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".

Childminder knowledge of shaken baby syndrome and the role played by childminders in prevention: An observational study in France.

BACKGROUND: Shaken baby syndrome (SBS) triggers negative short- and long-term outcomes. In France, registered childminders are the principal source of daycare. They may encounter SBS imparted by caregivers or simply excessive infant crying. The aim of the study was to explore childminder knowledge on SBS, the source of information, the responses to infant crying, how childminders perceived their roles in terms of caregiver SBS prevention, and the factors associated with a good knowledge of SBS. METHODS: The participants were registered childminders working in the French department of Gironde who had email accounts. This observational study employed an anonymous online questionnaire distributed by the maternal and child health services unit of the Gironde department over 5 weeks from 16 September 2021. Data on childminder characteristics, knowledge on SBS, responses to infant crying, and perceptions of their roles in SBS prevention were collected. The knowledge score ranged from 0 (all wrong answers) to 30 (all correct answers). RESULTS: A total of 779 registered childminders participated; 43.9 % had learnt about SBS during their initial training and 75 % before (other training) or after initial training. The median knowledge score was 19/30 (interquartile range [16; 21]). A higher educational level, previous other professional experience, training on SBS, and responsibility for few children were associated with higher scores. Ten reported that they did not advise caregivers who complained of infant crying. CONCLUSION: Childminders require training on SBS and SBS prevention.

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.

The Effectiveness of Parenting Programs in Preventing Abusive Head Trauma: A Systematic Review and Meta-Analysis.

Parenting programs are the most common intervention for preventing the lethal form of child maltreatment, abusive head trauma (AHT). However, certain results of the effects of these programs have not yet been compared across studies. A systematic review with meta-analysis is warranted to quantitively synthesize the available evidence to identify effective elements and strategies of the programs for preventing AHT. This review aims to estimate AHT preventive parenting programs' pooled effect on the reduction of AHT incidence, the improvement of parental knowledge, and the increased use of safe strategies in response to infants' inconsolable crying. Studies published in English and Mandarin were searched and retained if they were randomized control trials (RCTs) or with a quasi-experimental design, included an AHT preventive parenting program, and provided data that quantified targeted outcomes. Eighteen studies were included in this review. AHT preventive parenting programs had a pooled effect on improving parents' knowledge and increasing the use of safe coping strategies in response to inconsolable crying but not on the incidence of AHT and parents' emotional self-regulation. Subgroup analyses showed that the intervention effects were mostly present across study designs or measurements and emerged in the reduction of AHT incidence compared with historical controls. The findings suggest that AHT preventive parenting programs enhance parenting knowledge and skills to provide safe care for infants. Further efforts to evaluate AHT parenting programs on the reduction of AHT incidence are necessary for decision-making on allocating and disseminating interventions.

Shaken baby syndrome in an infant treated for retinopathy of prematurity with anti-VEGF injection.

We present the case of an infant who received bevacizumab treatment for retinopathy of prematurity (ROP) and developed retinal hemorrhages 12 weeks later. Although preretinal hemorrhages along the ROP's ridge were a concern for recurrence, we decided to investigate other etiologies because of numerous retinal hemorrhages in different retinal layers and their concentration in the posterior pole. Cranial magnetic resonance imaging revealed a new-onset subdural hemorrhage. Factors that were suspicious for trauma were identified in the detailed history taken from the family by the hospital's child abuse team. This case highlights the importance of considering the characteristics of retinal hemorrhages in infants with ROP and conducting any necessary investigation.

The Eyes Have It: How Critical are Ophthalmic Findings to the Diagnosis of Pediatric Abusive Head Trauma?

Pediatric abusive head trauma (AHT), still colloquially known as shaken baby syndrome, is a leading cause of morbidity and mortality among infants. Controversy has grown surrounding this diagnosis, and the specificity of the clinical findings-subdural hemorrhage, cerebral edema, and retinal hemorrhages-has been challenged. A literature search of peer reviewed publications on PubMed pertaining to the history, clinical, and pathologic features of AHT was conducted using the terms "shaken baby syndrome," "non-accidental trauma," "abusive head trauma," "inflicted traumatic brain injury," "shaken impact syndrome," and "whiplash shaken infant syndrome." Focus was placed on articles discussing ophthalmic findings in AHT. Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies.

Shaken Baby Syndrome Education for Mothers Awaiting Appointments in Rural OB/GYN Office.

A partnership between a nursing program and a rural obstetric office provided education to pregnant and postpartum women about coping with infant crying and the dangers of shaking a baby. Undergraduate nursing students delivered the Period of PURPLE Crying (PURPLE) educational program to 148 mothers. Change in knowledge about infant crying and the community clinical experience was evaluated. Pre and post intervention data were collected. Descriptive statistics indicated higher scores on mothers' posttest for knowledge about normal newborn crying behaviors and coping strategies. Students further developed the role of educator and researcher. These findings suggest the intervention contributed to mothers' improved knowledge about infant crying. Results of the pilot study are encouraging because the intervention had a significant effect on mothers' knowledge about infant crying and Shaken Baby Syndrome (SBS).

Shaken Baby Syndrome (SBS) or Pediatric Abusive Head Trauma from Shaking: Guidelines for Interventions During the Perinatal Period from the French National College Of Midwives.

Shaken baby syndrome is the most severe head injury in children. Shaking is an extremely violent gesture, often repeated. The children affected are generally less than a year old, in 2/3 of cases, less than 6 months old. More than 10% of them die, and more than three-quarters of the survivors have long-term effects. Prevention is therefore essential. When a parent (or any person) is strongly upset by an infant's uncalmable crying, the best thing for them to do is to lay the child down in a supine position in his or her bed, leave the room, and then ask for help.

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 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.

The role of the pediatric neurosurgeon in abusive head injuries: a survey of members of the International Society for Pediatric Neurosurgery.

BACKGROUND AND PURPOSE: Pediatric neurosurgeons are at the forefront of the clinical management of abusive head injuries (AHI) all over the world. However, the discrepancies regarding medical practice and legal requirements in different centers have not been assessed before. MATERIAL AND METHODS: We decided to perform an online survey among members of the International Society for Pediatric Neurosurgery (ISPN) regarding their activity, their usual clinical practice regarding the medical and legal management of AHI, and their involvement in judiciary proceedings, research, and prevention campaigns. RESULTS: Ninety members of the ISPN participated in the survey, representing 26% of the registered members. Most responders were senior pediatric neurosurgeons practicing in a university hospital. Their responses show great homogeneity regarding surgical, intensive care, and legal management. We also noted the widespread use of invasive intracranial pressure monitoring and decompressive craniotomy. By contrast, the responses show great disparity regarding the circuit of patients. This disparity may be an obstacle to the collection of data and clinical research, as well as for the involvement of neurosurgeons in multidisciplinary evaluation. A minority of neurosurgeons were engaged in research and actions of prevention. CONCLUSION: Pediatric neurosurgeons play a pivotal role in the diagnosis and medical management of AHI. Because of their proficiency in head trauma and cerebrospinal fluid disorders, it is desirable that they become more implicated in multidisciplinary meetings, medical expertise, and scientific research, as well as actions of prevention.