Shaken baby syndrome
This article may require unbalanced to certain viewpoints, in particular, it does not clearly state the controversy surrounding the topic (see talk page). (June 2021) ) |
Shaken baby syndrome | |
---|---|
Other names | abusive head trauma, non-accidental head injury, non-accidental trauma |
Usual onset | Less than 5 years old[3] |
Causes | Blunt trauma, vigorous shaking[1] |
Diagnostic method | CT scan[1] |
Prevention | Educating new parents[1] |
Prognosis | Long term health problems common[3] |
Frequency | 3 per 10,000 babies per year (US)[1] |
Deaths | ≈25% risk of death[3] |
Shaken baby syndrome (SBS), also known as abusive head trauma (AHT), is a medical condition in children younger than five years old,
The condition is often caused as a result of a parent or caregiver becoming frustrated due to the child crying.[3] Diagnosis can be difficult as symptoms may be nonspecific.[1] A CT scan of the head is typically recommended if a concern is present.[1] If there are concerning findings on the CT scan, a full work-up for child abuse should occur, including an eye exam and skeletal survey. Retinal hemorrhage is highly associated with AHT, occurring in 78% of cases of AHT versus 5% of cases of non-abusive head trauma.[6][7]
Diagnosing the syndrome has proven to be both challenging and contentious for medical professionals because objective witnesses to the initial trauma are generally unavailable.
Educating new parents appears to be beneficial in decreasing rates of the condition.[1] SBS is estimated to occur in three to four per 10,000 babies a year.[1] These signs have evolved through the years as accepted and recognized signs of child abuse. Medical professionals strongly suspect shaking as the cause of injuries when a young child presents with retinal bleed, fractures, soft tissue injuries, or subdural hematoma that cannot be explained by accidental trauma or other medical conditions.[11]
Retinal hemorrhage (bleeding) occurs in around 85% of SBS cases and the severity of retinal hemorrhage correlates with severity of head injury.[6] The type of retinal bleeds are often believed to be particularly characteristic of this condition, making the finding useful in establishing the diagnosis.[12]
Fractures of the
Infants may display irritability,
Risk factors
Caregivers that are at risk for becoming abusive often have unrealistic expectations of the child and may display "role reversal", expecting the child to fulfill the needs of the caregiver.[15] Substance abuse and emotional stress, resulting for example from financial troubles, are other risk factors for aggression and impulsiveness in caregivers.[15] Caregivers of any gender can cause SBS.[15] Although it had been previously speculated that SBS was an isolated event, evidence of prior child abuse is a common finding.[15] In an estimated 33–40% of cases, evidence of prior head injuries, such as old intracranial bleeds, is present.[15]
Mechanism
Effects of SBS are thought to be
and damage delicate brain tissue, although witnessed shaking events have not led to such injuries.Traumatic shaking occurs when a child is shaken in such a way that its head is flung backwards and forwards.[17] In 1971, Guthkelch, a neurosurgeon, hypothesized that such shaking can result in a subdural hematoma, in the absence of any detectable external signs of injury to the skull.[17] The article describes two cases in which the parents admitted that for various reasons they had shaken the child before it became ill.[17] Moreover, one of the babies had retinal hemorrhages.[17] The association between traumatic shaking, subdural hematoma and retinal hemorrhages was described in 1972 and referred to as whiplash shaken infant syndrome.[17] The injuries were believed to occur because shaking the child subjected the head to acceleration–deceleration and rotational forces.[17]
Force
There has been controversy regarding the amount of force required to produce the brain damage seen in SBS. There is broad agreement, even amongst skeptics, that shaking of a baby is dangerous and can be fatal.[18][19][20]
A biomechanical analysis by F. A. Bandak published in 2005 reported that "forceful shaking can severely injure or kill an infant, this is because the cervical spine would be severely injured and not because subdural hematomas would be caused by high head rotational accelerations... an infant head subjected to the levels of rotational velocity and acceleration called for in the SBS literature, would experience forces on the infant neck far exceeding the limits for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for SBS."[21] Other authors were critical of the mathematical analysis by Bandak, citing concerns about the calculations the author used concluding "In light of the numerical errors in Bandak's neck force estimations, we question the resolute tenor of Bandak's conclusions that neck injuries would occur in all shaking events."[22] Other authors critical of the model proposed by Bandak concluding "the mechanical analogue proposed in the paper may not be entirely appropriate when used to model the motion of the head and neck of infants when a baby is shaken."[23] Bandak responded to the criticism in a letter to the editor published in Forensic Science International in February 2006.[24]
Diagnosis
Diagnosis can be difficult as symptoms may be nonspecific.
