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Insufficient evidence for ‘shaken baby syndrome’ - a systematic review

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  • Karolinska Institutet and University Hospital, Stockholm

Abstract and Figures

Shaken baby syndrome has typically been associated with findings of subdural haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad. During the last decade, however, the certainty with which the triad can indicate that an infant has been violently shaken has been increasingly questioned. The aim of this study was to determine the diagnostic accuracy of the triad in detecting that an infant had been shaken. The literature search was performed using PubMed, Embase and the Cochrane Library up to October 15, 2015. Relevant publications were assessed for the risk of bias using the QUADAS tool and were classified as having a low, moderate or high risk of bias according to predefined criteria. The reference standards were confessions or witnessed cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed as possibly relevant and read as full texts, and 30 studies were ultimately included. Of these, 28 were assessed as having a high risk of bias, which was associated with methodological shortcomings as well as circular reasoning when classifying shaken baby cases and controls. The two studies with a moderate risk of bias used confessions and convictions when classifying shaken baby cases, but their different designs made a meta-analysis impossible. None of the studies had a low risk of bias. Conclusion: The systematic review indicates that there is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). It was also demonstrated that there is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).
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REVIEW ARTICLE
Insufficient evidence for shaken baby syndromea systematic review
Niels Lynøe (niels.lynoe@ki.se)
1
,G
oran Elinder
2
, Boubou Hallberg
3
,M
ans Ros
en
4
, Pia Sundgren
5
, Anders Eriksson
6
1.Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
2.Department of Clinical Science and Education, S
odersjukhuset, Karolinska Institutet, Stockholm, Sweden
3.Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
4.Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
5.Department of Diagnostic Radiology, Clinical Sciences, Lund University, Lund, Sweden
6.Department of Community Medicine and Rehabilitation, Forensic Medicine, Ume
a University, Ume
a, Sweden
Keywords
Encephalopathy, Retinal haemorrhage, ‘Shaken
baby syndrome’, Subdural haematoma, Triad
Correspondence
Niels Lynøe, MD, PhD, Department LIME, Stockholm
Centre for Healthcare Ethics, Karolinska Institutet,
Stockholm SE-171 77, Sweden.
Tel: 0046 8 524 8 60 58 |
Fax: 468339512 |
Email: niels.lynoe@ki.se
Received
19 December 2016; accepted 24 January 2017.
DOI:10.1111/apa.13760
ABSTRACT
Shaken baby syndrome has typically been associated with findings of subdural
haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad.
During the last decade, however, the certainty with which the triad can indicate that an
infant has been violently shaken has been increasingly questioned. The aim of this study
was to determine the diagnostic accuracy of the triad in detecting that an infant had been
shaken. The literature search was performed using PubMed, Embase and the Cochrane
Library up to October 15, 2015. Relevant publications were assessed for the risk of bias
using the QUADAS tool and were classified as having a low, moderate or high risk of bias
according to predefined criteria. The reference standards were confessions or witnessed
cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed
as possibly relevant and read as full texts, and 30 studies were ultimately included. Of
these, 28 were assessed as having a high risk of bias, which was associated with
methodological shortcomings as well as circular reasoning when classifying shaken baby
cases and controls. The two studies with a moderate risk of bias used confessions and
convictions when classifying shaken baby cases, but their different designs made a meta-
analysis impossible. None of the studies had a low risk of bias.
Conclusion: The systematic review indicates that there is insufficient scientific evidence
on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking
(very low-quality evidence). It was also demonstrated that there is limited scientific
evidence that the triad and therefore its components can be associated with traumatic
shaking (low-quality evidence).
INTRODUCTION
Rationale
The effects of abusively shaking an infant were first sug-
gested by the paediatric neurosurgeon Norman Guthkelch
in 1971. Based on a few cases, he introduced the hypo-
thesis that shaking a baby backwards and forwards in a
whiplash-like manner might cause subdural haematoma
and eventually other symptoms and signs, namely, retinal
haemorrhages and encephalopathy, referred to as the triad
(1,2). These symptoms and signs could occur without visible
signs of impact to the head and were associated with
isolated violent shaking. An inverse version of the hypoth-
esis was also eventually derived: if the triad was identified
and no other ‘acceptable’ explanation was provided, the
infant had been violently shaken (2).
