The 'unified hypothesis' of Geddes et al. is not supported by the data

The Eyes Have It: How Critical are Ophthalmic Findings to the Diagnosis of Pediatric Abusive Head Trauma?

Pediatric abusive head trauma (AHT), still colloquially known as shaken baby syndrome, is a leading cause of morbidity and mortality among infants. Controversy has grown surrounding this diagnosis, and the specificity of the clinical findings-subdural hemorrhage, cerebral edema, and retinal hemorrhages-has been challenged. A literature search of peer reviewed publications on PubMed pertaining to the history, clinical, and pathologic features of AHT was conducted using the terms "shaken baby syndrome," "non-accidental trauma," "abusive head trauma," "inflicted traumatic brain injury," "shaken impact syndrome," and "whiplash shaken infant syndrome." Focus was placed on articles discussing ophthalmic findings in AHT. Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies.

Thrombosis is not a marker of bridging vein rupture in infants with alleged abusive head trauma

Aim

Thrombosis of bridging veins has been suggested to be a marker of bridging vein rupture, and thus AHT, in infants with subdural haematoma.

Methods

This is a non‐systematic review based on Pubmed search, secondary reference tracking and authors’ own article collections.

Results

Radiological studies asserting that imaging signs of cortical vein thrombosis were indicative of traumatic bridging vein rupture were unreliable as they lacked pathological verification of either thrombosis or rupture, and paid little regard to medical conditions other than trauma. Autopsy attempts at confirmation of ruptured bridging veins as the origin of SDH were fraught with difficulty. Moreover, microscopic anatomy demonstrated alternative non‐traumatic sources of a clot in or around bridging veins. Objective pathological observations did not support the hypothesis that a radiological finding of bridging vein thrombosis was the result of traumatic rupture by AHT. No biomechanical models have produced reliable and reproducible data to demonstrate that shaking alone can be a cause of bridging vein rupture.

Conclusion

There is no conclusive evidence supporting the hypothesis that diagnostic imaging showing thrombosed bridging veins in infants correlates with bridging vein rupture. Hence, there is no literature support for the use of thrombosis as a marker for AHT.

Abusive head trauma: experience improves diagnosis

PURPOSE

The diagnosis of abusive head trauma (AHT) is complex and neuroimaging plays a crucial role. Our goal was to determine whether non-neuroradiologists with standard neuroradiology knowledge perform as well as neuroradiologists with experience in pediatric neuroimaging in interpreting MRI in cases of presumptive AHT (pAHT).

METHODS

Twenty children were retrospectively evaluated. Patients had been diagnosed with pAHT (6 patients), non-abusive head trauma-NAHT (5 patients), metabolic diseases (3 patients), and benign enlargement of the subarachnoid spaces (BESS) (6 patients). The MRI was assessed blindly, i.e., no clinical history was given to the 3 non-neuroradiologists and 3 neuroradiologists from 2 different institutions.

RESULTS

Blindly, neuroradiologists demonstrated higher levels of sensitivity and positive predictive value in the diagnosis of pAHT (89%) than non-neuroradiologists (50%). Neuroradiologists chose correctly pAHT as the most probable diagnosis 16 out of 18 times; in contrast, non-neuroradiologists only chose 9 out of 18 times. In our series, the foremost important misdiagnosis for pAHT was NAHT (neuroradiologists twice and non-neuroradiologists 5 times). Only victims of motor vehicle accidents were blindly misdiagnosed as pAHT. No usual household NAHT was not misdiagnosed as pAHT. Neuroradiologists correctly ruled out pAHT in all cases of metabolic diseases and BESS.

CONCLUSION

MRI in cases of suspected AHT should be evaluated by neuroradiologists with experience in pediatric neuroimaging. Neuroradiologists looked beyond the subdural hemorrhage (SDH) and were more precise in the assessment of pAHT and its differential diagnosis than non-neuroradiologists were. It seems that non-neuroradiologists mainly assess whether or not a pAHT is present depending on the presence or absence of SDH.

Prevalence, Patterns, and Clinical Relevance of Hypoxic-Ischemic Injuries in Children Exposed to Abusive Head Trauma

BACKGROUND AND PURPOSE

Hypoxic-ischemic injuries (HIIs) are a scarcely investigated but important cause of morbidity and mortality in children who suffered abusive head trauma (AHT). The purpose of this study is to determine: (a) prevalence, types, and clinical relevance of cytotoxic edema compatible with HII in nonpenetrating AHT, (b) their relationship to other classic neuroimaging findings of AHT, and (c) their correlation with clinical outcomes.

