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Abstract

In the decades since Dr. John Caffey described a series of children with chronic subdural hematoma and long bone fractures, there has been a substantial increase in the medical recognition of various forms child abuse. In the United States, the term shaken baby syndrome was coined to explain a constellation of injuries assumed to be the result of violent shaking of infants. After improved understanding of the variety of mechanisms that occur when children are abused, abusive head trauma (AHT) has become the recommended terminology. AHT is a more comprehensive term that reflects the brain injuries that children suffer as the result of abuse. AHT continues to include shaking as a mechanism of injury as well as shaking with impact, impact alone, crushing injuries or combinations of several mechanisms. The medical community in the United States has led the way in developing new terminology and research to describe this unique and devastating form of abuse. The globalization of medicine and rapid information transfer has resulted in AHT becoming well-recognized internationally as a form of serious and fatal child abuse. This paper will review the historical basis in the United States for the diagnosis of AHT. We will also review some of the current international issue in epidemiology, diagnosis, legal processes and outcomes in selected countries/regions where child abuse physicians are actively involved in the evaluation of AHT.

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... In many cases, the perpetrator is a close member of the family. Most estimates of the incidence of NAHI fall between 20 and 30 per 100,000 (Frasier, Kelly, Al-Eissa, & Otterman, 2014;Hinds, Shalaby-Rana, Jackson, & Khademian, 2015;Parks, Kegler, Annest, & Mercy, 2012). NAHI is of significant concern in New Zealand where rates of abuse continue to rise (Kelly, John, Vincent, & Reed, 2015). ...
... Non-accidental head injury (NAHI) is a diagnosis understood by various terminology including; abusive head trauma (AHT), shaken baby syndrome (SBS), inflicted traumatic brain injury (TBI), infant whiplash-shake injury syndrome, and intentional head injury (Parks et al., 2012). Originally, the term SBS was used to describe a collection of injuries assumed to have been caused by the violent shaking of infants (Frasier et al., 2014) characterized by acute encephalopathy with subdural or subarachnoid and retinal hemorrhages, combined with an inconsistent history as to how the injuries occurred (Gill et al., 2009). This triad of symptoms implies a mechanism of injury where tearing of the bridging veins occurs as a consequence of shaking (Paul & Adamo, 2014). ...
... This triad of symptoms implies a mechanism of injury where tearing of the bridging veins occurs as a consequence of shaking (Paul & Adamo, 2014). However, this mechanism of injury is yet to be proven and does not account for impact injuries (Frasier et al., 2014;Paul & Adamo, 2014). AHT and NAHI are now the preferred terms used (Hinds et al., 2015) reflecting the brain injuries children have experienced as a result of abuse including shaking, shaking with impact, impact alone, crushing injuries, or a combination of these mechanisms (Frasier et al., 2014). ...
Article
Child abuse remains a significant issue. Non-accidental head injury (NAHI) is a major cause of mortality in young children with survivors often having to live a life with severe developmental and neurological dysfunction. The aim of this hermeneutic phenomenological research study was to examine the lived experiences of nurses who care for children and their families admitted to hospital with a non-accidental head injury. Semi-structured interviews were conducted with six nurses who had at least five years’ experience of nursing children with NAHI. Following the interpretive approach described by van Manen data was analyzed and two essential themes identified. Firstly, nursing children with NAHI is different from the care of children admitted with a similar neurological injury related to accidental injuries or medical conditions. Secondly, when nursing these children nurses adopt protective qualities, conceptualized in this study as a shield of protection. The findings of this study support the findings of other studies in regard to the emotional labor required of nurses caring for children who have been subject to child abuse and the importance for nurses of maintaining a professional demeanor. The study highlighted the tensions of sustaining a family-centered care approach when caring for a child with NAHI. It is argued that greater acknowledgment and emotional support for nurses is needed and that a child-centered approach offers a more compatible model of care than Family-Centered Care in the acute phase of caring for children with a NAHI.
... 23 In 2008, Stockholm County Council published clinical guidelines for the investigation of SBS according to the AHT criteria and the document has been adapted for use in other parts of Sweden. 24 In 2009, the Swedish Paediatric Society established a child abuse task force to foster awareness of and training in child abuse recognition and reporting, and implementation of the guidelines for investigation and diagnosis of AHT. Subsequently, regional hospital-based child protection centres were established. ...
... Whether there is an increase in true positive or in false positive cases, the Swedish doubling in cases coincides with the fact that there has been an increased awareness of SBS/AHT among Swedish paediatricians during the latter period of our study, 24,28 and that doctors may therefore have become more likely to make an infant abuse diagnosis. A similar findingwas reported from a New Zealand hospital study where the incidence of diagnosis of AHT quadrupled from 1991 to 2010 after the establishment of a specialist child protection team; however, the possibility of overdiagnosis was not discussed. ...
... 29 Unlike our national data for the years 2008-2014, national statistics from New Zealand on infant maltreatment-related injury admissions did not show an increase during the years 1995-2010 8 contrary to the hospital study. 29 One argument proposed for the hidden statistics hypothesis is a previously low identification rate due to a low proportion of Swedish paediatricians receiving training on child abuse, 24 and that there are hidden cases of child abuse among infant deaths classified as 'unknown cause of death'. 30 However, this hypothesis was disproved in a recent study where all records of infants deceased in 1994-2013 were analyzed for diagnosis of AHT, and where, compared with international statistics on AHT death, a tenfold lower incidence is reported. ...
Article
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Background: The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods: This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results: Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities. Conclusions: Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.
... However, six months later, most participants could recall the program's content. Furthermore, none of the infants whose parents were educated had abusive head trauma (Frasier et al., 2014). ...
... A pilot awareness program done in Saudi Arabia reported that 77% of their participants had little to no knowledge of SBS risk factors, mechanisms and complications. However, after six months, the participants could recall at least 50% of the program (Frasier et al., 2014). This indicated that it is possible to prevent SBS in the following ways by teaching parents how to care for newborns and by providing information through maternity nurses and educational videos. ...
... In 1974, Caffey 3) proposed the concept of "the whiplash shaken infant syndrome" as a condition in which head shaking causes intracranial and intraocular hemorrhage, resulting in irreversible brain damage and mental retardation. Since then, this condition with intraocular hemorrhage and subdural hematoma has been called "shaken baby syndrome" mainly in the USA, and more broadly, "abusive head trauma (AHT)" in recent years, and it has come to be regarded as a positive finding that raises suspicion of abuse 7,17) . The mechanism of retinal hemorrhage associated with subdural hematoma has been postulated to be due to traction between the retina and vitreous body caused by shaking 15) . ...
... Therefore, it is now suspected that the papers were not about minor household head trauma, but about abused cases 20) . Subsequently, interest in AHT increased in Japan, and a systematic review published in the USA and Europe pointed out that cases with head trauma and retinal hemorrhage were more likely to have been abused 7,17,21) . In Japan today, it is mandatory to notify the Child Guidance Center of suspected cases of child abuse. ...
Article
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Subdural hematoma in infants can be caused by abuse, and is thought to be more likely if subdural hematoma is associated with retinal hemorrhage and cerebral edema. In Japan, few doctors disagree that cases of subdural hematoma with retinal hemorrhage and cerebral edema with multiple findings on the body are more likely to have been caused by abuse rather than by household accident. On the other hand, in cases where there are no other significant physical findings, only subdural hematoma and retinal hemorrhage, there is a difference of opinion as to whether the injury was caused by an accident or abuse. The reason for this is that neurosurgeons in Japan promoted the concept that infants can develop subdural hematomas and retinal hemorrages due to minor trauma at home before the concept of abusive head trauma became known. In addition, the age distribution of subdural hematomas in Japan differs from that in other countries, with peaks at around 8 months, and the reason for this remains unclear. Therefore, the etiology of infant subdural hematoma in Japan needs to be investigated in greater detail.