During the last 40 or so years, a number of studies have
been conducted on ‘shaken baby syndrome’ (SBS), which is
currently a subset of more general labels such as abusive
head trauma, nonaccidental head injury and similar terms
(2, Box 1). It has been maintained by paediatricians and
child protection teams (CPTs) that there is a scientifically
robust body of knowledge supporting the general assump-
tion that when the triad is observed, the infant has been
violently shaken (3,4). The criteria used to identify shaken
baby cases (5) have also been used in criminal trials in order
to prosecute and convict suspected perpetrators with the
Key notes
Shaken baby syndrome has typically been associated
with findings of subdural haematoma, retinal
haemorrhages and encephalopathy.
However, the diagnostic accuracy of this triad in
detecting that an infant has been shaken has been
questioned.
This systematic review indicates that there is insufficient
scientific evidence on which to assess the diagnostic
accuracy of the triad in identifying traumatic shaking
(very low-quality evidence).
©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2017 106, pp.1021–1027 1021
Acta Pædiatrica ISSN 0803-5253
help of expert testimony. If the criteria are not reliable,
however, this might result in either underdiagnosis or
overdiagnosis, and the classification of shaken baby cases in
scientific studies might be mistaken. Underdiagnosis is
linked to an increased risk that the infant is not protected
sufficiently as he or she is not separated from the perpetra-
tor, while overdiagnosis might carry an increased risk of
unjustly separating a family and prosecuting and convicting
an innocent parent or guardian. Hence, robust and evi-
dence-based knowledge about the effects of shaking an
infant has important medical and societal consequences for
the concerned infant, the family, the general public’s trust in
the medicolegal system and science in general.
Over the last decade, questions about the validity of the
allegedly strong link between the triad and traumatic shaking
have successively increased (68). Norman Guthkelch, and
others, has questioned the manner in which his own original
hypothesis, as well as the subsequent inverse version of the
hypothesis, became dogma and has claimed that the evidence
on which the hypothesis was based is poor (9).
Objectives
The main objective of this systematic review was to
determine the diagnostic accuracy of the triad in detecting
that an infant had been violently shaken.
METHODS
Protocol and registration
This systematic review was conducted at the Swedish
Agency for Health Technology Assessment and Assessment
of Social Services and published in Swedish in October
2016 as a report at www.sbu.se/2016. The agency used a
peer-reviewed protocol, including prespecified objectives in
accordance with standards in health and technology
assessments. For the used terms traumatic shaking and
SBS, see Box 1.
As this study is based on a literature review, no patients
or participants were involved.
Eligibility criteria
The eligibility criteria were as follows. The population was
infants of 12 month or under 12 months of age, and the
index test was the presence of the triad in suspected
traumatic shaking. The gold standard reference test was
either that someone had confessed to shaking a baby, or
other documented trauma, and the outcome was diagnostic
accuracy.
Casecontrol and cohort studies with fewer than 10
individuals were excluded to minimise the risk of selec-
tion bias. For possible differential diagnoses, also studies
of single cases could challenge the hypothesis that the
triad always is caused by traumatic shaking. Studies of
differential diagnoses were not assessed regarding quality
and were consequently not a basis for the results. Studies
including children older than 12 months of age, or with
signs of impact to the head, were included only if a
subgroup of 12 month or under 12 months of age, and/or
a subset of isolated shaking, was identified.
Information sources and search terms
The electronic literature search was performed by an
information specialist and included PubMed, Embase and
the Cochrane Library up to October 15, 2015. A comple-
mentary manual search was conducted among the refer-
ences in literature reviews and publications not identified in
the main search. Studies published in English, German,
French, Swedish, Norwegian and Danish were included.
Grey literature, such as conference abstracts or disserta-
tions, was not included.
The search terms included, but were not restricted to,
infant, subdural haematoma, retinal haemorrhage, cerebral
oedema, encephalopathy, accidental and nonaccidental
injury, shaken baby and SBS (2).
Study selection
Six reviewers were engaged in the process and were
split into three groups of two reviewers. They indepen-
dently screened the titles and abstracts identified
through the search strategy. The full texts of all studies of
potential relevance according to the inclusion criteria were
obtained, and each group of two reviewers assessed
one-third of them for inclusion. Any disagreement
was resolved by discussion until a consensus was
reached.
Box 1. Explanations of the terminology used in the present
text.
The term ‘shaken baby syndrome’ (SBS) signifies a
constellation of symptoms and signs, viz. subdural
haematoma, retinal haemorrhages and encephalopathy,
often referred to as ‘the triad’ as caused by violent shaking.