METHODS

Diffusion-weighted imaging sequences of magnetic resonance imagings performed on children under 5 years diagnosed with AHT were reviewed to detect the most common patterns of acute parenchymal damage. Patterns of cytotoxic edema were described, and HII-compatible ones divided in subtypes. Correlation between HII, fractures, and subdural hemorrhages (SDHs) and with clinical outcomes was determined using imaging and available follow-up data.

RESULTS

Out of 57 patients, 36.8% showed lesions compatible with HII. A predominantly asymmetric cortical distribution was observed in 66.7% of cases, while 33.3% had diffused both cortical and deep gray/white matter distribution injury. Traumatic axonal injuries and focal contusions were less common. There was no significant correlation between the presence of SDH (P = .6) or skull fractures (P = .53) and HII. HII was the most severe form of parenchymal damage in terms of in-hospital mortality and morbidity at follow-up.

CONCLUSIONS

HII is the most common type of parenchymal damage in children victim of AHT, being present in 1/3 of patients with this condition, and correlates with more severe outcomes. Its presence is independent from other classic traumatic findings such as SDH and fractures.

Consensus statement on abusive head trauma in infants and young children

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.

Head kinematics during shaking associated with abusive head trauma

Abusive head trauma (AHT) is a potentially fatal result of child abuse but the mechanisms of injury are controversial. To address the hypothesis that shaking alone is sufficient to elicit the injuries observed, effective computational and experimental models are necessary. This paper investigates the use of a coupled rigid-body computational modelling framework to reproduce in vivo shaking kinematics in AHT. A sagittal plane OpenSim computational model of a lamb was developed and used to interpret biomechanical data from in vivo shaking experiments. The acceleration of the head during shaking was used to provide in vivo validation of the associated computational model. Results of this study demonstrated that peak accelerations occurred when the head impacted the torso and produced acceleration magnitudes exceeding 200ms(-)(2). The computational model demonstrated good agreement with the experimental measurements and was shown to be able to reproduce the high accelerations that occur during impact. The biomechanical results obtained with the computational model demonstrate the utility of using a coupled rigid-body modelling framework to describe infant head kinematics in AHT.

Subdural hemorrhage and hypoxia in infants with congenital heart disease

BACKGROUND AND OBJECTIVES

It has been suggested that there is a causal relationship between hypoxia and subdural hemorrhage (SDH) in infancy. The purpose of this study was to review the incidence of SDH in infants with congenital heart disease and explore the relationship between SDH and hypoxia.

METHODS

Review of data collected for a prospective longitudinal cohort study of infants undergoing surgery for congenital heart disease in New Zealand and Australia. Infants underwent serial MRI scans of the brain in the first 3 months of life. All oxygen saturation recordings and MRI results were extracted and infants assigned to categories by degree of hypoxia. The data were then examined for any statistically significant relationship between hypoxia and SDH.

RESULTS

One hundred fifty-two infants underwent MRI scans, and 66 (43%) had 145 loci of SDH. New SDH was seen in 12 infants after cardiac surgery. Of the loci of SDH, 63 (43%) were supratentorial, and most of these were interhemispheric, parietal, or temporal. SDH present on the first MRI persisted beyond 28 days of life in 8 infants. There was no demonstrable relationship between SDH and hypoxia.

CONCLUSIONS

Asymptomatic SDH is common in young infants with congenital heart disease, at a frequency similar to that of those without congenital heart disease. These SDHs may occur in locations where they occur in abusive head trauma, but they are typically small and resolve within 3 months of birth. We were unable to demonstrate any association between hypoxia and SDH in this cohort.

Factors associated with hemispheric hypodensity after subdural hematoma following abusive head trauma in children

Abusive head trauma (AHT) is a unique form of pediatric TBI with increased mortality and neurologic sequelae. Hemispheric hypodensity (HH) in association with subdural blood after AHT has been described. Though risk factors for HH are not understood, we hypothesized that risk factors could be identified. We retrospectively enrolled children under 5 years with TBI secondary to AHT (child advocacy diagnosis) who had undergone initial and interval brain imaging. Records were interrogated for prearrival and in-hospital physiologic and radiographic findings. HH was determined by a blinded observer. Twenty-four children were enrolled and 13 developed HH. HH was not significantly associated with age, initial Glascow Coma Scale, or mortality. Pediatric Intensity Level of Therapy (PILOT) scores (p=0.01) and daily maximal intracranial pressure (ICPmax; p=0.037) were higher in HH. Hypoxia, hypotension, cardiopulmonary arrest, need for blood transfusion, and daily blood glucoses tended to be greater in HH. Whereas all children with HH had acute subdural hematoma (SBH), many children without HH also had subdural blood; the presence of skull fracture was more likely in the children who did not develop HH (p=0.04), but no other intracranial radiographic pattern of injury was associated with HH. Surgical intervention did not appear to protect against development of HH. A variety of insults associated with ischemia, including intracranial hypertension, ICP-directed therapies, hypoxia, hypotension, and cardiac arrest, occurred in the children who developed HH. Given the morbidity and mortality of this condition, larger studies to identify mechanisms leading to the development of HH and mitigating clinical approaches are warranted.