... According to CDC, the incidence in the US was 0.76 fatal cases of AHT per 100,000 children <4 years, increasing to 2.14 when considering only children <1 year [12]. In Scandinavian countries, there is a lack of reports from population-based studies in terms of the incidence of AHT [13]. Myhre et al. reported a retrospective case series of infants and toddlers admitted with AHT to a tertiary intensive care unit in Norway [14]. ...
... The suspected perpetrators include males (60%), unemployed, and/or with low levels of education of parents/caregivers. The mortality rate was 25% and most of the surviving children (70%) were discharged with moderate to severe neurological disorders [13]. ...
Article
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Background and objectives: To examine abusive head trauma (AHT) trends using data obtained from hospital-based child protection centers (CPCs) and the distribution of age in months among young children in Saudi Arabia. Methods: A retrospective study was conducted that includes data obtained from 58 hospital-based CPCs in all 13 regions of Saudi Arabia registered in the National Family Safety Registry from 2010 to 2020. AHT cases (n=106) were identified for inclusion in the registry by a daily review of the emergency department logbooks. Results: Over the 11-year period, there was a sharp increase in the number of cases, specifically after 2014, from seven cases per year in 2010 to 16 cases in 2020. AHT affects predominantly children aged 0-12 months (72.6%), followed by 13-24 months (17.9%), 25-36 months (3.8%), 37-48 months (3.8%), and 49-60 months (1.9%). Victims were characterized by a predominance of crying infants (23.6%), past history of abuse (13.2%), a child's chronic disease and disability (7.6%), and prematurity (2.8%). Conclusion: Different training and educational programs need to be performed to raise awareness of AHT. Enacting the pediatrician's mandatory reporting law will improve the rate of reporting cases.
... This is highlighted by the result of an educational program, which was conducted in Saudi Arabia in 2014 where a pilot awareness program done initially reported that 77% of their participants had little to no knowledge of SBS risk factors and complications. However, after six months, the participants could recall at least 50% of the educational program [20]. AlOmran et al. found that gender, marital status, and occupation were significantly associated with awareness level [2]. ...
Article
Full-text available
Shaken baby syndrome (SBS) is a form of traumatic brain injury. Shaking babies can cause the brain matter to bounce within the cranium causing bruising and bleeding, which can result in permanent brain injury. Understanding the attitudes and knowledge of mothers on SBS would help establish effective interventions to raise awareness and establish preventive measures and education programs to avoid debilitating sequelae from SBS in newborns and infants. This study aimed to explore the awareness and attitude regarding SBS. An observational, cross-sectional study was conducted from April 1st through July 31st, 2023. The study population is comprised of mothers who are residents of the Eastern Province of Saudi Arabia and excluded females with no children and those who refused to participate, in addition to mothers not in the Eastern Province. The final sample size included 403 participants. An online-based validated questionnaire was used in the Arabic language. The questionnaire included demographic information and questions to assess the knowledge and attitude of participants regarding SBS. The chi-square test was used to test for significant associations. The majority of the participants were married (72%), while 15.6% were divorced and 10.2% were widowed. Only 7.4% of the participants were illiterates, 30.5% had primary education only, and 15.9% had postgraduate studies. Of note, 37% of the participants said that they would shake their children to calm them if they started to cry. Only 33% of the participants said that shaking babies is harmful. The most commonly reported complications of shaking babies were intracranial bleeding (48.1%), behavioral changes (23.8%), and learning disability (23.5%). Regarding attitude toward SBS, more than two-thirds (72.5%) of the participants said that they want to know more about SBS. Only the educational level had statistically significant relationship between the awareness and the sociodemographic level of the participants. This study concludes that Saudi mothers’ knowledge about SBS is inadequate despite the favorable attitude toward gaining information about it. The awareness level is significantly associated with educational status, which reflects the importance of education programs, especially during the pregnancy period, in raising awareness about SBS and its complications.
... An additional factor for consideration when considering intra-cranial trauma is the associated mortality risks (up to 25% of victims dying as a result). 26 Such presentation is likely to see patients supported by a senior clinical team with arguably greater insight into the wider circumstances. However, the radiographer still has the potential to offer their insight and indeed this is still mandated by HCPC standards that do not take into account different imaging modalities. ...
Article
Introduction: Child safeguarding and the appropriate identification of suspected victims represents a global phenomenon. Diagnostic imaging is acknowledged as a contributory diagnostic service but the role of the radiographer in the identification and escalation process is less well understood. Method: A Knowledge, Attitude and Practice (KAP) survey was constructed to evaluate knowledge base in the context of the patient-radiographer interaction, the shaping of attitude towards child safeguarding and attitudes held towards their role plus the actual practical experiences of managing child safeguarding concerns. Results: Respondents demonstrated a inconsistent knowledge base with respect to physical, social and radiographic signs and symptoms of child safeguarding concern. A positive attitude towards the role of the radiographer in child safeguarding was demonstrated but one that was shaped more by experience than pre-registration education. Assessment of concerns was chiefly influenced by clinical history and appreciation of aetiology. Practically, radiographers have infrequent involvement with the identification and escalation of concerns. Whilst some statistically significant relationships between responses and demographics did exist, these were either sporadic or argued to be a result of natural variation. Conclusion: Assessment of physical and social signs of child safeguarding concern are argued to be becoming more challenging. Radiological signs continue to be visible to radiographers but with increasing use of other imaging modalities these signs are becoming more varied in nature and are providing new challenges. Radiographers are capable of escalation when required to do so. Implications for practice: To maximise the contribution of the profession, education needs to account for imaging modality worked with, in combination with an understanding of related aetiology. Previously existing concerns with respect to escalating processes are no longer in evidence and radiographers are both willing and able to contribute to that process.
... Recent survey research (Flaherty et al., 2018) has identified that eMR child protection alert systems are being developed and used in a number of countries as a policy response to information sharing about interpersonal violence, abuse and neglect concerns. These include Australia (Agency for Clinical Innovation, 2017), New Zealand (Frasier et al., 2014), England (Low, 2016), the USA and Canada (Children's Hospital of Eastern Ontario, 2017). ...
Article
The aim of this systematic literature review was to identify peer‐reviewed publications on the use and/or evaluation of child protection or domestic violence alerts in electronic medical records. A systematic literature search yielded 751 results, with four articles retained for review. Two articles related to the Child Protection – Information Sharing electronic medical record alert system in England and two articles described a clinical decision‐support alert operating in the background of an electronic medical record system in the emergency department of the Pittsburgh Children's Hospital, Pennsylvania, USA. No articles were identified that described domestic violence electronic medical record alert systems. Child protection electronic medical record alert systems are operating in healthcare facilities in several countries. However, despite their promise in terms of improving healthcare and service coordination for children and their families, research testing the efficacy of these systems is limited. ‘Identif[ies] peer‐reviewed publications on the use and/or evaluation of child protection or domestic violence alerts in electronic medical records’ Key Practitioner Messages • Child protection alerts in electronic medical records are used in a number of countries. • No published examples of the use of domestic violence alerts in electronic medical records could be found. • Alerts on linked electronic medical records can convey standardised, current, clinically significant information to a multitude of clinicians across several health services at once. • Two evaluation studies of a child protection electronic medical record alert system were found; therefore, more evaluation studies are required.
... Biochemical markers for metabolic bone disease should be measured as soon as possible. In the case-series, only two thirds had any taken blood tests for a metabolic panel, with no uniformity in the biochemical testing ordered, which might be explained by such testing not being recommended in the screening protocol for maltreatment during the study period [35,36]. Nor could a consistent profile of metabolic bone disease from blood analytes be seen, as previously reported [20]. ...