The present review demonstrates that there is insufficient
scientific evidence to support claims that the triad indi-
cates that an infant has been violently shaken (very low-
quality evidence), and that there is limited scientific
evidence to support the assumption that shaking an infant
can cause the triad (low-quality evidence). The term ‘SBS’
is thus not justified, as it includes both the medical findings
and the alleged, but scientifically unproven, injurious
mechanism and even the intent behind this mechanism.
The same applies to a number of other ill-defined terms
used in the literature, for example ‘abusive head trauma’
(AHT), ‘nonaccidental head injury’ (NAHI), ‘inflicted
head injury’ (IHI) or ‘NAHT’, which can symbolize two
completely opposite meanings, viz. ‘nonabusive head
trauma’ and ‘nonaccidental head trauma’.
Hence, the authors have in this study avoided the
acronyms above and chosen to differ distinctly between
the injurious mechanism (‘traumatic shaking’) and the
medical findings (the symptoms and signs, ‘the triad’).
Intent is not, for obvious reasons, for the medical com-
munity to decide.
1022 ©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2017 106, pp. 1021–1027
The triad in ’shaken baby syndrome’ Lynøe et al.
Data collection process and data items
Information concerning the study design, population and
results was extracted from the included papers with a low or
moderate risk of bias.
Risk of bias in individual studies
Two reviewers independently assessed the risk of bias in
individual studies using a modified version of the QUADAS
tool (10). Each study was rated as having a low, moderate
or high risk of bias. The judgement of the risk of bias
focused on the risk of systematic errors due to method-
ological flaws, including circular reasoning in the classifi-
cation of shaken baby cases and controls. Systematic
literature reviews were assessed using the AMSTAR instru-
ment (11).
Studies were assessed as having a low risk of bias when
the study cases, namely shaken babies, were unequivocally
confirmed as having been violently shaken and when the
shaking preceded the symptoms associated with the triad,
for example by a video recording or independent witness
information. Furthermore, the control cases needed to have
been age-matched and unequivocally subjected to other
defined types of trauma.
Studies were assessed as having a moderate risk of bias
when the shaken baby study cases were identified as the
result of a detailed confession by the suspected perpetra-
tor and/or when there were shortcomings regarding
controls, for example no age match or even a lack of
controls. Each individual study underwent an overall
assessment with regard to the significance of such
shortcomings.
Studies were assessed as having a high risk of bias when
additional deficiencies were present, and it was judged that
the results could not provide reliable information in
response to the questions addressed in this systematic
review, for example insufficient definition of the study cases
and circular reasoning.
Risk of circular reasoning
In many studies, the authors referred to a child
protection team (CPT) when classifying shaken baby
cases and controls. The CPT and concerned paediatri-
cians often took for granted that if the triad was
present, and no other acceptable explanations were
provided, that the infant had been violently shaken (12).
The criteria for what was considered an ‘acceptable’
explanation had also been developed, and if these criteria
were not fulfilled, a case was classified, by default, as a
shaken baby case (Table 1). The research question for this
study concerned the certainty of the conclusion that an
infant had been violently shaken when the triad was
observed. But if what was going to be examined had
already been taken for granted by those who were
classifying the cases, the result was judged to have been
based on circular reasoning. To avoid circular reasoning,
only studies in which someone had confessed to shaking
the child were included.
Method of analysis
As sensitivity and specificity were not presented, or could
not be calculated from the included studies, it was not
possible to conduct a meta-analysis.
RESULTS
Study selection
The literature search generated 3773 records, of which 1064
were original papers of potential relevance and were read as
full texts. Of these, 1034 did not fulfil the inclusion criteria
and were subsequently excluded, resulting in 30 included
papers. Of these, 28 were assessed as having a high risk of
bias (1340), two as having a moderate risk (41,42) and
none as having a low risk (Fig. 1).
The assessed systematic literature reviews were all ranked
as being of low quality (4349).
Study characteristics and risk of bias within studies
The strength of the two included studies with a moderate
risk of bias (41,42) one retrospective and one prospective
was the fact that their study groups were based on
confessions. One study provided detailed information about
the shaking event in 14 of 29 cases (41), while the control
group in the other study entailed witnessed accidents in
public areas (42). One methodological weakness of both the
included studies was the risk of false confessions, but there
were also other methodological flaws.
