Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study.

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

Widening of the pericerebral space in infants - consultative problems

The study was an attempt to characterize symptoms and factors suggesting a traumatic cause of pericerebral space widening in infants. This heterogeneous group of disorders, rarely observed in forensic pathological practice, poses consultative problems, as it may be difficult to distinguish between spontaneous disease-related changes and traumatic complications, and differentiate accidental from non-accidental trauma. The study is based on the records of two cases submitted for examination in order to determine the degree of health impairment. In both cases, a female infant was indicated as the injured person. A review of medical records, particularly medical imaging findings, provided evidence to conclude that the subdural hygromas diagnosed in both infants had a post-traumatic origin. On that basis, factors were selected for consideration in medicolegal assessment, including history of head injury, retinal haemorrhage, presence of other external and internal injuries suggesting battered or shaken baby syndromes, onset and rate of symptom aggravation, perinatal anamnesis, presence of arachnoid cysts, and diseases from the group of metabolic defects.

Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Part I: A systematic review of animal models.

Inflicted blunt force trauma and/or repetitive acceleration-deceleration trauma in infants can cause brain injury. Yet, the exact pathophysiologic mechanism with its associated thresholds remains unclear. In this systematic review an overview of animal models for shaking trauma and their findings on tissue damage will be provided. A systematic review was performed in MEDLINE and Scopus for articles on the simulation of inflicted head injury in animals. After collection, the studies were independently screened by two researchers for title, abstract, and finally full text and on methodological quality. A total of 12 articles were included after full-text screening. Three articles were based on a single study population of 13 lambs, by one research group. The other 9 articles were separate studies in piglets, all by a single second research group. The lamb articles give some information on tissue damage after inflicted head injury. The piglet studies only provide information on consequences of a single plane rotational movement. Generally, with increasing age and weight, there was a decrease of axonal injury and death. Future studies should focus on every single step in the process of a free movement in all directions, resembling human infant shaking. In part II of this systematic review biomechanical models will be evaluated.

From Child Protection to Paradigm Protection-The Genesis, Development, and Defense of a Scientific Paradigm.

A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome (SBS) paradigm. The point of departure of the analysis is a recently conducted systematic literature review, which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present (and no other "acceptable" explanations are provided) the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of "groupthink," aggravating the difficulties in considering critics' questioning the criteria established by the teams.

Understanding Subdural Collections in Pediatric Abusive Head Trauma.

Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects.

Development of a finite-element eye model to investigate retinal hemorrhages in shaken baby syndrome.

Retinal hemorrhages (RH) are among injuries sustained by a large number of shaken baby syndrome victims, but also by a small proportion of road accident victims. In order to have a better understanding of the underlying of RH mechanisms, we aimed to develop a complete human eye and orbit finite element model. Five occipital head impacts, at different heights and on different surfaces, and three shaking experiments were conducted with a 6-week-old dummy (Q0 dummy). This allowed obtaining a precise description of the motion in those two specific situations, which was then used as input for the eye model simulation. Results showed that four parameters (pressure, Von Mises stress and strain, 1st principal stress) are relevant for shaking-fall comparison. Indeed, in the retina, the softest shaking leads to pressure that is 4 times higher than the most severe impact (1.43 vs. 0.34 kPa). For the Von Mises stress, strain and 1st principal stress, this ratio rises to 4.27, 6.53 and 14.74, respectively. Moreover, regions of high stress and strain in the retina and the choroid were identified and compared to what is seen on fundoscopy. The comparison between linear and rotational acceleration in fall and shaking events demonstrated the important role of the rotational acceleration in inducing such injuries. Even though the eye model was not validated, the conclusion of this study is that compared to falls, shaking an infant leads to extreme eye loading as demonstrated by the values taken by the four mentioned mechanical parameters in the retina and the choroid.

Retroocular and Subdural Hemorrhage or Hemosiderin Deposits in Pediatric Autopsies.

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.

Cyclic Head Rotations Produce Modest Brain Injury in Infant Piglets.

