Article

Interval Duration Between Injury and Severe Symptoms in Nonaccidental Head Trauma in Infants and Young Children

Authors:
To read the full-text of this research, you can request a copy directly from the author.

Abstract

Forensic pathologists are frequently asked to describe the interval between injury and the onset of symptoms in child abuse head injury deaths. A prospective, postmortem study examined the interval between injury and onset of symptoms in 76 head injury deaths in which this information was available. The head injury deaths were divided by mechanism of injury. The mechanisms were shake (no impact), combined shake and blunt impact, and blunt impact (no history of shaking). The interval was less than 24 hours in 80% of shakes, 71.9% of combined, and 69.2% of blunt injuries. The interval was greater than 24 hours in more than 25% of each of these latter groups and was more than 72 hours in four children. The variable intervals between injury and severe symptoms warrant circumspection in describing the interval for investigators or triers of fact. It should be noted that in all of the cases where information was supplied by someone other than the perpetrator, the child was not normal during the interval.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the author.

... Dating is based on interview data, a set of clinical and radiological data (from repeated examinations, if need be) and, in some cases, pathological evidence. In a prospective study of 76 dead children, Gilliland [59] found that there was no lucid interval whenever the information was given by a person who was not the perpetrator of the trauma. ...
... Gilliland [59], dans une étude prospective sur 76 enfants décédés, a retrouvé qu'il n'y avait pas d'intervalle libre à chaque fois que les informations étaient données par une personne qui n'était pas l'auteur du traumatisme. ...
... Von forensisch herausragender Bedeutung ist die Folgerung aus der beschriebenen Pathogenese, dass ein manifestes Schütteltrauma-Syndrom aufgrund der diffusen Hirnschädigung kein freies (luzides) Intervall aufweisen kann, wie es bei dem alleinigen Auftreten epiduraler oder massen-und druckwirksamer subduraler Hämatome beschrieben wird. Es kommt zwingend zu einer sofort manifesten neurologischen Symptomatik [12]. ...
... Auch wenn diese in ihrer Ausprägung variabel ist, ist ein geschüttelter Säugling, der später signifikante klinischneurologische Folgen aufweist, niemals primär völlig unauffällig. Eine Progressi-on ist durch die Ausbildung eines Hirnödems möglich[8,12,27].Der tatsächlich prognostisch relevante Mechanismus der Hirnschädigung ist nicht restlos geklärt und Gegenstand intensiver wissenschaftlicher Diskussion. Am plausibelsten ist eine komplexe Interaktion von diffusen traumatischen neuronalen Schäden in Verbindung mit hypoxischen, ischämischen und neurometabolisch-toxischen Mechanismen, die in der Endstrecke eines diffusen Hirnödems münden und durch sekundäre, inflammatorische Prozesse verstärkt werden.STS Schütteltrauma-Syndrom, SDB subdurale Blutungen, RB retinale BlutungenTab. ...
... Dating is based on interview data, a set of clinical and radiological data (from repeated examinations, if need be) and, in some cases, pathological evidence. In a prospective study of 76 dead children, Gilliland [59] found that there was no lucid interval whenever the information was given by a person who was not the perpetrator of the trauma. ...
... Gilliland [59], dans une étude prospective sur 76 enfants décédés, a retrouvé qu'il n'y avait pas d'intervalle libre à chaque fois que les informations étaient données par une personne qui n'était pas l'auteur du traumatisme. ...
... In fact, this is partially explained by the papers rejected by Lynøe et al. [1], which show that perpetrators often underestimate the degree of injury (most likely because they recognize the socially reprehensible nature of the act or in an attempt to limit their criminal punishment) [16,17]. As global evidencegathering efforts continue to improve, overlapping injury patterns and consistent after-the-fact statements from perpetrators will continue to demonstrate that confession evidence can help to establish the cause of inflicted head injuries [4][5][6][7][8][9][10][11][12][16][17][18][19][20][21][22][23], including one case in which the medical evidence for shaking is compelling and the details of how the confession was made are provided in stark detail [21]. ...
... Auch wenn diese in ihrer Ausprägung variabel ist, ist ein geschüttelter Säugling, der später signifikante klinisch-neurologische Folgen aufweist, niemals primär völlig unauffällig. Eine Progression ist durch die Ausbildung eines Hirnödems möglich [12,16,31]. ...
Article
Full-text available
Verletzungen des Zentralnervensystems, insbesondere das Schütteltrauma, führen bei über zwei Drittel der Überlebenden zu oft ausgeprägten neurologischen Folgeschäden; die Letalität beträgt 12–27%. Typisch ist die Konstellation subduraler Hämatome und meist ausgeprägter retinaler Blutungen mit schweren diffusen Hirnschäden, in der Regel ohne äußerlich sichtbare Verletzungen. Ein Schütteltrauma mit signifikanten Folgeschäden erfordert massives, heftiges, gewaltsames Schütteln eines Kindes, das zu unkontrolliertem Umherrotieren des Kopfes führt. Dadurch kommt es zu subduralen und retinalen Blutungen, die für die Prognose jedoch nicht entscheidend sind. Pathogenetisch wird die Kombination diffuser axonaler Traumatisierung mit einer traumatischen Apnoe mit konsekutiver Hypoxie und Ischämie für die ausgeprägten Gehirnschäden bis hin zu einem diffusen Hirnödem angeschuldigt. Klinische Hinweise sind Irritabilität, Trinkschwierigkeiten, Somnolenz, Apathie, zerebrale Krampfanfälle, Erbrechen, Apnoen, Koma und Tod. Das Schütteltrauma ist eine syndromale Diagnose, die mithilfe der typischen Symptomkonstellation, der Fundoskopie und der zerebralen Bildgebung gestellt wird.
