Fatal child abuse detected by systematic post-mortem fundus photograph in sudden death in infancy.

In living children, the use of a wide field fundus camera such as RetCam is the gold standard practice to document retinal haemorrhages in suspected cases of abusive head trauma (AHT). In case of sudden unexpected death in infancy (SUDI), child abuse must be considered as a possible cause of death and an eye examination is required. However, no example of post-mortem fundus photograph (PMFP) of retinal haemorrhages related to AHT is yet available for clinicians.We report a SUDI case, with no external traumatic lesions or limb fractures, for which prompt PMFP showed retinal haemorrhages typical of AHT: child abuse was subsequently confirmed by the forensic investigation. We discuss why PMFP is a relevant screening test to detect retinal haemorrhages in the case of SUDI and why the use of the RetCam should be further investigated.

Prosecuting cases of abusive head trauma in Switzerland: a descriptive study of the impact of medical documentation and delay of reporting on judicial outcome.

Abusive head trauma (AHT) is a criminal offence that is prosecuted ex officio, following report to the police from physicians or child protection services. The aim of this study was to assess whether the judicial outcome (dismissal vs indictment) was influenced by the quality of the medical documentation and/or the time span between AHT diagnosis and reporting child abuse to the police. The cohort was divided in two groups: 13/23 dismissals (57%) and 10/23 indictments (43%). The diagnostic probability of the AHT cases was certain for both groups. Nonetheless, in fraction of dismissed cases, alternative explanations for the observed lesions seemed plausible to the public prosecutor. Legal files of only 3/12 dismissed cases had a forensic report, while 6/10 cases that were indicted included a forensic report. Further, the legal file of several dismissed cases entirely lacked medical documentation (3/12), which was not the cases for indicted cases. The period between AHT diagnosis and reporting to the police was not different for dismissals (29 ± 19 days) and indictments (7 ± 4 days) (p = 0.32). Physicians filed reports more rapidly (6 ± 1 days) compared to childhood protection service (70 ± 46 days) (p = 0.01) and that may increase the rate of indictments (9/18) compared to reporting via the childhood protection service (1/5). Despite diagnostic certainty, other causes for the lesions were considered as plausible alternative explanations to judicial professionals in several dismissed cases. These seemed to have less medical documentation and forensic evaluations. In addition, more rapid reporting to the police by physicians seems to increase the likelihood of indictments.

Abusive head trauma and crying infant-Public awareness of newborn and infant trauma.

AIM: Crying seems to be a common trigger for abusive head trauma (AHT), which is the leading cause of fatalities from physical abuse in infants. Our objective was to evaluate knowledge of AHT, crying infants and correct behavioural measures in a general population. METHODS: An online questionnaire (LimeSurvey) was created to assess the risk of shaking. The online survey contained a total of 41 questions, including a demonstration of a previously recorded video in which an infant doll is shaken. RESULTS: A total of 319 people, 245 of them (76.8%) with own children, participated in the study. Almost all respondents (98.4%) were aware of serious injuries due to shaking, even to the point of death (98.1%). Most participants (97.5%) had heard the term 'shaking trauma' prior but did not receive any professional information, neither before nor after birth (85.2% or 86%), or during follow-up examinations (88.5%). The majority of the participants (95%) considered that useful coping strategies in infant crying were inappropriate. CONCLUSION: The consequences of shaking an infant were common knowledge in a normal population, whereas there was a knowledge gap regarding the management of excessive crying infants. Prevention programmes should mainly focus on male caregivers during postnatal care.

Clinical and neuroimaging characteristics in mild-type infantile acute subdural hematoma: report of four cases.

PURPOSE: Infantile acute subdural hematoma (IASDH) has a limited age distribution and mostly benign clinical features. Mild-type IASDH has a stereotypical clinical course which, however, has been described in only a few studies. METHODS: Four male infants (aged 6-10 months; mean age: 7.5 months) were diagnosed as mild-type IASDH associated with retinal hemorrhage (RH) after suffering from occipital impact in a fall. The present case series reviews their clinical features and neuroimaging findings, including CT and MRI findings. RESULTS: All the infants fell backwards from a standing or sitting position onto a soft surface, striking the occipital region. They began crying on impact and then soon afterwards exhibited seizure-like activity or recurrent vomiting. CT and MRI revealed a thin, unclotted subdural hematoma (SDH) without mass effect or brain parenchymal abnormality. Various degrees of bilateral RH were observed. On the day of symptom onset, all infants returned to baseline, and follow-up more than 5 years revealed normal development with no deficits. CONCLUSIONS: Mild-type IASDH with retinal hemorrhage presents with seizure-like activity or recurrent vomiting preceded by crying after an occipital impact on a soft surface. The clinical course of IASDH is followed by rapid recovery on the day of symptom onset. CT and MRI findings reveal a small, unclotted SDH without a mass effect or cerebral parenchymal abnormality.

