Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence.

The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine.

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.

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".

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.

Re-evaluation of medical findings in alleged shaken baby syndrome and abusive head trauma in Norwegian courts fails to support abuse diagnoses.

AIM: The criteria for diagnosing abusive head trauma (AHT) are not well defined and this condition might be diagnosed on failing premises. Our aim was to review criminal AHT cases in Norwegian courts by scrutinising the underlying medical documentation. METHODS: Cases were identified in the data registry for Norwegian courts from 2004 to 2015. Documentation was obtained from relevant health institutions. The medical co-authors first made independent evaluations of the documentation for each child, followed by a consensus evaluation. RESULTS: A total of 17 children (11 boys) were identified, all diagnosed as AHT by court appointed experts, 15 were infants (mean age 2.6 months). A high proportion (41.2%) was born to immigrant parents and 31.3% were premature. The medical findings could be explained by alternative diagnoses in 16 of the 17 children; 8 boys (7 infants - mean age 2.9 months) had clinical and radiological characteristics compatible with external hydrocephalus complicated by chronic subdural haematoma. Six children (five infants with mean age 2.1 months) had a female preponderance and findings compatible with hypoxic ischaemic insults. CONCLUSION: The medical condition in most children had not necessarily been caused by shaking or direct impact, as was originally concluded by the court experts.

The legal challenges to the diagnosis of shaken baby syndrome or how to counter 12 common fake news.

BACKGROUND: The shaken baby syndrome (SBS) is a common cause of severe traumatic lesions in infants. Although well established for almost five decades, SBS and its diagnosis are becoming more and more aggressively challenged in courts. These challenges feed on the scientific debate and controversies regarding the pathophysiology and the differential diagnoses, scientific uncertainty being readily exploited by specialized barristers. MATERIAL AND METHODS: In the present review, we analyze the most common challenges to the concept of SBS and its diagnosis, as well as the scientific evidence available to counter these challenges, the differential diagnoses, and how SBS can be diagnosed with confidence. RESULTS: We found that the pathophysiology of SBS is well documented, with stereotyped descriptions by perpetrators, in good correlation with experimental studies and computer models. SBS is a well-defined clinico-pathological entity with a characteristic constellation of lesions; with a rigorous evaluation protocol, its diagnosis can be made rapidly and with excellent accuracy beyond a reasonable doubt. CONCLUSION: It is important that medical experts master an extensive knowledge regarding the pathophysiology of the lesions of SBS, in particular infantile subdural hematomas, as well as other CSF-related conditions. This emphasizes the role that pediatric neurosurgeons should play in the clinical and medicolegal management of these patients.

Answer to Squier et al.

The author responds to critics formulated by W Squier regarding our paper "The legal challenges to the diagnosis of shaken baby syndrome Or: how to counter 12 common fake news.

Animal models of pediatric abusive head trauma.

BACKGROUND: Abusive head trauma (AHT), previously known as the shaken baby syndrome, is a severe and potentially fatal form of traumatic brain injury in infant children who have been shaken, and sometimes also sustained an additional head impact. The clinical and autopsy findings in AHT are not pathognomonic and, due to frequent obfuscation by perpetrators, the circumstances surrounding the alleged abuse are often unclear. The concept has evolved that the finding of the combination of subdural hemorrhage, brain injury, and retinal hemorrhages ("the triad") is the result of shaking of an infant ("shaken baby syndrome") and has led to the ongoing controversy whether shaking alone is able to generate sufficient force to produce these lesions. OBJECTIVE: In an attempt to investigate whether shaking can engender this lesion triad, animal models have been developed in laboratory rodents and domestic animal species. This review assesses the utility of these animal models to reliably reproduce human AHT pathology and evaluate the effects of shaking on the immature brain. RESULTS: Due largely to irreconcilable anatomic species differences between these animal brains and human infants, and a lack of resemblance of the experimental head shaking induced by mechanical devices to real-world human neurotrauma, no animal model has been able to reliably reproduce the full range of neuropathologic AHT changes. CONCLUSION: Some animal models can simulate specific brain and ophthalmic lesions found in human AHT cases and provide useful information on their pathogenesis. Moreover, one animal model demonstrated that shaking of a freely mobile head, without an additional head impact, could be lethal, and produce significant brain pathology.