Subdural Hemorrhage and Hypoxia in Children Less than Two Years Old

The majority of subdural hemorrhages (SDH) are due to acceleration-deceleration forces associated with blunt head injury. So-called spontaneous subdural hemorrhages are described with coagulopathies, hemodialysis, hemophilia, and as extensions of hemorrhages due to other causes such as ruptured cerebral artery aneurysms. Recently, some have proposed that hypoxia causes subdural hemorrhage in infants and children.

Materials and Methods

Of 1,190 deaths of children younger than two years of age, we analyzed 366 that were due to asphyxial mechanisms, respiratory disease, prematurity, seizures, and perinatal hypoxic-ischemic encephalopathy. All underwent autopsy and 97% included a consultant neuropathology examination.

Results

Of the 366 decedents, hypoxic-ischemic encephalopathy (HIE) was diagnosed in 73 (20%) and evidence of subdural hemorrhage in 34 (9%). Of the 73 HIE deaths, 14 (19%) had SDH. Among these 14, 12 involved prematurity and/or perinatal HIE. Among the 20 fatalities with SDHs but without HIE, all were premature infants and/or had a SDH that pathologically pre-dated the putative hypoxic-ischemic event. Of the 34 SDHs, 24 were organized neomembranes and ten were organizing hemorrhages.

Discussion

SDHs that are not caused by acceleration-deceleration forces are routinely recognized in infants and children. Usually, they are clinically silent and may be associated with prematurity and perinatal birth events. At autopsy, subdural neomembranes frequently are incidental findings in infants and children who die from a variety of causes. This study does not support the theory that hypoxic-ischemic injury in infants and children causes subdural hemorrhage.

Child Abuse and Neglect

It is important for surgeons to be able to accurately assess and diagnose child abuse. While they are generally not the only medical professionals involved in the care of children with suspected abuse, they are highly regarded by hospital and social service staff, and their input regarding the cause of injury is unlikely to be ignored. Appropriate diagnosis of abusive injury can prevent future morbidity and mortality in these vulnerable patients, and can also reduce the trauma to families from false accusations of abuse. A sensitive and open-ended history, thorough physical examination, appropriate diagnostic workup with consideration of child abuse as an underlying cause, appropriate documentation of findings, and determination of safety for discharge can greatly improve an abused child's current and future health and safety.

Shaken Infants Die of Neck Trauma, Not of Brain Trauma

Shaken baby syndrome (SBS) is routinely diagnosed on the basis of a classic triad of autopsy findings, namely retinal hemorrhage, subdural hemorrhage, and anoxic encephalopathy. However, ongoing controversy exists regarding the specificity and potential causes of these signs, and hence their reliability as de facto markers of SBS, or of non-accidental head injury, where no external signs of trauma are evident.

We investigated the deaths of 35 infants and young children, which fell into two broad groups: those with suspected hyperflexion/extension neck injuries, and those without. At autopsy, the entire cervical spinal column (spinal cord, vertebrae, intervertebral discs, neurovascular structures and adjacent soft tissues) was removed, formalin-fixed, decalcified, dissected, and microscopically evaluated.

Of the 12 cases in which hyperflexion/extension was either suspected or confirmed, all had evidence of either bilateral or unilateral hemorrhages within or surrounding the C3, C4, and/or C5 cervical spinal nerve roots.

We provide evidence that hyperflexion/extension forces as experienced by shaken and impacted infants and young children lead to injury of the cervical spinal nerve roots that innervate the diaphragm, with resulting asphyxia and hypoxic brain injury. Therefore, we propose that trauma to the third through fifth cervical spinal nerve roots induced by hyperflexion/extension of the neck is the cause of the anoxic encephalopathy of the classic SBS triad, and is therefore not only a more specific indicator of hyperflexion/extension injury than subdural hemorrhage alone, but is the mechanism of injury in these cases.

