Cerebral hemorrhage caused by shaking adult syndrome? Evidence from biomechanical analysis using 3D motion capture and finite element models.

The present study combined three-dimensional (3D) motion capture with finite element simulation to reconstruct a real shaking adult syndrome (SAS) case and further explore the injury biomechanics of SAS. The frequency at which an adult male can shake the head of another person, head-shaking amplitude, and displacement curves was captured by the VICON 3D motion capture system. The captured shaking frequency and shaking curve were loaded on the total human model for safety (THUMS) head to simulate the biomechanical response of brain injury when a head was shaken in anterior-posterior, left-right, and left anterior-right posterior directions at frequencies of 4 Hz (Hz), 5 Hz, 6 Hz, and 7 Hz. The biomechanical response of the head on impact in the anterior, posterior, left, left anterior, and right posterior directions at the equivalent velocity of 6 Hz shaking was simulated. The violent shaking frequency of the adult male was 3.2-6.8 Hz; head shaking at these frequencies could result in serious cerebral injuries. SAS-related injuries have obvious directionality, and sagittal shaking can easily cause brain injuries. There was no significant difference between the brain injuries caused by shaking in the simulated frequency range (4-7 Hz). Impact and shaking at an equivalent velocity could cause brain injuries, though SAS more commonly occurred due to the cumulative deformation of brain tissue. Biomechanical studies of SAS should play a positive role in improving the accuracy of forensic identification and reducing this form of abuse and torture in detention or places of imprisonment.

For Victims of Fatal Child Abuse, Who Has the Right to Consent to Organ Donation?

In rare circumstances, children who have suffered traumatic brain injury from child abuse are declared dead by neurologic criteria and are eligible to donate organs. When the parents are the suspected abusers, there can be confusion about who has the legal right to authorize organ donation. Furthermore, organ donation may interfere with the collection of forensic evidence that is necessary to evaluate the abuse. Under those circumstances, particularly in the context of a child homicide investigation, the goals of organ donation and collection and preservation of critical forensic evidence may seem mutually exclusive. In this Ethics Rounds, we discuss such a case and suggest ways to resolve the apparent conflicts between the desire to procure organs for donation and the need to thoroughly evaluate the evidence of abuse.

Abusive Head Trauma in Infants and Children.

Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.

Shaken baby syndrome: what certainty do we have?

BACKGROUND: Shaken baby syndrome is a common and devastating disease in infants. In spite of its frequency, many controversies persist, regarding the pathophysiology, diagnosis, and management. AIM OF THE STUDY: We reviewed several salient and challenging issues related to SBS, like its pathogenesis, predisposing factors, differential diagnosis, and prevention programs. MATERIAL AND METHODS: We derive arguments from the literature and from our prospective registry of accidental and non-accidental traumas in infants. CONCLUSIONS: Much remains to be understood in SBS, and prevention programs for this entirely man-made disaster are still in their infancy. Pediatric neurosurgeons should be involved actively in the medical management and research on SBS.

Biomechanical Response of the Infant Head to Shaking: An Experimental Investigation.

Controversy exists regarding whether violent shaking is harmful to infants in the absence of impact. In this study, our objective was to characterize the biomechanical response of the infant head during shaking through use of an instrumented anthropomorphic test device (commonly referred to as a "crash test dummy" or surrogate) representing a human infant and having improved biofidelity. A series of tests were conducted to simulate violent shaking of an infant surrogate. The Aprica 2.5 infant surrogate represented a 5th percentile Japanese newborn. A 50th percentile Japanese adult male was recruited to shake the infant surrogate in the sagittal plane. Triaxial linear accelerometers positioned at the center of mass and apex of the head recorded accelerations during shaking. Five shaking test series, each 3-4 sec in duration, were conducted. Outcome measures derived from accelerometer recordings were examined for trends. Head/neck kinematics were characterized during shaking events; mean peak neck flexion was 1.98 radians (113 degrees) and mean peak neck extension was 2.16 radians (123 degrees). The maximum angular acceleration across all test series was 13,260 radians/sec2 (during chin-to-chest contact). Peak angular velocity was 105.7 radians/sec (during chin-to-chest contact). Acceleration pulse durations ranged from 72.1 to 168.2 ms. Using an infant surrogate with improved biofidelity, we found higher angular acceleration and higher angular velocity than previously reported during infant surrogate shaking experiments. Findings highlight the importance of surrogate biofidelity when investigating shaking.