Prepartum and postpartum mothers' and fathers' feelings of frustration in response to infant crying.

In this cross-sectional study performed in Canada, we evaluated the frustration levels of prepartum and postpartum mother and father couple-pairs. Our goal was to determine if there were differences in frustration levels between mothers and fathers while listening to prolonged infant crying, and further, how frustration levels might differ between prepartum and postpartum samples. Using two discrete groups, prepartum (Sample 1; N = 48) and postpartum (Sample 2; N = 44) mother and father couple-pairs completed 600 s of listening to audio-recorded infant cry sounds. Participants continuously reported their subjective frustration using a computerized Continuous Visual Analog Scale (CVAS). There was no significant difference in frustration responses between mothers and fathers across both prepartum and postpartum samples. Postpartum mothers and fathers experienced greater frustration than their prepartum counterparts, and frustration increased faster in postpartum couples compared to prepartum couples. Informing first-time parents of the universal experiences of frustration to prolonged crying bouts that are characteristic of their infant's early weeks of life may lead to greater understanding towards their infant, and perhaps decreased instances of harmful responses.

En este estudio transeccional, evaluamos los niveles de frustración de las parejas de mamás y papás antes y después del parto. Nuestro propósito fue determinar si hay diferencias entre mamás y papás en cuanto a los niveles de frustración mientras escuchan el prolongado llanto del infante, y cómo los niveles de frustración pudieran diferir entre grupos­muestra antes y después del parto. Usando dos grupos discretos, antes del parto (grupo­muestra 1; N = 48) y después del parto (grupo­muestra 2; N = 44), las parejas de mamás y papás completaron 600 segundos escuchando sonidos grabados en audio de llanto de infante. Los participantes continuamente reportaron su frustración subjetiva usando una escala análoga visual continua computarizada (CVAS). No hubo diferencia significativa en las respuestas de frustración entre mamás y papás a lo largo de los grupos­muestra tanto antes del parto como después del parto. Las mamás y papás en el grupo­muestra después del parto experimentaron mayor frustración que sus homólogos en el grupo­muestra antes del parto, y la frustración aumentó más rápido en las parejas del grupo­muestra después del parto tal como se les comparó con las parejas del grupo­muestra antes del parto. Estos resultados sugieren que las parejas primíparas posterior al parto están más propensas a experimentar considerables cantidades de frustración como respuesta al llanto del infante después que el bebé ha nacido. Informarles a los progenitores primerizos acerca de las experiencias generales de la frustración a los prolongados ataques de llanto que son característicos de las primeras semanas de vida de su infante pudiera llevar a una mayor comprensión hacia su infante y quizás disminuir las instancias de respuestas dañinas.

Dans cette étude transversale nous avons évalué les niveaux de frustration des couples­paires mère et père avant et après la naissance. Notre but était de déterminer s'il existe des différences entres les mères et les pères dans leurs niveaux de frustration en entendant des pleurs de bébé prolongés et de quelle manière les niveaux pourraient différer entre les échantillons avant la naissance et après la naissance. En utilisant deux groupes discrets, avant la naissance (Echantillon 1; N = 48) et après la naissance (Echantillon 2; N = 44) les couples­paires mère et père ont écouté 600 seconds d'enregistrements de pleurs de bébés. Les participants ont fait état de leur frustration subjective en utilisant une échelle analogique visuelle continue informatisée (CVAS). Il s'est avéré n'y avoir aucune différence importante dans les réactions de frustration entre les mères et les pères au travers des échantillons à la fois avant l'accouchement et après l'accouchement. Ces résultats suggèrent que les coupes postpartum primipares sont plus à même de faire l'expérience de niveaux élevés de frustration en réaction aux pleurs du bébé une fois le bébé arrivé. Informer les parents qui sont parents pour la première fois des expériences universelles de frustration aux crises de pleurs prolongées qui caractérisent les premières semaines de la vie des bébés peut mener à une plus grande compréhension de leur bébé et peut­être à une baisse des case d réactions néfastes.