... The scope of injuries resulting from shaken baby syndrome comprises not only intracranial injuries, but also frequently injuries of the skeletal system in particular rib fractures and finger marks [7]. Based on literature one can assume that shaken babies show clinically diagnosable symptoms [8]. ...
Article
Full-text available
Advanced and specialized radiological diagnostic procedures are essential in cases of clinically diagnosed injuries to the head, thorax, abdomen or extremities of a child, especially if there is no case history or if the reporting of an inadequate trauma suggests battered child syndrome. In particular, these diagnostic procedures should aim at detecting lesions of the central nervous system (CNS), so that the treatment can be immediately initiated. If the diagnostic imaging reveals findings typically associated with child abuse, accurate documentation constituting evidence, which will stand up in court, is required to prevent any further endangerment of the child's welfare.
... If the injury or injuries had no alleged date, the date of the onset of the first symptoms was considered as the date of injury [16]. Indeed after cranial traumatism (shaking and or impact), a child cannot be without clinical symptoms [17,18]. Among the information resulting from medical and police questioning of the parents, the first criterion to be taken into account is the moment at which the first clinical sign is reported to have appeared. ...
Article
Background: Dating the traumatic event is usually done on subdural hematoma (SDH). After infant deaths due to Abusive head trauma (AHT) without SDH available, the magistrates still ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of AHT. We aimed to develop a subarachnoid hemorrhage (SAH) and retinal hemorrhage (RH) dating system applicable to infants aged under 3 years. Methods and results: We studied a retrospective multicenter collection of 235 infants who died between the ages of 0 and 36 months, diagnosed with SAH and/or RH by forensic pathological examination and with known posttraumatic interval (PTI). Two pathologists assessed blindly and independently 12histomorphological features in 83 infants (35 girls, 48 boys) whose median age was 3.8 months. For SAH, histopathological changes were significantly correlated with PTI for the appearance of red blood cells, of fibrino-plaquetted organization, the quantity of lymphocytes and macrophages and the presence or absence of siderophages, collagen and fibroblast formation and presence or absence of neovascularization. For RH, histopathological changes were significantly correlated with PTI for the appearance of red blood cells, the presence or absence of siderophages and sclerosis of the retina. Conclusion: Our HAS dating system improves the precision and reliability of forensic pathological expert examination of AHT, when SDH are not available, for age estimation in infants. The study of RH histomorphological changes does not allow for reliable dating.
... Auch wenn diese in ihrer Ausprägung variabel ist, ist ein geschüttelter Säugling, der später signifikante klinisch-neurologische Folgen aufweist, niemals primär völlig unauffällig. Eine Progression ist durch die Ausbildung eines Hirnödems möglich [12,16,31]. ...
... If the injury or injuries had no alleged date, the date of the onset of the first neurological symptoms was considered the date of injury [18]. It is widely agreed that after being shaken, a child cannot be unhurt and without clinical symptoms [19,20]. Among the information resulting from medical and police questioning of the parents, the first criterion to be taken into account is the moment at which the first clinical sign is reported to have appeared. ...
Article
Full-text available
Background After infant deaths due to non-accidental head injury (NAHI) with subdural hematoma (SDH), the magistrates ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of NAHI. We aimed to develop an SDH dating system applicable to infants aged under 3 years. Methods and results We studied a retrospective multicenter collection of 235 infants who died between the ages of 0 and 36 months, diagnosed with SDH by forensic pathological examination and with known posttraumatic interval (PTI). Two pathologists assessed blindly and independently 12 histomorphological criteria relating to the clot and 14 relating to the dura mater in 73 victims (31 girls, 42 boys) whose median age was 3.8 months. Histopathological changes were significantly correlated with PTI for the appearance of red blood cells (RBCs) and the presence or absence of siderophages, and regarding the dura mater, the quantity of lymphocytes, macrophages, and siderophages; presence or absence of hematoidin deposits; collagen and fibroblast formation; neomembrane thickness; and presence or absence of neovascularization. Dating systems for SDH in adults are not applicable to infants. Notably, neomembrane of organized connective tissue is formed earlier in infants than in adults. Conclusion Our dating system improves the precision and reliability of forensic pathological expert examination of NAHI, particularly for age estimation of SDH in infants. However, the expert can only define a time interval. Histopathology is indispensable to detect repetitive trauma.
... To make a diagnosis this powerful, a physician must rely on only the most solid evidence. Although the original SBS hypothesis has enjoyed decades of general acceptance, results from repeated biomechanical studies continue to undermine the reliability of the basic model, while timing of the symptoms also remains controversial [23, 26] and researchers in other specialties continue to raise questions about various aspects of the classic model [4,20, 21, 30]. ...
Article
Full-text available
Abusive shaking of infants has been asserted as a primary cause of subdural bleeding, cerebral edema/brain swelling, and retinal hemorrhages. Manual shaking of biofidelic mannequins, however, has failed to generate the rotational accelerations believed necessary to cause these intracranial symptoms in the human infant. This study examines the apparent contradiction between the accepted model and reported biomechanical results. Researchers collected linear and angular motion data from an infant anthropomorphic test device during shaking and during various activities of daily life, as well as from a 7-month-old boy at play in a commercial jumping toy. Results were compared among the experimental conditions and against accepted injury thresholds. Rotational accelerations during shaking of a biofidelic mannequin were consistent with previous published studies and also statistically indistinguishable from the accelerations endured by a normal 7-month-old boy at play. The rotational accelerations during non-contact shaking appear to be tolerated by normal infants, even when repetitive.