Repetitive back-and-forth head rotation from vigorous shaking is purported to be a central mechanism responsible for diffuse white matter injury, subdural hemorrhage, and retinal hemorrhage in some cases of abusive head trauma (AHT) in young children. Although animal studies have identified mechanisms of traumatic brain injury (TBI) associated with single rapid head acceleration-decelerations at levels experienced in a motor vehicle crash, few experimental studies have investigated TBI from repetitive head rotations. The objective of this study was to systematically investigate the post-injury pathological time-course after cyclic, low-velocity head rotations in the piglet and compare them with single head rotations. Injury metrics were the occurrence and extent of axonal injury (AI), extra-axial hemorrhage (EAH), red cell neuronal/axonal change (RCNAC), and ocular injury (OI). Hyperflexion/extension of the neck were purposefully avoided in the study, resulting in unscaled angular accelerations at the lower end of reported infant surrogate shaking kinematics. All findings were at the mild end of the injury spectrum, with no significant findings at 6 h post-injury. Cyclic head rotations, however, produced modest AI that significantly increased with time post-injury (p < 0.035) and had significantly greater amounts of RCNAC and EAH than noncyclic head rotations after 24 h post-injury (p < 0.05). No OI was observed. Future studies should investigate the contributions of additional physiological and mechanical features associated with AHT (e.g., hyperflexion/extension, increased intracranial pressure from crying or thoracic compression, and more than two cyclic episodes) to enhance our understanding of the causality between proposed mechanistic factors and AHT in infants.

Exploring the controversy in child abuse pediatrics and false accusations of abuse.

There is a controversy in child abuse pediatrics between an established corps of child abuse pediatricians aligned with hospital colleagues and law enforcement, and a multi-specialty challenger group of doctors and other medical professionals working with public interest lawyers. The latter group questions the scientific validity of the core beliefs of child abuse pediatricians and believes that there are a substantial number of false accusations of abuse occurring. An unproven primary hypothesis, crafted around 1975 by a small group of pediatricians with an interest in child abuse, lies at the foundation of child abuse pediatrics. With no scientific study, it was hypothesized that subdural hemorrhage (SDH) and retinal hemorrhage (RH) were diagnostic of shaking abuse. That hypothesis became the so-called "shaken baby syndrome." Through the period 1975-1985, in a coordinated manner, these child abuse specialists coalesced under the American Academy of Pediatrics and began working with district attorneys and social workers, informing them of the ways in which their hypothesis could be applied to prosecutions of child abuse and life-altering social service interventions. In a legal context, using then-prevailing evidentiary rules which treated scientific expert testimony as valid if it was "generally accepted" in the field, they represented falsely that there was general acceptance of their hypothesis and therefore it was valid science. As the ability to convict based on this unproven prime hypothesis (SDH and RH equals abuse) increased, some defense attorneys were professionally compelled by their own doubts to reach out to experts from other fields with experience with SDH and RH, trauma, and biomechanics, for second opinions. Medical and legal challenges to the established thinking soon emerged, based on both old and new evidenced-based literature. As the intensity of the controversy increased, the probability of false accusation became more apparent and the need to address the issue more pressing. Since false accusations of child abuse are themselves abusive, efforts to eliminate such false accusations must continue.

Long-term outcome in a case of shaken baby syndrome.

Shaken baby syndrome is one of the most common causes of disability and death in infants younger than one year of age. The syndrome is the result of major mechanical forces affecting the head and central nervous system. The outcome for surviving children is often poor, with both physical and mental disabilities. Multicystic encephalomalacia has been reported as a finding after such shaking. The present case involves a one-month-old boy who was brought to hospital by his father because of somnolence and feeding aversion. Radiological imaging revealed subdural haematomas, and fundoscopy found retinal haemorrhages. During police interrogation, the father confessed to having shaken the infant. Cranial ultrasonography subsequently showed increasing damage of the brain; the boy's general condition worsened. Eight weeks after admission, he died due to renal insufficiency. Upon autopsy, the brain was atrophic, with massive pseudocystic changes of the parenchyma. The case presented impressively shows the possible serious outcome of an admitted incident of shaking and emphasises the importance of an accurate education of parents about its severe and possible lethal consequences.

An inability to learn to read caused by shaken baby syndrome.

