Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy

'Compressed Baby Head': A New 'Abusive Head Trauma' Entity?

BACKGROUND

Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts.

DISCUSSION

The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'.

CONCLUSIONS

To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.

Injuries from alleged accidental minor head trauma in a prospective cohort of children aged 0-3 years in an emergency department

INTRODUCTION

Minor head trauma in the child, whether accidental or inflicted, is a frequent reason for seeking medical attention. Our aim is to describe the characteristics of minor head trauma in children aged 0-3 years and the resulting injuries. This in order to help the clinician to suspect and thelegal expert to confirm intentional abuse.

STUDY DESIGN

Children aged from 0 to 3 years with minor head trauma and attending the pediatric emergency department were included in the study between January 2013 and June 2014. The correlation between the characteristics of trauma and the resulting injuries was analyzed using a prospective data collection questionnaire completed by the physicians who cared for the child.

RESULTS

A total of 709 children with minor head trauma were included in the study. In nearly 90% of cases, fall height was less than 1 m. Only one-third of children aged less than 6 months had external head injury. Low-intensity trauma, such as a low-velocity fall from a height of less than 1.5 m does not cause intracranial injury. External injuries were more frequent in children who had a fall with an anterior impact, while internal injuries were found only in posterior and lateral impacts.

CONCLUSION

In the context of minor head trauma, the physician must be vigilant and must ask for a full and clear description of the trauma, its mechanisms and other characteristics, when external or internal head injuries are observed in children aged less than 6 months.

Predictors of long-term neurological outcomes in non-accidental head injury

BackgroundNon-accidental head injury (NAI) is an inflicted injury usually on a child, often resulting in long-term neurological impairment and occasionally death. This study aimed to investigate the predictive values of acute findings, especially ocular, for long-term neurological outcomes.MethodsMedical records including retinal images of all children who attended the local Children's hospital with a diagnosis of NAI from over a period of 5 years were reviewed and data collected via the electronic patient record system. Patient demographics, injuries sustained, wide-field digital retinal images, visual acuity and sequalae, neurological function, and global function was noted. IBM SPSS software program was used for statistical analysis.ResultsOf the 38 patients (24 males, 14 females), 12 children died acutely from the head injury with the remaining 26 children available for long-term follow-up. A younger age of injury (P=0.004) was the only statistically significant predictor of good neurological outcome as compared with absence of macular retinoschisis, unilateral retinal haemorrhage, and unilateral subdural haemorrhage. Of the 38 children, 17 children had retinoschisis; 9 children with macular retinoschisis died acutely while 4 suffered a degree of developmental delay and only 4 were developmentally normal at the last follow-up. Long-term visual acuity data was available for 18 of the 26 survivors (range: NPL to Snellen 6/5). A statistical significance was noted between retinoschisis and worsened visual acuity (P<0.05).ConclusionsBilateral macular retinoschisis on acute presentation of NAI is associated with a seven-fold and unilateral with a four-fold increase in the development of a poor neurological outcome and eventual death. Conflicting to other studies, younger children presented better neurological outcomes.

Shaken Baby Syndrome: a review

Shaken Baby Syndrome occurs in infants as a result of the brain pushing against the skull due to severe acceleration-deceleration forces. Symptoms of Shaken Baby Syndrome include subdural, subarachnoid, and retinal hemorrhages. MRI and ocular examinations are used to determine the extent of mental and visual damage and β-amyloid precursor protein immunohistochemical staining is used to detect axonal injuries. Surgeries such as Subdural hemorrhage (SDH) evacuation surgery and the Burr hole craniotomy are used to treat Shaken Baby Syndrome; however, the prognosis is poor in many cases. Because of the severity of Shaken Baby Syndrome and its traumatic and sometimes fatal effects, it is important to educate new parents, nurses, and doctors on the syndrome in order to prevent incidents.

