Head injury--abuse or accident?

Transfer of knowledge to diagnose infant abuse and its incidence - a time-series analysis from Sweden

Aim

To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault).

Methods

Design: retrospective population-based and quasi-experimental. Setting: Sweden 1987–2019. Patients: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm. Main outcome measure: Abuse diagnoses (maltreatment or assault). Analyses: Incidence rate, incidence rate ratio (IRR).

Results

The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987–2019. It was rather stable 1987–2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002–2007, peaking in 2008–2013 [IRR 1.63 (95% confidence interval 1.34–1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014–2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71–0.99)].

Conclusion

An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01188-6.

Preliminary observations of the sequence of damage in excised human juvenile cranial bone at speeds equivalent to falls from 1.6 m

There is much debate within the forensic community around the indications that suggest a head injury sustained by a child resulted from abusive head trauma, rather than from accidental causes, especially when a fall from low height is the explanation given by a caregiver. To better understand this problem, finite element models of the paediatric head have been and continue to be developed. These models require material models that fit the behaviour of paediatric head tissues under dynamic loading conditions. Currently, the highest loading rate for which skull data exists is 2.81 ms^-1. This study improves on this by providing preliminary experimental data for a loading rate of 5.65 ± 0.14 ms^-1, equivalent to a fall of 1.6 m. Eleven specimens of paediatric cranial bone (frontal, occipital, parietal and temporal) from seven donors (age range 3 weeks to 18 years) were tested in three-point bending with an impactor of radius 2 mm. It was found that prompt brittle fracture with virtually no bending occurs in all specimens but those aged 3 weeks old, where bending preceded brittle fracture. The maximum impact force increased with age (or thickness) and was higher in occipital bone. Energy absorbed to failure followed a similar trend, with values 0.11 and 0.35 mJ/mm³ for age 3 weeks, agreeing with previously published static tests, increasing with age up to 9 mJ/mm³ for 18-year-old occipital bone. The preliminary data provided here can help analysts improve paediatric head finite element models that can be used to provide better predictions of the nature of head injuries from both a biomechanical and forensic point of view.

Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study

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.

Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

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.

Finite element models and material data for analysis of infant head impacts

Finite element (FE) models of the infant human head may be used to discriminate injury patterns resulting from accidents (e.g. falls) and from abusive head trauma (AHT). Existing FE models of infant head impacts are reviewed. Reliability of the material models is the major limitation currently. Infant head tissue properties differ from adults (notably in suture stiffness and strain-to-failure), change with age, and experimental data is scarce. The available data on scalp, cranial bone, dura, and brain are reviewed. Data is most scarce for living brain. All infant head model to date, except one, have used linear elastic models for all tissues except the brain (viscoelastic or Ogden hyperelastic), and do not capture the full complexity of tissue response, but the predicted whole-head response may be of acceptable accuracy. Recent work by Li, Sandler and Kleiven has used hyperelastic models for scalp and dura, and an orthotropic model for bone. There is a need to simulate falls from greater than one metre, and blunt force impacts.

A proclaimed accidental fall of an infant-an experimental case reconstruction study

The differentiation between a non-accidental injury and injuries resulting from accidents, such as falls to the ground or onto various objects, is a challenge not only for forensic experts but also for all clinicians caring for children. The forensic-biomechanical analysis of accidents in infants aims at the assessment of the loading characteristics based on the reconstruction of the particular incident. It includes an evidence-based analytical comparison between the actual injuries presented and the injuries that should be expected as a result of the proclaimed accident. With the help of kinematical and dynamical parameters of the described actions and the resulting loading situations, the forensic-biomechanical analysis can assess the plausibility of the proclaimed course of the event and thus contribute to the differentiation between accidental and non-accidental injuries. The quality of such a forensic-biomechanical expert opinion depends on the accuracy and quantity of available data regarding biomechanical tolerance of tissues, organs, and body parts. Case-specific measurements can contribute significantly to the insight of the kinematics and dynamics of the proclaimed event, its feasibility, etc. The present article demonstrates, based on one case report, the potential as well as the limits of such an analysis of proclaimed accidental fall injuries.