Article
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Objectives: To assess cases with rib fractures in infants under observation for or with an abuse diagnosis, and to compare risk factors with that in infants with fractures but no abuse diagnosis. Methods: Design was case-series and register case-control of infants (aged <1 year) with rib fractures. Data was clinical records for the case-series (n = 26) and from national health registers for the case-controls (n = 28 and n = 31). Outcome measures were maternal and perinatal characteristics, reasons for appointment, examination, diagnoses, blood tests, and radiologic findings. Results: The case-series had a median age of 70 days. A majority were detected through a skeletal survey for abuse investigation. Sixteen were boys, three were preterm and six were small-for-gestational age. Three carers had noticed popping sound from the chest; no infants showed signs of pain at physical examination. Mean number of fractures was 4.2, and 24 had callus. Bone mineralisation was scarcely reported. Metabolic panel was not uniformly analysed. The register case-control had a median age of 76 days, sharing risk factors such as maternal overweight/obesity, male sex, prematurity, and being small-for-gestational age. Cases more often had subdural haemorrhage, retinal haemorrhage, or long-bone fractures, controls more often had neonatal morbidity, respiratory infection, or a fall accident. Detection of fracture at time of a major surgery (n = 6) and rickets/vitamin D deficiency (n = 5) appeared in both groups, but was delayed among the cases. Conclusions: Rib fractures in young infants, diagnosed as abuse, are usually asymptomatic and healing. A substantial proportion had metabolic risk factors, suggesting false positive cases.
... In the United States, AHT is a leading cause of physical child abuse deaths in children less than 5 years of age and accounts for about one-third of all child maltreatment deaths [1] . Incidence of AHT is estimated to occur in 3-4 per 10,0 0 0 infants a year and between 5 and 35% of infants or children who are AHT victims die from their AHT [2][3][4][5] . ...
Article
Background : Abusive head trauma (AHT) is a leading cause of morbidity and mortality among young children. We aimed to evaluate the long-term impact of AHT. Methods : Using administrative claims from 2000-2018, children <3 years old with documented AHT who had follow-up through ages 5 and 11 years were identified. The primary outcome was incidence of neurodevelopmental disability and the secondary outcome was the effect of age at time of AHT on long-term outcomes. Results : 1,165 children were identified with follow-up through age 5; 358 also had follow-up through age 11. The incidence of neurodevelopmental disability was 68.0% (792/1165) at 5 years of age and 81.6% (292/358) at 11 years of age. The incidence of disability significantly increased for the 358 children followed from 5 to 11 years old (+14.3 percentage points, p<0.0001). Children <1 year old at the time of AHT were more likely to develop disabilities when compared to 2 year olds. Conclusions : AHT is associated with significant long-term disability by age 5 and the incidence increased by age 11 years. There is an association between age at time of AHT and long-term outcomes. Efforts to improve comprehensive follow-up as children continue to age is important. Level of Evidence : IV
... Child abuse occurs in all ethnicities, socioeconomic groups, and races, with boys more commonly affected. Infants tend to have increased morbidity and mortality with physical abuse [32]. ...
Article
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Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
... In 2007, the Child Protection Team was established at Karolinska Sjukhuset. This group developed guidelines for SBS/AHT-screening that have since been disseminated among paediatricians [27]. Additional Child Protections Teams were then established in five Swedish Paediatric University Hospitals [28]. ...
Article
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Objectives To explore parents’ experiences of seeking health care for their children and instead being accused by healthcare professionals of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT), being reported to Social Services, undergoing judiciary processing, and the impact of these events on family (dis)integration. Methods Design: A qualitative study based on qualitative content analysis. Participants: Twelve parents in Sweden, mothers and fathers, seeking health care for their infants, encountering allegations of SBS/AHT, losing custody of their infants, and being subjected to a judiciary process, and finally regaining custody of their children. Data collection: In-depth interviews. Results An overarching theme ‘Fighting for protection of their child after being trapped by doctors’ and four sub-themes were developed to reflect the parents’ experiences, reactions and interpretations. The first sub-theme, ‘Being accused of injuring the child’, illuminated the shock experienced when seeking care and instead being accused of being a perpetrator. The second, ‘Chaos and powerlessness’, refers to the emotions experienced when losing custody of the child and being caught in the enforcement of legislation by the authorities. The third, ´The unified fight against the doctors’ verdict´, illustrates the parents’ fight for innocence, their worry for the lost child, and their support and resistance. The fourth, ‘The wounded posttraumatic growth’, describes the emotions, grief, panic, anxiety, and challenges in reuniting the family, but also the parents’ reflections on personal growth. Unanimously, they had experienced the authorities’ inability to reconsider, and expressed a deep mistrust of paediatric care. Conclusions Being wrongly accused of child abuse and alleged SBS/AHT evoked emotions of intense stress, but parents endured because of a successful fight to regain custody of their child. However, the trauma had a long-term impact on their lives with residual posttraumatic stress symptoms and mistrust towards healthcare services and the authorities. The results provide important inferences for restoring system failures within child protection services.
Article
Intimate partner violence (IPV) is a public health problem of epidemic proportions. IPV often starts early in adolescence and continues throughout an individual's lifespan. IPV is defined as abuse or aggression occurring in the context of a romantic relationship that is perpetrated by a current or former partner. IPV victims often experience severe psychological trauma, physical injury, and even death. The direct recipient of the violence is often not the only individual impacted. Children are often peripheral victims of IPV. It is vital that pediatric health care providers, including pediatric nurse practitioners, recognize that IPV is indeed a pediatric health care crisis requiring strategies for both identification and intervention. This continuing education article will discuss IPV and its impact on children from conception to adolescence while exploring implications for practice.
Article
The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.
Article
The eye, with its distinctive anatomy, not only reflects a wide variety of diseases in life but also undergoes a myriad of post-mortem changes. Consequently, the eye has long been an area of interest in forensic science, primarily for the estimation of post-mortem interval and therefore the time of death and also for assistance in ascertaining the cause of death. There has been significant progress in the knowledge of ophthalmic forensic science using new technologies which have allowed further possibilities to arise where understanding of this field can assist the forensic pathologist. This review aims to highlight the current knowledge which exists in this field and also to identify important avenues for further investigation. Post-mortem changes of the eye along with its current applications and challenges will be discussed. These include the important areas of post-mortem iris biometrics, pupil size correlation with post-mortem interval, use of point-of-care technology on vitreous humor, and the use of ophthalmic imaging in pediatric abusive head trauma.
Article
Men and women experience severe domestic violence (DV) and intimate partner violence (IPV); however, women and children remain especially vulnerable. Violence along the DV/IPV continuum has been recognized as a type of child maltreatment and a child's awareness that a caregiver is being harmed or at risk of harm is sufficient to induce harmful sequelae. Consequences of these abusive behaviors are associated with mental and physical health consequences. Health care professionals can screen, identify, and manage this pathology in affected families while educating communities to these pernicious effects.
Article
Background: Abusive head trauma (AHT) warrants particular attention in terms of prevention. One of the key questions asked is how often AHT occurs in infant day care centers compared with private parental or nonparental homes. To investigate this, we studied the caretaking arrangement and child's location at the time of injury in a cohort of cases involving AHT from the courts. Methods: This multicenter retrospective study covering an 18-year period included all medical and court records of 323 children (2.5 months to 3 years) with AHT, confirmed by the authors acting as medical experts. All markers for abuse and forensic written reports were analyzed by using a standardized data collection tool. The usual child care arrangement and the child's location at the time of injury were noted. The percentage of day care centers found in the study was compared to the expected rate in the French population (19.5%) by using the χ2 test. Results: In 317 AHT cases (98.5%), the assault occurred in a private home (4 in other indoor settings and 1 with missing data). In only 1 case, shaking occurred in a day care center when the nurse was alone with the infant for a few minutes. In 317 cases (98.5%), the usual child care arrangement was by a single adult in charge of 1 or more children. Conclusions: The fact that AHT is an unusual occurrence in day care centers could help social service agencies make decisions in terms of prevention. Recent government policies regarding stay-at-home orders during a pandemic have given this issue new relevance.