A suspected case of shaken baby syndrome-clinical management in Germany: a case-based overview.

PURPOSE: Each year, between 100 and 200 cases with shaken baby syndrome (SBS) are hospitalized in Germany. The reported incidence is 14 in 100,000 children. About 10 to 30% of the affected children do not survive. A high number of unreported cases are assumed. The rate of lifelong disability is high. The current situation in respect of abusive head injuries in infants has been investigated. MATERIAL AND METHODS: A case-based overview on the management of SBS in a German reference center for pediatric neurosurgery is presented and discussed against the background of forensic data and child protection network institutions and guidelines. RESULTS: The presented case is an example of a typical SBS presentation. All necessary diagnostic and therapeutic steps are explained and evaluated according to the existing guidelines in Germany. The authors state that hospital SOP can help to detect suspected cases of SBS and define the role of the pediatric neurosurgeon. Although the abusive mechanism of a head trauma is clear in most cases, forensic methods lack the precision to identify a perpetrator in all of them. According to an analysis of a multi-center study on criminal proceedings in Germany, 50% of the proceedings were closed without judgment due to lack of suspicion. Out of the remaining half with judgment, in 17%, the court decided on acquittal since the perpetration could not be assigned to a specific individual. CONCLUSION: Prevention is the most important factor to protect children from death and disability caused by inflicted brain injury. Pediatric healthcare professionals must be aware of typical signs of suspected child abuse, SBS in particular, and institutional SOP can help to improve management and outcome in these children. Forensic methods lack the precision to identify a perpetrator in every case.

Abusive head injuries in infants: from founders to denialism and beyond.

INTRODUCTION: Abusive head injuries is a major cause of severe morbidity and the main cause of mortality by head trauma in infants. MATERIAL AND METHODS: Based on published data and their own clinical and medicolegal practice, the authors review briefly the historical roots and emergence of the concept of abusive head injuries (AHI), until the present scientific understanding of shaken baby syndrome (SBS) and Silverman syndrome. They then discuss the present epidemic of denialism and how this challenge to science should be seen as a stimulus to increase research and improve the accuracy of diagnosis and medical practice. RESULTS: The denial of SBS is especially damaging because it undermines the possibilities of prevention and reparation for victims. The authors expand on AHI being part of a wider context of domestic violence and the prevention of child abuse being part of a broad and long-term endeavor to defend civilization values. CONCLUSIONS: Prevention of AHI is a major challenge for the future. In the fields of science and prevention of child abuse, the input of pediatric neurosurgeons should not be underestimated.

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.

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.

The diagnosis and management of abusive head injuries in infancy in Egypt.

Child death owed to abuse and negligence is not uncommon, and its real incidence is unknown. The most common cause of fatal child abuse is head trauma. Abusive head injuries (AHI) most often involve brain injury of infants and young children. The outcomes of AHI vary from complete recovery to severe brain damage and death. This article highlights the diagnosis and management of AHI in infancy in Egypt, with a special focus on the social, medical, and legal aspects. The authors emphasize the importance of reporting cases suspected of AHI to the relevant authorities; this will guard against the recurrence of abuse to the child and will have a positive impact on the community.

Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

BACKGROUND: Criteria for diagnosing abusive head trauma (AHT) or "shaken baby syndrome" are not well defined; consequently, these conditions might be diagnosed on failing premises. METHODS: The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)-mean age 5.1 month, without age difference between genders. RESULTS: Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH). CONCLUSIONS: BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors' experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

Attacked and Shaken by a Dog: A Cause of Traumatic Brain and Carotid Injury in an Infant.

