Abusive head trauma in small children - a single-centre experience in Finland.

Shaken baby syndrome (SBS) is a challenging condition from both a medical and legal perspective. The path of the patients differs significantly from those with noninflicted traumas. While treating these cases, it is essential that all history, information and treatment are comprehensively documented. This article describes the investigations and interventions necessary as soon as SBS is suspected. The Oulu University Hospital protocol for suspected child abuse is described. Authors also give an overview of the SBS path in Finland from the police and prosecution's point of view.

Parental awareness, knowledge, and attitude about shaken baby syndrome in Riyadh, Saudi Arabia: a cross-sectional study.

Introduction: shaken baby syndrome (SBS) is an abusive head trauma inflicted on infants and young children. Injuries induced by shaking can result in death or permanent neurologic disability. It is difficult to know the exact number of SBS cases per year because many cases of SBS are not reported and/or never receive a diagnosis. From a public health perspective, creating greater awareness about SBS is important. Previous studies have revealed poor awareness and knowledge about shaken baby syndrome. In this study our aims to investigate the awareness, knowledge level, and attitude regarding shaken baby syndrome and to highlight the sources and factors associated with SBS knowledge among parents of the pediatric population in Riyadh, Saudi Arabia. Methods: a cross-sectional study was conducted between January 2021 and September 2021. A validated electronic questionnaire was distributed among parents of the pediatric population in Riyadh, Saudi Arabia using the convenient random sampling method; SPSS version 22 was used to analyze the collected data. Results: the study involved 577 participants; 59.8% were mothers and 96.5% were Saudis. A total of 32.1% had previously heard about SBS. The overall knowledge mean score was low (2.95 + 1.74), and attitude was positive among 82.5% of the participants. The factors significantly associated with knowledge level were gender, marital status, and occupation. Conclusion: the participants had poor knowledge and awareness about SBS, but, despite that, they expressed a positive attitude toward learning more about it. This should prompt health authorities to increase efforts to improve public awareness and knowledge about SBS.

Ophthalmological lesions in shaken baby syndrome: A retrospective analysis of 133 consecutive cases (1992-2018).

INTRODUCTION: Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data. PATIENTS AND METHODS: This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992-2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded. RESULTS: Mean age at diagnosis was 131days (range, 14days-10months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6months: 80%. CONCLUSION: This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.

Transfer of knowledge to diagnose infant abuse and its incidence - a time-series analysis from Sweden.

AIM: To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault). METHODS: Design: retrospective population-based and quasi-experimental. SETTING: Sweden 1987-2019. PATIENTS: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm. MAIN OUTCOME MEASURE: Abuse diagnoses (maltreatment or assault). ANALYSES: Incidence rate, incidence rate ratio (IRR). RESULTS: The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987-2019. It was rather stable 1987-2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002-2007, peaking in 2008-2013 [IRR 1.63 (95% confidence interval 1.34-1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014-2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71-0.99)]. CONCLUSION: An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process.

Confessed versus denied inflicted head injuries in infants: similarities and differences.

BACKGROUND AND PURPOSE: Abusive head injuries (AHI), and in particular shaken baby syndrome (SBS), are common causes of mortality and morbidity in infants. Although SBS is a well-established entity, based on clinical experience and experimental data, and confirmed by the perpetrators' confessions, a growing number of publications challenge the diagnostic criteria, and even the validity of the perpetrators' confession. We decided to study AHI in infants and compare cases with and without confession. MATERIAL AND METHODS: We collected prospectively all cases of infantile traumatic head injuries hospitalized in our institution between 2001 and 2021. From this database, we selected victims of AHI, comparing cases for which the perpetrator confessed during police inquiry ("confession" group) versus cases without confession ("denial" group). RESULTS: We studied 350 cases of AHI in infants; 137 of these (39.1%) were confessed. We found no statistically significant difference between the two groups regarding the child's previous history, as well as the personality and previous history of the caretakers. However, the "confession" group showed significantly more severe clinical presentation, cerebral lesions, retinal hemorrhages, and a more pejorative outcome. CONCLUSIONS: We conclude that the diagnosis of AHI was confirmed by the confession in a large number of cases, indicating that the diagnostic criteria of AHI are robust. We also found that denial, although possibly sincere, was likely ill-founded, and that the perpetrators' decision to confess or deny was markedly influenced by the severity of the inflicted lesions.

External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused.

BACKGROUND: Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. PURPOSE: The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. MATERIAL AND METHODS: Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. RESULTS: Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC. CONCLUSION: A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma.

BACKGROUND: Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS: This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS: A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE: Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.

Overturned abusive head trauma and shaken baby syndrome convictions in the United States: Prevalence, legal basis, and medical evidence.

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.

Abusive head trauma: Canadian and global perspectives.