Results of individual studies
In the retrospective casecontrol study (41), the group of
confessed shaking cases was compared to a group contain-
ing people who were suspected of, but denied, having
shaking the infant. In the confessed shaking group, 13 of the
29 cases were allegedly injured through isolated shaking,
and detailed information about the shaking event was
provided in 14 of the 29 cases. A similar specification was
not provided in the denial group, which comprised 82 cases.
The authors found no statistically significant differences
Table 1 The child protection teamsand the scientistscriteria for cases classified as
shaken babies and controls
Shaken babies Controls
Lack of explanation Yes
Accidental fall <1 m Yes
Accidental fall >1 m Yes
Not witnessed accidents Yes Yes
Witnessed accidental fall Yes
Witnessed shaking Yes
Confessed shaking +details Yes
False confession +details Yes
Confessed milder resuscitation shaking Yes
Cases in which someone is convicted Yes
Cases in which caretakers change story Yes
©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2017 106, pp.1021–1027 1023
Lynøe et al. The triad in ’shaken baby syndrome’
between the cases in the two groups, with regard to their
age, sex, mortality, symptoms, etc.
In the prospective study (42), the authors compared a
group of infants in which someone had confessed to and/or
been convicted of having shaken the baby (n =45) with a
group in which the infants had been exposed to an accident
that was witnessed in a public area (n =39). The authors
stated that ‘Information on the confessions was obtained by
a forensic paediatrician from judicial sources during exper-
tise or after the judicial hearings were made public’ (42). No
detailed information was provided regarding what had been
confessed or under what circumstances the confessions had
been obtained. The authors used a triad that comprised
subdural haematoma, diffuse retinal haemorrhages and an
absence of scalp swelling. For the applied triad, the authors
reported a sensitivity of 0.244, a specificity and positive
predictive value of 1.0 and a negative predictive value of
0.534.
Different conditions or events that might have caused the
triad or its components included accidental trauma, such as
a fall or motor vehicle accident, sequelae of normal delivery,
prematurity, macrocephaly and external hydrocephalus,
coagulopathies, infections, metabolic diseases, leukaemia,
immunological conditions, vascular malformations in the
brain and asphyxia (2).
DISCUSSION
Summary and evidence
The main finding was that 28 of the 30 included studies
were assessed as having a high risk of bias, while two had a
moderate risk and none had a low risk. There were two
main indications of a high risk of bias: methodological flaws
and circular reasoning when classifying shaken baby cases
and controls. Two conclusions were drawn. The first was
that there is insufficient scientific evidence on which to
assess the diagnostic accuracy of the triad in identifying
traumatic shaking [very low-quality evidence according to
GRADE measure (50)]. The second was that there is limited
scientific evidence that the triad and therefore its compo-
nents can be associated with traumatic shaking [low-quality
evidence according to GRADE (50)].
Limitations of the studies identified
The included studies were observational, and many of them
used comparison groups and were performed as retrospec-
tive casecontrol studies extracted from medical records or
registers. Some studies were designed as prospective cohort
studies. Apart from the usual methodological bias issues
associated with retrospective casecontrol studies, other
issues were also observed. In most studies, the average age
of the control group was significantly higher than that of the
shaken baby group, particularly in accidental falls (51).
Furthermore, the radiological and ophthalmological exam-
inations were rarely blinded, and, when they were, a poor or
moderate inter-rater agreement was reported (52).
The criteria for classifying study cases and controls
varied. Sometimes the composition of the comparison
group was explicitly presented, whereas sometimes there
was simply a deferral to the judgement of a CPT. Sometimes
the criteria for shaken baby cases were related to contro-
versies concerning the height of a fall. If the fall was below a
certain height, for example 1 m, the case was classified as
a shaken baby, but if it was above 1 m, it was classified as a
control (see Table 1). Such classifications were applied,
despite the fact that several studies have shown that a minor
fall could have caused the triad, particularly in cases of
increased head circumference due to macrocephaly
benign enlargement of the subarachnoid space in infancy
(5356) or long-term sequelae of a chronic subdural
haematoma after an uncomplicated vaginal delivery (20,57
59). Such classification criteria resulted in uncertainty as to
whether the groups of shaken babies also included acci-
dental injury cases and whether the control groups also
contained shaken babies.
The other main reason for the low quality was the issue of
circular reasoning linked to the classification criteria. As
illustrated in Table 1, in many cases, the applied criteria
focused more on the suspect’s trustworthiness than on
scientifically based criteria.