Medical and Legal Uncertainties and Controversies in "Shaken Baby Syndrome" or Infant "Abusive Head Trauma".

Uncertainties and controversies surround "shaken baby syndrome" or infant "abusive head trauma". We explore Vinaccia v The Queen (2022) 70 VR 36; [2022] VSCA 107 and other selected cases from Australia, the United Kingdom and the United States. On expert opinion alone, a "triad" of clinical signs (severe retinal haemorrhages, subdural haematoma and encephalopathy) is dogmatically attributed diagnostically to severe deliberate shaking with or without head trauma. However, the evidence for this mechanism is of the lowest scientific level and of low to very low quality and therefore unreliable. Consequently, expert opinion should not determine legal outcomes in prosecuted cases. Expert witnesses should reveal the basis of their opinions and the uncertainties and controversies of the diagnosis. Further, the reliability of admissions of guilt while in custody should be considered cautiously. We suggest abandonment of the inherently inculpatory diagnostic terms "shaken baby syndrome" and "abusive head trauma" and their appropriate replacement with "infantile retinodural haemorrhage".

Blood proteome of acute intracranial hemorrhage in infant victims of abusive head trauma.

Abusive head trauma (AHT) is a leading cause of mortality and morbidity in infants. While the reported incidence is close to 40 cases per 100'000 births/year, misdiagnoses are commonly observed in cases with atypical, subacute, or chronic presentation. Currently, standard clinical evaluation of inflicted intracranial hemorrhagic injury (ICH) in infants urgently requires a screening test able to identify infants who need additional investigations. Blood biomarkers characteristic of AHT may assist in detecting these infants, improving prognosis through early medical care. To date, the application of innovative omics technologies in retrospective studies of AHT in infants is rare, due also to the blood serum and cerebrospinal fluid of AHT cases being scarce and not systematically accessible. Here, we explored the circulating blood proteomes of infants with severe AHT and their atraumatic controls. We discovered 165 circulating serum proteins that display differential changes in AHT cases compared with atraumatic controls. The peripheral blood proteomes of pediatric AHT commonly reflect: (i) potentially secreted proteome from injured brain, and (ii) proteome dysregulated in the system's circulation by successive biological events following acute ICH. This study opens up a novel opportunity for research efforts in clinical screening of AHT cases.

Assessing retinal hemorrhages with non-invasive post-mortem fundus photographs in sudden unexpected death in infancy.

INTRODUCTION: In the case of sudden unexpected death in infancy (SUDI), eye examination is systematic to detect retinal hemorrhages (RH) that are a crucial hallmark for abusive head trauma (AHT). The aim of this study is to assess the ability of non-invasive post-mortem fundus photographs (PMFP) to detect RH in case of SUDI. METHODS: Bicentric retrospective analysis of consecutive cases of SUDI under 2 years of age were managed by two French SUDI referral centers with PMFP by RetCam (Clarity Medical Systems USA). PMFP were reviewed randomly, twice, by three independent ophthalmologists blinded for clinical data. RESULTS: Thirty cases (60 eyes) were included. Median age was 3.5 months (interquartile [1.6; 6.0]). No child died of AHT. Image quality was sufficient to assert presence or absence of RH in 50 eyes (83%). Sufficient quality rate was significantly higher when the post-mortem interval was inferior to 18 h (91%, 42/46) as opposed to over 18 h (57%, 8/14, p=0.0096). RH were found in six eyes (10%), four children (13%), with excellent inter and intra-raters' concordance (Cohen's Kappa from 0.81 [0.56-1.00] to 1.00 [1.00-1.00]). CONCLUSION: PMFP can detect RH in case of SUDI and is a relevant systematic screening test to be carried out as soon as the deceased child arrives in the hospital. It can decrease the need of eye removal for pathological examination, but further studies are needed to define the best decision algorithm.

Pediatric abusive head trauma: visual outcomes, evoked potentials, diffusion tensor imaging, and relationships to retinal hemorrhages.

PURPOSE: Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures. METHODS: Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR). RESULTS: Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping. DISCUSSION: Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics.

