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.

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.

Ophthalmological lesions in shaken baby syndrome: A retrospective analysis of 133 consecutive cases (1992-2018).

INTRODUCTION: Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data. PATIENTS AND METHODS: This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992-2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded. RESULTS: Mean age at diagnosis was 131days (range, 14days-10months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6months: 80%. CONCLUSION: This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.

A baby carrier fall leading to intracranial bleeding and multilayered retinal hemorrhages.

Significant intracranial and retinal hemorrhages are often seen in infants with abusive head trauma, although accidental injury and previously undiagnosed medical disorders are important considerations in the differential diagnosis. We present the case of an infant with confirmed accidental trauma sustained from an adult-worn baby carrier fall with superimposed head crush injury, which resulted in significant cranial, intracranial, and retinal findings.

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.

External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused.

BACKGROUND: Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. PURPOSE: The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. MATERIAL AND METHODS: Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. RESULTS: Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC. CONCLUSION: A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma.

BACKGROUND: Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS: This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS: A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE: Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.

Medical findings and symptoms in infants exposed to witnessed or admitted abusive shaking: A nationwide registry study.

BACKGROUND: Many physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high. METHODS: Infants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions. RESULTS: All identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma. CONCLUSIONS: The present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors.

Biomechanism of resistance to retinal injury in woodpecker's eyes.

Retinal injury is the most common ocular impairment associated with shaken baby syndrome (SBS), which could lead to vision loss and blindness. However, a woodpecker does not develop retinal hemorrhages or detachment even at a high acceleration of 1,000×g during pecking. To understand the mechanism of retinal injury and its resistance strategy, we put insight into the special ability of the woodpecker to protect the retina against damage under acceleration-deceleration impact. In this study, the structural and mechanical differences on the eyes of the woodpecker and human were analyzed quantitatively based on anatomical observation. We developed finite element eye models of the woodpecker and human to evaluate the dynamic response of the retina to the shaking load obtained from experimental data. Moreover, several structural parameters and mechanical conditions were exchanged between the woodpecker and human to evaluate their effects on retinal injury in SBS. The simulation results indicated that scleral ossification, lack of vitreoretinal attachment, and rotational acceleration-deceleration impact loading in a woodpecker contribute to the resistance to retinal injuries during pecking. The above mentioned special physical structures and mechanical behavior can distribute the high strain in the posterior segment of the woodpecker's retina, which decrease the risk of retinal injury to SBS.

[Unilateral retinal hemorrhage in infants-two cases of shaken baby syndrome?] / Unilaterale Netzhautblutungen bei Säuglingen ­ 2 Fälle von Schütteltrauma?

A 2.5-month-old boy and a 2-month-old girl were admitted to a pediatric intensive care unit with impaired consciousness. Both infants had subdural hemorrhages. Because of presumed non-accidental head injury (NAHI) funduscopy was performed, which revealed unilateral hemorrhage in both children. After intensive differential diagnostics NAHI was suspected in both cases and a forensic medical examination was initiated. This case series is important because it shows that unilateral retinal bleeding does not exclude NAHI.

Understanding Subdural Collections in Pediatric Abusive Head Trauma.

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