3773 records
identified from
the literature
1064
reports
retrieved
and read
in full
text
2614
records
excluded
1034
reports
excluded
30 reports
assessed for
risk of bias
28 trials
with high
risk of
bias
Five
additional
reports
retrieved
0 (zero)
trials
with low
risk of
bias
2 trials
with
moderate
risk of
bias
Figure 1 Flow chart illustrating the literature search.
1024 ©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2017 106, pp. 1021–1027
The triad in ’shaken baby syndrome’ Lynøe et al.
The two studies of moderate quality
The two studies of moderate quality included samples in
which a person had confessed to and/or been convicted of
having shaken an infant (41,42).
In one study (41), those who had confessed provided
detailed information about the shaking event in approxi-
mately half of the cases. No significant difference was found
between the two groups of those who had confessed and
those who had not. Three interpretations seem plausible:
either the group who confessed to a shaking event included
false confessions, or the group who denied a shaking event
actually included shaken babies, or both. The circumstances
under which a confession was obtained might have
involved false confessions, because of police pressure, or
be the result of plea-bargaining procedures, which also
entail an increased risk of false confession (60,61). It is not
known whether police-induced confessions or plea-bar-
gaining procedures were applied in any of the two studies.
In the other study of moderate quality (42), the authors
compared a group in which someone had confessed to having
shaken an infant to a control group where an accidental
trauma had been witnessed in a public area. However, as the
authors used a different triad with encephalopathy replaced
by the absence of scalp swelling it was not possible to
calculate specificity and positive predictive value for the
traditional triad. The shaking group was compared to a group
with accidental injuries, all of which were very likely to have
had signs of external impact to the head or skull. Accordingly,
it is no surprise that the authors obtained a specificity and
predictive value of 100%. Furthermore, as the authors used
different ratings of retinal haemorrhages, the modified triad
was even more complicated. Moreover, the nature of the
confessions was not reported.
Due to the low quality of the reviewed studies, the
incidence and prevalence of SBS remain unknown.
Other conditions and events that could have caused
the triad
The literature search identified a large range of diseases and
events that were associated with the triad or its components.
The various diagnoses and events were more or less
common, and the various conditions were more or less
controversial, such as rebleeding after a minor fall in a child
with an enlarged head circumference (20,5359). Another
controversial issue was whether normal vaginal delivery
was associated with subdural haematoma and retinal
haemorrhages in around 30% of newborn infants (6265);
the incidence was reported to be higher in assisted deliveries
and significantly lower in scheduled Caesarean deliveries. As
far as we know, these phenomena were clinically asymp-
tomatic and the haematomas and haemorrhages resorbed
within months. In a few cases, however, the subdural
haematoma might have developed into a chronic subdural
haematoma or hygroma, which might have resulted in
symptomatic rebleeding, either spontaneously or after a
minor trauma (20,5759). These possibilities complicate the
picture when an infant suddenly presents with symptoms
such as apnoea and its parent or guardian is unable to
provide an ‘acceptable’ explanation for these symptoms.
Ethical considerations
All children must be protected from abuse, and it is also
important that families are not unnecessarily separated and
that innocent parents or guardians are not convicted. From
the clinical perspective of a CPT, it might be more
important to protect the infant from abuse than to prevent
the conviction of an innocent parent or guardian. But it is a
problem if scientists base their classifications on the
preferences of a CPT. To date, such teams have provided
scientists with biased classification criteria, resulting in
biased studies that by default support already established
but biased evidence. Epidemiologists found that the inci-
dence of homicide among infants from 1980 to 2005
sharply increased from a stable incidence during the period
19401979 (66). The authors suggested that the classifica-
tion of homicides and accidental deaths in recent decades
had been influenced by ethical considerations rather than
by scientifically based consideration.
To obtain valid knowledge, future research must avoid
circular reasoning when classifying shaken baby cases and
controls (Table 2).
CONCLUSION
This review showed there is insufficient scientific evidence
on which to assess the diagnostic accuracy of the triad in
Table 2 Recommendations and cautions when conducting future research within
the field of shaken baby
Prospective cohort and casecontrol studies
When classifying shaken baby cases, demand information about the
following:
police interrogation methods (risk of false confession)
the presence of plea bargain (risk of false confession)
role of child protection team
what the suspect has actually confessed
whether and how differential diagnoses were excluded
When classifying controls, demand information about the following:
witnessed events in a public area
age matching
role of child protection team
Avoid circular reasoning when classifying cases and controls!