Criteria for CT and Initial Management of Head Injured Infants: A Review

Criteria for computed tomography (CT) to head injured infants have not been established. Since the identification of neurological findings is difficult in infants, examination by CT may be necessary in some cases, but it may be difficult to perform CT because of problems with radiation exposure and body movement. Moreover, even though no intracranial abnormality was found immediately after injury, abnormal findings may appear after several hours. From this viewpoint, course observation after injury may be more important than CT in the initial treatment of head trauma in infants. The complaints and neurological manifestations of infants, particularly those aged 2 or younger, are frequently unclear; therefore, there is an opinion that CT is recommended for all pediatric patients. However, the appropriateness of its use should be determined after confirming the mechanism of injury, consciousness level, neurological findings, and presence/absence of a history of abuse. Among the currently available rules specifying criteria for CT of infants with head trauma, the Pediatric Emergency Care Applied Research Network (PECARN) study may be regarded as reliable at present. In Japan, where the majority of emergency hospitals are using CT, it may be necessary to develop criteria for CT in consideration of the actual situation. CT diagnosis for pediatric head trauma is not always necessary. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on a state of the patients by telephone is useful for both patients and physicians.

Nonaccidental head injury is the most common cause of subdural bleeding in infants <1 year of age

OBJECTIVE

Subdural bleeding (SDB) in infants is considered an essential symptom of nonaccidental head injury (NAHI). Recently, this view has been challenged by the "unified hypothesis," which claims that SDB in infants is related to hypoxia and brain swelling rather than to traumatic shearing of bridging veins. We analyzed a large series of infants' autopsies for the presence and causes of SDB, which should be a common event according to the unified hypothesis.

METHODS

Autopsy, clinical, and legal information for infants <1 year of age from a single institution over 50 years were analyzed regarding cause of death, presence, morphology, and cause of SDB, and brain weight.

RESULTS

From a total of 16 661 autopsies during the study period, 715 (4.3%) involved infants <1 year of age. Fifty (7.0%) of those had SDB. NAHI was identified in 17 patients. The most common cause of SDB was trauma (15 cases [30.0%]), with NAHI accounting for 14 cases. SDB was present in 82.4% of patients with NAHI but only 5.2% of infants with other causes of death. Four patients (8.0%) had unexplained SDB with no discernible cause of bleeding. Statistical analysis did not reveal any correlation between the presence of SDB and brain weight.

CONCLUSIONS

In the study population, unexplained SDB in infants was an extreme rarity. Moreover, a correlation between brain swelling and the presence of SDB could not be drawn. Our data argue strongly against the unified hypothesis and strengthen the association between SDB and NAHI in infancy.

A review of social factors in the investigation and assessment of non-accidental head injury to children

Investigation and assessment work in non-accidental head injury cases is complex and challenging. This article discusses briefly the professional systems involved and the conditions necessary for effective practice. It then reviews briefly the literature on social factors in serious and fatal child abuse in order to provide a context for discussion of recent UK studies of non-accidental head injuries/shaken baby syndrome. The findings on social factors are compared and areas for further research are suggested. The article then considers how best to use the existing knowledge base about these cases within assessment frameworks currently in use and considers issues in presenting assessment conclusions to decision-makers.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

BACKGROUND

Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality.

METHODS

Selective literature review including an overview over national and international recommendations.

RESULTS

Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations.

CONCLUSIONS

The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

What predicts injury from physical punishment? A test of the typologies of violence hypothesis

OBJECTIVE

This study examined the power of child, perpetrator, and socio-economic characteristics to predict injury in cases of reported child physical abuse. The study was designed to assess the validity of the assumption that physically injurious incidents of child physical abuse are qualitatively different from those that do not result in injury, that their generative factors are distinctive, and that the quality of caregiving in these two types of incidents is different.

METHOD

A weighted, nationally representative sample of 8,164 substantiated punishment abuse cases in Canada was used. Various models were constructed and evaluated through logistic regression.

RESULTS

Of six potential predictors - child age, perpetrator sex, child functioning, parent functioning, economic stress, and social stress - none predicted injury to the child.

