Síndrome de niño agredido: reporte de caso / Battered child síndrome: case report

La valoración médico legal en los casos de Síndrome de niño agredido debe ser minuciosa, y abarcar todos los aspectos que indican los artículos y guías nacionales e internacionales, para tener una certeza diagnóstica, debe incluir una historia médico legal completa, examen físico detallado y estudios complementarios, así como diagnóstico diferencial. El presente artículo abarca algunos de los aspectos principales a tomar en cuenta ante la sospecha de abuso infantil, mediante la presentación y abordaje de un caso clínico.

The medical legal assessment in the cases of Attacked Child Syndrome must be thorough and cover all the aspects indicated in the articles and national and international guides, to have a diagnostic certainty, it must include a complete legal medical history, detailed physical examination and complementary studies, as well as differential diagnosis. This article covers some of the main aspects to consider when suspected of child abuse, through the presentation and approach of a clinical case.

A four-year-old Nigerian boy with battered child syndrome: implications for public health.

Battered child syndrome (BCS) is a form of physical abuse that is characterised by multiple injuries and potentially fatal outcome. Despite the high prevalence of physical abuse in developing countries, BCS is rarely reported. Hence, this report highlighted a four-year-old Nigerian boy who suffered multiple injuries (scalp haematoma, bruises, right clavicular fracture, and burns) from the paternal uncle's wife. This case report is discussed along the line of public health approach for curbing the social menace.

The Implementation of a Pediatric Nonaccidental Trauma Evaluation Protocol: A Quality Improvement Analysis.

BACKGROUND: Pediatric nonaccidental trauma (NAT) accounts for more than 1500 deaths annually and is a source of incalculable lifelong morbidity. Evidence-based NAT evaluation protocols are available; however, compliance studies are lacking. Here, we analyze the quality of implementation of a new NAT evaluation protocol. METHODS: A review of registry data from a level 3 trauma center was performed for patients with a suspicion of NAT from September 2014 to May 2016. Compliance rates and results of 2 new age-based evaluation protocols were examined before (phase 1) and after (phase 2) a multidisciplinary conference was initiated to improve performance. RESULTS: Seventy-five children underwent evaluation for NAT during the study period. In phase 1, median compliance rates with all of the protocol elements were low (63%). After a bimonthly multidisciplinary conference was initiated, compliance rates improved to 75%. Some elements, which were often missed, were found to be clinically irrelevant. If only clinically relevant elements were included, median compliance in phase 2 is 86%. CONCLUSIONS: Compliance with a new protocol for NAT was improved with the institution of a multidisciplinary conference. Protocol elements, which are shown to be clinically unnecessary, have also been identified and will be eliminated.

Histological ageing of fractures in infants: a practical algorithm for assessing infants suspected of accidental or non-accidental injury.

AIMS: This study is the first to systematically document histological features of fractures of known age in infants (≦12 months). It has been used to develop a tabulated database specifically to guide histopathologists to age fractures in children considered to have suffered accidental or non-accidental injury (NAI). Currently in the United Kingdom there are insufficient pathologists with experience in histological ageing of fractures to meet the medicolegal need for this examination. This study provides a practical tool that will allow those skilled paediatric and forensic pathologists currently involved in assessing infants for evidence of accidental or non-accidental injury a basis for extending their assessment into this area of unmet need. METHODS AND RESULTS: One hundred and sixty-nine fractures of known age at death were obtained from 52 anonymised infants over a period of 32 years (1985-2016 inclusive). Sections stained using haematoxylin and eosin (H&E) and Martius scarlet blue (MSB) were used to identify specific histological features and to relate them to fracture age. In 1999 the data were entered into a tabulated database for fractures accumulated between from 1985 to 1998 inclusive. Thereafter cases were added, and at 2-yearly intervals the accumulated data were audited against the previous database and adjustments made. CONCLUSIONS: This paper describes the final data set from the 2017 audit. The study was terminated at the end of 2016, as there had been no material changes in the data set for three consecutive audits.

