869837 DOI: 10.1385/fsmp:1:1:053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2005] [Indexed: 11/11/2022]
Abstract
The terms abusive head injury and shaken baby syndrome are used to describe a unique pattern of nonaccidental traumatic injuries occurring in children that many clinicians and researchers have good reason to believe is caused by violent shaking. Typical injuries include severe brain injury, with intracranial and retinal hemorrhages, but the pathogenesis of injuries is poorly understood. A major paradox in head trauma in infants is that the injuries induced by a shaking event are much more severe than those caused by even very violent single-impact head trauma, despite the relatively low accelerations in shaking.We have developed a finite element computer model of the eye, orbit, and orbital bone and used it to simulate the effects of single-impact and oscillatory motion inputs. The model was informed by data from semiquantitative in vitro anatomical traction experiments on in situ rabbit eyes. The new results reported here strongly suggest that suction between the eye and its surrounding fat dominates the dynamical stability of the system composed of the eye, its socket, and the components and material supporting the eye. Computer simulations incorporating this functional anatomical relationship show that deceleration of the head generates pressure gradients inside and outside the eye; these could cause damaging shear stresses in structures such as the retina and blood vessels. Simulations also show that oscillating the bone of the orbit causes the eye to move anteriorly and posteriorly with an increasing amplitude, building up the stresses within the eye over time. This is the first time that any biomechanical mechanism has been identified that might explain the disproportionally severe injuries caused by an oscillatory mechanism such as violent shaking of an abused infant. However, further study is required and this conclusion is therefore preliminary and provisional.
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Affiliation(s)
- S Cirovic
- Department of Mechanical Engineering, the University of Sheffield, Sheffield, UK
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Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol 2014; 58:476-85. [PMID: 23969021 DOI: 10.1016/j.survophthal.2012.10.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 10/11/2012] [Accepted: 10/16/2012] [Indexed: 11/25/2022]
Abstract
Eighteen million people worldwide have uniocular blindness from traumatic injury. Injuries occur disproportionally commonly in childhood. Every year a quarter of a million children present with serious ocular trauma. For the vast majority the injury is preventable. We review the international literature that identifies high-risk circumstances.
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Affiliation(s)
- Joseph Abbott
- Moorfields Eye Hospital, University College London Partners, London, UK.
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Affiliation(s)
- P Watts
- Department of Ophthalmology, University Hospital of Wales, Cardiff, UK
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den Otter JJ, Smit Y, dela Cruz LB, Özkalipci Ö, Oral R. Documentation of torture and cruel, inhuman or degrading treatment of children: A review of existing guidelines and tools. Forensic Sci Int 2013. [PMID: 23199437 DOI: 10.1016/j.forsciint.2012.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Forbes BJ, Rubin SE, Margolin E, Levin AV. Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma. J AAPOS 2010; 14:267-73. [PMID: 20603062 DOI: 10.1016/j.jaapos.2010.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/30/2010] [Accepted: 03/31/2010] [Indexed: 11/18/2022]
Abstract
Extensive intraocular hemorrhage in young infants in the setting of acute brain injury and in the absence of a history of severe accidental trauma or underlying medical cause must be considered to be nonaccidental injury until otherwise proven. In the absence of any obvious explanation, the presence of any retinal hemorrhage should raise the possibility of abusive head trauma in the differential diagnosis and perhaps lead to such testing as skeletal radiography and neuroimaging, consultation with a child abuse specialist, as well as workup for other relevant systemic conditions. Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that the proper steps are taken to protect their patients from the potential for further harm. Ascertainment of abusive head trauma is critical to prevent a potentially fatal recurrence.
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Affiliation(s)
- Brian J Forbes
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Wygnanski-Jaffe T, Morad Y, Levin AV. Pathology of retinal hemorrhage in abusive head trauma. Forensic Sci Med Pathol 2009; 5:291-7. [PMID: 20024631 DOI: 10.1007/s12024-009-9134-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2009] [Indexed: 12/01/2022]
Abstract
Abusive head injury, characterized by repeated acceleration-deceleration forces, is associated with retinal hemorrhages as demonstrated in many clinical and postmortem studies. The theory that vitreoretinal traction is the major factor in the pathogenesis of retinal hemorrhages is presently the most widely accepted explanation based on different lines of research. Postmortem examination of the eye and orbital structures is essential for recognizing abusive head injury and also for identifying other possible medical conditions which can cause retinal hemorrhage.
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Matschke J, Herrmann B, Sperhake J, Körber F, Bajanowski T, Glatzel M. Shaken baby syndrome: a common variant of non-accidental head injury in infants. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:211-7. [PMID: 19471629 PMCID: PMC2680569 DOI: 10.3238/arztebl.2009.0211] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 01/02/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality. METHODS Selective literature review including an overview over national and international recommendations. RESULTS Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations. CONCLUSIONS The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.