Article
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Background and aims Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out‐of‐home care. The objective of this study was to analyse infants placed in out‐of‐home care in Sweden by incidence, medical diagnoses, and perinatal factors. Methods This was a population‐based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out‐of‐home care categories: (a) “Problems Related to Social Environment/Upbringing”, (b) “Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture”, and (c) “SDH, RH, rib fracture, or long bone fracture.” As a reference population, we randomly selected infants without medical diagnoses born the same year. Results Overall incidence of out‐of‐home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out‐of‐home care, children in category (c), “SDH, RH, rib fracture, or long bone fracture”, had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08‐2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32‐0.75) and a smoker (aOR 0.60; 95% CI, 0.37‐0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small‐for‐gestational age (5.2% versus 2.1%). Conclusion SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out‐of‐home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.
Chapter
Pediatric head injury can be a consequence of impact head injury, rotational head injury or penetrating head injury. The clinical features of pediatric neurotrauma are varied, being determined by age, severity of insult and underlying pathology. Perinatal head injuries can develop as a result of excessive molding of the cranial bones, or excessive force applied to the skull during delivery. Fatal accidental traumatic brain injury in childhood is usually the result of falls or road traffic accidents, often with massive crush fractures. Extradural hematomas are typically associated with skull fracture after a motor vehicle accident or fall, and most commonly are located in the temporoparietal region. The clinical diagnosis of diffuse axonal injury is based on the clinical presentation and the typical imaging appearances showing small parenchymal hemorrhages. Acute subdural hemorrhage is traumatic in the vast majority of cases, and when nontraumatic, the cause is usually evident.
Chapter
In most countries, including France, the epidemiology of child abuse is nearly nonexistent, especially as concerns measuring the size of the problem. The definition of child abuse should be broadened and include all situations in which the fundamental needs of infants and young children are not recognized. With the exception of figures for homicide, data in many countries are rare. However, homicide is not an extreme form of abuse, it is abuse gone wrong, and risk factors for lethal and nonlethal abuse are the same. A study carried out by Inserm on homicides of under-one children showed official mortality statistics appearing to be 15 times lower than those provided by hospital data. Under-investigation, nondiagnosis, no reporting, or dissimulation of child abuse leads to major risks of repetition of violence. Training of health professionals and setting up effective statistical tools for epidemiological surveillance are needed to reduce child abuse.
Article
Anecdotal experiences raise concerns that abusive head trauma (AHT) is significantly underdiagnosed and perhaps poorly recognized in Latin American settings. With increasing interest in international collaboration in pediatrics, differences in perspectives regarding complex diagnoses should be explored to facilitate a productive exchange of knowledge and ideas. The purpose of this study was to describe the medical literature pertaining to AHT available to physicians who read only in Spanish. In this review, LILACS, SciELO (major Spanish language databases) and Pubmed were searched with appropriate terms and filters in English, Spanish, and Portuguese for Spanish language articles on AHT. Identified articles' reference lists were then examined for possible additional articles on AHT. All relevant articles were sorted by country and examined for article type and content. Thirty-four unique articles were located for review from 8 of 21 countries. Most of the articles identified were case reports, case series, or educational, and there were no studies regarding overall incidence or prevalence of AHT. Some scientific information contained in the articles varied considerably from that in the English language literature in the areas of etiology and preventive strategies. This survey highlights that the Spanish language literature regarding AHT is sparse and variable. This must be considered when working collaboratively in a global setting. Additionally, identification of this gap presents an opportunity for education and information exchange among global medical communities.
Article
"Shaken baby syndrome" is a term often used by the physicians and public to describe abusive trauma inflicted on infants and young children. Advances in the understanding of the mechanisms and the associated clinical spectrum of injury has lead us to modify our terminology and address it as "abusive trauma" (AT). Pediatric abusive head trauma is defined as an injury to the skull or intracranial contents of an infant or a young child (< 5 y age) due to inflicted blunt impact and/or violent shaking. This chapter focuses on the imaging aspects of childhood abusive trauma along with a brief description of the mechanism and pathophysiology of abusive injury. The diagnosis of AT is not always obvious, and abusive injuries in many infants may remain unrecognized. Pediatricians should be cognizant of AT since pediatricians play a crucial role in the diagnosis, management and prevention of AT.
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Caring for young infants can be stressful. Non-accidental brain or head injury (shaken baby syndrome) is a result of parental stress, and a lack of knowledge of how to respond to a crying infant and the dangers of shaking a child. This article demonstrates the value of international collaboration in projects to prevent child maltreatment. It includes reports of prevention of shaken baby syndrome programmes in Australia, Hungary, Greece, Brazil and Turkey.
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Background: Abusive head trauma of infants is a significant cause of morbidity and mortality. The incidence in Australia has been estimated at 29.6 cases of abusive head trauma for which hospital admission is required per 100 000 infants aged 0-24 months and under per year; more frequent than low speed runovers, drowning and childhood neoplasms. Objective: This article provides a review of the significant incidence and outcomes of abusive head trauma and seeks to raise awareness of the potential of evidence based interventions to reduce infant injury and its consequences in the community. Discussion: An evidence based program, the Period of PURPLE Crying®, has been shown to reduce infant injury. An evaluation of the suitability of program materials for different cultural groups in Australia needs to be assessed. Such a scoping project is proposed as a necessary prerequisite to a pilot clinical intervention.
Article
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This study describes the incidence of head injuries caused by abuse in an Australian infant sample. The frequency of abusive head trauma established by the study is comparable with that reported both internationally and for age-incidence peaks of alternate forms of childhood injury, highlighting the need for investment in prevention initiatives.
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The objective of this study was to assess the knowledge, perception, and professional experience of pediatricians in Saudi Arabia regarding child abuse and neglect. Descriptive study during a one day pediatric conference held on King King Abdulaziz University Hospital , a tertiary care teaching hospital in western Saudi Arabia. The study targeted 198 attendees who were invited from different healthcare sectors in the country. The overall knowledge of participants about some important aspects of child abuse and negligence was adequate, ranging between 82% and 91%. However, their knowledge about reporting cases of child abuse and neglect was quite deficient, ranging between 66% and 79%. As for professional experience about child abuse and negligence it showed considerable variation between participants ranging between 43% and 82%, in which pediatricians who received their medical education in Saudi Arabia scored statistically significantly higher, while pediatricians who received their medical education in Western countries scored higher in all other aspects of the study. Currently, the knowledge and clinical experience on the subject of child abuse and neglect in Saudi Arabia is enough to adopt a comprehensive strategy for the prevention and interventions of child maltreatment at all levels. Pediatricians are expected to play a key role by leading and facilitating this process.
Article
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Although child abuse and neglect (CAN) have been recognized by medical professionals for the last 20 years, child protection services and child maltreatment prevention programs are still emerging in Saudi Arabia. This paper will review the progress made in the country in terms of recognition and implementation of child protection services. Furthermore, it will draw attention to the essential steps required to start child maltreatment prevention programs, as CAN prevention is currently viewed as a global healthcare priority with an emphasis on evidence-based interventions. In addition, this paper will assess Saudi Arabia's readiness to prevent CAN and the challenges that will be faced by the professionals in implementing evidence-based CAN prevention programs.
Article
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To protect children, pediatricians must be willing to raise the possibility of abuse and not be intimidated by the consequences. We consider that the United Kingdom General Medical Council does not understand child protection matters and has no system for dealing adequately with complaints submitted by parents who claim false allegations of abuse. The actions of the General Medical Council in the recent cases of Drs Roy Meadow and David Southall conflict with current child protection laws and guidance for professionals. By deterring doctors from raising concerns about a child's safety and giving opinions on child deaths, the General Medical Council may be increasing the risk of serious child abuse. Although the rate of registrations by child protection authorities decreased by 28% between 1995 and 2005 (ie, there are fewer multiagency child protection plans), the number of criminal convictions for cruelty to or neglect of a child increased by 247% between 1998 and 2005. It is unacceptable that to date the General Medical Council has refused training in child protection offered by the Royal College of Paediatrics and Child Health.