Risk factors for avoidable transfer to a pediatric trauma center among patients 2 years and older.

BACKGROUND: Effective and sustainable pediatric trauma care requires systems of regionalization and interfacility transfer. Avoidable transfer, also known as secondary overtriage, occurs when a patient is transferred to a regional trauma center after initial evaluation at another facility that is capable of providing definitive care. The purpose of this study was to identify risk factors for avoidable transfer among pediatric trauma patients in southwest Florida. METHODS: All pediatric trauma patients 2 years and older transferred from outlying hospitals to the emergency department of a single state-designated pediatric trauma center between 2009 and 2017 were obtained from the institutional registry. Transfers were classified as avoidable if the patient suffered only minor injuries (International Classification of Diseases-9th Rev. Injury Severity Score > 0.9), did not require invasive procedures or intensive care unit monitoring, and was discharged within 48 hours. Demographics and injury characteristics were compared for avoidable and nonavoidable transfers. Logistic regression was used to estimate the independent effects of age, sex, insurance type, mechanism of injury, diagnosis, within region versus out-of-region residence, suspected nonaccidental trauma, and abnormal Glasgow Coma Scale score on the risk of avoidable transfer. RESULTS: A total of 3,876 transfer patients met inclusion criteria, of whom 1,628 (42%) were classified as avoidable. Among avoidable transfers, 29% had minor head injuries (isolated skull fractures, concussions, and mild traumatic brain injury not otherwise specified), and 58% received neurosurgery consultation. On multivariable analysis, the strongest risk factors for avoidable transfer were diagnoses of isolated skull fracture or concussion. Suspected nonaccidental trauma was predictive of nonavoidable transfer. CONCLUSION: Among injured children 2 years and older, those with minor head injuries were at greatest risk for avoidable transfer. Many were transferred because of a perceived need for evaluation by a pediatric neurosurgeon. Future projects seeking to reduce avoidable transfers should focus on children with isolated skull fractures and concussions, in whom there is no suspicion of nonaccidental trauma. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Síndrome del niño maltratado con repercusión psicosocial / Abused child syndrome with psychological and social implication

El maltrato infantil es un problema universal y multicausal que involucra una gran variedad de factores biopsicosociales. Es toda agresión producida a los menores por sus padres, familiares u otras personas para castigarles o hacerles daño, incluida también la desatención de sus necesidades básicas de alimentación, hogar, vestido, salud, protección y cariño, por lo cual en este artículo se comenta en torno al tema y se expone la experiencia traumática vivida por 2 menores

Child abuse is an universal problem which has many causes that involve a great variety of biological psychological and social factors. It is all type of aggression of parents, family or other people to a child to punish or to damage him. It also includes the lack of care for his basic needs of feeding, housing, dressing, health, protection and affection, reason why in this work it is commented about the topic, and the traumatic experience lived by 2 children is exposed

The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups?

The purpose of this study was to evaluate narrower age groups in children aged 0-4 years to determine whether guidelines should be refined when investigating femur fractures for nonaccidental trauma (NAT). This was a retrospective review of the pediatric trauma database at our level 1 pediatric trauma center. The database was examined from 2009 to present. We examined rates of NAT in the less than or equal to 12-month, 13-24-month, 25-36-month, and 37-48-month age groups. χ was used to compare rates of NAT between these groups, and P less than 0.05 was considered to be significant. Over the indicated time period, there were 138 femur fractures in children aged 0-4 years, of which 30 were determined to be NAT. The rate of NAT in the less than or equal to 12-month age group was 74.1%, accounting for 20 of the 30 NAT femur fractures. A significant difference in rates of NAT was found between the less than or equal to 12-month age group and all other age groups (P<0.00001). No significant difference in rates of NAT was found between the 13-24-month, 25-36-month, and 37-48-month age groups. Although our institution has generally felt that NAT should be universally evaluated in patients below 36 months of age with femur fractures, our data suggest that there is little justification for universally evaluating 13-36-month-old patients with femur fractures for NAT when the rates do not differ for 37-48-month-old patients. NAT does exist in femur fractures in children above 12 months of age, but it is most worrisomely high in patients of less than or equal to 12 months of age.