We report a 12-year-old boy who suffered from shaken baby syndrome at the age of 4 months and has been unable to learn to read even high-frequency, three-letter words, despite slow but accurate letter naming. He had a right homonymous hemianopia and evidence of impaired higher visual function, but not at a severe enough level to account for his inability to read. Speech production and reception of language were impaired for his age but at least of an order of magnitude better than his reading performance. MRI scanning revealed focal damage to the dorsal and ventral reading pathways. This case challenges the Kennard principle, a widely accepted assumption which claims that the earlier a brain injury occurs, the better the recovery. It also adds to the growing literature suggesting that early damage to multiple parts of the language learning network can result in relatively selective impairments later in life.

Hypopituitarism in pediatric survivors of inflicted traumatic brain injury.

Endocrine dysfunction is common after accidental traumatic brain injury (TBI). Prevalence of endocrine dysfunction after inflicted traumatic brain injury (iTBI) is not known. The aim of this study was to examine endocrinopathy in children after moderate-to-severe iTBI. Children with previous iTBI (n=14) were evaluated for growth/endocrine dysfunction, including anthropometric measurements and hormonal evaluation (nocturnal growth hormone [GH], thyrotropin surge, morning and low-dose adrenocorticotropin stimulated cortisol, insulin-like growth factor 1, IGF-binding protein 3, free thyroxine, prolactin [PRL], and serum/urine osmolality). Analysis used Fisher's exact test and Wilcoxon's rank-sum test, as appropriate. Eighty-six percent of subjects had endocrine dysfunction with at least one abnormality, whereas 50% had two or more abnormalities, significantly increased compared to an estimated 2.5% with endocrine abnormality in the general population (p<0.001). Elevated prolactin was common (64%), followed by abnormal thyroid function (33%), short stature (29%), and low GH peak (17%). High prolactin was common in subjects with other endocrine abnormalities. Two were treated with thyroid hormone and 2 may require GH therapy. In conclusion, children with a history of iTBI show high risk for endocrine dysfunction, including elevated PRL and growth abnormalities. This effect of iTBI has not been well described in the literature. Larger, multi-center, prospective studies would provide more data to determine the extent of endocrine dysfunction in iTBI. We recommend that any child with a history of iTBI be followed closely for growth velocity and pubertal changes. If growth velocity is slow, PRL level and a full endocrine evaluation should be performed.

Confessed abusive blunt head trauma.

It is generally accepted that terms referring to specific craniocerebral injury mechanisms must be replaced by the more general term abusive head trauma (AHT). Although blunt impact trauma remains an essential part of AHT, it has received far less attention in the literature than shaken-impact injuries. The current article presents 19 confessed cases of a series of 47 highly suspected AHT cases. Of these, 13 were confessed shaken-impact cases, and the other 6 confessed blunt trauma cases. There were no significant differences in the appearance of subdural hematoma, which was present in each case. Retinal hemorrhage, which was present in 10 of the 13 shaken-impact cases in which an ophthalmologic examination was conducted, occurred in 2 of the 6 blunt trauma cases. In 1 case, retinal hemorrhage probably had of metabolic origin. Skull fractures with an overlying subgaleal hematoma and a subdural hematoma below the fracture side were found in 5 of the blunt trauma cases but was also seen in the 2 shaken-impact cases with a skull fracture. The most important finding was a lucid interval (LI) in 3 blunt AHT cases. An LI does not seem to occur in shaking injuries because of the immediate and persistent effect of brain damage that such injuries involve. Therefore, LI makes it important to conduct a detailed investigation of the clinical course in time in suspected AHT cases.

Abusive head trauma: report of 3 cases.

Abusive head trauma (AHT) is perpetrated when an infant or young child is shaken violently by an abuser, resulting in injuries to various intracranial structures, historically called "shaken baby syndrome" (SBS). Three cases of AHT with different constellations of clinical symptoms are presented here. Case 1- Three-month-old female infant was admitted with recurrent seizures, drowsiness, and low grade fever. Ophthalmologic examination revealed retinal hemorrhages (RH) in the left eye. Computed tomography of cranium showed left frontal intra-parenchymal subdural hematoma (SDH). Case 2- Twelve-month-old male infant was admitted with a history of favoring left leg. Ophthalmologic examination revealed RH in the right eye. Cranial magnetic resonance imaging (MRI) revealed subacute SDH in the right frontoparietal region. Case 3- Three-month-old male infant was admitted with irritability and seizures. Ophthalmologic examination revealed bilateral disseminated RH. Cranial MRI scan showed bilateral frontoparietal subacute SDH. All cases were reported to Child Protective Services, who decided not to remove children from homes, but evaluated psychosocial risks and developed a safety plan, including home visits and family education. Physicians must be aware of possibility of AHT in infants presenting both subtle and overt neurologic symptoms. It is important to provide training on AHT to staff involved in the management of these cases.