Shaken baby syndrome: pathogenetic mechanism, clinical features and preventive aspects.

The shaken baby syndrome (SBS) is an extremely serious form of child abuse and a leading cause of death and disability in childhood. The syndrome usually occurs in infants younger than 1 year when a parent or a care-giver tries to stop the baby from crying by vigorous manual shaking. The repetitive oscillations with rotational acceleration of the head can result in injuries of both vascular and neuronal structures. The most frequent injuries associated with SBS include encephalopathy, retinal hemorrhages, and subdural hemorrhage. Fractures of the vertebrae, long bones, and ribs may also be associated with the syndrome. Victims of abuse have various presenting signs and symptoms ranging from irritability, decreased responsiveness and lethargy to convulsions, and death. Diagnosis is often difficult because usually parents or caregivers not tell the truth about what has happened to their child and because usually there is no external evidence of trauma. However, the syndrome might be suspected if the information provided are vague or changing and when the child presents with retinal hemorrhages, subdural hematoma, or fractures that cannot be explained by accidental trauma or other medical conditions. Of infants who are victims of SBS, approximately 15% to 38% die and 30% are at risk of long-term neurologic sequelae, including cognitive and behavioural disturbances, motor and visual deficits, learning deficits and epilepsy. Parents and caregivers must be warned about the dangers of shaking infants.

Still an unknown topic: child abuse and "shaken baby syndrome".

BACKGROUND: Shaken baby syndrome (SBS) is a severe form of physical child abuse, and can even cause death. In this study, we aimed to investigate whether or not the primary healthcare workers had received any education regarding child abuse and neglect, whether they could diagnose the cases, whether they had sufficient knowledge about SBS as a part of child abuse, and whether they were in need of education on the topic. METHODS: Health workers in the primary healthcare centers in the province of Kayseri were enrolled. A questionnaire was applied. RESULTS: In this study, 35.0% of the study group were physicians. 43.7% of the study group stated that they had not recieved any education regarding child abuse and neglect, and 52.1% stated that they believed that physical abuse was the most prominent form of abuse in society. While 64.1% of the participants stated that they had heard about SBS, 10.4% of these stated that they had heard about it, but did not have adequate knowledge on the topic. CONCLUSION: There is a lack of knowledge and a need for education regarding child abuse and neglect among the personnel working in primary healthcare, especially on the subject of SBS. Undergraduate and postgraduate education regarding child abuse and SBS will help to increase the number of people well-informed and sensitive to this important issue.

The "Shaken Baby" syndrome: pathology and mechanisms.