-
A skull fracture from abusive head trauma in an infant
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3D CT reconstruction showing a skull fracture in an infant
-
3D CT reconstruction showing a skull fracture in an infant
Triad
While the findings of SBS are complex and many,
SBS may be misdiagnosed, underdiagnosed, and overdiagnosed,
The terms non-accidental head injury or inflicted traumatic brain injury have been used in place of "abusive head trauma" or "SBS".[33]
Classification
The US Centers for Disease Control and Prevention identifies SBS as "an injury to the skull or intracranial contents of an infant or young child (< 5 years of age) due to inflicted blunt impact and/or violent shaking".[34] In 2009, the American Academy of Pediatrics recommended the use of the term abusive head trauma (AHT) to replace SBS, in part to differentiate injuries arising solely from shaking and injuries arising from shaking as well as trauma to the head.[35]
The Crown Prosecution Service for England and Wales recommended in 2011 that the term shaken baby syndrome be avoided and the term non accidental head injury (NAHI) be used instead.[36]
Differential diagnosis
Vitamin C deficiency
Some authors have suggested that certain cases of suspected shaken baby syndrome may result from vitamin C deficiency.[37][38][39] This contested hypothesis is based upon a speculated marginal, near scorbutic condition or lack of essential nutrient(s) repletion and a potential elevated histamine level. However, symptoms consistent with increased histamine levels, such as low blood pressure and allergic symptoms, are not commonly associated with scurvy as clinically significant vitamin C deficiency. A literature review of this hypothesis in the journal Pediatrics International concluded the following: "From the available information in the literature, concluded that there was no convincing evidence to conclude that vitamin C deficiency can be considered to be a cause of shaken baby syndrome."[40]
The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C,
In one study vaccination was shown not associated with retinal hemorrhages.[47]
Gestational problems
Gestational problems affecting both mother and fetus, the birthing process, prematurity and nutritional deficits can accelerate skeletal and hemorrhagic pathologies that can also mimic SBS, even before birth.[48][49][50][51][verification needed]
Prevention
Interventions by neonatal nurses include giving parents information about abusive head trauma, normal infant crying and reasons for crying, teaching how to calm an infant, and how to cope if the infant was inconsolable may reduce rates of SBS.[52]
Treatment
Treatment involves monitoring
Prognosis
Prognosis depends on severity and can range from total recovery to severe disability to death when the injury is severe.[16] One third of these patients die, one third survives with a major neurological condition, and only one third survives in good condition; therefore shaken baby syndrome puts children at risk of long-term disability.[53][54] The most frequent neurological impairments are learning disabilities, seizure disorders, speech disabilities, hydrocephalus, cerebral palsy, and visual disorders.[31]
Epidemiology
Small children are at particularly high risk for the abuse that causes SBS given the large difference in size between the small child and an adult.[15] SBS usually occurs in children under the age of two but may occur in those up to age five.[15] In the US, deaths due to SBS constitute about 10% of deaths due to child abuse.[55]
History
In 1971,
Legal issues
The association of diagnosed SBS with deliberate assault is a matter of legal and medical contention, with conflicting opinions as to whether one necessarily implies the other.
The
In July 2005, the Court of Appeal of England and Wales heard four appeals of SBS convictions: one case was dropped, the sentence was reduced for one, and two convictions were upheld.[63] The court found that the classic triad of retinal bleeding, subdural hematoma, and acute encephalopathy are not 100% diagnostic of SBS and that clinical history is also important. In the Court's ruling, they upheld the clinical concept of SBS but dismissed one case and reduced another from murder to manslaughter.[63] In their words: "Whilst a strong pointer to NAHI [non-accidental head injury] on its own we do not think it possible to find that it must automatically and necessarily lead to a diagnosis of NAHI. All the circumstances, including the clinical picture, must be taken into account."[64]
The court did not believe the "unified hypothesis", proposed by British physician J. F. Geddes and colleagues, as an alternative mechanism for the subdural and retinal bleeding found in suspected cases of SBS.
On 31 January 2008, the Wisconsin Court of Appeals granted Audrey A. Edmunds a new trial based on "competing credible medical opinions in determining whether there is a reasonable doubt as to Edmunds's guilt." Specifically, the appeals court found that "Edmunds presented evidence that was not discovered until after her conviction, in the form of expert medical testimony, that a significant and legitimate debate in the medical community has developed in the past ten years over whether infants can be fatally injured through shaking alone, whether an infant may suffer head trauma and yet experience a significant lucid interval prior to death, and whether other causes may mimic the symptoms traditionally viewed as indicating shaken baby or shaken impact syndrome."[65][66]
In 2012, Norman Guthkelch, the neurosurgeon often credited with "discovering" the diagnosis of SBS,[67] published an article "after 40 years of consideration," which is harshly critical of shaken baby prosecutions based solely on the triad of injuries.[68] Again, in 2012, Guthkelch stated in an interview, "I think we need to go back to the drawing board and make a more thorough assessment of these fatal cases, and I am going to bet ... that we are going to find in every – or at least the large majority of cases, the child had another severe illness of some sort which was missed until too late."[69] Furthermore, in 2015, Guthkelch went so far as to say, "I was against defining this thing as a syndrome in the first instance. To go on and say every time you see it, it's a crime... It became an easy way to go into jail."[70]
Teri Covington, who runs the National Center for Child Death Review Policy and Practice, worries that such caution has led to a growing number of cases of child abuse in which the abuser is not punished.[67]
In March 2016, Waney Squier, a paediatric neuropathologist who has served as an expert witness in many shaken baby trials, was struck off the medical register for misconduct.[71] Shortly after her conviction, Squier was given the "champion of justice" award by the International Innocence Network for her efforts to free those wrongfully convicted of shaken baby syndrome.[72]
Squier denied the allegations and appealed the decision to strike her off the medical register.
In 2022, Channel 4 in the UK broadcast a documentary called The Killer Nanny: Did She Do It? concerning the Louise Woodward case. In it, civil rights lawyer Clive Stafford Smith stated, "shaken baby syndrome is bullshit".[77]
See also
References
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- ^ a b Oral R (August 2003). "Intentional head trauma in infants: Shaken baby syndrome". Virtual Children's Hospital. Archived from the original (Archived) on 14 February 2005. Retrieved 9 October 2006.
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Vaccination injections should not be considered a potential cause of retinal hemorrhage in children, and this unsupported theory should not be accepted clinically or in legal proceedings.
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: CS1 maint: archived copy as title (link) - ^ Oxford doctor Waney Squire vows to fight suspension over 'shaken baby' trial evidence "Oxford doctor struck off over evidence in 'shaken baby' court cases vows to fight suspension". 4 May 2016. Archived from the original on 10 August 2016. Retrieved 6 May 2016.
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External links
- Centers for Disease Control and Prevention – Abusive head trauma