Comparison of system identification techniques in the analysis of a phantom for studying shaken-baby syndrome

This article compares two techniques for estimating the parameters describing the motion of a phantom designed to investigate shaking baby syndrome. Parameters of a simple computational model and an impulse response function for a linear second order system were both fitted using kinematic measurements of the motion of an inverted jointed pendulum. From the two methods respectively, the rotational stiffness of the joint was calculated to be 1.396 kgm(2) s(-2) and 1.355 kgm(2) s(-2) and the damping coefficient was calculated to be 0.0142 kgm(2) s(-1) and 0.0133 kgm(2) s(-1). The parameter estimates were similar demonstrating that the two techniques were comparable. Identifying accurate parameters will allow more complex phantoms to be modeled, and will provide insight into the relationship between the shaking of the torso and the resultant head motion during shaken baby syndrome.

Retinal hemorrhage in abusive head trauma

Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.

Nonaccidental head injury is the most common cause of subdural bleeding in infants <1 year of age

OBJECTIVE

Subdural bleeding (SDB) in infants is considered an essential symptom of nonaccidental head injury (NAHI). Recently, this view has been challenged by the "unified hypothesis," which claims that SDB in infants is related to hypoxia and brain swelling rather than to traumatic shearing of bridging veins. We analyzed a large series of infants' autopsies for the presence and causes of SDB, which should be a common event according to the unified hypothesis.

METHODS

Autopsy, clinical, and legal information for infants <1 year of age from a single institution over 50 years were analyzed regarding cause of death, presence, morphology, and cause of SDB, and brain weight.

RESULTS

From a total of 16 661 autopsies during the study period, 715 (4.3%) involved infants <1 year of age. Fifty (7.0%) of those had SDB. NAHI was identified in 17 patients. The most common cause of SDB was trauma (15 cases [30.0%]), with NAHI accounting for 14 cases. SDB was present in 82.4% of patients with NAHI but only 5.2% of infants with other causes of death. Four patients (8.0%) had unexplained SDB with no discernible cause of bleeding. Statistical analysis did not reveal any correlation between the presence of SDB and brain weight.

CONCLUSIONS

In the study population, unexplained SDB in infants was an extreme rarity. Moreover, a correlation between brain swelling and the presence of SDB could not be drawn. Our data argue strongly against the unified hypothesis and strengthen the association between SDB and NAHI in infancy.

Violence is not necessary to produce subdural and retinal haemorrhage: a reply to Puntet al

In this article we reply to the recent critique by Punt et al. in Pediatric Rehabilitation. Our hypothesis about the pathogenesis of intracranial bleeding in infants has three important implications. First, in the case of an infant with a swollen brain, subdural and retinal haemorrhage but no objective evidence of trauma, the findings by themselves are not certain evidence of abuse; second, violence is not necessary to produce subdural and retinal haemorrhage; and lastly, non-traumatic events producing apnoea with a catastrophic rise in intracranial pressure could produce a clinical picture identical to that seen in trauma.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

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.

Neuroimaging of nonaccidental head trauma: pitfalls and controversies

Although certain neuroimaging appearances are highly suggestive of abuse, radiological findings are often nonspecific. The objective of this review is to discuss pitfalls, controversies, and mimics occurring in neuroimaging of nonaccidental head trauma in order to allow the reader to establish an increased level of comfort in distinguishing between nonaccidental and accidental head trauma. Specific topics discussed include risk factors, general biomechanics and imaging strategies in nonaccidental head trauma, followed by the characteristics of skull fractures, normal prominent tentorium and falx versus subdural hematoma, birth trauma versus nonaccidental head trauma, hyperacute versus acute on chronic subdural hematomas, expanded subarachnoid space versus subdural hemorrhage, controversy regarding subdural hematomas associated with benign enlarged subarachnoid spaces, controversy regarding hypoxia as a cause of subdural hematoma and/or retinal hemorrhages without trauma, controversy regarding the significance of retinal hemorrhages related to nonaccidental head trauma, controversy regarding the significance of subdural hematomas in general, and pitfalls of glutaric aciduria type 1 and hemophagocytic lymphohistiocytosis mimicking nonaccidental head trauma.

Cerebral traumatism with a playground rocking toy mimicking shaken baby syndrome

Shaken baby syndrome (SBS), one of the most deadly and devastating forms of child abuse, is caused by violent shaking. The combination of subdural hematoma, retinal hemorrhage, brain swelling, and diffuse axonal injury is highly typical of this syndrome and faced with these autopsy findings, induced traumatic lesions are strongly considered. However, it is known that motor-vehicle accidents and falls from great height can also produce this pattern of injury. Nevertheless, stories of arms fall, couch fall, or bumped head while the baby is being carried are generally considered incompatible with SBS. We here report a case of a 2-year-old boy presenting with all the classic autopsy findings of SBS from a playground rocking toy shaken by an older child.