... Von forensisch herausragender Bedeutung ist die Folgerung aus der beschriebenen Pathogenese, dass ein manifestes Schütteltrauma-Syndrom aufgrund der diffusen Hirnschädigung kein freies (luzides) Intervall aufweisen kann, wie es bei dem alleinigen Auftreten epiduraler oder massen-und druckwirksamer subduraler Hämatome beschrieben wird. Es kommt zwingend zu einer sofort manifesten neurologischen Symptomatik [12]. Wiederholt wurde behauptet, dass Schütteln allein nicht die traumatischen Schwellenwerte für die beschriebenen schweren Schäden erkläre. ...
Article
Full-text available
Inflicted traumatic brain injury, in particular the shaken baby syndrome, leads to significant neurological disability in more than two-thirds of surviving victims, and is fatal in 12–27% of cases. It is characterized by a constellation of subdural hematoma and mostly marked retinal hemorrhages with severe diffuse brain injury, usually without external injuries. Shaken baby syndrome resulting in significant brain damage requires extensive, violent shaking of a child leading to uncontrolled rotation of the head. The resulting subdural and retinal hemorrhages are, however, not important for the prognosis. The combination of diffuse axonal injury and initial traumatic apnea leading to hypoxia, ischemia and intracranial hypertension is assumed to be responsible for the marked brain damage. Clinical symptoms are irritability, feeding problems, somnolence, apathy, cerebral convulsions, vomiting, apnea, coma and death. Shaking injury is a syndromic diagnosis dependant on the total picture of clinical, ophthalmological, radiological and brain imaging features.
Article
Ever since the syndrome was first recognized in the 1960s, a diagnosis of shaken baby syndrome ("SBS") was believed to be pathognomonic of abuse. New data calls into question the accuracy of the diagnosis and its association with nonaccidental death. This data points to alternative causes of brain injuries in infants and small children and casts doubt on the validity of evidence frequently used at trial. This Note explores problems associated with expert testimony in the context of SBS. It argues that despite the ability to accurately present general causation evidence at trial, introduction of specific causation testimony is often premature and unsupported by existing scientific proof. A careful application of John Monahan and Laurens Walker's social frameworks theory provides the groundwork for new evidentiary techniques in the defense and prosecution of SBS. By limiting expert testimony to that of social frameworks, courts can encourage thorough exploration of pertinent scientific and corroborating evidence, while simultaneously preventing inappropriate specific causation testimony. Finally, this Note compares SBS to other crimes, such as rape and arson, because applying lessons learned from the use of social frameworks evidence in other litigation contexts can help lawyers more accurately and equitably try SBS cases.
Article
Shaken baby syndrome is not a new phenomenon, with changes in the brains of abused children having been described as early as the nineteenth century. It is, however, a complex condition in which controversies abound. This introduction to the literature includes both medical and sociolegal perspectives on the history, prevalence and nature of shaken baby syndrome. Both diagnosis and management require a comprehensive, multidisciplinary approach, including input from ophthalmology and radiology. All professionals involved in managing shaken baby syndrome need to be aware of the many debates on the subject, including issues around a lucid interval following the trauma; the degree of trauma required; the mechanism of the injury; and differential diagnoses that need to be considered. Copyright © 2003 John Wiley & Sons, Ltd.
Article
Subdurale und subarachnoidale Blutungen in Kombination mit Retinahämorrhagien bei einem Säugling sind richtungsweisend für die Verdachtsdiagnose „Schütteltrauma“ („shaken baby syndrome“, SBS). Auslösende Ursache hierfür ist ein heftiges Schütteln des Säuglings, wobei der im Verhältnis zum Körper schwere, noch instabile Kopf ungeschützt Scherkräften infolge von Ak- und Dezeleration ausgesetzt wird. Das klinische Bild ist gekennzeichnet durch Lethargie, epileptische Anfälle, muskuläre Hyper- und Hypotonie, Erbrechen sowie Atemunregelmäßigkeiten bis hin zur Apnoe. Bei tödlichen Verläufen ist die Todesursache nach SBS ein malignes Hirnödem. Differenzialdiagnostisch müssen Stürze auch aus geringer Höhe, vorbestehende internistische Erkrankungen wie Infektionen, systemische metabolische Erkrankungen und Gerinnungsstörungen ausgeschlossen werden. Die gutachterliche Qualifikation „Schütteltrauma“ sollte, da in der Regel wenige Monate alte Säuglinge betroffen sind, die möglichst lückenlose Kenntnis des Geburtsverlaufes, der bis zum Auffälligwerden des Säuglings dokumentierten Entwicklung bzw. einer etwaigen Krankenvorgeschichte umfassen sowie eine kritische Würdigung der angeblichen vorfallskausalen Umstände beinhalten.
Chapter
Full-text available
Etwa 1–10% der Kindesmisshandlungen betreffen den Kopf und das Zentralnervensystem (ZNS). Diese Verletzungen haben die gravierendsten Auswirkungen aller Misshandlungsformen, d. h. die höchste Morbidität und Mortalität. Nach amerikanischen Schätzungen sind 80% der Todesfälle durch ZNS-Verletzungen im Säuglingsalter auf Misshandlungen zurückzuführen. Insgesamt sind sie mit 66–75% die häufigste misshandlungsbedingte Todesursache und die häufigste Säuglingstodesursache im 2. Lebenshalbjahr.