The "Shaken Baby" syndrome (SBS) is the subject of intense controversy; the diagnosis has in the past depended on the triad of subdural haemorrhage (SDH), retinal haemorrhage and encephalopathy. While there is no doubt that infants do suffer abusive injury at the hands of their carers and that impact can cause catastrophic intracranial damage, research has repeatedly undermined the hypothesis that shaking per se can cause this triad. The term non-accidental head injury has therefore been widely adopted. This review will focus on the pathology and mechanisms of the three physiologically associated findings which constitute the "triad" and are seen in infants suffering from a wide range of non-traumatic as well as traumatic conditions. "Sub" dural bleeding in fact originates within the deep layers of the dura. The potential sources of SDH include: the bridging veins, small vessels within the dura itself, a granulating haemorrhagic membrane and ruptured intracranial aneurysm. Most neuropathologists do not routinely examine eyes, but the significance of this second arm of the triad in the diagnosis of Shaken Baby syndrome is such that it merits consideration in the context of this review. While retinal haemorrhage can be seen clinically, dural and subarachnoid optic nerve sheath haemorrhage is usually seen exclusively by the pathologist and only rarely described by the neuroradiologist. The term encephalopathy is used loosely in the context of SBS. It may encompass anything from vomiting, irritability, feeding difficulties or floppiness to seizures, apnoea and fulminant brain swelling. The spectrum of brain pathology associated with retinal and subdural bleeding from a variety of causes is described. The most important cerebral pathology is swelling and hypoxic-ischaemic injury. Mechanical shearing injury is rare and contusions, the hallmark of adult traumatic brain damage, are vanishingly rare in infants under 1 year of age. Clefts and haemorrhages in the immediate subcortical white matter have been assumed to be due to trauma but factors specific to this age group offer other explanations. Finally, examples of the most common causes of the triad encountered in clinical diagnostic and forensic practice are briefly annotated.

Study of an infant brain subjected to periodic motion via a custom experimental apparatus design and finite element modelling.

This paper presents a rig that was specifically designed to simulate the shaking of mechanical models of biological systems, especially those related to shaken baby syndrome (SBS). The scope of this paper includes the testing of an anthropomorphic model that simulates an infant head and provides validation data for complex finite element (FE) modelling using three numerical methods (Lagrangian, Arbitrary-Lagrangian-Eulerian (ALE) and Eulerian method) for fluid structure coupling. The experiments for this study aim to provide an understanding of the influence of two factors on intracranial brain movement of the infant head during violent shaking: (1) the specific paediatric head structure: the anterior fontanelle and (2) the brain-skull interface. The results show that the Eulerian analysis method has significant advantages for the FSI modelling of brain-CSF-skull interactions over the more commonly used methods, e.g. the Lagrangian method. To the knowledge of the authors, this methodology has not been discussed in previous publication. The results indicate that the biomechanical investigation of SBS can provide more accurate results only if the skull with paediatric features and the brain-skull interface are correctly represented, which were overlooked in previous SBS studies.

Revisiting the measurement of Shaken Baby Syndrome Awareness.

UNLABELLED: In the last 10 years, over 80% of adults surveyed report some familiarity with Shaken Baby Syndrome (SBS) and the dangers of shaking infants younger than 2 years of age (Dias et al., 2005; Russell & Britner, 2006). Hence, in the context of SBS prevention, the question of whether caregivers knew the safety risks of shaking an infant becomes less meaningful than questioning whether caregivers have an awareness of alternate responses they could use to respond safely to the relatively normative occurrence of inconsolable crying (Barr, Trent, & Cross, 2006). OBJECTIVE: The present work is a continuation of efforts to prevent abusive head injury during infancy particular to SBS by raising awareness and provides prevention professionals with a reliable and shorter, single-page version of the Shaken Baby Syndrome Awareness Assessment (Russell & Britner, 2006). METHODS: A sample of 370 adults completed the short version of the measure during 2008. RESULTS: Psychometric results, including Cronbach's alphas and Pearson's correlations, are all significant and meet acceptability standards. CONCLUSION: These results indicate the short version of the measure is ready for use in the prevention field. PRACTICE IMPLICATIONS: The Shaken Baby Syndrome Awareness Assessment-short version is best used to support child abuse prevention professionals in engaging caregivers in a conversation about responding to a crying infant safely. By talking about the responses a caregiver might be willing to use in the high-stress context of an infant's inconsolable crying bout, intervention efforts can be tailored to maximize on caregiver strengths and achieve a high degree of goodness of fit with the values held in the care environment. Increasing the goodness of fit between caregivers' values and the steps recommended through an intervention program supports the likelihood that the behavior described in the program's service plan will be used.

Reflections on the syndrome of the "shaken baby".