Other requested studies
Screening of newborns for subdural haematoma and retinal
haemorrhages
Natural course of subdural haematoma and retinal haemorrhages
among newborns
Vulnerability of infants with macrocephaly
Blinding of observations of subdural haematoma and retinal
haemorrhages
Physiological mechanisms of shaking
©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2017 106, pp.1021–1027 1025
Lynøe et al. The triad in ’shaken baby syndrome’
identifying traumatic shaking (very low-quality evidence).
Furthermore, there is limited scientific evidence that the
triad and therefore its components can be associated with
traumatic shaking (low-quality evidence).
As valid knowledge is necessary to determine whether or
not an infant has been violently shaken, future research
requires that circular reasoning be avoided when classifying
shaken baby cases and controls.
ACKNOWLEDGEMENTS
We gratefully acknowledge the administrative and secre-
tarial support provided by Anna Attergren Granath, Irene
Edebert, Frida Mowafi and the literature searches con-
ducted by documentation specialist Hanna Olofsson.
FINANCE
This review was funded by, and conducted at, the Swedish
Agency for Health Technology Assessment and Assessment
of Social Services.
CONFLICTS OF INTEREST
None of the authors have any conflict of interests to
declare.
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Lynøe et al. The triad in ’shaken baby syndrome’
... SBS triad refers to a set of three critical findings often seen in infants who have been violently shaken-these are subdural hematoma, retinal hemorrhages, and encephalopathy [5]. According to a research conducted in Turkey, there was a history of seizure and cardiopulmonary arrest in 67.5% and 75% of infants respectively [6]. ...
Article
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Introduction Shaken baby syndrome (SBS) is a severe form of child abuse that results in a triad of clinical findings: subdural hematoma, retinal hemorrhages, and encephalopathy. These injuries can lead to significant brain damage, developmental delays, disabilities, or even death. In addition to these, other indicative signs include bruises, vomiting, full fontanelles, sleepiness, seizures, and fractures. Methods This paper reviews the existing literature on SBS in Nigeria, identifies the challenges contributing to its underrecognition, and provides evidence-based recommendations for improving diagnosis, management, and prevention strategies in the region. Conclusions Despite the profound impact of SBS, its recognition and management are inadequate, particularly in low- and middle-income countries (LMICs) like Nigeria, due to limited diagnostic capabilities and documentation. Addressing these gaps is crucial for safeguarding the well-being of infants and young children in Nigeria.
... Few studies have sought to validate the SBS triad. Recently, Lynøe et al. systematically reviewed 30 relevant publications using the QUADAS (quality assessment for diagnostic accuracy of studies) tool and concluded that there was insufficient scientific evidence to assess the diagnostic accuracy of the triad [29]. Levin subsequently countered that numerous reports describe such lesions in victims of verified shaking. ...
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Objectives Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. Methods We retrospectively surveyed the National Trauma Data Bank 2008–2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. Results Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin’s edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. Conclusions Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin’s edema was significantly associated with both intracerebral and subdural hemorrhages.
... The diagnosis of SBS is made in the presence of a triad of subdural hemorrhage, retinal hemorrhage, and encephalopathy with the exclusion of any other differential [4]. SBS has a high mortality rate of up to 38%, and survivors might suffer from long-lasting neurogenic, cognitive, developmental, and visual disabilities, which would require ongoing multidisciplinary care for the remainder of their lives [5,6]. ...
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Objective: This study aimed to determine the level of knowledge, awareness, and attitude about shaken baby syndrome (SBS) among parents in the Qassim region, Saudi Arabia. Methods: A cross-sectional descriptive study was conducted that evaluated the SBS knowledge and attitude among the Qassim population by distributing a questionnaire to a sample that matches the criteria. Results: In total, 373 parents participated in the study, with 82.0% mothers, 49.1% over 40 years old, 98.1% Saudi citizens, and 95.7% married. Out of the 373 participants, 70% were not aware of SBS. The majority (85%) had poor knowledge about SBS, while only 15% had an excellent understanding. However, 85.3% of the individuals expressed interest in learning more about SBS. The preferred sources of information were the internet and social media (39.2%) and doctors or medical personnel during vaccination visits (31%). Interestingly, there were no significant differences in parental knowledge based on gender (p=0.722) or nationality (p=0.957). Conclusions: Parents in the studied region had low knowledge of shaken baby syndrome. Educational programs and awareness campaigns are needed to inform them about the grave consequences of this form of child abuse.
Chapter
Pediatric (childhood) mortality has a powerful public presence. The vast majority (85%) of pediatric deaths occur in the first 5 years of life [1]. There are various causes of death that fall under all manners of death. Awareness of child abuse began to emerge in the 1960s in many countries.