Long-term outcome of abusive head trauma

Abusive head trauma is a severe inflicted traumatic brain injury, occurring under the age of 2 years, defined by an acute brain injury (mostly subdural or subarachnoidal haemorrhage), where no history or no compatible history with the clinical presentation is given. The mortality rate is estimated at 20-25% and outcome is extremely poor. High rates of impairments are reported in a number of domains, such as delayed psychomotor development; motor deficits (spastic hemiplegia or quadriplegia in 15-64%); epilepsy, often intractable (11-32%); microcephaly with corticosubcortical atrophy (61-100%); visual impairment (18-48%); language disorders (37-64%), and cognitive, behavioral and sleep disorders, including intellectual deficits, agitation, aggression, tantrums, attention deficits, memory, inhibition or initiation deficits (23-59%). Those combined deficits have obvious consequences on academic achievement, with high rates of special education in the long term. Factors associated with worse outcome include demographic factors (lower parental socioeconomic status), initial severe presentation (e.g., presence of a coma, seizures, extent of retinal hemorrhages, presence of an associated cranial fracture, extent of brain lesions, cerebral oedema and atrophy). Given the high risk of severe outcome, long-term comprehensive follow-up should be systematically performed to monitor development, detect any problem and implement timely adequate rehabilitation interventions, special education and/or support when necessary. Interventions should focus on children as well as families, providing help in dealing with the child's impairment and support with psychosocial issues. Unfortunately, follow-up of children with abusive head trauma has repeatedly been reported to be challenging, with very high attrition rates.

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.

A review of social factors in the investigation and assessment of non-accidental head injury to children

Investigation and assessment work in non-accidental head injury cases is complex and challenging. This article discusses briefly the professional systems involved and the conditions necessary for effective practice. It then reviews briefly the literature on social factors in serious and fatal child abuse in order to provide a context for discussion of recent UK studies of non-accidental head injuries/shaken baby syndrome. The findings on social factors are compared and areas for further research are suggested. The article then considers how best to use the existing knowledge base about these cases within assessment frameworks currently in use and considers issues in presenting assessment conclusions to decision-makers.

Neuroimaging evaluation of non-accidental head trauma with correlation to clinical outcomes: a review of 57 cases

OBJECTIVE

To review the clinical presentation and neuroimaging findings in patients with high clinical suspicion for non-accidental trauma (NAT) of the head, to investigate associations between imaging findings and long-term neurologic outcome in abused children.

STUDY DESIGN

A retrospective review of 57 cases of NAT of the head from a single institution was performed. Neuroimaging studies (computed tomography [CT] and magnetic resonance imaging [MRI]) were reviewed by a senior neuroradiologist, a neuroradiology fellow, and a radiology resident. Clinical history and physical findings, including retinal examination, imaging, and follow-up assessment, were reviewed.

RESULTS

The mean time between the patient's arrival at the hospital and CT and MRI imaging was 2.9 hours and 40.6 hours, respectively. The most common clinical presentation was mental status changes, seen in 47% of patients. The most common neuroimaging finding was subdural hematoma, seen in 86% of patients. In the 47 patients who underwent both MRI and CT, 1 case of suspected NAT was missed on head CT. CT detected signs of global ischemia in all 11 patients who died (mean time after arrival at the hospital until undergoing CT, 1.1 hours). MRI detected additional signs of injury in patients who developed mild to moderate developmental delay.

CONCLUSION

CT was able to detect evidence of NAT of the head in 56 of 57 abused children included in our cohort and predicted severe neurologic injury and mortality. MRI was useful in detecting additional evidence of trauma, which can be helpful in risk stratification for neurologic outcomes as well in providing confirming evidence of repeated injury.