Combined rapid sequence MRI protocol and skull radiography as an alternative to head CT in the evaluation of abusive head trauma in children: a pilot study.

The aim of our pilot study was to compare the performance of the RS-MRI protocol combined with skull radiography versus CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage in patients with abusive head trauma (AHT). Additionally, our study aimed to determine whether the presence of scalp hematoma predicts concurrent skull fracture. We conducted a pilot study through retrospective chart review of 24 patients between ages 0 and 15 months who experienced AHT and who received CT, MRI, and skull radiography between May 2020 and August 2021. Two blinded board certified neuroradiologists reviewed the skull radiographs alongside the rapid trauma MRI. Their impressions were documented and compared with findings derived from CT. Combination imaging detected ten out of the 12 skull fractures noted on CT (sensitivity 83.3%, specificity 100%, p=0.48). RS-MRI detected 15 out of the 16 intracranial hemorrhages detected by CT (sensitivity 93.75%, p >0.9). When scalp hematoma was detected on RS-MRI, nine out of the 12 had associated skull fractures when reviewed by radiologist 1 (sensitivity 75%, specificity 100%, p=0.22), and seven out of the 12 had associated skull fractures when reviewed by radiologist 2 (sensitivity 58%, specificity 92%, p=0.25). In pediatric patients with suspected AHT, we found that RS-MRI combined with skull radiographs was not significantly different than CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage. This combination has the potential to replace the use of CT as a screening tool for abusive head trauma, while avoiding the risks of sedation often required for routine MRI.

Prevalence of cerebral sinovenous thrombosis in abusive head trauma.

BACKGROUND: Cerebral sinovenous thrombosis (CSVT) has been proposed in legal settings to be an atraumatic mimic of abusive head trauma (AHT). OBJECTIVE: The objective of this study was to determine the prevalence of CSVT and subdural hemorrhage (SDH) in a large AHT population. MATERIALS AND METHODS: This retrospective cohort study measured the prevalence of CSVT and SDH on magnetic resonance venograms in 243 patients diagnosed with AHT at a single center. We also reported additional intra- and extracranial injuries, head injury severity and length of hospital stay. RESULTS: Among 243 patients diagnosed with AHT, 7% (16/243) had CSVT. SDH was present in 94% (15/16) of the CSVT cases. Cytotoxic edema and subarachnoid hemorrhage were in 88% (14/16) and 69% (11/16) of the CSVT cases, respectively. Extracranial signs of abuse were also in 100% (16/16) of the patients with CSVT. Critical to maximal head injury severity (abbreviated injury scale >=5) was in 75% (12/16) of the CSVT population vs. 33% (82/243) in the total AHT population. Length of hospital and pediatric intensive care unit stay was greater in those with CSVT (10 vs. 21.9 and 3.5 vs. 7.3 days). CONCLUSION: These findings suggest that CSVT is uncommon in AHT and is associated with additional traumatic injuries and greater injury severity.

Benign enlargement of the subarachnoid spaces and subdural collections-when to evaluate for abuse.

In infants without a history of trauma, subdural haemorrhages should raise the concern for an abusive head injury, particularly when they are associated with bridging vein clotting/rupture or with septations. However, non-haemorrhagic, fluid-appearing subdural collections (also called hygromas) may also be the result of abuse. Subdural collections have also been uncommonly observed in patients with benign enlargement of the subarachnoid spaces (BESS) and a few large-scale studies accurately investigate the incidence and the significance. Currently, there is a wide variation of practices in children with BESS and subdural collections. Due to the social risks associated with abuse evaluation and the perceived risk of radiation exposure, there might be a reluctance to fully evaluate these children in some centres. The diagnosis of physical abuse cannot be substantiated nor safely excluded in infants with BESS and subdural collection(s), without investigation for concomitant traumatic findings. The exact prevalence of occult injuries and abuse in these infants is unknown. In macrocephalic infants with subdural collections and imaging features of BESS, thorough investigations for abuse are warranted and paediatricians should consider performing full skeletal surveys even when fundoscopy, social work consult, and detailed clinical evaluation are unremarkable.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma.

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

Effective Epilepsy Surgery for Post-Traumatic West Syndrome Following Abusive Head Trauma.