A full appreciation of the development of current concepts concerning the "shaken baby syndrome" requires a systematic review of historic and more recent interpretations of scientific data that form the bases for diagnosis in these cases. This discussion relates to the dilemma in determining the cause of shaking injuries in this age group that are not obviously accidental or inflicted. The cases in question can present with similar clinical and pathological findings and possibly result from innocent activity. Shaking of infants and children for any reason should be avoided. Debates related to the circumstances and forces required for the development of intracranial and ophthalmic pathology as a result of shaking are discussed. References to the application of "markers of abuse" and other criteria in determining guilt or innocence in these specific situations are presented and evaluated.

Non-accidental head injury in New Zealand: the outcome of referral to statutory authorities.

OBJECTIVES: To describe the outcome of referral to the statutory authorities for infants under 2 years with non-accidental head injury (NAHI), and to establish whether the authorities held sufficient information to develop a risk profile for these cases. METHODS: Retrospective review of cases admitted to hospital in Auckland, New Zealand from 1988 to 1998. Records from the hospital admission, child protective services and Police were reviewed, up to 19 years from diagnosis. RESULTS: Of 39 infants, 33 survived to leave hospital. Documentation of risk factors was erratic, and sometimes incongruent between agencies. Inter-agency case conferences took place in 17/39 (44%). The Department of Child, Youth and Family Services (CYF) used an informal family agreement to secure safety in 15/33 survivors (45%). Family Group Conferences occurred in 17/33 (52%). Nine of 33 were placed permanently outside the home (27%), two (6%) with unrelated caregivers. Charges were laid in 18/39 cases (46%). Fifteen cases came to trial, with 14 convictions (36%). Of the survivors, 44% were later renotified to CYF. There was no obvious relationship between type of intervention and re-notification. CONCLUSIONS: Ensuring the safety of an infant with NAHI, and identifying and taking appropriate action with regard to the offender, are complex tasks. In New Zealand, data collection is often incomplete and inter-agency practice and collaboration is variable. Although the rate of prosecution was relatively high by international standards, many children were later notified again for further concerns of abuse or neglect, suggesting that our interventions have been only partially successful. PRACTICE IMPLICATIONS: This paper suggests that all infants admitted to hospital with non-accidental head injury should become part of a prospective inter-agency research study, using a standardised data collection instrument. This should include the systematic collection of all data known or suspected to be associated with risk of child abuse, and incorporate long-term prospective follow-up, regardless of child protective or legal outcomes. Without large numbers followed prospectively and according to sound methodology, it is difficult to prove which forms of intervention are better than others at reducing the risk of further abuse.

Development and evaluation of a shaken baby syndrome prevention program.

OBJECTIVE: To evaluate parents' and nurses' opinions regarding the adequacy of an educational program on shaken baby syndrome: the Perinatal Shaken Baby Syndrome Prevention Program (PSBSPP). DESIGN: Qualitative and quantitative assessments in the form of interviews and questionnaires administered in French. SETTING: Two birthing institutions in Montréal, QC, Canada: a university hospital and a regional center. PARTICIPANTS: Two hundred and sixty-three parents (73.8% mothers, 26.2% fathers) received the intervention after the birth of their child, and 69 nurses administered it. METHODS: Parents' and nurses' assessments of the adequacy and relevance of the program and nurses' assessments of the training they received to administer the program were evaluated. RESULTS: Both parents and nurses supported this initiative. Most parents appreciated the usefulness of the information. Nurses believed the program was adequate, and their training to deliver the program was satisfactory. All participants reported that the program was highly relevant, especially for new parents. CONCLUSION: The Perinatal Shaken Baby Syndrome Prevention Program achieves the goals of (a) increasing parents' knowledge about infant crying, anger, and shaken baby syndrome and (b) helping parents identify coping strategies. The relevance of introducing the PSBSPP in all birthing institutions is supported. Future studies should focus on vulnerable and culturally diverse populations, and longitudinal follow-up could help determine if the PSBSPP reduces the incidence of shaken baby syndrome.

Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse.

OBJECTIVES: Missed diagnosis of child abuse may lead to chronic abuse with potential for death. This paper reports 3 such cases. METHODS: This is a retrospective chart review of 38 cases diagnosed as abusive head trauma between January 1, 2004 and December 31, 2006 at a university hospital. We sought to identify fatal cases with a past medical history of physical abuse that was missed by the medical staff. RESULTS: Three cases (7.9%) had a past medical history of physical abuse that was missed by the medical staff. Infants were 2 males and 1 female. Their ages were 2.5, 3.5, and 6 months, respectively. Missed abuse episodes involved rib fractures, a metaphyseal tibial fracture, and a shaking episode, respectively. The intervals that had elapsed between the missed and the fatal abuse episodes were 24 hours, 12 days, and 6 weeks, respectively. Perpetrators of fatal head trauma were all biological fathers. One plead guilty, and 2 were convicted of involuntary manslaughter. The infants were in the care of the perpetrators of the fatal abuse episodes at the time the missed abuse episodes occurred. CONCLUSIONS: Physicians assessing children, especially infants, should be alert to indicators of abusive trauma to recognize abuse early on. Including abusive trauma in the differential diagnostic list and taking appropriate steps to rule out or confirm the diagnosis are of paramount importance in establishing child protective services and preventing further abuse and neglect that may at times be fatal.

Intervention type matters in primary prevention of abusive head injury: event history analysis results.

PURPOSE: The current study sought to compare interventional materials intended to raise public awareness of the caregiving practices connected to Shaken Baby Syndrome (SBS). Two hundred and sixty four adults (mean age 32 years) were recruited for participation through convenience sampling at a large Northeastern university. Participants fell into two groups-those who regularly cared for children (46%) and those who did not (54%). METHODS: SBS awareness was surveyed prior to an educational intervention and at three times points (2, 6, and 12 weeks post-intervention) longitudinally. Three intervention levels were used: Two different video conditions, each with an informational brochure, and the brochure-only condition. Survey responses were combined into five factor scores. Changes in factor score over time were modeled using event history analysis to predict the conditional probability of change in awareness as a discreet event. RESULTS: The resulting models show consistent results for three of the five factors, predicting the highest likelihood of increased awareness for a teaching video intervention, followed by a testimonial video, and the lowest probability for increased awareness for the use of an intervention using only a brochure. Negative change, or decreased awareness, was not predicted by the type of intervention materials. Demographic variables were not significant predictors of either positive or negative change. CONCLUSION: The results indicate that the addition of video materials, and in particular material focusing on teaching alternative behaviors, significantly increases the likelihood of positive changes in SBS awareness over interventions which use only a brochure. IMPLICATIONS FOR PRACTICE OR RESEARCH: The present study uses a two by three design to describe levels of improved awareness of Shaken Baby Syndrome across two groups of participants (those who regularly care for children and those who do not) and type of educational material (a brochure versus two different videos each in combination with the brochure). Results show a differential effect for each intervention level, and indicate a need for careful selection of educational materials for intervention programs concerned with preventing SBS through public awareness.

The shaken baby syndrome: an odyssey. II Origins and further hypotheses.

Subdural bleeding in the so-called "shaken baby syndrome" is recognized as a hallmark of this syndrome, and is often noted as chronic in nature, indicating an earlier time of origin than clinical presentation. In infants and neonates, the timeframe for generating such chronic intracranial bleeding is therefore limited. Neurosurgical, obstetric, and pediatric literature all recognize the significance of birth trauma in the generation of intracranial bleeding. This possibility is explored further here, with emphasis on features peculiar to Homo sapiens predisposing to intracranial bleeding during this timeframe. Encephalization and bipedalism combine to render the infant and mother susceptible to injury at birth.