Inflicted head injury in infants

There is scant neuropathological information in the child abuse literature; even the best reviews include assumptions based on the findings of a few inadequate early studies. Our recent series of 53 fatal cases (Brain 124 (2001) 1290, 1299 [1,2]) demonstrated age-related patterns of brain injury and showed the substrate of severe encephalopathy in the infants to be hypoxic brain damage, not diffuse traumatic axonal injury ('DAI'), as had previously been thought. About one-third had craniocervical injuries, particularly in the brain stem, suggestive of stretch injury to the neuraxis. Our interpretation was that this finding implied a mechanism of injury--brain stem damage from stretch injury to the neck with resultant apnoea--that could account for the clinical scenario in many cases, and for which violence would not necessarily be required. Since publishing this study we have turned our attention to the subgroup of infants who die without objective signs of injury, such as skull fracture or impact, whose carers are accused of abuse, usually, "violent shaking", on the pathologic findings alone. Given the striking discrepancy that there often is in such cases between the relatively trivial findings in the brain and the accusations of violence, we have been looking at the pathogenesis of the typical intracranial bleeding. A histologic study of dura from 50 paediatric autopsies, none of whom had suffered a head injury, has led us to propose that the subdural and retinal bleeding in such cases may well have a physiological aetiology, rather than being caused directly by trauma.

Perpetrator accounts in infant abusive head trauma brought about by a shaking event

OBJECTIVE

To analyze perpetrator and medical evidence collected during investigations of infant abusive head trauma (IAHT), with a view to (a) identifying cases where injuries were induced by shaking in the absence of any impact and (b) documenting the response of infant victims to a violent shaking event.

METHOD

A retrospective study was undertaken of IAHT cases investigated by the Queensland Police Service over a 10-year period. Cases of head trauma involving subdural and/or subarachnoid hematoma and retinal hemorrhages, in the absence of any evidence of impact, were defined as shaking-induced. Perpetrator statements were then examined for further evidence to support the shaking hypothesis and for descriptions of the victim's immediate response to a shaking event.

RESULTS

From a total of 52 serious IAHT cases, 13 (25%) were found to have no medical or observer evidence of impact. In 5 of those 13 cases, there was a statement by the perpetrator to the effect that the victim was subjected to a shaking event. In several cases both with and without evidence of associated impact, perpetrator accounts described an immediate neurological response on the part of the victim.

CONCLUSION

The study confirms that IAHT resulting in death or serious neurological impairment can be induced by shaking alone. In cases where the infant's medical condition was adequately described, the symptoms of head injury presented immediately.

Cortical hypoxic-ischemic brain damage in shaken-baby (shaken impact) syndrome: value of diffusion-weighted MRI

Shaken-baby syndrome (SBS) is a type of child abuse caused by violent shaking of an infant, with or without impact, and characterized by subdural hematomas, retinal hemorrhages, and occult bone fractures. Parenchymal brain lesions in SBS may be missed or underestimated on CT scans, but can be detected at an earlier stage with diffusion-weighted MRI (DW-MRI) as areas of restricted diffusion. We demonstrate the value of DW-MRI in a 2-month-old baby boy with suspected SBS. The pattern of diffusion abnormalities indicates that the neuropathology of parenchymal lesions in SBS is due to hypoxic-ischemic brain injuries, and not to diffuse axonal injury.

Neuropathological and biochemical features of traumatic injury in the developing brain

Trauma to the developing brain constitutes a poorly explored field. Some recent studies attempting to model and study pediatric head trauma, the leading cause of death and disability in the pediatric population, revealed interesting aspects and potential targets for future research. Trauma triggers both excitotoxic and apoptotic neurodegeneration in the developing rat brain. Excitotoxic neurodegeneration develops and subsides rapidly (within hours) whereas apoptotic cell death occurs in a delayed fashion over several days following the initial traumatic insult. Apoptotic neurodegeneration contributes in an age-dependent fashion to neuronal injury following head trauma, with the immature brain being exceedingly sensitive. In the most vulnerable ages the apoptosis contribution to the extent of traumatic brain damage far outweighs that of the excitotoxic component. Molecular and biochemical studies indicate that both extrinsic and intrinsic mechanisms are involved in pathogenesis of apoptotic cell death following trauma. Interestingly, in infant rats a pan-caspase inhibitor ameliorated apoptotic neurodegeneration with a therapeutic time window of up to 8 h after trauma. These results help explain unfavorable outcomes of very young pediatric head trauma patients and imply that regimens which target slow active forms of cell death may comprise a successful neuroprotective approach.