Persistent homological sparse network approach to detecting white matter abnormality in maltreated children: MRI and DTI multimodal study.

We present a novel persistent homological sparse network analysis framework for characterizing white matter abnormalities in tensor-based morphometry (TBM) in magnetic resonance imaging (MRI). Traditionally TBM is used in quantifying tissue volume change in each voxel in a massive univariate fashion. However, this obvious approach cannot be used in testing, for instance, if the change in one voxel is related to other voxels. To address this limitation of univariate-TBM, we propose a new persistent homological approach to testing more complex relational hypotheses across brain regions. The proposed methods are applied to characterize abnormal white matter in maltreated children. The results are further validated using fractional anisotropy (FA) values in diffusion tensor imaging (DTI).

Neuropathological changes in a lamb model of non-accidental head injury (the shaken baby syndrome).

Non-accidental head injury (NAHI), also termed the "shaken baby syndrome", is a major cause of death and severe neurological dysfunction in children under three years of age, but it is debated whether shaking alone is sufficient to produce brain injury and mortality or whether an additional head impact is required. In an attempt to resolve this question, we used a lamb model of NAHI since these animals have a relatively large gyrencephalic brain and weak neck muscles resembling those of a human infant. Three anaesthetised lambs of lower body weight than others in the experimental group died unexpectedly after being shaken, proving that shaking alone can be lethal. In these lambs, axonal injury, neuronal reaction and albumin extravasation were widely distributed in the hemispheric white matter, brainstem and at the craniocervical junction, and of much greater magnitude than in higher body weight lambs which did not die. Moreover, in the eyes of these shaken lambs, there was damage to retinal inner nuclear layer neurons, mild, patchy ganglion cell axonal injury, widespread Muller glial reaction, and uveal albumin extravasation. This study proved that shaking of a subset of lambs can result in death, without an additional head impact being required.

Progression of chronic subdural haematomas in an infant boy after abusive head trauma.

Abusive head trauma is a serious form of child abuse that can lead to severe neuropsychological sequelae or death in infants. In questionable cases, without a confession from the caregivers and ambiguous clinical information, evidence for the diagnosis of abusive head trauma is often based on typical patterns that have been observed in neuro-imaging. This study shows the progressive evolution of multifocal chronic subdural haematomas, including re-bleedings, in a case of abusive head trauma in an infant boy who was documented with repeated magnetic resonance imaging. The chronic subdural haematomas occurred during closely monitored in-patient rehabilitative care, and repeated maltreatment did not appear to be likely. Due to excessive growth, neurosurgical intervention with endoscopic craniotomy, evacuation of the subdural haematomas and temporal external cerebrospinal fluid drainage was performed with a favourable recovery. This study discusses the current pathophysiological knowledge concerning the development and clinical course of chronic subdural haematomas and draws relevant conclusions for the clinical practice and psychosocial management of caring for victims of abusive head trauma.

[Clinical forensic examination findings and legal outcome in cases of suspected physical child abuse]. / Klinisch-forensische Untersuchungsergebnisse und rechtliche Folgen bei körperlicher Kindesmisshandlung.

Clinical forensic examinations performed at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected physical abuse of children were analyzed retrospectively with special emphasis on the legal consequences. Altogether, 192 children (85 girls, 107 boys) with a median age of 4.4 years were examined. In 47 cases (24.5 %), the clinical forensic examination findings were interpreted as accidental injuries, birth traumas or unspecific findings. 29 victims (20.0 %) had suffered a shaken baby syndrome. Only part of the presented cases ended with conviction, which was more likely if the victims were aged between 7 and 11 years. Prison terms of 2 years and more were imposed only if the child suffered potentially or acute life-threatening injuries or if additional anogenital lesions were diagnosed indicating sexual child abuse.