West syndrome, an infantile developmental and epileptic encephalopathy with a deleterious impact on long-term development, requires early treatment to minimize developmental abnormality; in such cases, epilepsy surgery should be considered a powerful therapeutic option. We describe a 10-month-old female admitted with West syndrome associated with a hemispheric lesion following abusive head trauma. Her seizures were suppressed by hemispherotomy at 12 months of age, leading to developmental improvement. Surgical treatment of West syndrome following traumatic brain injury has not been reported previously but is worth considering as a treatment option, depending on patient age and brain plasticity.

Comparisons of characteristics and outcome between abusive head trauma and non-abusive head trauma in a pediatric intensive care unit.

BACKGROUND: Abusive head trauma (AHT) is the leading cause of death in infants with traumatic brain injury (TBI). Early recognition of AHT is important for improving outcomes, but it can be challenging due to its similar presentations with non-abusive head trauma (nAHT). This study aims to compare clinical presentations and outcomes between infants with AHT and nAHT, and to identify the risk factors for poor outcomes of AHT. METHODS: We retrospectively analyzed infants of TBI in our pediatric intensive care unit from January 2014 to December 2020. Clinical manifestations and outcomes were compared between patients with AHT and nAHT. Risk factors for poor outcomes in AHT patients were also analyzed. RESULTS: 60 patients were enrolled for this analysis, including 18 of AHT (30%) and 42 of nAHT (70%). Compared with those with nAHT, patients with AHT were more likely to have conscious change, seizures, limb weakness, and respiratory failure, but with a fewer incidence of skull fractures. Additionally, clinical outcomes of AHT patients were worse, with more cases undergoing neurosurgery, higher Pediatric Overall Performance Category score at discharge, and more anti-epileptic drug (AED) use after discharge. For AHT patients, conscious change is an independent risk factor for a composite poor outcome of mortality, ventilator dependence, or AED use (OR = 21.9, P = 0.04) CONCLUSION: AHT has a worse outcome than nAHT. Conscious change, seizures and limb weaknesses but not skull fractures are more common in AHT. Conscious change is both an early reminder of AHT and a risk factor for its poor outcomes.

Suspected abusive head trauma in children - when do they really need to be transferred to a neurosurgical unit?

OBJECTIVES: Transferring paediatric patients with suspected abusive head trauma (AHT) to paediatric neurosurgical centres, disrupts safeguarding investigations. Therefore, it is desirable that suspected AHTs are transferred only when clinically necessary. The aim of this study was to describe referral patterns of patients referred to a tertiary paediatric neurosurgical centre with suspected AHT, with the view of informing future transfer of AHT patients. DESIGN: A retrospective review was performed of all suspected AHT patients referred to the University Hospital of Wales between 2012 and 2021. METHODS: Rates of surgery, intubation and ventilation, radiological findings and presenting GCS were compared between referred patients and those transferred for neurosurgical care. Variables were compared between the transferred and the non-transferred groups. For categorical variables, Chi-squared tests were performed, with Fisher's exact test used where the expected count was less than 5. Odds ratios (OR) for neurosurgical transfer with radiological or clinical features at presentation were calculated. RESULTS: A total of 76 patients were referred, of which 18 were transferred for neurosurgical care. Of these, six were intubated and ventilated. Only one transferred patient required surgery, with the remainder receiving supportive care. Amongst the transferred group, 77.8% had SDHs and 68.6% had a GCS ≥ 13 at presentation. Patients with a GCS ≥ 13 and SDHs, bilateral haematomas or a history of vomiting were significantly more likely to be transferred (OR = 4.27, 95%CI 1.01-18.00, p = .05). CONCLUSIONS: Most transferred patients with suspected AHT did not receive surgical intervention. We suggest that patients should be transferred when it is likely that they will require surgery, otherwise they should stay locally in order to complete their safeguarding investigations. Immediate transfer may not be necessary for AHT patients with a GCS ≥ 13 and either vomiting, SDHs or bilateral haematomas, provided they are unlikely to require emergency surgery.

Abusive Head Trauma Animal Models: Focus on Biomarkers.