Canada has come a long way since Dr. C. Henry Kempe first described battered-child syndrome in 1962. The year 1999 was crucial in Canada's battle against shaken baby syndrome/abusive head trauma (SBS/AHT), when the first national conference on the topic was held in Saskatoon. This was followed by the issuance of a national statement and multidisciplinary guidelines, recently updated in 2020. Incidence of AHT in Canada is similar to that found in population-based studies from Switzerland and New Zealand. The mainstay of prevention of AHT in Canada is education of parents and caregivers with respect to their response to infant crying. Population-based data for global incidence of AHT are lacking, largely because of social and cultural differences contributing to poor understanding of AHT as a medico-legal entity. India faces a distinct challenge in the battle against female feticide and infanticide.

Preventing abusive head trauma: can educating parents reduce the incidence?

Abusive head trauma (AHT) is the most lethal form of child abuse; preventing AHT should be a national priority, but research into this area is woefully underfunded. Prevention programs have primarily focused on universal parent education during the neonatal period, a time when parents are a captive audience of the health care establishment whose focus is on the needs of their newborn infant, and who will soon be exposed to the frustration and anger of infant crying. Research has suggested a strong causal link between infant crying and AHT, and parents - particularly fathers and father figures - have been identified as the most common perpetrators of AHT. A number of studies have suggested that educating parents during the postnatal period about the normalcy of inconsolable infant crying and its evolution over the first several months of postnatal life improves parental knowledge about infant crying and a number of positive parenting behaviors, and decreases emergency room visits for crying. In 1998, we began a pilot program in Upstate New York near Buffalo that led to a 47% reduction in AHT incidence. Similar studies have demonstrated 35-75% reductions in incidence, which has led to enthusiasm for this approach to preventing AHT. We, as well as another group, have enacted statewide programs in Pennsylvania and North Carolina; unfortunately, these two large statewide replication trials failed to demonstrate any impact of such an intervention on AHT rates. Serial messages for parents, provided repeatedly over the period of greatest risk for AHT, might be another avenue of research.

Shaken baby syndrome resulting in death: a case series.

BACKGROUND: The aim of this study was to raise the awareness of all healthcare personnel, primarily Emergency Department physicians, forensic physicians, and paediatricians about cases of shaken baby syndrome (SBS), which can be difficult to diagnose, require a high level of suspicion in diagnosis and there is a high likelihood of missed diagnosis. METHODS: A retrospective examination was made of 3400 forensic cases applied with autopsy between 2012 and 2018 to the Forensic Medicine Institution of Malatya Group Directorate. RESULTS: Of the total cases, 113 were aged < 2 years and head trauma was determined in 35. Eight cases were determined as SBS. Of the 8 cases that resulted in death, 75% were male and the mean age was 8.3 months. The trauma had been perpetrated by the father in 50% of cases. There was a history of seizure in 67.5% of the infants and 75% were taken to the Emergency Department with cardiopulmonary arrest. Subdural hematoma and subarachnoid hemorrhage were determined in 37.5% of the cases, subdural hematoma, subarachnoid hemorrhage and intracranial hemorrhage in 50%, and epidural hemorrhage and subarachnoid hemorrhage in 12.5%. In the microscopic examination of the medulla spinalis, focal subdural fresh bleeding was seen in 50% of cases. Bleeding around the optic nerves was determined in 37.5% of cases bilaterally and in 37.5% unilaterally. Retinal hemorrhage was determined in all the cases, which was bilateral in 75%. CONCLUSIONS: The actual worldwide incidence of SBS is not known, and in Turkey, it is thought to be much higher than has been determined. The most important reason for this is thought to be that the diagnosis of child abuse is difficult and physicians do not have a sufficient level of knowledge.

Medical findings and symptoms in infants exposed to witnessed or admitted abusive shaking: A nationwide registry study.

BACKGROUND: Many physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high. METHODS: Infants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions. RESULTS: All identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma. CONCLUSIONS: The present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors.

Evaluation of the effect of the child protection act on serious child physical abuse in Taiwan.

BACKGROUND: Few studies have examined the effects of the Child Protection Act on child maltreatment in Taiwan. OBJECTIVE: This study estimated the secular trends in the incidence rate of physical abuse of children requiring hospitalization between 1996 and 2013, and the subsequent in-hospital death proportion before and after implementation of the Act in 2003. PARTICIPANTS AND SETTING: The cases were children younger than 12 years old who were hospitalized due to child abuse, shaken-baby syndrome, neglect, or homicide between 1996 and 2013. A comparison group consisted of children requiring hospitalization for other reasons. We used the National Health Insurance database to identify patients. METHODS: The Joinpoint Regression Program was used to estimate temporal trends in the standardized incidence rates. RESULTS: Between 1996 and 2013, 2050 children required hospitalization for physical abuse. Before 2005, the annual percent change increased by 9.40 [95% confidence interval (CI), 4.98-14.00] per year, and after 2005 the annual percent change was -4.80 (95% CI, -9.53-0.17) per year. Among the 2050 physically abused children requiring hospitalization, 83 (4%) died in hospital. The in-hospital death proportion was 2.62% before 2003 and 4.90% after 2003, and the ratio of these two proportions was 1.43 (95% CI, 0.80-2.58). CONCLUSIONS: The trend in the incidence of hospitalization of children due to physical-abuse-related injuries started to decline 2 years after implementation of the Child Protection Act. However, the proportion of children who died in hospital as a result of physical abuse requiring hospitalization did not change.