Article
Shaken Baby Syndrome (SBS) occurs in infants when the head is subjected to excessive acceleration and deceleration. Guthkelch first identified SBS when he noticed that infants with subdural hematoma did not always have gross markings, indicating the possibility of a baby shaking. The rotational force pushes the brain against the skull, causing various types of head and neck injuries. Ophthalmologic testing for retinal haemorrhages and ocular fundus, which can rule out SBS, is one of the tests for SBS. Immunohistochemical staining for -amyloid precursor protein (-APP) and magnetic resonance imaging (MRI) accurately identify brain injuries and bleeding, resulting in a more accurate diagnosis of SBS. SBS symptoms are shared by other etiologies, making it difficult to determine the true cause of infantile injury. Experiments using biomechanical models to recreate the whiplash movement have not revealed subdural haemorrhaging, but limitations in the models have doubt to these results.
Article
In recent years, there has been a substantial increase in the number of published reports in the medical literature that specifically describe outcomes after inflicted traumatic brain injury (TBI) during the first years of life. Though much more work is needed, these early reports are soberinginflicted cranial injuries have been linked to devastating morbidity and mortality in infants and young children. In this article, we will analyze this emerging body of literature and discuss the implications of these early studies for early intervention specialists. In the United States, inflicted head trauma is the leading cause of traumatic death and morbidity during infancy.1–3 Inflicted traumatic brain injury (TBI) occurs behind closed doors. The caregiver's explanation for an infant's traumatic cranial injuries is frequently absent, changing, or inadequate, and therefore unreliable. Although a single, compelling account of adult TBI induced by violent shaking has been published in the medical literature, presently there is no published account from an independent witness that directly links violent shaking to pediatric TBI in an infant or young child. Unfortunately, most of the published reports of perpetrator admissions of inflicted head trauma are second-hand accounts that are lacking in specific and detailed information regarding the injury events. Nevertheless, these reports are compelling.5–13 Admitted perpetrators of inflicted pediatric head trauma have described violent shaking; blows to the head; and/or cranial impacts against walls, furniture, or the floor. Furthermore, their abusive actions have been linked specifically to their victims' rapid clinical deterioration and devastating intracranial injuries.14
Neurosurgeons are mainly concerned with child abuse in cases of severe cranio-cerebral trauma. Aim of the present paper is to highlight the clinical picture and symptoms in cases of child abuse and our multidisciplinary approach to reveal a solid diagnosis. The detection of child abuse requires a high index of suspicion, especially in cases of subtle injuries. Besides reporting to the appropriate agencies primary goals are to terminate suspected abuse and to prevent further harm to the child. All this requires a confirmed diagnosis.
Article
Full-text available
Previous literature includes numerous reports of acute stereotactic ablation for epilepsy. Most reports focus on amygdalotomies or amygdalohippocampotomies, some others focus on various extra-limbic targets. These stereotactic techniques proved to have a less favourable outcome than that of standard surgery, so that their rather disappointing benefit/risk ratio explains why they have been largely abandoned. However, depth electrode recordings may be required in some cases of epilepsy surgery to delineate the best region of cortical resection. We usually implant depth electrodes according to Talairach's stereo electroencephalography (SEEG) methodology. Using these chronically implanted depth electrodes, we are able to perform radiofrequency (RF)-thermolesions of the epileptic foci. This paper reports the technical data required to perform such multiple cortical thermolesions, as well as the results in terms of seizure outcome in a group of 41 patients. TECHNICAL DATA: Lesions are placed in the cortex areas showing either a low amplitude fast pattern or spike-wave discharges at the onset of the seizures. Interictal paroxysmal activities are not considered for planning thermocoagulation sites. All targets are first functionally evaluated using electrical stimulation. Only those showing no clinical response to stimulation are selected for thermolesion, including sites located inside or near primary functional area. Lesions are performed using 120mA bipolar current (50 V), applied for 10-30 sec. Each thermocoagulation produces a 5-7mm diameter cortical lesion. A total of 2-31 lesions were performed in each of the 41 patients. Lesions are placed without anaesthesia. 20 patients (48.7%) experienced a seizure frequency decrease of at least 50% that was more than 80% in eight of them. One patient was seizure free after RF thermocoagulation. In 21 patients, no significant reduction of the seizure frequency was observed. Amongst the characteristics of the disease (age and sex of the patient, lobar localization of the EZ) and the characteristics of the thermocoagulations (topography, lateralization, number, morphology of the lesions on MRI) no factor was significantly linked to the outcome. However, the best results were clearly observed in epilepsies symptomatic of a cortical development malformation (CDM), with 67% of responders in this group of 20 patients (p = 0.052). Three transient post-procedure side-effects, consisting of paraesthetic sensations in the mouth (2 cases), and mild apraxia of the hand, were observed. SEEG-guided-RF-thermolesioning is a safe technique. Our results indicate that such lesions can lead to a significant reduction of seizure frequency. Our experience suggests that SEEG-guided RF thermocoagulation should be dedicated to drug-resistant epileptic patients for whom conventional resection surgery is risky or contra-indicated on the basis of invasive pre-surgical evaluation, particularly those suffering from epilepsy symptomatic of cortical development malformation.
Article
Full-text available
Clinical audits have suggested up to 40% of patients with disorders of consciousness may be misdiagnosed, in part, due to the highly subjective process of determining, from a patient's behaviour, whether they retain awareness of self or environment. To address this problem, objective neuroimaging methods, such as positron emission tomography and functional magnetic resonance imaging have been explored. Using these techniques, paradigms, which do not require the patient to move or speak, can be used to determine a patient's level of residual cognitive function. Indeed, visual discrimination, speech comprehension and even the ability to respond to command have been demonstrated in some patients who are assumed to be vegetative on the basis of standard behavioural assessments. Functional neuroimaging is now increasingly considered to be a very useful and necessary addition to the clinical assessment process, where there is concern about the accuracy of the diagnosis and the possibility that residual cognitive function has remained undetected. In this essay, the latest neuroimaging findings are reviewed, the limitations and caveats pertaining to interpretation are outlined and the necessary developments, before neuroimaging becomes a standard component of the clinical assessment are discussed.