CONCLUSIONS

The findings suggest that injurious and non-injurious physical abuse cannot be distinguished on the basis of the personal characteristics or circumstances of the child or perpetrator.

PRACTICE IMPLICATIONS

A common criterion for child welfare intervention into cases of suspected physical abuse is injury or risk of injury. This criterion assumes that injurious and non-injurious assaults are qualitatively different phenomena, predicted by different risk factors. In the present study an attempt was made to differentiate between injurious and non-injurious cases of punitive physical abuse on the basis of characteristics of the child, perpetrator, family, and social context. None of these factors explained the likelihood of injury, suggesting that the prediction of injury as an intervention criterion may be questionable.

Subdural haematomas and physical abuse in the first two years of life

OBJECTIVE

To analyze our institution's work-up for patients with a diagnosis of subdural haematoma (SDH) in order to determine how many of them are secondary to child abuse, as well as to examine their final functional outcome.

METHODS

Retrospective review of children under 2 years of age diagnosed as having SDH between 1995 and 2005.

RESULTS

A total of 35 cases were identified. Fifteen patients that had underlying conditions that predispose them to bleed were excluded. Among the remaining 20 patients, seizures and head trauma were the main causes for consultation. All patients had a coagulation study and a head computed tomography carried out, 11 of these had a magnetic resonance imaging and 1 had a post-mortem examination. Bilateral SDHs in different stages of evolution was the most common pattern of intracranial haemorrhage. Fourteen infants had a skeletal survey, 4 had a bone scintigraphy and 19 had an ophthalmoscopic examination. Fractures were diagnosed in 7 patients and retinal haemorrhages in 11. The final diagnoses were: 10 shaken baby syndromes, 4 idiopathic SDH, 3 strokes, 2 coagulopathies and 1 accidental head injury. Upon follow-up, 1 patient had died and 9 had sustained permanent disabilities.

CONCLUSIONS

Cases of infantile SDH are usually thoroughly investigated. In spite of this, sometimes it is not possible to determine the SDH aetiology. Nonetheless, shaken baby syndrome remains the most frequent cause of SDH in infants, and it carries a poor prognosis.

The dark figure of infanticide in England and Wales: complexities of diagnosis

Infants aged younger than 12 months have the highest homicide victimization rate of any single age group in England and Wales. In addition, there are good grounds for believing that the official homicide statistics for this particular age group are an underestimate and subject to distortion. At the same time there is evidence mounting in the United Kingdom that some parents have been incorrectly convicted of infanticide. This article first explores all recorded cases of infanticide in England and Wales for the period 1995-2002 (298 cases in total). Characteristics of the offenders, victims, offense, and court outcomes are examined. The second part of the article takes a critical gaze at the complexities involved in distinguishing infanticide from sudden infant death syndrome (SIDS) and other sudden unexplained deaths in infancy (SUDI). The article ends by considering in what ways infant deaths might be more effectively investigated.

Perpetrator accounts in infant abusive head trauma brought about by a shaking event

OBJECTIVE

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.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

A case of shaken baby syndrome after discharge from the newborn intensive care unit

Preterm infants may be at higher risk of physical abuse after hospital discharge. Nonaccidental or inflicted head neurotrauma is the most common cause of mortality and morbidity in physical-abuse cases, and shaken baby syndrome (SBS) is the most common form of abuse. In the majority of the cases, parents who shake their infant do not intend to harm the infant. This article presents a report of a former preterm infant who presented to the pediatrician's office with a maternal report of an accidental fall. Shaken baby syndrome was suspected based on bilateral subdural hemorrhages of varying ages, which were inconsistent with the history provided. The differential diagnosis and systematic clinical evaluation for SBS are provided, and medical and nursing management is discussed. Patient care, advocacy, and mandatory reporting are reviewed. The newborn intensive care unit caregivers' role in preventing SBS in this high-risk population, including specific parent teaching and anticipatory guidance, is reviewed with an emphasis on teaching all caregivers about the dangers of shaking an infant.