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To describe increased child abuse and neglect (CAN) reporting and the characteristics of the reports in the context of the development of a system of intervention for one of the hospital-based child protection centers in Riyadh, Saudi Arabia aligned with the United Nations Convention on the Rights of the Child (CRC) Article 19. A retroprospective collection of data on all children evaluated by the Suspected Child Abuse and Neglect (SCAN) team in King Abdulaziz Medical City for the National Guard from 2000 to 2008. The cases were further divided into 3 subgroups corresponding to the years 2000-2004, 2005-2006, and 2007-2008 parallel to the stages of development of the national child protection system. During the study period, there were a total of 188 referrals to the SCAN team. Of these 133 (70.7%) were further investigated as CAN cases. The total number of referred cases increased 10-fold from 6.4 cases per year in the first period to 61.5 cases per year in the third period. The mean age was 5 years, evenly represented by males and females. Physical abuse was the most common form of abuse in the first (2000-2004) period at 61% and second (2005-2006) period at 76%, which changed to neglect (41.6%) as the most common form of maltreatment in the third (2007-2008) period. Parents were the perpetrators in 48.9% of cases throughout the 3 periods. Overall fatality rates were 4.4%, 14.3%, and 7.9% in the first, second, and third periods respectively. Recognition of CAN is expanding in Saudi Arabia. This is due to the successful adoption of a system of intervention consisting of child protection centers in the medical facilities, in conjunction with mandatory reporting and data collection strategies. In addition, the changes in public attitudes towards a better understanding of CAN enhanced further recognition and reporting of neglect and milder forms of abuse. We believe that the number of reported CAN cases in Saudi Arabia will continue to rise, hence adequate multi-sectoral services for the abuse victims require further development and improvements throughout the country.
Article
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Trauma is the most common cause of death in childhood and non-accidental injury is the leading cause of death in infants between one month and one year of life. This is a newly emerging entity in Saudi Arabia. However, there is little available literature on the extent of child maltreatment in Saudi Arabia and other Arab countries. In this review, we will discuss various aspects of the central nervous system insults resulting from the inflicted trauma of child abuse. We aim to raise awareness in the region as the tragic loss of life and function is unequalled in childhood beyond the perinatal period.
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Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted traumatic brain injury (TBI) in US children is unknown. To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger. All North Carolina children aged 2 years or younger who were admitted to a pediatric intensive care unit or who died with a TBI in 2000 and 2001 were identified prospectively. Injuries were considered inflicted if accompanied by a confession or a medical and social service agency determination of abuse. Incidence of inflicted TBI. Multivariate logistic regression models were used to compare children with inflicted injuries with those with noninflicted injuries and with the general state population aged 2 years or younger. A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (< or =21 years), non-European American, or products of multiple births. In this population of North Carolina children, the incidence of inflicted TBI varied by characteristics of the injured children and their mothers. These data may be helpful for informing preventive interventions.
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To analyze perpetrator and medical evidence collected during investigations of infant abusive head trauma (IAHT), with a view to (a) identifying cases where injuries were induced by shaking in the absence of any impact and (b) documenting the response of infant victims to a violent shaking event. A retrospective study was undertaken of IAHT cases investigated by the Queensland Police Service over a 10-year period. Cases of head trauma involving subdural and/or subarachnoid hematoma and retinal hemorrhages, in the absence of any evidence of impact, were defined as shaking-induced. Perpetrator statements were then examined for further evidence to support the shaking hypothesis and for descriptions of the victim's immediate response to a shaking event. From a total of 52 serious IAHT cases, 13 (25%) were found to have no medical or observer evidence of impact. In 5 of those 13 cases, there was a statement by the perpetrator to the effect that the victim was subjected to a shaking event. In several cases both with and without evidence of associated impact, perpetrator accounts described an immediate neurological response on the part of the victim. The study confirms that IAHT resulting in death or serious neurological impairment can be induced by shaking alone. In cases where the infant's medical condition was adequately described, the symptoms of head injury presented immediately.
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To explore pediatricians' attitudes and experiences with the court system in child maltreatment cases. An anonymous, cross-sectional survey of a random sample of pediatricians registered with the North Carolina Medical Board. The response rate of the study was 60% (N=270). Few pediatricians (10%) reported that they had "ever" suspected maltreatment but decided not to report it. Pediatricians were equally likely to recall positive and negative experiences in court for child abuse cases. Pediatricians with negative court experiences were more likely to view reporting as time-consuming and were more than twice as likely not to report suspected cases of maltreatment (OR 2.4, 95% CI 1.04, 6.0). Seventy-five percent of pediatricians felt that court is harmful or distressing for children. The majority of pediatricians report suspected cases of child maltreatment. Pediatrician's court experiences play a role in the response to child maltreatment cases, influencing attitudes towards the legal system and the process of caring for maltreated children. Future research efforts should address physicians' concerns about the impact of court on children, ways to improve the working relationship between the legal system and physicians, and the training needs of physicians in child maltreatment, including testifying and understanding the court process.
Article
Intracranial hemorrhage with the formation of a subdural hematoma is a common condition in infancy and early childhood. In the Infants' and the Children's hospitals during the past ten years we have studied and treated it in more than fifty cases. Of these, the last eleven, occurring in the year ended July 1, 1938, form the specific basis for this discussion. There are several phases of this question which seem to us to be of general interest, and we should like to suggest a routine for the management of the majority of the patients. The condition occurs more frequently in undernourished children, and in the majority of instances there is a history of trauma. Sherwood¹ pointed out that subdural hematoma occurs more frequently in infants cared for in foster homes, and Peet and Kahn² refer to Rosenberg's³ extensive experience with this condition, during which he had never
Article
In the first modern discussion in 1946 of the parent-infant stress syndrome (PITS), or battered baby syndrome, I described six infants, 13 months or younger, who suffered from the combination of subdural hematomas and characteristic bone lesions.1 During the last 25 years2-5 substantial evidence, both manifest and circumstantial, has gradually accumulated which suggests that the whiplash-shaking and jerking of abused infants are common causes of the skeletal as well as the cerebrovascular lesions; the latter is the most serious acute complication and by far the most common cause of early death.6 Today we invite your attention to the evidence which supports our concept that the whiplash-shaking and jerking of infants are frequently pathogenic and often result in grave permanent damage to infantile brains and eyes. We shall also point out that potentially pathogenic whip-lash-shaking is practiced commonly in a wide variety of ways, under a wide
Article
The battered-child syndrome, a clinical condition in young children who have received serious physical abuse, is a frequent cause of permanent injury or death. The syndrome should be considered in any child exhibiting evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swellings or skin bruising, in any child who dies suddenly, or where the degree and type of injury is at variance with the history given regarding the occurrence of the trauma. Psychiatric factors are probably of prime importance in the pathogenesis of the disorder, but knowledge of these factors is limited. Physicians have a duty and responsibility to the child to require a full evaluation of the problem and to guarantee that no expected repetition of trauma will be permitted to occur.
Article
To examine whether case characteristics of alleged child physical abuse, such as severity, influence criminal investigation procedures and judicial outcomes. We identified all police-reported cases of non-fatal child physical abuse during 2006 in a Swedish metropolitan area (n=158). Case characteristics were abstracted from police records. Over half (56%) of the victims were boys and the median age group was 9-12 years. The severity of the alleged violence was low in 8% of cases, moderate in 51%, and high in 41%. Suspects were interviewed in 53% of cases, with fathers more likely to be interviewed than mothers. Children were forensically interviewed in 52% of cases, with 9% physically examined by a clinician and 2.5% by a forensic specialist. Seven per cent of the cases were prosecuted and 1.3% resulted in summary punishment. We found no association between severity of alleged abuse and whether the suspect was interviewed, the child was forensically interviewed or physically examined or whether the perpetrator was found guilty. Despite the high severity of alleged violence, physical examination rates were low, suggesting a need for criminal investigative procedures on child physical abuse to be reviewed in Sweden. This article is protected by copyright. All rights reserved.