Child abuse in the pediatric intensive care unit

Critically ill and injured children due to abusive or inflicted injury represent a growing challenge for pediatric intensive care unit personnel in terms of the number of patients seen each year in the United States and the intellectual and emotional response required to deal with this tragic problem. We present a distillation of the current knowledge of childhood physical abuse with a focus on the child with inflicted injury who is admitted to the pediatric intensive care unit. In addition to a discussion of the epidemiology, clinical presentation, an approach to diagnosis, and treatment strategies, we also explore the legal issues that confront pediatric intensive care unit physicians in relation to determination of brain death, suitability of victims for organ donation, and the physician's role in the criminal investigation of child abuse and as a witness for court proceedings.

Pediatric spine and spinal cord injury after inflicted trauma

Pediatric spine and spinal cord injury are rare sequelae of intentional trauma. They may easily be overlooked, however, and probably represent an underreported phenomenon. Recent autopsy data analyzed in conjunction with prior case series indicate that injury to the upper cervical spine and brainstem may significantly contribute to the major morbidity, mortality, and neuropathology in shaken infants. The findings in the previous case report illustrate several important points regarding spine and spinal cord injury after intentional trauma. First, the very young are susceptible to severe, higher cervical injury of both spine and spinal cord. Second, spine and spinal cord injury were initially overlooked because of masked neurologic findings with the concomitant head injury and multiple other systemic injuries. Finally, the child's outcome with significant cognitive delay because of global brain injury in conjunction with the focal high cervical cord injury may support the hypothesis that hypoxic damage could have occurred secondary to brainstem and high cervical cord injury. At the authors' institution, a detailed history and vigilant physical examination are stressed. When the mechanism of injury reported in the history is incongruous with the physical or initial radiographic findings and intentional trauma is suspected, a full skeletal survey, ophthalmologic evaluation, and social evaluation is undertaken. MRI and CT scanning are individualized according to the clinical assessment.

Ethical issues in imaging nonaccidental injury: child abuse

One of the most controversial areas of nonaccidental injury is the medical diagnosis of inflicted central nervous system injury and its impact on medical, social, and legal outcomes for children and families. This review addresses the role of the neuroradiologist in the clinical care of the pediatric patient and as an expert medical witness in the area of nonaccidental injury.

Winner of the young physician's section of the Gowers' prize 2000. Too good to be true? Thomas Willis--neonatal convulsions, childhood stroke and infanticide in seventeenth century England

A case of neonatal convulsion reported by Thomas Willis (1621-1675) together with its post mortem findings is quoted as being congenital intracerebral haemorrhage or strongly suggested as being the earliest pathological description of childhood cerebrovascular disease. However these authors only reviewed the incomplete written record left by Willis, describing how this case was the fourth consecutive child that the mother had lost to neonatal convulsions. The medical record is completed by notes taken by John Locke from a lecture delivered by Willis 3 or 4 years before the case was first published. Here, Locke relates how the mother subsequently had three further children who were all treated by Willis soon after birth and all survived uneventfully. Reviewing the post mortem findings and the full case histories modern medical science gives a different interpretation. Instead, I suggest that the case history given and pathological features described are more in keeping with a whiplash shaking injury than with cerebrovascular disease or a stroke. I believe that this is the earliest pathological description of shaking injury in childhood. We can never know why Willis did not publish the full success of his management of the subsequent children but it may have been due to his dramatic experience of a similar mother early on in his medical career.