Protocolo de atención en salud integral de niñas y niños en situación de maltrato infantil / Comprehensive health care protocol for girls and boys in situations of child abuse

A partir de la premisa, que el maltrato infantil se está convirtiendo en un problema cada vez más serio a nivel nacional, situación que es avalada por la Organización Panamericana de la Salud (OPS) que considera que la violencia y sus diferentes manifestaciones son un problema que afectan a la salud y al desarrollo social y económico de amplios sectores de la población. Este protocolo considera que es importante que los proveedores de salud desarrollen habilidades y competencias que ayuden a detectar los casos de niños maltratados, así como conocer las mejores estrategias de intervención. El objetivo de este protocolo es proponer una herramienta que proporcione los elementos básicos a proveedores y proveedoras de salud para brindar atención de calidad en salud integral y realizar la notificación oportuna de los casos de maltrato infantil. Para ello han seleccionado un modelo basado en el triage del AIEPI (Atención Integral a las Enfermedades Prevalentes de la Infancia). Es una estrategia elaborada por la Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (Unicef) presentada en 1996 como principal método para mejorar la salud en la niñez. La metodología del modelo se lleva a cabo por medio de tres componentes. El primero está dirigido a mejorar el desempeño del personal de salud para la prevención de enfermedades en la niñez y su tratamiento. El segundo se dirige a mejorar la organización y funcionamiento de los servicios de salud para que brinden atención de calidad apropiada; y el tercer componente está dirigido a mejorar las prácticas familiares y comunitarias de cuidado y atención de la niñez. Contiene un marco teórico, marco legal, así como una serie de anexos dirigidos a apoyar tanto el diagnóstico, como el seguimiento dado a las víctimas.

Conocimientos sobre maltrato infantil en adolescentes maltratados y padres o tutores / Knowledge on child maltreatment in maltreated adolescents and in parents or tutors

Introducción: el maltrato infantil es un problema universal y multicausal que involucra factores biopsicosociales, en el que intervienen las características del agresor, el agredido, el medio ambiente y otras, no siempre bien reconocidas.Objetivo: evaluar los conocimientos sobre maltrato infantil en adolescentes ingresados por lesiones, o circunstancias que hicieron sospechar presencia de maltrato infantil, y que después se confirmó, así como en sus padres y/o tutores legales.Métodos: estudio descriptivo transversal, en 50 adolescentes ingresados por lesiones o circunstancias que hicieron sospechar presencia de maltrato infantil, y que después se confirmó durante su estancia en los servicios del Hospital Pediátrico Juan Manuel Márquez, durante el período comprendido de octubre de 2013 a octubre de 2014. Se les aplicó encuesta confeccionada al efecto. Los datos fueron incluidos en una base de datos automatizada con la hoja de cálculo electrónica Excel 2003, resumidos y representados en tablas estadísticas, y expresados textualmente. Se utilizó la estadística descriptiva.Resultados: el 90 y 92 por ciento de los adolescentes y padres respectivamente no tenían conocimientos sobre el maltrato infantil. Los tipos de maltratos infantiles identificados fueron: el psicológico en 36 por ciento, la negligencia en 22 por ciento y el físico en 20 por ciento. El 78 por ciento de los adolescentes y el 84 por ciento de los padres no tenían percepción del maltrato recibido o impartido.Conclusiones: existe insuficiente conocimiento del maltrato infantil en los adolescentes, y sus padres o tutores(AU)

Paravertebral calcification as a potential indicator for nonaccidental trauma.

We report a case of nonaccidental trauma (NAT) involving a 23-month-old boy who presented with seizures, acute subarachnoid hemorrhage, and acute subdural hemorrhage. Ophthalmologic examination showed bilateral intraretinal hemorrhages. Further evaluation revealed that he had bilateral thoracolumbar paravertebral calcifications. The Children's Protective Services agency was involved in the case. The child was discharged to an inpatient rehabilitation facility. Vertebral fracture associated with paravertebral calcification has been reported as a sign of NAT. This case was unique because our patient had paravertebral calcifications without vertebral fracture. Paravertebral calcification alone could serve as an indicator of NAT.