Article
Inflicted pediatric head injury is a significant issue in New Zealand, fatal cases receiving extensive media attention. The primary aims of this article were to analyze injury patterns and reported mechanisms against both age and cause (accidental or inflicted). The secondary aims were to quantify these deaths and identify trends over time. We retrospectively reviewed pediatric deaths due to head injury in children younger than 15 years referred to the Coronial Service of Auckland, New Zealand, from January 1, 1991, to December 31, 2010. One hundred sixty-seven cases were identified. Overall incidence was stable over time; however, the rate of inflicted head injury increased significantly (from 0.1 to 0.4/100,000 per year). Evidence of impact was seen in 90% of cases. In children younger than 2 years, in the absence of motor vehicle or pedestrian trauma, subdural hemorrhage and diffuse axonal injury were both highly suggestive of inflicted injury. The absence of a history of trauma or a history of a fall less than 1 m was also highly suggestive of inflicted injury. Retinal hemorrhages in these fatal head injuries were severe in 77% of cases and moderate in the remainder.
Article
To examine trends in reports of child maltreatment to the Northern Territory Department of Children and Families among Aboriginal and non-Aboriginal children. A historical cohort study using administrative data collections of notifications and substantiated cases of maltreatment among children aged from 0 to 17 2012s. Annual rates of notification and substantiation of different types of child maltreatment. Results: From 1999 to 2010, the overall annual rates of notification for maltreatment of Aboriginal children showed an average increase of 21% (incidence rate ratio [IRR], 1.21; 95% CI, 1.19-1.24). The greatest increases were in notifications for neglect and emotional abuse. There were parallel increases in rates of substantiated cases of maltreatment. Among non-Aboriginal children, the overall annual rates of notification also increased (IRR, 1.10; 95% CI, 1.07-1.14); however, changes in annual rates of substantiated cases for all types of maltreatment were not statistically significant. There have been considerable increases in both notifications and substantiated cases of child maltreatment, most prominently among Aboriginal children. It is possible that the observed increases reflect increasing incidence of maltreatment; however, they are also consistent with a mix of increased surveillance, improved service access, changes in policy and a shift in public attitudes.
Article
Background: Abusive head injury is a major contributor to morbidity and mortality in infants and toddlers, but data comparing patterns of injury in corroborated accidental trauma and confessed child abuse are scarce. Methods: This is a retrospective review of head injuries with abnormal neuroimaging in children younger than 3 years during a 10-year period in Auckland, New Zealand. Histories were assumed to be true. Results were analyzed for incongruity then compared with data on confessed abuse and corroborated accidental injury. Results: Five hundred nineteen cases were analyzed. Most cases were congruent with the history, and their pattern was consistent with the literature on accidental head trauma in childhood. However, a spike of subdural hemorrhage was seen in the first 6 months of life, explained neither by mechanism nor by published data on birth trauma. The age distribution of retinal hemorrhage was also inconsistent with published data on birth trauma. In infants younger than 6 months, retinal and subdural hemorrhages were associated with the absence of a history of trauma. In older children (6 months-3 years), subdural hemorrhage was more common after minor falls (<1 m, 49%) than major falls (>2 m, 20%) (p = 0.002). Conclusion: We conclude that when a young child (particularly an infant younger than 6 months) presents with traumatic intracranial pathology and either no history of trauma or a history of a minor fall, it must be seriously considered that the history is false. Level of evidence: Epidemiologic study, level III.
Article
Objectives: To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program. Methods: A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs. Results: There were 52 cases of abusive head trauma in the sample. Hospital costs totaled NZ2,433,340,childprotectionNZ2,433,340, child protection NZ1,560,123, police investigation NZ1,842,237,criminaltrialsNZ1,842,237, criminal trials NZ3,214,020, punishment of offenders NZ4,411,852andcommunityrehabilitationNZ4,411,852 and community rehabilitation NZ2,895,848. Projected education costs for disabled survivors were NZ2,452,148,andthecostofprojectedlifetimecarewasNZ2,452,148, and the cost of projected lifetime care was NZ33,624,297. Total costs were NZ52,433,864,averagingNZ52,433,864, averaging NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes. Conclusions: Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention.
Article
The battered-child syndrome, a clinical condition in young children who have received serious physical abuse, is a frequent cause of permanent injury or death. The syndrome should be considered in any child exhibiting evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swellings or skin bruising, in any child who dies suddenly, or where the degree and type of injury is at variance with the history given regarding the occurrence of the trauma. Psychiatric factors are probably of prime importance in the pathogenesis of the disorder, but knowledge of these factors is limited. Physicians have a duty and responsibility to the child to require a full evaluation of the problem and to guarantee that no expected repetition of trauma will be permitted to occur.
Article
British pediatricians who diagnose and treat child abuse cases have come under attack by the British press and by parents who have been investigated for possible abuse. Now the General Medical Council also is intimidating these pediatricians. The General Medical Council is the licensing authority for physicians in the United Kingdom. This has resulted in fewer pediatricians being willing to care for abused children or to testify in child abuse cases. In the United States, the recent recognition of the pediatric subspecialty of child abuse pediatrics should help set standards for child abuse medical evaluation and testimony.
Article
This Classic Article is a reprint of the original work by John Caffey, Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma. An accompanying biographical sketch of John Caffey is available at DOI 10.1007/s11999-010-1665-1. The Classic Article is A (c) 1946, and is reprinted with permission of the American Journal of Roentgenology from Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Radiology. 1946;194:163-173.
Article
To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT). Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed. A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy. The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions. Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.
Article
To describe the outcome of referral to the statutory authorities for infants under 2 years with non-accidental head injury (NAHI), and to establish whether the authorities held sufficient information to develop a risk profile for these cases. Retrospective review of cases admitted to hospital in Auckland, New Zealand from 1988 to 1998. Records from the hospital admission, child protective services and Police were reviewed, up to 19 years from diagnosis. Of 39 infants, 33 survived to leave hospital. Documentation of risk factors was erratic, and sometimes incongruent between agencies. Inter-agency case conferences took place in 17/39 (44%). The Department of Child, Youth and Family Services (CYF) used an informal family agreement to secure safety in 15/33 survivors (45%). Family Group Conferences occurred in 17/33 (52%). Nine of 33 were placed permanently outside the home (27%), two (6%) with unrelated caregivers. Charges were laid in 18/39 cases (46%). Fifteen cases came to trial, with 14 convictions (36%). Of the survivors, 44% were later renotified to CYF. There was no obvious relationship between type of intervention and re-notification. Ensuring the safety of an infant with NAHI, and identifying and taking appropriate action with regard to the offender, are complex tasks. In New Zealand, data collection is often incomplete and inter-agency practice and collaboration is variable. Although the rate of prosecution was relatively high by international standards, many children were later notified again for further concerns of abuse or neglect, suggesting that our interventions have been only partially successful. This paper suggests that all infants admitted to hospital with non-accidental head injury should become part of a prospective inter-agency research study, using a standardised data collection instrument. This should include the systematic collection of all data known or suspected to be associated with risk of child abuse, and incorporate long-term prospective follow-up, regardless of child protective or legal outcomes. Without large numbers followed prospectively and according to sound methodology, it is difficult to prove which forms of intervention are better than others at reducing the risk of further abuse.