Abusive head trauma (AHT) is a serious traumatic brain injury and the leading cause of death in children younger than 2 years. The development of experimental animal models to simulate clinical AHT cases is challenging. Several animal models have been designed to mimic the pathophysiological and behavioral changes in pediatric AHT, ranging from lissencephalic rodents to gyrencephalic piglets, lambs, and non-human primates. These models can provide helpful information for AHT, but many studies utilizing them lack consistent and rigorous characterization of brain changes and have low reproducibility of the inflicted trauma. Clinical translatability of animal models is also limited due to significant structural differences between developing infant human brains and the brains of animals, and an insufficient ability to mimic the effects of long-term degenerative diseases and to model how secondary injuries impact the development of the brain in children. Nevertheless, animal models can provide clues on biochemical effectors that mediate secondary brain injury after AHT including neuroinflammation, excitotoxicity, reactive oxygen toxicity, axonal damage, and neuronal death. They also allow for investigation of the interdependency of injured neurons and analysis of the cell types involved in neuronal degeneration and malfunction. This review first focuses on the clinical challenges in diagnosing AHT and describes various biomarkers in clinical AHT cases. Then typical preclinical biomarkers such as microglia and astrocytes, reactive oxygen species, and activated N-methyl-D-aspartate receptors in AHT are described, and the value and limitations of animal models in preclinical drug discovery for AHT are discussed.

Value of stomach content in a case of fatal child homicide.

In death investigations, the volume of gastric contents may be useful concerning the time of death estimation, or to clarify the circumstances of death. Here, the case of a 4-month-old male infant who was found dead in his mother's bed is presented. SIDS was assumed as the cause of death after initial police investigations. Later, autopsy results revealed that this case was a homicide due to extensive abusive head trauma. The infant had three skull fractures on the back of his head with subdural hemorrhage and cerebral oedema. The survival time after feeding him formula and corresponding the time of death was determined to evaluate the mother's initial claims that the infant was alive several hours after feeding. In this case, the volume of stomach contents of the last meal was known. From the volume of milky fluid found in the stomach at autopsy, it was possible to estimate the time of death within a narrow time frame of less than one hour after feeding. The mother's claims could be ruled out, and she later confessed to having killed the child soon after feeding him. Even methods with low precision for estimating time of death, like examining stomach contents, can be essential for solving practical cases. To our knowledge, this is one of the first published cases in which an infant's stomach content was used successfully in the reconstruction of a homicide.

Pathogenic variant in NFIA associated with subdural hematomas mimicking nonaccidental trauma.

Subdural hematoma (SDH) in infants raises the concern for nonaccidental trauma (NAT), especially when presenting with associated injuries. However, isolated SDH could be caused by multiple etiologies. NFIA (MIM# 600727) encodes nuclear factor I A protein (NFI-A), a transcription factor which plays important roles in gliogenesis. Loss-of-function variants in NFIA are associated with autosomal dominant brain malformations with or without urinary tract defects (MIM# 613735). Intracranial hemorrhage of various types besides SDH has been reported in patients with this condition. Here, we report a patient with a heterozygous novel NFIA pathogenic variant affecting splicing who initially presented with SDH concerning for NAT. We also review previous NFIA-related disorder cases with intracranial hemorrhage. This report emphasizes the importance of genetic evaluation in infants presenting with isolated SDH.

The role of retinal imaging in the management of abusive head trauma cases.

BACKGROUND: As retinal hemorrhage (RH) is the most frequent and reliable finding of abusive head trauma (AHT), an ophthalmology consultation should be systematically required in suspected cases. Full retinal examination through pharmacologically dilated pupil can detect the type and pattern of RHs, helping to distinguish abusive from non-abusive head trauma. METHODS: We performed a retrospective analysis of a case series of 6 infants (aged 0.6-10 months) with AHT who were admitted to the Emergency Department of Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome with severe intracranial hemorrhages. Children underwent full multidisciplinary assessment including dilated fundus examination, optical coherence tomography (OCT) and digital wide-field fundus photography (DWFFP - in our case RetCam). In our paper we report the clinical presentation, the ocular findings and outcome at discharge. RESULTS: The mean age at the hospital admission was 6.28 months. In all infants, intracranial hemorrhages were found. Preretinal and intraretinal hemorrhages were detected, collecting good-quality retinal images. CONCLUSIONS: Imaging of retinal hemorrhages represents a fundamental moment of AHT diagnosis and documentation. Although RetCam is the gold standard for the acquisition of retinal images in suspected cases, OCT is extremely valuable in forensic evaluation since it can detect even small macular hemorrhages. Therefore, the combination of RetCam and OCT imaging can give relevant hints for the diagnosis of AHT, allowing to evaluate the extent, spread and morphology of RHs.