[Battered child syndrome: clinical and radiological aspects]. / Le syndrome des enfants battus: aspects cliniques et radiologiques.

Physical child abuse or battered child syndrome is responsible for over 75.000 deaths per year in France. This public health problem is under-diagnosed in Tunisia and in the world. The path toward the recognition of battered child syndrom was arduous even in some western societies. This study aims to highlight this problem to healthcare practitioners in order that accurate diagnosis and appropriate management may be provided. Physical child abuse has wrongly been referred to as Silverman syndrome that includes only skeletal lesions in children such as fractures.

No todo son malos tratos: pensando en un diagnóstico alternativo / Not always it’s a child abuse: thinking of an alternative diagnosis

Introducción: Los pediatras estamos muy concienciados sobre nuestro papel en el diagnóstico del maltrato, ya que si éste no se diagnostica y denuncia a tiempo, puede traer graves consecuencias en los niños, tanto físicas como psíquicas. Sin embargo, como médicos, también podemos incurrir en diagnósticos erróneos de maltrato, con la importancia que esta falsa afirmación supone desde el punto de vista legal y familiar. Material y métodos: Revisamos las historias de cuatro pacientes con patologías diversas que fueron diagnosticados inicialmente de maltrato. En todos ellos se encontró una causa médica que explicaba sus patologías y descartaba nuestra hipótesis inicial de maltrato. Conclusiones: Como pediatras, debemos estar alerta sobre los signos y síntomas que pueden hacernos pensar en maltrato. Sin embargo, también debemos conocer las patologías que pueden parecer efectos de un maltrato, y siempre debemos pensar en los posibles diagnósticos diferenciales cuando se nos plantea un posible caso de maltrato (AU)

Backgrounds: Paediatricians are concerned about our role in diagnosis of child abuse, due to the terrible consequences, both physical and psychological, that children can suffer if it’s not diagnosed and reported on time. However, as doctors, we can fall into misdiagnosis, with the importance of this wrong statement means legally and in their families. Material and methods: We have reviewed four medical records with different diseases. All of them were initially diagnosed of child abuse, but in all we found a medical cause that explained their diseases and child abuse could be ruled out. Conclusions: As paediatricians, we must be alert about signs and symptoms that might make us think about child abuse. However, we also must know diseases that can simulate child abuse and we must consider an alternative diagnoses always than we were thinking about the possibility of physical or sexual child abuse (AU)

Skeletal and radiological manifestations of child abuse: Implications for study in past populations.

Child abuse in its various types such as physical, emotional, sexual, and neglect has been document throughout history. However, before the mid-20th century, inflicted injuries to children was overlooked in part because children were often viewed as property. According to the World Health Organization, 57,000 children were the victims of homicide in the year 2000. In this paper we present the skeletal and radiological manifestation of physical abuse and fatal neglect and provide recommendations to assess child maltreatment from past populations. Pediatric biomechanical factors and healing are discussed as it is important to keep in mind that children are not just small adults. Skeletal and radiological indicators of nonaccidental or inflicted injuries are reviewed from the literature. Inflicted injuries are presented based on specificity to identify child abuse. In addition, skeletal indicators that could help assess fatal starvation are also reviewed and metabolic diseases are proposed as potential evidence of neglect. A recent child homicide is presented and used to illustrate the difficulty in assessing child maltreatment. Present-day clinical child abuse protocols are used to provide recommendations to assess child abuse in a bioarchaeological context. Clin. Anat. 29:844-853, 2016. © 2016 Wiley Periodicals, Inc.