Article
Full-text available
Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality. Selective literature review including an overview over national and international recommendations. Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations. The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.
Article
Child maltreatment remains a significant pediatric health problem despite 25 years since the establishment of the National Center on Child Abuse and Neglect. Federal funding for research on the medical aspects of abuse and neglect has been inadequate and, over time, declining in adjusted dollars. Nevertheless, important research has been conducted without federal support. Landmark research has occurred in the areas of physical abuse, sexual abuse, and neglect. Some of these accomplishments are noted, and a research agenda for future work is suggested.
Article
Excitotoxicity is an important mechanism in secondary neuronal injury after traumatic brain injury (TBI). Excitatory amino acids (EAAs) are increased in cerebrospinal fluid (CSF) in adults after TBI; however, studies in pediatric head trauma are lacking. We hypothesized that CSF glutamate, aspartate, and glycine would be increased after TBI in children and that these increases would be associated with age, child abuse, poor outcome, and cerebral ischemia. EAAs were measured in 66 CSF samples from 18 children after severe TBI. Control samples were obtained from 19 children who received lumbar punctures to rule out meningitis. Peak and mean CSF glycine and peak CSF glutamate levels were increased versus control values. Subgroups of patients with TBI were compared by using univariate regression analysis. Massive increases in CSF glutamate were found in children <4 years old and in child abuse victims. Increased CSF glutamate and glycine were associated with poor outcome. A trend toward an association between high glutamate concentration and ischemic blood flow was observed. CSF EAAs are increased in infants and children with severe TBI. Young age and child abuse were associated with extremely high CSF glutamate concentrations after TBI. A possible role for excitotoxicity after pediatric TBI is supported.
Article
Many children do not survive after presentation in extremis. Some survive varying intervals and are found to have bronchopneumonia at death. The question is raised whether bronchopneumonia is a consequence of survival rather than the initiating disease leading to collapse. A prospective study of the deaths of 156 children divided them into two groups: 80 children with head injury and 76 with causes of death other than sudden infant death syndrome. In 43 of the total group of children, bronchopneumonia was found. In the total group, 76 survived more than a day. Of these 39 had bronchopneumonia, 32 died of head injury, and 7 had other causes of death. Of the children surviving less than a day, 4 had bronchopneumonia at death--only 1 with head injury. If bronchopneumonia is present, it is more likely to have developed after the collapse than to have caused it in this population.
Article
This chapter discusses many of the significant legal, investigative and medical issues encountered when Shaken Baby Syndrome cases are prosecuted in court. Heavy emphasis is placed on trial strategies and techniques including theme development and motive evidence, opening and closing statements, lay and expert witness testimony, meeting untrue defenses and cross-examination of defense experts, and effective use of demonstration slides. Emphasis is also placed on the initial preparation of the case including coordination of a multidisciplinary response to the investigation, development of background investigation information to supplement medical findings and discovery of “prior bad acts” evidence, difficulties in making appropriate charging decisions, and pre-trial motion practice.
Article
This article presents the pathological findings in fatal shaken impact syndrome which reflect the current state of knowledge and the majority opinion of practicing forensic pathologists. The discussion is limited to issues related to fatal cases of shaken impact syndrome with a review of the pathophysiology, autopsy, and neuropathologic findings. Pathophysiology, presentation and autopsy techniques are discussed, with special emphasis on findings specific to SBS. The article concludes with a review of current knowledge of the timing of injuries in inflicted cerebral trauma.
Article
More than 3 million children are abused and/or neglected each year in the United States. Unfortunately, a significant percentage of these cases result in homicide by child abuse or child neglect. Causes of death range from blunt force trauma and shaking to asphyxia to immolation. We retrospectively reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over the past 10 years, from January 1986 to December 1995. Of these, we looked only at children ≤5 years of age. The majority (342 cases, 69%) of these deaths were classified as natural, 96 (19%) as accident, and 60 (12%) as homicide. Of the homicides, we examined the cause of death; age, gender, and race of the victim; relationship to the perpetrator; time interval between injury and death; and the initial history given as to the cause of the injury. The cause of death fell into nine categories, the number one category being head trauma. Forty-five percent of the homicides were by head trauma, 12% by abdominal or body trauma, 25% by asphyxia (with half of these due to drowning), 10% by carbon monoxide poisoning or thermal injury, and the remaining 8% involving cases of neglect, stabbing, and poisoning. The majority of the homicide victims were male (67%) and black (67%). Forty-six percent were ≤1 year of age. Approximately 25% of the homicide cases were designated as shaken baby syndrome (SBS). In 97% of the cases, the assailant was known to the victim and was a family relative in 77%. Sixty-three percent of the assailants were female and 45% of the assailants were male; in 12%, the assailants were both parents, and in 1 case, the assailant remains unknown. Of the asphyxia deaths, 87% of the assailants were female. The time interval between injury and death ranged from minutes to hours in most cases to months in cases of repeated abuse and chronic injury and sequelae. The time interval between injury and the onset of symptoms remains unknown in most cases due to inconsistencies in the history and lack of credibility of the caretaker. The most common initial history given was "a fall" (20%). We report our findings of a decade of pediatric homicides to increase awareness of the common scenarios and case histories, demographics of the victims, causes of death, and perpetrators of pediatric homicide.