Eight-year outcome of implementation of abusive head trauma prevention.

Low incidence rates and economic recession have hampered interpretation of educational prevention efforts to reduce abusive head trauma (AHT). Our objective was to determine whether the British Columbia experience implementing a province-wide prevention program reduced AHT hospitalization rates. A 3-dose primary, universal education program (the Period of PURPLE Crying) was implemented through maternal and public health units and assessed by retrospective-prospective surveillance. With parents of all newborn infants born between January 2009 and December 2016 (n = 354,477), nurses discussed crying and shaking while delivering a booklet and DVD during maternity admission (dose 1). Public health nurses reinforced Talking Points by telephone and/or home visits post-discharge (dose 2) and community education was instituted annually (dose 3). During admission, program delivery occurred for 90% of mothers. Fathers were present 74.4% of the time. By 2-4 months, 70.9% of mothers and 50.5% of fathers watched the DVD and/or read the booklet. AHT admissions decreased for <12-month-olds from 10.6 (95% CI: 8.3-13.5) to 7.1 (95% CI: 4.8-10.5) or, for <24-month-olds, from 6.7 (95% CI: 5.4-8.3) to 4.4 (95% CI: 3.1-6.2) cases per 100,000 person-years. Relative risk of admission was 0.67 (95% CI: 0.42-1.07, P = 0.090) and 0.65 (95% CI: 0.43-0.99, P = 0.048) respectively. We conclude that the intervention was associated with a 35% reduction in infant AHT admissions that was significant for <24-month-olds. The results are encouraging that, despite a low initial incidence and economic recession, reductions in AHT may be achievable with a system-wide implementation of a comprehensive parental education prevention program.

Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

Background: The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods: This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results: Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities. Conclusions: Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.

Association of adverse childhood experiences with shaking and smothering behaviors among Japanese caregivers.

Shaking and smothering in response to infant crying are life-threatening child abuse. Parental childhood abuse history is known to be one of the most robust risk factors for abusing their offspring. In addition to childhood abuse history, other adverse childhood exposures (ACEs) need to be considered due to co-occurrence. However, few studies have investigated the impact of ACEs on caregivers shaking and smothering their infant. This study aims to investigate the association of ACEs with shaking and smothering among caregivers of infants in Japan. A questionnaire was administered to caregivers participating in a four-month health checkup between September 2013 and August 2014 in Chiba City, Japan, to assess their ACEs (parental death, parental divorce, mentally ill parents, witness of intimate partner violence, physical abuse, neglect, psychological abuse and economic hardship), and shaking and smothering toward their infants (N=4297). Logistic regression analysis was used to examine the cumulative and individual impacts of ACEs on shaking and smothering. Analyses were conducted in 2015. A total of 28.3% reported having experienced at least one ACE during their childhood. We found that only witness of IPV had a significant association with shaking of infant (OR=1.93, 95% CI: 1.03-3.61). The total number of ACEs was not associated with either shaking or smothering. Our findings suggest that shaking and smothering in response to crying can occur regardless of ACEs. Population-based strategies that target all caregivers to prevent shaking and smothering of infants are needed.

Association between maternal intimate partner violence victimization during pregnancy and maternal abusive behavior towards infants at 4 months of age in Japan.

The purpose of this study was to investigate whether maternal intimate partner violence (IPV) victimization during pregnancy is associated with abusive behavior by the mother towards infants at 4 months of age. A population-based sample of 6590 mothers with 4-month-old infants participated in this study in Japan. Abusive behavior was assessed via questionnaire and defined as frequency of shaking and smothering during the preceding month. Both verbal and physical IPV during pregnancy were assessed retrospectively. Multiple logistic regression analysis was used, adjusting for types of IPV and potential covariates, specifically postpartum depression. Maternal exposure to verbal and physical IPV during pregnancy was reported by 10.9% and 1.2% of women, respectively. In the adjusted model, women exposed to verbal IPV alone were significantly more likely to abuse offspring (odds ratio: 1.59, 95% confidence interval: 1.17-2.16) while exposure to physical IPV did not have an additive effect for abusive behavior. Maternal victimization by verbal, but not physical IPV was associated with maternal abusive behavior towards their 4-month-old infant. Screening for verbal abuse during pregnancy might be an efficient approach to identify high-risk mothers of infant abuse.