Indicadores de detección y pautas de actuación ante situaciones de desprotección o malos tratos / Indicators of detection and standards of action when a situation of lack of protection of mistreatment exists

No disponible

Síndrome del niño sacudido o Shaken Baby Syndrome: Lesiones oculares / Shaken Baby Syndrome: Eye lesions

Introducción: el síndrome del niño sacudido se incluye en la clasificación del maltrato físico. Las lesiones oculares se deben a la tracción producida sobre la retina a partir del vítreo del niño, fuertemente unido a ella, con desgarro de las capas retinales y colección de sangre en la cavidad resultante (retinosquisis hemorrágica). Objetivo: describir las manifestaciones oftalmológicas iniciales y la evolución del síndrome del bebé sacudido. Materiales y métodos: se realiza un estudio descriptivo y retrospectivo de cuatro pacientes con el síndrome del niño sacudido. Las variables analizadas son: sexo, edad, fondo de ojos, ecografía ocular, tratamiento y evolución visual. Resultados: los casos 1 y 2 eran gemelos, uno de ellos presentó manifestaciones a nivel del fondo de ojos y el segundo no, ambos requirieron intervención neuroquirúrgica. El tercero presentaba lesiones a nivel ocular con opacidad de medios por lo cual se le realizó en ambos ojos vitrectomía exploradora. El cuarto caso se trataba de una paciente de 6 meses con hemovítreo en ojo derecho y retinosquisis hemorrágica en ojo izquierdo, y requirió vitrectomía para la resolución del hemovítreo, aunque el resultado visual fue desfavorable. Conclusión: el examen oftalmológico contribuye al diagnóstico del síndrome del bebé sacudido por lo que es necesario en la evaluación de los niños pequeños que presenten lesiones sospechosas de abuso (AU)

Introduction: Shaken baby syndrome is included in the classification of physical abuse. Ocular lesions in the infant are due to traction to the retina from the adjacent vitreous causing with tears of the retinal layers and blood collection in the resulting cavity (hemorrhagic retinoschisis). Objective: To describe early ocular manifestations and outcome of shaken baby syndrome. Material and methods: A retrospective, descriptive study was conducted in four patients with shaken baby syndrome. Sex, age, ocular fundus, ultrasonography, treatment, and visual outcome were analyzed. Results: Cases 1 and 2 were twins, one of them presented with fundus manifestations, the other did not; both required neurosurgical intervention. The third infant had eye lesions with media opacities and therefore exploratory vitrectomy was performed in both eyes. The fourth was a 6-month-old baby girl with hemovitreous in the right and hemorrhagic retinoschisis in the left eye. She required vitrectomy to resolve the hemovitreous, but the result was poor. Conclusion: Ophthalmological examination was useful in the diagnosis of shaken baby syndrome and should therefore be performed in little children in whom child abuse is suspected (AU)

Histologic Artifacts of Autolytic Müller Cell Foot Process Swelling in Postmortem Examination of Infant Eyes: Potential Pitfall in the Evaluation of Traumatic Retinal Hemorrhages.

IMPORTANCE: Retinal hemorrhages are an important sequela of fatal head trauma. The accurate pathologic diagnosis of retinal hemorrhages has critical implications for determination of the manner of death. OBSERVATIONS: We describe an autolytic postmortem histologic artifact of eosinophilic Müller cell foot process swelling that mimics a nerve fiber layer hemorrhage. From April 24, 2012, through November 11, 2014, we conducted postmortem examination of the eyes of 23 infants and children who were referred to our institution for possible nonaccidental head trauma. A focal artifact of Müller cell foot process swelling was identified in most patients (16 of 23) up to 4 years of age. Three infants, all of whom were younger than 3 months, demonstrated diffusely swollen Müller cell foot processes with intensely eosinophilic cytoplasm that mimicked erythrocytes of nerve fiber layer hemorrhages. The difference in the mean age between patients with diffuse eosinophilic artifacts (1.7 months) and patients with only a multifocal, focal, or absent artifact (13.3 months) was 11.6 months (95% CI, 6.5-16.7 months). Glycophorin C immunohistochemical analysis was useful to differentiate this artifact from nerve fiber layer hemorrhage. CONCLUSIONS AND RELEVANCE: Our case review demonstrates an artifact of eosinophilic Müller cell foot processes swelling in postmortem examination of young infant eyes, a potential pitfall in the diagnosis of retinal hemorrhages. Our findings have important implications for the diagnosis of retinal hemorrhages in potential cases of nonaccidental head injury.