Article
Shaken baby syndrome is a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children. Although the term is well known and has been used for a number of decades, advances in the understanding of the mechanisms and clinical spectrum of injury associated with abusive head trauma compel us to modify our terminology to keep pace with our understanding of pathologic mechanisms. Although shaking an infant has the potential to cause neurologic injury, blunt impact or a combination of shaking and blunt impact cause injury as well. Spinal cord injury and secondary hypoxic ischemic injury can contribute to poor outcomes of victims. The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required. The American Academy of Pediatrics recommends that pediatricians develop skills in the recognition of signs and symptoms of abusive head injury, including those caused by both shaking and blunt impact, consult with pediatric subspecialists when necessary, and embrace a less mechanistic term, abusive head trauma, when describing an inflicted injury to the head and its contents.
Article
The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI. A database search was performed to find all medical records over a period of one year relating to those children who had one AHI-related primary complaint and who had had a CT head-scan performed in conjunction with admission. Each medical record was reviewed, in order to assess whether potential abuse had been investigated and documented. Each CT-scan image was re-evaluated for missed indications of potential injuries attributable to AHI. Forty-seven such medical records were found. Of these, 87% showed the diagnosis to be head injuries. The largest group of children was in the age group 0-3 months (38%). Of the children admitted to the Paediatric ED due to a head injury, 54% had a history deemed to raise suspicions of abuse but only five of them had had a documented investigation of child abuse. The re-evaluation of the CT-scans showed no missed cases. In this study we found that among children with known risk factors for AHI, only a few had documentation regarding potential child abuse. The use of a standardized protocol could be helpful in the important work to help staff discover potential AHI.
Article
The battered-child syndrome is a term the authors used to describe young children who received serious physical abuse, generally from a parent or foster parent. In response to a survey, 71 hospitals reported that 302 battered children were seen in the past year. Characteristics of the battered-child syndrome were described and 2 cases were reported in detail. See PDF for full text of the original JAMA article.
Article
Child maltreatment remains a major public-health and social-welfare problem in high-income countries. Every year, about 4-16% of children are physically abused and one in ten is neglected or psychologically abused. During childhood, between 5% and 10% of girls and up to 5% of boys are exposed to penetrative sexual abuse, and up to three times this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden. Exposure to multiple types and repeated episodes of maltreatment is associated with increased risks of severe maltreatment and psychological consequences. Child maltreatment substantially contributes to child mortality and morbidity and has longlasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behaviour, obesity, and criminal behaviour, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. The high burden and serious and long-term consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood.
Article
Our evidence, both direct and circumstantial, indicates that manual whiplash shaking of infants is a common primary type of trauma in the socalled battered infant syndrome. It appears to be the major cause in these infants who suffer from subdural hematomas and intraocular bleedings. The label "battered infant" is a misnomer in many cases which may interfere with early diagnosis and proper preventive treatment. The essential elements in the infantile whiplash shaking syndrome present an extraordinary diagnostic contradiction. They include intracranial and intraocular hemorrhages, in the absence of signs of external trauma to the head or fractures of the calvaria, and are associated with traction lesions of the periosteums of the long bones in the absence of fractures and traumatic changes in the overlying skin of the extremities. Usually there is no history of trauma of any kind. Habitual, prolonged, casual whiplash shakings may produce an insidious progressive clinical picture, the latent whiplash shaken infant syndrome, which is often inapparent to both parents and physicians. It usually first becomes evident at school age when minor idiopathic cerebral motor defects are first detected along with mild idiopathic mental retardation. Permanent impairments of vision and hearing may also be identified at this time for the first time when the children are 5 to 6 years of age. The actual number of such cases is incalculable from current evidence but it appears to be substantial. This concept of the whiplash shaken infant syndrome warrants careful diagnostic consideration in all infants with unexplained convulsions, hyperirritability, bulging fontanel, paralyses, and forceful vomiting singly or in combination. The routine careful examination of the ocular fundi of all infants should provide a superior screening method for early and massive detection of pathogenic whiplash shakings along with radiographic examination of the long bones for confirmation in appropriate cases. Current evidence, though manifestly incomplete and largely circumstantial, warrants a nationwide educational campaign on the potential pathogenicity of habitual, manual, casual whiplash shaking of infants, and on all other habits, practices and procedures in which the heads of infants are habitually jerked and jolted (whiplashed). The proposed nationwide educational campaign against the shaking, slapping, jerking, and jolting of infants' heads is summarized in the following stanza: Guard well your baby's precious head, Shake, jerk and slap it never, Lest you bruise his brain and twist his mind, Or whiplash him dead, forever.
Article
Subdural haematoma is one of the commonest features of the battered child syndrome, yet by no means all the patients so affected have external marks of injury on the head. This suggests that in some cases repeated acceleration/deceleration rather than direct violence is the cause of the haemorrhage, the infant having been shaken rather than struck by its parent. Such an hypothesis might also explain the remarkable frequency of the finding of subdural haemorrhage in battered children as compared with its incidence in head injuries of other origin, and the fact that it is so often bilateral.
Article
The aim of this study was to determine the relative frequency of child abuse, accidents and disease as a cause of subdural hematomas in children under 2 years of age, and to determine the main clinical features at presentation, that may help to distinguish these groups of patients. A retrospective review was undertaken of the medical records of all children under 2 years of age admitted to the Royal Alexandra Hospital for Children with the diagnosis of subdural hematoma in the 10-year period January 1987 to December 1996. Thirty eight children were identified with subdural hematomas during the study period. The commonest cause was nonaccidental injury in 55% of cases, accidents in 39% and nontraumatic causes (6%) made up the remainder. The nonaccidental injury cases were significantly younger than the accidentally injured children. The most important clinical features were the significantly higher incidence of retinal hemorrhages and associated long bone and rib fractures in the abuse group. Delay in presentation for medical evaluation was also more commonly seen in the abused children. Nonaccidental injury is the commonest cause of subdural hematomas in children under 2 years of age. The presence of retinal hemorrhages, bone and rib fractures, delay in presentation and the young age of the infants, suggests child abuse is the most likely cause of these injuries.
Article
We looked at the incidence and demography of nonaccidental head injury in children in a prospective population-based study of paediatric units in Scotland during 1998-99. Shaken impact syndrome occurs with an annual incidence of 24.6 per 100000 children younger than 1 year (95% CI 14.9-38.5). Cases are more common in urban regions, and during autumn and winter months. The risk of a child suffering non-accidental head injury by age 1 year is one in 4065. These brain injuries occur almost exclusively in young infants (median age 2.2 months).
Article
To review the Auckland experience of traumatic subdural haematoma (SDH) in infants under 2 years of age, with particular regard to features which might help to differentiate accidental from non-accidental injury (NAI). Retrospective review of the medical records of children under 2 years of age, coded for subdural haematoma (SDH) and retinal haemorrhage (RH) over a 10-year period. Sixty-four cases of SDH were identified. Forty-one of these were due to non-accidental trauma, and 23 cases were accidental. Differences between these two groups related to the age of presentation, ethnicity, the type of explanation for the injury, and differences in aspects of the clinical presentation (apnoea, seizures, fractures, retinal haemorrhage). Mortality in the non-accidental group was far higher. Subdural haemorrhage is a significant cause of death and disability in infants presenting to hospital in Auckland. In the majority of cases, it is caused by child abuse, and there are certain features that are helpful in establishing this diagnosis. The long-term outcome in this group is unknown, but there is reason to believe that, in many cases, it is poor. There is considerable scope for further research.
Article
Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) is recognized as a major cause of disability and death in the paediatric population. To find out the incidence of ITBI in Estonia. 26 cases of ITBI were recognized: four children died, 22 survived. Of 26 children, 20 (77%) were boys and six (23%) were girls. Median age at admission to hospital was 3.9 mo, and the boys were younger than the girls. The overall incidence of ITBI was 28.7 per 100,000 infants. In the prospective group the incidence was 40.5 per 100,000, and in retrospective group 13.5 per 100,000. ITBI is not rare but not always a recognized form of child abuse. Healthcare professionals should be more aware of this condition.