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Affiliation(s)
- Jakob Matschke
- Forensische Neuropathologie, Institut für Neuropathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg.
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Ocular pathology in shaken baby syndrome and other forms of infantile non-accidental head injury. Int J Legal Med 2008; 123:189-97. [DOI: 10.1007/s00414-008-0293-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
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Herrmann B, Novak W, Pärtan G, Sperhake J. Nichtakzidentelle Kopfverletzungen und Schütteltrauma-Syndrom. Monatsschr Kinderheilkd 2008. [DOI: 10.1007/s00112-008-1785-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tang J, Buzney SM, Lashkari K, Weiter JJ. Shaken baby syndrome: a review and update on ophthalmologic manifestations. Int Ophthalmol Clin 2008; 48:237-246. [PMID: 18427274 DOI: 10.1097/iio.0b013e3181693236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Johnny Tang
- The Schepens Eye Research Institute, 20 Staniford Street, Boston, MA 02114, USA
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Guidelines for Postmortem Protocol for Ocular Investigation of Sudden Unexplained Infant Death and Suspected Physical Child Abuse. Am J Forensic Med Pathol 2007; 28:323-9. [DOI: 10.1097/paf.0b013e31815b4c00] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fledelius HC. Retinal haemorrhages in premature infants: a pathogenetic alternative diagnosis to child abuse. ACTA ACUST UNITED AC 2005; 83:424-7. [PMID: 16029264 DOI: 10.1111/j.1600-0420.2005.00471.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To present the occasional observation of retinal haemorrhages in premature babies, as a diagnostic alternative to those observed as part of shaken baby syndrome. METHODS We carried out an observational study on 11 infants in whom retinal and/or vitreous haemorrhages had been observed within their first months of life. Ten infants were under surveillance for retinopathy of prematurity (ROP), with gestational ages and birth weights in the ranges of 27--34 weeks and 790--1665 g, respectively. One infant was diagnosed with Zellweger's syndrome and one received substitution therapy for coagulation factor II deficiency. The last child had been delivered at 38 weeks, weighing 2070 g; he died on day 5 from severe brain oedema with incarceration and extensive bilateral fundus bleeding. RESULTS Four of the 11 infants had some evidence of ROP, and two later received retinal ablation therapy. Contrary to the quick absorption (<1-2 weeks only) usually seen in most newborn term infants, the ocular bleeding in preterms was generally longstanding. A quick increase in intracranial pressure probably played a role in the lethal case with delivery near term, and one infant received lung physiotherapy for pneumonia at the age of 6 months. Some bleeding appeared to be truly postnatal (i.e. it was observed as a new occurrence during the course of surveillance). CONCLUSIONS In the series under study there was no suspicion of child abuse. In term infants, retinal haemorrhages are extremely rare except when due to shaking, but other diseases should be ruled out, coagulopathies in particular. We suggest that prematurity as such is added to the list of possibly underlying causes when retinal bleedings are evaluated in very small infants and shaken baby mechanisms are suspected.
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Affiliation(s)
- Hans C Fledelius
- Rigshospitalet, Eye Department, Copenhagen University, Copenhagen, Denmark.
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Affiliation(s)
- James Le Fanu
- Mawbey Brough Health Centre, 39 Wilcox Close, London SW8 2UD, UK.
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Affiliation(s)
- James Le Fanu
- Mawbey Brough Health Centre, 39 Wilcox Close, London SW8 2UD, UK.
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Abstract
PURPOSE OF REVIEW The many forms of child maltreatment exact an unacceptably heavy toll on our children. Recent work exploring the risk factors for child abuse and neglect, long-term consequences of child maltreatment, and potential for primary prevention will be reviewed. In the past year there have been many notable contributions in the field of shaken baby syndrome that have deepened our understanding of this devastating form of child abuse. RECENT FINDINGS Evidence of the long-term sequelae of child abuse and neglect continues to accumulate, but with increased understanding of the clinical manifestations of child maltreatment has come greater ability to intervene early and perhaps improve long-term outcomes. Although the effectiveness of some home visiting programs to prevent child maltreatment is coming into question, rigorous review of program components is helping to improve quality. There remain controversies in the diagnosis of shaken baby syndrome but several carefully done case-series are clarifying our knowledge of the myriad presentations of this form of non-accidental head trauma. SUMMARY Pediatricians have an important role to play in the prevention and recognition of child maltreatment.
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Affiliation(s)
- Alice W Newton
- Department of Pediatrics, Harvard Medical School, and the Child Protection Program, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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