Chapter
The term shaken baby syndrome (SBS), defined by the triad of retinal hemorrhage (RH), encephalopathy, and subdural hemorrhage (SDH), despite being widely accepted for 40 years, can no longer be regarded as a valid diagnosis. Multiple lines of evidence, from biomechanics to advances in understanding the anatomy and pathophysiology of the developing infant brain and its coverings, have undermined the diagnosis, and the nomenclature has been revised to reflect this. It is important to shift the focus to the objective pathological findings in babies with these closely interrelated phenomena rather than speculating on mechanisms; the term retino-dural haemorrhage of infancy more accurately characterizes this syndrome. RHs have many causes and are more common after natural disease and accidents than after inflicted injury. Encephalopathy results from hypoxic-ischemic injury rather than from traumatic axonal injury. Trauma is a cause of infant SDH, but there are many natural causes; almost half of normal newborns have SDH identified on brain scan. Infant SDH is usually a thin bilateral film, its source traditionally ascribed to torn bridging veins, but this remains unproved and is rarely documented. The dura is an alternative source; the infant dura is richly vascularized and innervated and bleeding into it is common. SDH evolves into a reactive membrane containing thin-walled capillaries. Recurrent bleeding into these membranes is seen on microscopy. In some cases, SDH evolves into a chronic fluid collection; the causes for this are unknown. Biomechanical studies have shown that the forces generated by shaking are far less than those resulting from impact, but it remains correct to advise parents that babies should never be shaken. This article examines the pathology of each of these signs and their pathophysiology. The importance of considering the birth, early clinical history, and predisposing vulnerabilities when examining a case of suspected abuse is emphasized.
Article
Introduction: Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective: of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI. Method: A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis. Results: In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases. Conclusion Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.
Conference Paper
Full-text available
Article
Abusive head trauma (AHT) is the leading cause of child physical abuse fatalities, and survivors frequently face life-long consequences. Victims of AHT are typically infants, and many are subjected to repeat AHT if not accurately identified and protected. Identifying the timing of AHT is often a medical-forensic process, and investigative personnel use the determination of timing of AHT to guide safety decisions for the child victim. If the medical-forensic timing of AHT is incorrect, a child could be inappropriately placed and/or an innocent caregiver could be subject to prosecution. Victims of AHT who suffer severe/permanent injury are felt to demonstrate symptoms immediately after the trauma, and AHT victims with milder injury are thought to generally have persistent or recurrent clinical signs shortly after the trauma. Periods of normal neurologic appearance, in which a victim of AHT is completely asymptomatic for an extended time after the trauma, are felt to be rare and have not been well characterized in the literature. This case involves a 2-month-old infant victim of AHT who presented to medical care with mild neurologic symptoms that resolved without intervention from medical personnel. While hospitalized, the infant had an asymptomatic period of approximately 38 hours prior to more severe neurologic decompensation, then later returned to neurologic baseline. This case highlights the challenges in accurately timing AHT in very young victims who return to neurologic baseline by characterizing a verifiable prolonged period of normal neurologic appearance and function after AHT.
Article
Objectives: Nosocomial infection is a common source of morbidity in critically injured children including those with traumatic brain injury. Risk factors for nosocomial infection in this population, however, are poorly understood. We hypothesized that critically ill pediatric trauma patients with traumatic brain injury would demonstrate higher rates of nosocomial infection than those without traumatic brain injury. Design: Retrospective case-control study. Setting: PICU, single institution. Patients: Patients under 18 years old who were admitted to the PICU for at least 48 hours following a traumatic injury were included. Patients were admitted between September 2008 and December 2015. Patients with the following injury types were excluded: thermal injury, drowning, hanging/strangulation, acute hypoxic ischemic encephalopathy, or nonaccidental trauma. Data collected included demographics, injury information, hospital and PICU length of stay, vital signs, laboratory data, insertion and removal dates for invasive devices, surgeries performed, transfusions of blood products, and microbiology culture results. Initial Pediatric Risk of Mortality III and Pediatric Logistic Organ Dysfunction-2 scores were determined. Patients were classified as having an: 1) isolated traumatic brain injury, 2) a traumatic injury without traumatic brain injury, or 3) polytrauma with traumatic brain injury. Interventions: None. Measurements and main results: Two hundred three patients were included in the analyses, and 27 patients developed a nosocomial infection. Patients with polytrauma with traumatic brain injury demonstrated a significantly higher infection rate (30%) than patients with isolated traumatic brain injury (6%) or traumatic injury without traumatic brain injury (9%) (p < 0.001). This increased rate of nosocomial infection was noted on univariate analysis, on multivariable analysis, and after adjusting for other risk factors. Conclusions: In this single-center, retrospective analysis of critically ill pediatric trauma patients, nosocomial infections were more frequently observed in patients admitted following polytrauma with traumatic brain injury than in patients with isolated traumatic brain injury or trauma without traumatic brain injury.
Article
Full-text available
The editor of the journal Prometheus organised a debate about shaken baby syndrome. Following the editor's informative introduction, there is a proposition paper by Waney Squier, "Shaken baby syndrome: causes and consequences of conformity". Then there are responses to Squier's paper from ten commentators, written independently. The result is a fascinating range of perspectives on this controversial issue.
Chapter
Most abusive head trauma (AHT) takes the form of shaken baby syndrome (SBS), which primarily affects infants younger than 8 months of age.
