Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Update to parts I&II: A systematic review of animal, mathematical and physical models.

Inflicted shaking trauma can cause injury in infants, but exact injury mechanisms remain unclear. Controversy exists, particularly in courts, whether additional causes such as impact are required to produce injuries found in cases of (suspected) shaking. Publication rates of studies on animal and biomechanical models of inflicted head injury by shaking trauma (IHI-ST) in infants continue rising. Dissention on the topic, combined with its legal relevance, makes maintaining an up-to-date, clear and accessible overview of the current knowledge-base on IHI-ST essential. The current work reviews recent (2017-2023) studies using models of IHI-ST, serving as an update to two previously published reviews. A systematic review was conducted in Scopus and PubMed for articles using animal, physical and mathematical models for IHI-ST. Using the PRISMA methodology, two researchers independently screened the publications. Two, five, and ten publications were included on animal, physical, and mathematical models of IHI-ST, respectively. Both animal model studies used rodents. It is unknown to what degree these can accurately represent IHI-ST. Physical models were used mostly to investigate gross head-kinematics during shaking. Most mathematical models were used to study local effects on the eye and the head's internal structures. All injury thresholds and material properties used were based on scaled adult or animal data. Shaking motions used as inputs for animal, physical and mathematical models were mostly greatly simplified. Future research should focus on using more accurate shaking inputs for models, and on developing or and validating accurate injury thresholds applicable for shaking.

Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Part I: A systematic review of animal models.

Inflicted blunt force trauma and/or repetitive acceleration-deceleration trauma in infants can cause brain injury. Yet, the exact pathophysiologic mechanism with its associated thresholds remains unclear. In this systematic review an overview of animal models for shaking trauma and their findings on tissue damage will be provided. A systematic review was performed in MEDLINE and Scopus for articles on the simulation of inflicted head injury in animals. After collection, the studies were independently screened by two researchers for title, abstract, and finally full text and on methodological quality. A total of 12 articles were included after full-text screening. Three articles were based on a single study population of 13 lambs, by one research group. The other 9 articles were separate studies in piglets, all by a single second research group. The lamb articles give some information on tissue damage after inflicted head injury. The piglet studies only provide information on consequences of a single plane rotational movement. Generally, with increasing age and weight, there was a decrease of axonal injury and death. Future studies should focus on every single step in the process of a free movement in all directions, resembling human infant shaking. In part II of this systematic review biomechanical models will be evaluated.

Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Part II: A systematic review of mathematical and physical models.

Various types of complex biomechanical models have been published in the literature to better understand processes related to inflicted head injury by shaking trauma (IHI-ST) in infants. In this systematic review, a comprehensive overview of these models is provided. A systematic review was performed in MEDLINE and Scopus for articles using physical (e.g. dolls) and mathematical (e.g. computer simulations) biomechanical models for IHI-ST. After deduplication, the studies were independently screened by two researchers using PRISMA methodology and data extracted from the papers is represented in a "7-steps description", addressing the different processes occurring during IHI-ST. Eleven papers on physical models and 23 papers on mathematical models were included after the selection process. In both categories, some models focus on describing gross head kinematics during IHI-ST events, while others address the behavior of internal head- and eye structures in various levels of detail. In virtually all physical and mathematical models analyzed, injury thresholds are derived from scaled non-infant data. Studies focusing on head kinematics often use injury thresholds derived from impact studies. It remains unclear to what extent these thresholds reflect the failure thresholds of infant biological material. Future research should therefore focus on investigating failure thresholds of infant biological material as well as on possible alternative injury mechanism and alternative injury criteria for IHI-ST.

Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review.

PURPOSE: Glutaric aciduria type 1 (GA1) is a rare metabolic disorder of glutaryl-CoA-dehydrogenase enzyme deficiency. Children with GA1 are reported to be predisposed to subdural hematoma (SDH) development due to stretching of cortical veins secondary to cerebral atrophy and expansion of CSF spaces. Therefore, GA1 testing is part of the routine work-up in abusive head trauma (AHT). This systematic review addresses the coexistence of GA1 and SDH and the validity of GA1 in the differential diagnosis of AHT. METHODS: A systematic literature review, with language restriction, of papers published before 1 Jan 2015, was performed using Pubmed, PsychINFO, and Embase. Inclusion criteria were reported SDHs, hygromas or effusions in GA1 patients up to 18 years of age. Of 1599 publications, 20 publications were included for analysis. RESULTS: In total 20 cases, 14 boys and 6 girls, were included. In eight cases (40%) a child abuse work-up was performed, which was negative in all cases. Clinical history revealed the presence of trauma in eight cases (40%). In only one case neuroradiology revealed no abnormalities related to GA1 according to the authors, although on evaluation we could not exclude AHT. CONCLUSION: From this systematic review we conclude that SDHs in 19/20 children with GA1 are accompanied by other brain abnormalities specific for GA1. One case with doubtful circumstances was the exception to this rule.