A Biomechanical Analysis of the Causes of Traumatic Brain Injury in Infants and Children

There is significant disagreement among medical professionals regarding the mechanisms for infant brain injury. This disagreement is due in part to the failure by some to acknowledge and incorporate known biomechanical data and models into hypotheses regarding causes. A proper biomechanical understanding of the mechanisms of traumatic brain injury (TBI) challenges many published and testified assumptions regarding TBI in infants and children. This paper analyzes the biomechanical relationship between the causes of TBI in infants and children, and their physiological consequences. Loading characteristics, injury parameters and criteria, scaling, failure characteristics, differences between infants and adults, and impact due to falls are described and discussed in the context of the laws of mechanics. Recent studies are critiqued with reference to their contribution to an understanding of brain injury mechanisms. Finally, methods for improving our currently incomplete knowledge of infant head injuries, and their mechanisms, consequences and tolerances are proposed. There is an urgent need for close collaboration between physicians and biomechanicians to objectively and scientifically evaluate infant head injuries to further define their mechanical bases, and to assist in their diagnosis and treatment.

Apnoea and brain swelling in non-accidental head injury

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.

Shaking-impact syndrome of infancy

Shaking-impact syndrome (SIS) is a leading cause of traumatic brain injury in infants and young children. Evaluation of these children requires a detailed history and physical examination as well as documentation of intracranial injury with neuroimaging, a dilated fundoscopic examination, a skeletal survey and other laboratory studies. Debate still exists as to the exact mechanisms of brain injury in these patients. The various contributions of shaking alone, shaking with impact, and apnea are discussed. Differences of injury type and severity between accidental traumatic brain injury and SIS are delineated. The long-term neurodevelopmental outcome for survivors of SIS is generally poor. Because few treatment options are successful in reducing the morbidity and mortality of this syndrome, prevention may be the only reasonable solution.

Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies

Does an expanded subarachnoid space predispose to subdural bleeding? What does heterogeneity in the appearance of a subdural collection on CT or MRI imaging indicate? Spontaneous rebleeding? Minor re-injury? Major re-injury? In some specific cases, answers to these questions have important forensic implications. To conclude objectively that an infant's intracranial hemorrhage or rebleeding resulted from inflicted injury or re-injury requires an in-depth understanding of the pathogenesis of posttraumatic subdural and subarachnoid collections. The authors present two cases of indoor, accidental, pediatric, closed-head trauma that resulted in intracranial rebleeding. Both accidental cranial impacts occurred in medical settings and were independently witnessed by medical personnel. In addition, the authors summarize the relevant medical literature regarding pediatric intracranial bleeding and rebleeding.

Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome

PURPOSE

To report correlation between retinal and intracranial abnormalities and to evaluate pathogenesis of retinal hemorrhages in the shaken baby syndrome (SBS).

DESIGN

Observational case series.

METHODS

Seventy-five children with apparent nonaccidental head trauma consistent with SBS had complete physical examination, complete ophthalmologic examination, neuroimaging by CT or MRI, or both, and skeletal radiographic survey. In this retrospective review, ophthalmoscopic and intracranial abnormalities were correlated.

RESULTS

The age of patients ranged from 2 to 48 months (mean - SD, 10.6 +/- 10.4 months). Neuroimaging was abnormal in all 75 cases. Findings included subdural hematoma (70 children, 93%), cerebral edema (33 children, 44%), subarachnoid hemorrhage (12 children, 16%), vascular infarction (nine children, 12%), intraparenchymal blood (six children, 8%), parenchymal contusion (six children, 8%), and epidural hemorrhage (one child, 1%). Sixty-four (64/75, 85%) children had retinal abnormalities, mostly (53/64, 82%) confluent multiple hemorrhages that were subretinal, intraretinal, and preretinal in 47/64 (74%) and bilateral in 52/64 (81%). No association was found between anatomic site (left, right, or bilateral) of intracranial and retinal findings (McNemar test kappa = -0.026-0.106) or between any of the intracranial findings mentioned above and the following retinal findings: normal or abnormal retinal examination, multiple (>10) or few retinal hemorrhages (< or =10), symmetric or asymmetric retinal findings, or retinoschisis (kappa = -0.127-0.104). Signs of possible increased intracranial pressure were not correlated with any retinal abnormality (kappa = -0.03-0.073). There was no correlation between evidence of impact trauma to the head and retinal hemorrhages (kappa = 0.058). Total Cranial Trauma Score and Total Retinal Hemorrhage Score, both indicating the severity of injury, were correlated (P =.032).