Shaken baby syndrome in New Zealand, 2000-2002

AIM

To describe the epidemiology of subdural haemorrhage (SDH) in New Zealand infants.

METHODS

Prospective enrollment of all cases of infantile SDH from 2000 to 2002. Retrospective analysis of national discharge and death data for the same period.

RESULTS

Seventy-seven cases of infantile SDH were identified prospectively, and a further 49 cases retrospectively. Of these 126 cases, 92 resulted from non-birth-related trauma. Forty-eight of these were attributed to abuse and 28 to accidental injury. Sixteen cases were undetermined. The 'minimum' annual incidence of inflicted infantile SDH in New Zealand is 14.7 per 100,000 (95% confidence interval(CI) 10.8-19.4), and the 'maximum' 19.6 per 100,000 (95% CI 15.1-25.0). Among Maori, the 'minimum' is 32.5 per 100,000 (95% CI 21.4-47.3), and the 'maximum' 38.5 per 100,000 (95% CI 26.3-54.4).

CONCLUSIONS

The epidemiology of infantile subdural haemorrhage in New Zealand is similar to that described elsewhere. Non-accidental head injury is a significant child health issue in New Zealand, and the incidence is particularly high among Maori.

Shaken baby syndrome: the quest for evidence

Shaken baby syndrome (SBS), characterized by the triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, was initially based on the hypothesis that shaking causes tearing of bridging veins and bilateral subdural bleeding. It remains controversial. New evidence since SBS was first defined three decades ago needs to be reviewed. Neuropathology shows that most cases do not have traumatic axonal injury, but hypoxic-ischaemic injury and brain swelling. This may allow a lucid interval, which traumatic axonal injury will not. Further, the thin subdural haemorrhages in SBS are unlike the thick unilateral space-occupying clots of trauma. They may not originate from traumatic rupture of bridging veins but from vessels injured by hypoxia and haemodynamic disturbances, as originally proposed by Cushing in 1905. Biomechanical studies have repeatedly failed to show that shaking alone can generate the triad in the absence of significant neck injury. Impact is needed and, indeed, seems to be the cause of the majority of cases of so-called SBS. Birth-related subdural bleeds are much more frequent than previously thought and their potential to cause chronic subdural collections and mimic SBS remains to be established.

Lack of evidence for a causal relationship between hypoxic-ischemic encephalopathy and subdural hemorrhage in fetal life, infancy, and early childhood

It has been asserted that hypoxic-ischemic encephalopathy (HIE) with cerebral swelling in the absence of marked trauma may be responsible for subural hemorrhage in the young. As this may have considerable implications in determining both the mechanism of death and the degree of force required to cause injury in certain cases of inflicted head injury in infancy, clarification is required. A retrospective study of 82 fetuses, infants, and toddlers with proven HIE and no trauma was undertaken from forensic institutes in Australia, the United Kingdom, Germany, Denmark, and the United States. The age range was 35 weeks gestation to 3 years, with a male to female ratio of 2:1. All cases had histologically confirmed HIE. Causes of the hypoxic episodes were temporarily resuscitated sudden infant death syndrome with delayed death (N = 30), drowning (N = 12), accidental asphyxia (N = 10), intrauterine/delivery asphyxia (N = 8), congenital disease (N = 6), aspiration of food/gastric contents (N = 4), inflicted asphyxia (N = 3), epilepsy (N = 1), dehydration (N = 1), drug toxicity (N = 1), complications of prematurity (N = 1), and complications of anesthesia (N = 1). The initiating event was not determined in 4 instances. In no case was there macroscopic evidence of subdural hemorrhage. In this study no support could be given to the hypothesis that HIE in the young in the absence of trauma causes subdural hemorrhage.

Community paediatrics: soft science or firm foundations?

Community paediatrics strives to integrate the biology of health into the social and psychological worlds within which children grow and develop. Consumer demand for limited community paediatric clinical services is increasing and medico-legal pressures escalate professional and personal concern. Meanwhile, the profession, through training and professional support, has struggled to keep up. Research into community paediatrics and its integration into policy and clinical practice remains limited, raising the perception that it is a 'soft' science. Our viewpoint is that necessary progress in this field requires leadership, apprenticeship and research. We argue that to build firm foundations for the future requires structures to enable clinical specialisation and continuing professional development in this area.

Shaken baby syndrome

Before the Court of Appeal