Multicystic encephalopathy in abusive head trauma.

OBJECTIVE: The proof of abusive head trauma (AHT) in infants is difficult, especially in cases with a long posttraumatic survival period. In the acute phase, injury to the cranio-cervical junction causes disturbances in respiratory and cardiac control, leading to apnea and bradycardia. Infants who survive the acute phase may subsequently develop multicystic encephalopathy. Because some types of changes are age-dependent, examination of the patterns of brain damage in these cases could provide information about the time in which they were inflicted. In particular, this could apply to the extent of the cystic changes, namely that the severity thereof may decrease with older age upon infliction of the trauma. This could potentially date the injury and thereby help to identify the perpetrator. We present an analysis of the patterns of brain damage in cases of AHT-induced multicystic encephalopathy and comment on the possible etiology and the implications thereof. MATERIALS: Nine archival cases of trauma-induced multicystic encephalopathy, originating between the years 2005 and 2011, were identified. In 8 of these cases, hematoxilin-eosin-stained whole-hemisphere histologic slides, as well as small histologic slides of cerebellar hemispheres, were available for the evaluation of the topographic distribution of the macroscopic and microscopic changes. RESULTS: The cerebral hemispheres were more affected than the cerebellum. The magnitude of the cystic changes did not correlate with the age at which the trauma had occurred, nor the surviva period. All cases showed asymmetrical affection of the cerebral hemispheres, which in 3 cases was very pronounced. The analysis revealed both ischemia- and hypoperfusion-induced injury patterns. CONCLUSION: Analysis of the magnitude and the distribution of the damage do not assist in the estimation of the period at which the trauma had occurred. The evaluation showed that ischemia, and to a lesser extent, hypoperfusion, were the major mechanisms of brain injury in these cases, which does not narrow the differential diagnosis of the underlying problem. However, in cases of multicystic encephalopathy, in the absence of a plausible medical explanation for the development of this condition, a remote (abusive) head trauma should be considered.

Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse.

AIM: We investigated the prevalence of risk factors for and the prevalence of prior abuse in abusive head trauma victims in the Netherlands. METHODS: We performed a retrospective file review of all abusive head trauma cases in the Netherlands in which forensic medical expertise was requested by the courts, between 2005 and 2010. Outcome measures were risk factors and indicators for prior abuse. RESULTS: Eighty-nine cases were included; 62% boys, median age 3.5 months. Impact trauma was found in 48% of cases, with a male perpetrator in 79%. Prematurity, dysmaturity and twins/triplets were found in 27%, 23% and 10% of cases, respectively, maternal age under 20 years in 17%. Of the parents, 60% had completed only primary or secondary education, 38% of the families were known to child welfare authorities. There was evidence for prior abuse in 81% of the cases. CONCLUSION: The high number of families with prior abuse indicates that both the healthcare system and child welfare authorities failed to protect some of the children that have been in their care. Our results highlight the importance of training healthcare and child welfare professionals in recognizing physical abuse, as well as the importance of optimizing abusive head trauma prevention strategies.

In vitro validation of vaginal sampling in rape victims: the problem of Locard's principle.

PURPOSE: Intra-vaginal traces can serve as supporting physical evidence of vaginal penetration in sex-crime cases. Vaginal trace sampling guidelines prescribe using a speculum and swabs or swabs only. The use of Locard's exchange theory requires samples of trace materials to always be contamination-free and of accurately known origin. If traces from the outer genital area are accidentally introduced into the vagina during sampling, these traces may be recorded as originating in a location where they were not present at the time of evidence collection. The goal of this study was to assess the risks of false positive findings in vitro of traces found inside the vagina due to trace dislocation caused by current vaginal trace sampling methods (swab-only or with speculum), and for a new method that uses a sleeve accessory to prevent trace dislocation. METHODS: Starch solution was applied to the labia of three clean female genitalia mock-ups with vaginas of various diameters and structures. The speculum, swab-only, and sleeve methods were each used 30 times on each mock-up, giving a total of 90 repetitions of each method. Iodine was used to determine whether any starch traces had been introduced vaginally. RESULTS: The speculum and swab-only methods gave 100 and 63-87 % false positive results respectively due to trace dislocation. The sleeve method reduced this to 2 % (0 % after correction). CONCLUSIONS: The results suggest that there is a need to conduct clinical in vivo studies to determine whether these results translate into everyday practice and to ensure reliable trace sampling in sex-crime cases.