Significance of platelet function diagnostics for clarification of suspected battered child syndrome.

The manifestation of an unclear bleeding tendency in childhood calls for an extended coagulation work-up, particularly when a battered child syndrome is suspected and typical concomitant injuries are absent. The chosen diagnostic tests should be able to detect the presence of relatively common coagulation defects such as von Willebrand syndrome or hemophilia, but also rare diseases such as inherited thrombocytopathies. The PFA-100® test does not help to provide a definite diagnosis especially in cases of mild inherited thrombocytopathies, since in most cases the PFA-100® test results are normal. For this purpose, specific platelet function testing is needed. However, the methods are only available in some coagulation laboratories. Also, other limitations need to be taken into consideration such as pre-analytical problems and difficulties in the interpretation of test results especially in infants. We present two cases that were diagnosed with an aspirin-like defect as an inherited thrombocytopathy, even though their PFA-100 closure times were within the normal range. Based on pathological findings in the platelet aggregometry test, this diagnosis could be made.

[Insufficient knowledge about battered child syndrome among doctors in the emergency department].

The aim of the study was to determine the present knowledge regarding battered child syndrome (BCS) among doctors in the emergency department. Nineteen doctors with different educational levels from seven hospitals in Denmark were interviewed. For children younger than 18 months, 68%, 65% and 25% of the participants related femur-, collum costae- and corner fractures to BCS respectively. We found that more than one third of the 19 doctors did not know which fractures to look for when suspecting BCS.

Estado epiléptico refractario como forma de presentación del síndrome del bebé zarandeado / Refractory status epilepticus presenting as shaken baby syndrome

Introducción. El estado convulsivo en el lactante suele ser desencadenado por un síndrome febril secundario a una infección intercurrente o una infección del sistema nervioso central. El síndrome del bebé zarandeado se caracteriza porla asociación de hemorragia subdural bilateral o multifocal, hemorragia retiniana y encefalopatía. Los niños menores de 1 año constituyen el grupo de mayor riesgo, con un pico de incidencia máxima entre las 10 y 16 semanas de vida. Los procesos intercurrentes, como los cólicos del lactante o los síndromes febriles que favorecen el llanto, suelen ser factores precipitantes del zarandeo. Casos clínicos. Presentamos los casos de dos lactantes que en el contexto de un síndrome febril comenzaron con un estado epiléptico. En las pruebas de imagen se evidenciaron hematomas subdurales bilaterales en diferente estadio evolutivo y en el fondo de ojo se observaron hemorragias retinianas bilaterales en ambos niños. Conclusiones. En un niño con un proceso febril inespecífico que desarrolla un estado convulsivo se debe pensar, además de en los problemas más habituales, en el síndrome del bebé zarandeado como posible causa etiológica, sobre todo si es menor de 6 meses (AU)

Introduction. A convulsive status in infants is usually triggered by a febrile syndrome secondary to an intercurrent infection or an infection affecting the central nervous system. Shaken baby syndrome is characterised by its association with bilateral or multifocal haemorrhage, retinal haemorrhage and encephalopathy. Children under one year old are the group with the highest risk, with a maximum incidence reaching a peak between 10 and 16 weeks of age. Intercurrent processes, such as baby colic or febrile syndromes that tend to step up crying, are usually precipitating factors of shaking. Case reports. We present the cases of two infants who began with a status epilepticus within a context of a febrile syndrome. Imaging tests revealed bilateral subdural haematomas in different stage of progress and bilateral retinal haemorrhages were observed in the fundus oculi of both children. Conclusions. In a child with an unspecific febrile process that develops a convulsive status, the professional should suspect, in addition to more usual problems, shaken baby syndrome as a possible causation, above all if the child is under six months old (AU)