Article
To analyse medical and witness evidence collected during investigations of infant abusive head trauma with a view to (i) isolating cases where a functional time limit could be established and (ii) examining those cases for evidence of the onset of neurological symptoms. A retrospective study was undertaken of severe infant abusive head trauma cases investigated by the Queensland Police Service over a 10-year period. In cases where sufficient reliable (non-perpetrator) evidence was available, a functional time limit was documented. Those files were then examined for further medical, witness or perpetrator evidence of the infant victim's response to the assault. A functional time limit was established in 16 of 52 cases (31%). In 11 of the 16 cases there was evidence of an immediate neurological response on the part of the victim. The study suggests that the period between assault and onset of symptoms in infant abusive head trauma is brief, particularly in cases of an acute deterioration where proximate medical intervention is required. In those cases with sufficient evidence of the victim's condition post-injury, the symptoms presented without delay.
Article
On examination, the patient was unconscious, with generalized convulsions and irregular breathing. Both eyes were deviated to the right side with excessive salivation. The right pupil was 6 mm rounded and the left pupil was pinpoint, and both were non-reactive to light. The anterior fontanelle was tense and the baby had extensive swelling extending from the right temporoparietal region to the frontal area, involving the right eye with ecchymosis. There were two ecchymotic spots over the right side of the forehead. The baby showed decerebrated posture. The bleeding profile for the patient was normal. Plain x-ray skull showed no fracture, but chest x-ray showed fracture of the right clavicle. CAT scan of the brain showed evidence of acute right frontoparietal subdural hematoma, with massive infarction of the right cerebral hemisphere, and part of the left frontal lobe with midline shift. Also, there was a compression of the right lateral ventricle (Figure 1). The patient was operated upon by right frontoparietal craniotomy, evacuation of the acute subdural hematoma and duraplasty. The bone flap was kept outside. The postoperative period was uneventful. The patient was weaned from the ventilator on the fourth postoperative day, and became conscious and active, moving all limbs, and sucking well. Two weeks later, eye consultation showed improving right oculomotor nerve palsy secondary to the right subdural hematoma with bilateral vitreous hemorrhage. The other ocular examination was within normal limits, including the intraocular pressure in both eyes. The patient was discharged several days later, with an urgent referral to King Khaled Eye Specialist Hospital for possible vitrectomy.
Article
Violence towards children should be considered a major national problem, and should become a focal point of substantial public and governmental attention in our country. A National Committee on Prevention and Management of Child Abuse and Neglect should be urgently established to assume an active leadership role in attacking the problem, to provide a mechanism for increasing knowledge about the causes of this problem, and to identify steps that can be taken to prevent and treat abuse. Professional representatives from the Ministries of Education, Health, Interior, Justice, Labor and Social Affairs, Colleges of Medicine, Law and Social Work, and major health institutes should constitute this committee. The committee should establish an understood local policy for the management of child abuse and neglect, facilitate existing programs of interdisciplinary teams for the management of child abuse and neglect in the tertiary hospitals, and work with other academic institutions to educate health professionals about their role in the identification and management of child abuse and neglect. It should also legally mandate health professionals to report suspected child abuse and neglect, and distribute educational materials to the professional and public media.
Article
To describe the presenting characteristics, type of injury and hospital course in young children with traumatic head injury, and to identify characteristics indicating that the trauma was inflicted. A retrospective medical record review of 91 children less than 3 years of age who were admitted to a tertiary teaching hospital in Norway from 1995 through 2005 with a traumatic head injury. Patients were identified by diagnostic codes, and categorized by type of injury as skull fractures (n = 39), epidural haemorrhage (EDH) (n = 12), subdural haemorrhage (n = 27) and parenchymal brain injury (n = 13). Further the cases were classified as inflicted injury (n = 17), accident (n = 35) or indeterminate (n = 39). The mechanism of injury was similar for EDHs and isolated skull fractures, and none were classified as inflicted. Sixty-three percent of the cases with subdural haematoma were classified as inflicted. When compared to the accident group, children in the inflicted group more frequently had subdural haemorrhage without a skull fracture (OR = 6.9, CI = 1.7-28.2), and seizures (OR = 9.5, CI = 2.1-43.3). Inflicted and accidental head injuries differed in presenting characteristics and injury type. Nearly two-third of the subdural haemorrhages were classified as inflicted, but none of the epidural EDHs or skull fractures. Inflicted injuries tended to present with seizures.
Article
Ten abused children under five years of age (four males, six females) were seen in King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1989G and 1992G. Two children died, five had serious injuries and three had moderately severe injuries. In one of the fatalities, the diagnosis was not suspected until four years after death, when her sister was diagnosed as a case of child abuse. Six children suffered varying degrees of physical neglect and abuse and sexual abuse. The remaining four children had Munchausen syndrome by proxy. Parentally induced illness should therefore be considered in the differential diagnosis of unusual illness with bizarre features, even if the parents' behavior appears normal.
Article
To describe the epidemiology of subdural haemorrhage (SDH) in New Zealand infants. Prospective enrollment of all cases of infantile SDH from 2000 to 2002. Retrospective analysis of national discharge and death data for the same period. Seventy-seven cases of infantile SDH were identified prospectively, and a further 49 cases retrospectively. Of these 126 cases, 92 resulted from non-birth-related trauma. Forty-eight of these were attributed to abuse and 28 to accidental injury. Sixteen cases were undetermined. The 'minimum' annual incidence of inflicted infantile SDH in New Zealand is 14.7 per 100,000 (95% confidence interval(CI) 10.8-19.4), and the 'maximum' 19.6 per 100,000 (95% CI 15.1-25.0). Among Maori, the 'minimum' is 32.5 per 100,000 (95% CI 21.4-47.3), and the 'maximum' 38.5 per 100,000 (95% CI 26.3-54.4). The epidemiology of infantile subdural haemorrhage in New Zealand is similar to that described elsewhere. Non-accidental head injury is a significant child health issue in New Zealand, and the incidence is particularly high among Maori.
Article
To improve detection and quality of assessment of child and partner abuse within a health service. A formal organisational change approach was used to implement the New Zealand Family Violence Intervention Guidelines in a mid-sized regional health service. The approach includes obtaining senior management support, community collaboration, developing resources to support practice, research, evaluation and training. Formal pre-post evaluations were conducted of the training. Barriers and enablers of practice change were assessed through 85 interviews with 60 staff. More than 6000 clinical records were audited to assess rates of questioning for partner abuse. Identifications of partner abuse and referrals made were counted through the Family Violence Accessory File. Referrals to the Department of Child, Youth and Family Services (CYFS) were recorded routinely by the CYFS. Audits assessed quality of assessment of child and partner abuse, when identified. More than 700 staff were trained in dual assessment for child and partner abuse. Evaluations demonstrate improved confidence following training, though staff still need support. Barriers and enablers to asking about partner abuse were identified. Referrals from the health service to the CYFS increased from 10 per quarter to 70 per quarter. Identification of partner abuse increased from 30 to 80 per 6-month period. Routine questioning rates for partner abuse vary between services. Achieving and sustaining improved rates of identification and quality of assessment of child and partner abuse is possible with a formal organisational change approach.
Article
Commentary on the methods available for ascertaining the incidence of inflicted traumatic brain injury (inflicted TBI) and the difficulties involved in defining and measuring this condition in young children. Review of published and unpublished international data regarding parental shaking of infants compared to studies assessing incidence. Review of parental report data reveal that the shaking of young children is a surprisingly common act in a wide variety of countries and cultures. While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of "discipline," survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied. Methodologic challenges to epidemiologic work to develop better estimates are discussed. These data highlight the challenges faced in ascertaining the epidemiology of inflicted TBI in young children. While there is scientific evidence that the shaking of young children can produce profound destruction of children's brains and lives, these data reveal that there are many other children who are shaken by their caregivers but escape the acute clinical presentation of "shaken baby syndrome" or for whom the injuries are not recognized as due to inflicted TBI. The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.