Chapter
Etwa 1–10% der Kindesmisshandlungen betreffen den Kopf und das Zentralnervensystem (ZNS). Diese Verletzungen haben die gravierendsten Auswirkungen aller Misshandlungsformen, d. h. die höchste Morbidität und Mortalität. Nach amerikanischen Schätzungen sind 80% der Todesfälle durch ZNS-Verletzungen im Säuglingsalter auf Misshandlungen zurückzuführen. Insgesamt sind sie mit 66–75% die häufigste misshandlungsbedingte Todesursache und die häufigste Säuglingstodesursache im 2. Lebenshalbjahr.
Chapter
Varying degrees of violence against children and adolescents is an age-old phenomenon in many countries and cultures. The boundary between acceptable violence in the context of so-called necessary educational measures by parents or as part of accepted tradition, such as genital mutilation, and unacceptable violence leading to death or severe injury is not always clear. The association between chronic suffering in adults as a result of abuse suffered in childhood and adolescence (WHO 2002) is well known. A definition of child abuse could be formulated as follows:
Article
Effective prevention of abusive head trauma (AHT) requires the identification of potential perpetrators. Current evidence suggests that infant shaking, as a mechanism of AHT, produces immediate symptoms, allowing for the dating of the event based on clinical symptoms. Determining precisely when symptoms occurred may help law enforcement to identify the perpetrator. We retrieved written legal statements and medical records from birth to age at diagnosis of 100 infants consecutively diagnosed with AHT through shaking (2011–17), using forensic expertise files. Timing of abuse allowed for the identification of perpetrators in 91 cases. All abusive events occurred inside a home (parent's or nanny's), never outdoors or in a public place, and always in the presence of only one adult. Approximately one-third (n = 32) of the perpetrators were males (31 fathers) and two-thirds (n = 59) were females: 49 of them were the infant's nanny and ten were the infant's mother. Infants were not described as crying habitually. Better knowledge of the context of AHT events and risk situations, including recent implementation of a new or unusual modality of childcare, and being the only adult in a home with an infant, should facilitate prevention, including targeted training and avoidance of situations associated with risk. Key Practitioner Messages • Abusive events occur in the presence of a single adult, within the privacy of a home. • First signs of abuse most commonly occur in a recent, therefore unusual, form of childcare. • With rare exceptions, the perpetrator is either the nanny or one of the parents. • Identification of the perpetrator and better knowledge of the context of abuse should allow improving targeted prevention.
Chapter
Etwa 1–10% aller Kindesmisshandlungen betreffen den Kopf und das Zentralnervensystem (ZNS). Als charakteristische Konstellation beim klassischen Schütteltrauma-Syndrom wird die Koinzidenz einer variablen, oft aber schweren und prognostisch ungünstigen diffusen Hirnschädigung (Enzephalopathie) mit subduralen Hämatomen und meist ausgeprägten retinalen Blutungen beschrieben. Bei einer bislang hohen Variabilität der Terminologie ist »Abusive Head Trauma« (AHT) mittlerweile der international empfohlene und anerkannte Begriff. Diese Verletzungen haben die gravierendsten Auswirkungen aller Misshandlungsformen, d. h. die höchste Morbidität und Mortalität. Nach amerikanischen Schätzungen sind 80% der Todesfälle durch ZNS-Verletzungen im Säuglingsalter auf Misshandlungen zurückzuführen. Insgesamt sind sie mit 66–75% die häufigste misshandlungsbedingte Todesursache und die häufigste Säuglingstodesursache im 2. Lebenshalbjahr. In etwa jeweils einem Drittel kommt es zu schweren, mittleren oder leichten bzw. fehlenden Folgeschäden. Das Risiko für junge männliche Säuglinge, Kinder aus belasteten sozioökonomischen Lebensumständen und Kinder alleinerziehender, junger Mütter ist erhöht. In etwa einem Drittel aller Fälle finden sich Hinweise auf vorhergehende Misshandlungen mit Schädigungen sowohl des Gehirns als auch anderer Organsysteme und vorherige Kontakte zur Jugendhilfe.
Chapter
Head injury remains a major cause of death in traumatic deaths [1-4] and in medico-legal cases is one of the most difficult areas in interpretation of, not only the mode of injury, but also such issues as timing of injury and significance to the cause of death.
Chapter
Physical child abuse is as old as documented civilisation. King Solomon adjures us that “he that loveth his son chastiseth him betimes” [1]. One suspects that many more children suffer physical assault entirely devoid of any such good intention.There are references to the practice in Nordic folk songs and Irish ballads [2]. For an account of the history of child abuse over several centuries, see De Mause [3]. Mrs Brownrigg “whipped two female apprentices to death” [4]
Article
If murder cannot be proved, the conviction cannot be safe. In a criminal case, it is simply not enough to be able to establish even a high probability of guilt. Unless we are sure of guilt the dreadful possibility always remains that a mother, already brutally scarred by the unexplained death or deaths of her babies, may find herself in prison for life for killing them when she should not be there at all. In our community, and in any civilised community, that is abhorrent.
Article
Abusive head trauma (AHT) (e.g. shaken baby syndrome) is the leading cause of death from child abuse. Proper diagnosis of AHT is critical; if AHT is not identified, children can be inadvertently returned to a violent environment where they can be re-injured or killed. The intensivist plays a critical role in the identification, evaluation, and treatment of AHT. This chapter will focus on the clinical presentation of AHT, the medical evaluation for cranial and non-cranial injuries in cases of suspected AHT as well as the management and treatment of AHT with a focus on the differences between management of children with AHT vs. non-abusive TBI. Current data related to the mechanism of injury and pathophysiology of AHT will also be discussed. Finally, issues related to mandated reporting and legal proceedings related to AHT cases will be discussed as will the role of the intensivist in all of the above.