Chapter
Injuries due to blunt trauma are commonly seen in medicolegal autopsy practice. In contrast to cases of penetrating trauma where evidence, i.e., a bullet or victim’s blood on a knife, can be collected and analyzed to link a firearm or a sharp instrument, respectively, connecting cutaneous blunt trauma injuries to their specific origins, i.e., patterned injuries, is the exception. Compared with penetrating trauma where tissue damage is confined to defined wound tracks, scenarios causing internal blunt trauma injuries can affect a wide range of organs and tissues. “Multiple blunt trauma injuries” may appear random at autopsy, but recognition by the pathologist of an injury pattern, i.e., an anatomic distribution of injuries typically associated with a certain trauma scenario, advances the medicolegal death investigation by establishing the circumstances of a person’s death. The immediate sequela or mechanism of death, i.e., hemorrhage in a body cavity is usually apparent, but its origin may have a number of differential causes that need to be explored during the postmortem to accurately determine the cause of death. In some cases, the circumstances and injury patterns indicate that other mechanisms of death have occurred or are possible.
Article
Aim Crying seems to be a common trigger for abusive head trauma (AHT), which is the leading cause of fatalities from physical abuse in infants. Our objective was to evaluate knowledge of AHT, crying infants and correct behavioural measures in a general population. Methods An online questionnaire (LimeSurvey) was created to assess the risk of shaking. The online survey contained a total of 41 questions, including a demonstration of a previously recorded video in which an infant doll is shaken. Results A total of 319 people, 245 of them (76.8%) with own children, participated in the study. Almost all respondents (98.4%) were aware of serious injuries due to shaking, even to the point of death (98.1%). Most participants (97.5%) had heard the term ‘shaking trauma’ prior but did not receive any professional information, neither before nor after birth (85.2% or 86%), or during follow‐up examinations (88.5%). The majority of the participants (95%) considered that useful coping strategies in infant crying were inappropriate. Conclusion The consequences of shaking an infant were common knowledge in a normal population, whereas there was a knowledge gap regarding the management of excessive crying infants. Prevention programmes should mainly focus on male caregivers during postnatal care.
Article
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There is a controversy in child abuse pediatrics between an established corps of child abuse pediatricians aligned with hospital colleagues and law enforcement, and a multi-specialty challenger group of doctors and other medical professionals working with public interest lawyers. The latter group questions the scientific validity of the core beliefs of child abuse pediatricians and believes that there are a substantial number of false accusations of abuse occurring. An unproven primary hypothesis, crafted around 1975 by a small group of pediatricians with an interest in child abuse, lies at the foundation of child abuse pediatrics. With no scientific study, it was hypothesized that subdural hemorrhage (SDH) and retinal hemorrhage (RH) were diagnostic of shaking abuse. That hypothesis became the so-called “shaken baby syndrome.” Through the period 1975–1985, in a coordinated manner, these child abuse specialists coalesced under the American Academy of Pediatrics and began working with district attorneys and social workers, informing them of the ways in which their hypothesis could be applied to prosecutions of child abuse and life-altering social service interventions. In a legal context, using then-prevailing evidentiary rules which treated scientific expert testimony as valid if it was “generally accepted” in the field, they represented falsely that there was general acceptance of their hypothesis and therefore it was valid science. As the ability to convict based on this unproven prime hypothesis (SDH and RH equals abuse) increased, some defense attorneys were professionally compelled by their own doubts to reach out to experts from other fields with experience with SDH and RH, trauma, and biomechanics, for second opinions. Medical and legal challenges to the established thinking soon emerged, based on both old and new evidenced-based literature. As the intensity of the controversy increased, the probability of false accusation became more apparent and the need to address the issue more pressing. Since false accusations of child abuse are themselves abusive, efforts to eliminate such false accusations must continue.