Abusive head trauma Part II: radiological aspects.

UNLABELLED: Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis. CONCLUSION: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Educational paper: Abusive Head Trauma part I. Clinical aspects.

UNLABELLED: Abusive Head Trauma (AHT) refers to the combination of findings formerly described as shaken baby syndrome. Although these findings can be caused by shaking, it has become clear that in many cases there may have been impact trauma as well. Therefore a less specific term has been adopted by the American Academy of Pediatrics. AHT is a relatively common cause of childhood neurotrauma with an estimated incidence of 14-40 cases per 100,000 children under the age of 1 year. About 15-23% of these children die within hours or days after the incident. Studies among AHT survivors demonstrate that approximately one-third of the children are severely disabled, one-third of them are moderately disabled and one-third have no or only mild symptoms. Other publications suggest that neurological problems can occur after a symptom-free interval and that half of these children have IQs below the 10th percentile. Clinical findings are depending on the definitions used, but AHT should be considered in all children with neurological signs and symptoms especially if no or only mild trauma is described. Subdural haematomas are the most reported finding. The only feature that has been identified discriminating AHT from accidental injury is apnoea. CONCLUSION: AHT should be approached with a structured approach, as in any other (potentially lethal) disease. The clinician can only establish this diagnosis if he/she has knowledge of the signs and symptoms of AHT, risk factors, the differential diagnosis and which additional investigations to perform, the more so since parents seldom will describe the true state of affairs spontaneously.

[Unnatural death due to child abuse--forensic autopsies 1996-2009]. / Niet-natuurlijk overlijden door kindermishandeling; gerechtelijke secties 1996-2009.

OBJECTIVE: To evaluate the number of cases of fatal child abuse in minors on whom forensic autopsy was carried out in the Netherlands during the period 1996-2009 and to compare the 1996 data with Dutch data published earlier by Kuyvenhoven et al. (a questionnaire study among general practitioners and paediatricians). DESIGN: Descriptive retrospective study. METHOD: Cases of unnatural death from all forensic autopsies on fetuses, children and young adults (> 24 weeks and < 18 years; n = 688) over the past 14 years (1996-2009) were retrospectively analyzed for child abuse. By means of death certificates and suspected cause of death, the actual outcomes of the 1996 data were compared with those of the study of Kuyvenhoven et al. RESULTS: Over the past 14 years, in 445 of 688 forensic cases (65%) in this study population, cause of death was demonstrated to be unnatural. Of these deaths, 54% (n = 239/445) were unnatural and non-accidental due to child abuse. This corresponded with an annual average of 15 (30%) 'proven' and 2 (5%) 'highly probable' cases of fatal child abuse. The total number of abandoned babies, foundlings and otherwise, was on average 4 per year. In 1996 57% (13/23) of fatal child abuse cases were not represented in the data published by Kuyvenhoven et al. CONCLUSION: Of the 49 foetuses, children and young adults on whom forensic autopsy was carried out in the Netherlands each year, 17 (35%) died due to proven or highly probable child abuse. In 1996 more than half of the number of fatal cases of child abuse of the Netherlands Forensic Institute were not represented in the study of Kuyvenhoven et al. In both this study and in the one of Kuyvenhoven underreporting is highly probable.

Birth-related mid-posterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature.

BACKGROUND: Posterior rib fractures in young children have a high positive predictive value for non-accidental injury (NAI). Combined data of five studies on birth trauma (115,756 live births) showed no cases of rib fractures resulting from birth trauma. There have, however, been sporadic cases reported in the literature. OBJECTIVE: We present three neonates with both posterior rib fractures and ipsilateral clavicular fractures resulting from birth trauma. A review of the literature is also presented. The common denominator and a possible mechanical aetiology are discussed. MATERIALS AND METHODS: In total, 13 cases of definitive birth-related posterior rib fractures were identified. RESULTS: Nearly all (9/10) posterior rib fractures were (as far as reported in the original publications) in the midline. In 12 of the 13 children, birth weight was high and in 7 children birth was complicated by shoulder dystocia. An interesting finding was that in cases where a clavicular fracture was present, this was on the ipsilateral side. CONCLUSION: Radiologists, when presented with a neonate with posterior rib fractures, should be aware of this rare differential diagnosis.