CONCLUSIONS

Our study supports previous observations that the severity of retinal and intracranial injury is correlated in SBS. We cannot support the suggestions that in most children with SBS retinal bleeding is caused by sustained elevated intracranial, elevated intrathoracic pressure, direct tracking of blood from the intracranial space, or direct impact trauma. The correlation in severity of both eye and head findings may suggest, however, that retinal abnormalities are the result of mechanical shaking forces.

Ethical issues in imaging nonaccidental injury: child abuse

One of the most controversial areas of nonaccidental injury is the medical diagnosis of inflicted central nervous system injury and its impact on medical, social, and legal outcomes for children and families. This review addresses the role of the neuroradiologist in the clinical care of the pediatric patient and as an expert medical witness in the area of nonaccidental injury.

Isolated extradural hematoma in children presenting to an emergency department in Australia

BACKGROUND

Isolated extradural hematoma (EDH) is becoming more frequently recognized in emergency departments (EDs) in children. We describe the natural history of children with isolated EDH presenting to a large Children's Hospital ED.

METHODS

This is a descriptive case series study using a retrospective review of the medical records of children presenting to the ED with a diagnosis of isolated EDH over 8 years. Comparison was made with children having other injuries in addition to EDH. The cause, nature of injury, presentations to hospital, management, outcome, and any association with nonaccidental injuries (NAI) were analyzed.

RESULTS

Of the 35 cases with a final diagnosis of isolated EDH initially presenting to the ED, 70% were over 3 years of age (mean 6.6 years), and 60% were boys. A fall of less than half a meter was the cause of isolated EDH in 51.4% of patients. The remaining cases resulted from a fall from a height greater than half a meter (17.1%), a motor vehicle accident (11.4%), being hit by an object (8.6%), a bicycle accident (5.7%), and a skateboard accident (5.7%). Children younger than 3 years presented within 24 hours of injury in 70% of cases, compared with 65% of older children. In 95% of cases, presentation was nonspecific, suggesting a medical rather than a surgical problem. This resulted in a delay in seeking emergency care and a delay in final diagnosis for these patients. Surgical drainage was required in 68.6% of cases, with older children being more likely to be managed conservatively. In 23.4% of cases, minor residual neurologic deficit occurred; there were no cases of serious long-term problems. There were no cases of NAI in the children studied.

CONCLUSION

This report highlights falls as a common cause of isolated EDH in children. Delay in presentation for clinical assessment is common, because many children have nonspecific presentation that is suggestive of a medical problem. No cases of NAI were reported in this study.

Unexplained subdural hematoma in young children: is it always child abuse?

BACKGROUND

In the published reports of the developed society, subdural hematoma and/or retinal hemorrhages, in the absence of documented history of major trauma, should be considered diagnostic of child abuse. Many people used the above criteria for diagnosis, but subsequently found that retinal hemorrhages were more common in non-accidental injuries (NAI). To what extent is the proposed pathognomonic association between unexplained subdural hematoma/retinal hemorrhages and child abuse a self-fulfilling prophecy?

METHODS

Clinical details of nine children under 2 years with unexplained subdural hematoma admitted to Prince of Wales Hospital between 1995 and 1998 were reviewed.

RESULTS

Four had no other physical signs of injury, five had retinal hemorrhages and one had multiple bruises over the body. Following multidisciplinary case conferences for seven children, a diagnosis of NAI was concluded in four cases, but in no case could the abuser be definitely identified. Clinical outcome was poor with seven children showing either profound disability (n = 5) or evidence of developmental delay (n = 2).

CONCLUSION

In this series, NAI were not established in three of the seven cases. Did we underdiagnose child abuse in these cases? Despite a magnitude of opinion to the contrary, the issue of whether "trivial" head injury can cause subdural hemorrhages and/or retinal hemorrhages is yet unresolved. Clearly much more information on this very sensitive and serious issue is required and these data should be collected with an open mind.