Article
Objective. To determine whether children presenting with epidural hemorrhage (EDH) are as likely to have been abused as are children presenting with subdural hemorrhage (SDH). Design. Retrospective chart review. Setting. Level I regional trauma center and a regional children's hospital. Patients. All children at both institutions 3 years old or younger with a diagnosis of EDH or SDH identified by a search of the computerized trauma registry and hospital medical records from 1985 through 1991. Measurement and Results. Complete records were found for 93 of 94 eligible subjects. The diagnosis of accidental or inflicted injury was ascertained from the patient's hospital medical record or the records of Child Protective Services. Of all subjects (n = 93), 52% (48/93) were male and the median age was 15 months. Abuse was diagnosed in 47% (28/59) of children with SDH and 6% (2/34) of those with EDH. Other significant injuries were found in 47% of children with SDH and 18% of children with EDH. There was no statistically significant difference between the two groups with respect to the likelihood of identifying a skull fracture, the need for surgical evacuation of the hemorrhage, or mortality. Conclusions. Our data are consistent with current biomechanical concepts of intracranial injury. EDHs result from brief linear contact forces that commonly occur in unintentional falls. SDHs are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated in episodes of abuse. Compared with SDH, EDH rarely results from abuse.
Article
Objective: To assess the current general acceptance within the medical community of shaken baby syndrome (SBS), abusive head trauma (AHT), and several alternative explanations for findings commonly seen in abused children. Study design: This was a survey of physicians frequently involved in the evaluation of injured children at 10 leading children's hospitals. Physicians were asked to estimate the likelihood that subdural hematoma, severe retinal hemorrhages, and coma or death would result from several proposed mechanisms. Results: Of the 1378 physicians surveyed, 682 (49.5%) responded, and 628 were included in the final sample. A large majority of respondents felt that shaking with or without impact would be likely or highly likely to result in subdural hematoma, severe retinal hemorrhages, and coma or death, and that none of the alternative theories except motor vehicle collision would result in these 3 findings. SBS and AHT were comsidered valid diagnoses by 88% and 93% of the respondents, respectively. Conclusions: Our empirical data confirm that SBS and AHT are still generally accepted by physicians who frequently encounter suspected child abuse cases, and are considered likely sources of subdural hematoma, severe retinal hemorrhages, and coma or death in young children. Other than a high-velocity motor vehicle collision, no alternative theories of causation for these findings are generally accepted.
Article
In the era of evidence based medicine, with systematic reviews as its cornerstone, adequate quality assessment tools should be available. There is currently a lack of a systematically developed and evaluated tool for the assessment of diagnostic accuracy studies. The aim of this project was to combine empirical evidence and expert opinion in a formal consensus method to develop a tool to be used in systematic reviews to assess the quality of primary studies of diagnostic accuracy. METHODS: We conducted a Delphi procedure to develop the quality assessment tool by refining an initial list of items. Members of the Delphi panel were experts in the area of diagnostic research. The results of three previously conducted reviews of the diagnostic literature were used to generate a list of potential items for inclusion in the tool and to provide an evidence base upon which to develop the tool. RESULTS: A total of nine experts in the field of diagnostics took part in the Delphi procedure. The Delphi procedure consisted of four rounds, after which agreement was reached on the items to be included in the tool which we have called QUADAS. The initial list of 28 items was reduced to fourteen items in the final tool. Items included covered patient spectrum, reference standard, disease progression bias, verification bias, review bias, clinical review bias, incorporation bias, test execution, study withdrawals, and indeterminate results. The QUADAS tool is presented together with guidelines for scoring each of the items included in the tool. CONCLUSIONS: This project has produced an evidence based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies. Further work to determine the usability and validity of the tool continues
Article
Aims: (1) To identify whether infants and young children admitted to hospital with subdural haematomas (SDH) secondary to non-accidental head injury (NAHI), suffer from apnoea leading to radiological evidence of hypoxic ischaemic brain damage, and whether this is related to a poor prognosis; and (2) to determine what degree of trauma is associated with NAHI. Methods: Retrospective case series (1992–98) with case control analysis of 65 children under 2 years old, with an SDH secondary to NAHI. Outcome measures were presenting symptoms, associated injuries and apnoea at presentation, brain swelling or hypoxic ischaemic changes on neuroimaging, and clinical outcome (KOSCHI). Results: Twenty two children had a history of apnoea at presentation to hospital. Apnoea was significantly associated with hypoxic ischaemic brain damage. Severe symptoms at presentation, apnoea, and diffuse brain swelling/hypoxic ischaemic damage were significantly associated with a poor prognosis. Eighty five per cent of cases had associated injuries consistent with a diagnosis of non-accidental injury. Conclusions: Coma at presentation, apnoea, and diffuse brain swelling or hypoxic ischaemia all predict a poor outcome in an infant who has suffered from SDH after NAHI. There is evidence of associated violence in the majority of infants with NAHI. At this point in time we do not know the minimum forces necessary to cause NAHI. It is clear however that it is never acceptable to shake a baby.