BACKGROUND: Posttraumatic carotid artery dissection (PTCAD) is a common injury in motor vehicle accidents and other extension and rotation injuries, but rarely developed from being shaken vigorously. CASE DESCRIPTION: A 7-day-old infant presented to our facility after being attacked by a large dog. Initial examination revealed multiple puncture wounds and lacerations with visible dura. Head CT demonstrated subarachnoid, intraparenchymal, and epidural hemorrhages as well as left hemispheric loss of gray-white differentiation. Thus, the patient presented similarly to shaken baby syndrome (SBS). The patient was taken emergently to the operating room for hematoma evacuation and dural repair. Postoperatively, worsened left hemispheric ischemia was noted and an MRA demonstrated a Grade IV left ICA dissection. No intervention, including anticoagulation, was sought as the stroke was determined to be complete with irreversible damage. Hospital course was complicated by worsening exam, seizures, and a retinal hemorrhage. At 2 years follow-up, the patient still has notable delays but is progressing slowly through milestones. CONCLUSION: Large animal attacks are a rare cause of PTCAD but may be due to the mechanism of shaking during the attack. We propose either CTA or MRA be considered as part of the initial workup in cases where an infant is attacked by a dog or other large animals, preventing delay of treatment.

[Shaken Baby Syndrome, legal aspects]. / Syndrome du bébé secoué, aspects juridiques.

In July 2017, the French National Authority for Health published a recommendation for good practice specific to shaken baby syndrome specifying the diagnostic approach, the mechanisms involved in shaking and the date of injury. This recommendation details the legal aspects in the case of a diagnosis of non-accidental head trauma, as well as the procedure to follow to report these situations. The High Authority for Health reaffirms this recommendation in December 2019, insisting on the importance of the role of carers in the identification, diagnosis and prevention of these situations.

[Neurological sequels and follow-up of the child victim of non-accidental head trauma]. / Séquelles neurologiques et suivi de l'enfant victime.

Babies who suffer non-accidental head injuries systematically show sequels, whether they are neurological, cognitive or behavioural. Some of these disorders are immediately identified, such as neurological sequels, but others, such as cognitive or behavioural disorders, are revealed much later. Regular monitoring by a neuro-paediatrician is therefore essential in order to be able to adapt the child's care as closely as possible to his or her needs according to the sequels presented.

[Caring for the shaken child and his/her family]. / Prendre soin de l'enfant victime de secouement et de sa famille.

The infant victim of shaken baby syndrome, also known as non-accidental head trauma, is, in some cases, admitted to a social nursery after hospitalisation, within the framework of a legal placement. Professionals are then in charge of accompanying him and his family, in order to lead them on the path of psychological and physical reconstruction.

[Hospital management of the child victim of non-accidental head injury]. / Prise en charge hospitalière de l'enfant victime de traumatisme crânien non accidentel.

The baby victim of a shock is not always diagnosed at the time of his first visit to the emergency room. The recommendation for good practice in situations of shaken baby syndrome, published in July 2017 by the French National Authority for Health, helps in the diagnosis and management of these infants by health care providers. When this diagnosis is made, the baby's care pathway is generally long and punctuated by multiple examinations.

Swept-source OCT findings in shaken baby syndrome: case report.

BACKGROUND: Our purpose was to document the swept source optical coherence tomography (SSOCT) findings in a patient with Shaken baby syndrome (SBS). CASE PRESENTATION: SSOCT was obtained without sedation in a six-month-old girl with bilateral multilayered retinal hemorrhages due to SBS. It documented vitreoretinal interface abnormalities, including internal limiting membrane (ILM) detachment with retinal traction, in association with other specific changes in the inner and outer retinal layers. Six weeks later, retinal hemorrhages had substantially resolved, and there was optic disc pallor. OCT showed ILM reattachment with release of retinal traction and the development of severe diffuse retinal atrophy involving the fovea. CONCLUSIONS: SS OCT can provide useful information in SBS, revealing a wide variety of vitreoretinal interface, inner, and outer retinal changes not detected by clinical examination. It also may have a prognostic value over follow-up.