Investigating subdural haemorrhage in infants

When an infant or young child presents with subdural haemorrhage, the diagnostic priority is to exclude physical child abuse. A team approach should be adopted for the clinical child protection investigation. The diagnostic process is inevitably one of detective work; appropriate radiological, ophthalmological, haematological, biochemical, and postmortem investigations are discussed.

Winner of the young physician's section of the Gowers' prize 2000. Too good to be true? Thomas Willis--neonatal convulsions, childhood stroke and infanticide in seventeenth century England

A case of neonatal convulsion reported by Thomas Willis (1621-1675) together with its post mortem findings is quoted as being congenital intracerebral haemorrhage or strongly suggested as being the earliest pathological description of childhood cerebrovascular disease. However these authors only reviewed the incomplete written record left by Willis, describing how this case was the fourth consecutive child that the mother had lost to neonatal convulsions. The medical record is completed by notes taken by John Locke from a lecture delivered by Willis 3 or 4 years before the case was first published. Here, Locke relates how the mother subsequently had three further children who were all treated by Willis soon after birth and all survived uneventfully. Reviewing the post mortem findings and the full case histories modern medical science gives a different interpretation. Instead, I suggest that the case history given and pathological features described are more in keeping with a whiplash shaking injury than with cerebrovascular disease or a stroke. I believe that this is the earliest pathological description of shaking injury in childhood. We can never know why Willis did not publish the full success of his management of the subsequent children but it may have been due to his dramatic experience of a similar mother early on in his medical career.

Minor head injury in the pediatric patient

Minor head injury is a common occurrence in children of all ages; however, controversy exists regarding the management of these children. Reports of neurologically intact children with intracranial injuries have caused many to recommend cautious management, while the infrequency of serious intracranial injuries after minor head trauma have prompted others to be less conservative. Based on recent literature reports, strategies for the management of children with minor head trauma are presented.

Shaken baby syndrome and the death of Matthew Eappen: a forensic pathologist's response

Subdural hemorrhage, retinal hemorrhage, and cerebral edema have been considered diagnostic for a "shaken infant" since the syndrome was described almost 30 years ago. However, the specificity of these findings has been disputed by defense witnesses in recent U.S. criminal prosecutions. This review examines the scientific basis for the shaken baby syndrome.

Subdural haemorrhages in infants: population based study

OBJECTIVES

To identify the incidence, clinical outcome, and associated factors of subdural haemorrhage in children under 2 years of age, and to determine how such cases were investigated and how many were due to child abuse.

DESIGN

Population based case series.

SETTING

South Wales and south west England.

SUBJECTS

Children under 2 years of age who had a subdural haemorrhage. We excluded neonates who developed subdural haemorrhage during their stay on a neonatal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention.

MAIN OUTCOME MEASURES

Incidence and clinical outcome of subdural haemorrhage in infants, the number of cases caused by child abuse, the investigations such children received, and associated risk factors.

RESULTS

Thirty three children (23 boys and 10 girls) were haemorrhage. The incidence was 12.8/100 000 children/year (95% confidence interval 5.4 to 20.2). Twenty eight cases (85%) were under 1 year of age. The incidence of subdural haemorrhage in children under 1 year of age was 21.0/100 000 children/year and was therefore higher than in the older children. The clinical outcome was poor: nine infants died and 15 had profound disability. Only 22 infants had the basic investigations of a full blood count, coagulation screen, computed tomography or magnetic resonance imaging, skeletal survey or bone scan, and ophthalmological examination. In retrospect, 27 cases (82%) were highly suggestive of abuse.

CONCLUSION

Subdural haemorrhage is common in infancy and carries a poor prognosis; three quarters of such infants die or have profound disability. Most cases are due to child abuse, but in a few the cause is unknown. Some children with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a full multidisciplinary social assessment, an ophthalmic examination, a skeletal survey supplemented with a bone scan or a skeletal survey repeated at around 10 days, a coagulation screen, and computed tomography or magentic resonance imaging. Previous physical abuse in an infant is a significant risk factor for subdural haemorrhage and must be taken seriously by child protection agencies.