Chapter
Shaken baby syndrome (SBS) is defined by the presence of a triad of findings (subdural hemorrhage [SDH], retinal hemorrhages [RH], and hypoxic-ischemic encephalopathy [HIE]) in the absence of scalp and/or skull fracture that indicate head injury in an infant or young child caused by violent shaking. While some authorities accept the triad as diagnostic of SBS, there is some skepticism by other experts, creating some controversy. The core evidence shows that shaking alone is not as frequently fatal as are blunt impacts of the head. It is apparent that, in some instances, shaking itself can cause fatal head injury. Although short falls rarely cause fatal head injury with the triad, an overlap between the clinicopathological findings of SBS and short falls can be seen, which sometimes seems inseparable. In the majority of accidental and nonaccidental fatal head injury cases studied, the infants became immediately unconscious at the time of incident. If not immediately unconscious, only a brief lucid interval with symptoms is present followed by progressive deterioration. Subject to few exceptions, the majority of infants who acutely collapse with the triad have a head injury. Therefore, it is important for the forensic pathologist to keep an open mind, acknowledging the existence of both traumatic and non-traumatic causes of the triad, in the differential diagnosis. Although many sources indicate that shaking causes characteristic RH, there is also contrary evidence showing that so-called characteristic RH can have causes other than shaking. Due to such persistent controversies, there is no uniform consensus on the reliability of diagnosing SBS simply from the presence of RH.
Chapter
Aufgrund des Erfahrungsschatzes in der Erhebung, Protokollierung und Dokumentation von Verletzungsbefunden sind Rechtsmediziner seit altersher auch mit der Untersuchung Lebender nach rechtserheblichen Körperverletzungen befasst (Beweismittelsicherung am Lebenden), damit sich entsprechend erhobene Befunde und ihre Beurteilung im weiteren Verfahrensablauf als tragfähig erweisen. Das rechtsmedizinische Untersuchungsspektrum inkl. Asservation nach Sexualdelikten ist weitgehend normiert. Bei Kindesmisshandlung steht die Abgrenzung von häufig behaupteten akzidentellen Verletzungen im Vordergrund. Selbstbeschädigungen weisen typische Verletzungscharakteristika auf. In den letzten Jahren spielt die forensische Altersdiagnostik bei Lebenden eine zunehmende Rolle. Aufgabe eines Altersgutachtens ist eine Aussage zum chronologischen Alter aufgrund des physischen Entwicklungszustandes eines Individuums, welcher als biologisches Alter bezeichnet wird.
Book
Incorporating the most recent literature and state-of-the-art methods, this practical work and atlas covers the entire domain of neuropathology for forensic pathologists as well as for specialists in associated fields. Its concise, direct style provides the reader with succinct and easy-to-find answers to forensic, pathological, pathophysiological, biomechanical, and molecular biology problems. Additionally, the authors cover several basic and practical problems that may stimulate further research. Each chapter includes an overview of the literature as well as specified references, and features a wealth of figures, graphs, and tables. The present volume deals with specific aspects of neuropathology, and is particularly appropriate for all those interested and involved in the field of forensic pathology, forensic sciences, clinical pathology, neurology, neurosurgery, law, and criminology. Special emphasis is placed on expertise concerning the field's relevance for everyday practice and also on up-to-date data in basic research.
Article
This article represents the work of the National Association of Medical Examiners Ad Hoc Committee on shaken baby syndrome. Abusive head injuries include injuries caused by shaking as well as impact to the head, either by directly striking the head or by causing the head to strike another object or surface. Because of anatomic and developmental differences in the brain and skull of the young child, the mechanisms and types of injuries that affect the head differ from those that affect the older child or adult. The mechanism of injury produced by inflicted head injuries in these children is most often rotational movement of the brain within the cranial cavity. Rotational movement of the brain damages the nervous system by creating shearing forces, which cause diffuse axonal injury with disruption of axons and tearing of bridging veins, which causes subdural and subarachnoid hemorrhages, and is very commonly associated with retinal schisis and hemorrhages. Recognition of this mechanism of injury may be helpful in severe acute rotational brain injuries because it facilitates understanding of such clinical features as the decrease in the level of consciousness and respiratory distress seen in these injured children. The pathologic findings of subdural hemorrhage, subarachnoid hemorrhage, and retinal hemorrhages are offered as "markers" to assist in the recognition of the presence of shearing brain injury in young children.
Article
Many health care professionals believe that there is a very short interval between an act of ultimately lethal infant shaking and the onset of symptoms (altered consciousness, convulsions, respiratory distress, and so on). We reviewed the English-language medical literature on the shaken baby syndrome for case reports or other information that documents the time of onset of symptoms after an act of ultimately lethal infant shaking. The medical literature contains minimal data that substantiate or contradict the contention that is stated here.
Article
The presence and location of ocular hemorrhages were prospectively studied in 169 randomly selected child deaths referred to a medical examiner. Causes of death in the study group included natural diseases and various injuries involving the head, trunk, and asphyxia. Retinal hemorrhages were identified in 70 cases: 62 head injuries, four central nervous system diseases (but not other natural diseases), and four deaths of undetermined cause. The presence of retinal, peripheral retinal, optic nerve sheath, and intrascleral hemorrhages were strongly associated with head injury as compared to other injuries and natural diseases (Yates corrected P-values < 0.001). Among the head-injured with retinal hemorrhages, nine had a history of severe traumatic event (e.g., an unrestrained rear-seat passenger in high-speed collision) and 53 were victims of inflicted injury (e.g. violent shaking). In the absence of a verifiable history of a severe head injury or life-threatening central nervous system disease, retinal and ocular hemorrhages were diagnostic of child abuse.