[Insufficient knowledge about battered child syndrome among doctors in the emergency department]

The aim of the study was to determine the present knowledge regarding battered child syndrome (BCS) among doctors in the emergency department. Nineteen doctors with different educational levels from seven hospitals in Denmark were interviewed. For children younger than 18 months, 68%, 65% and 25% of the participants related femur-, collum costae- and corner fractures to BCS respectively. We found that more than one third of the 19 doctors did not know which fractures to look for when suspecting BCS.

[The use of electronic medical records can contribute in diagnosing a case of battered child]

Child abuse is a very serious offence and is often underdiagnosed. This case report shows how the use of electronic medical records from different hospitals aided in diagnosing a case of battered child in a 16-month-old girl with an unusual acromion fracture. This illustrates the need for thorough investigation of the records in cases where a fracture might not raise suspicion on its own.

PTSD as a criminal defense: a review of case law

Posttraumatic stress disorder (PTSD) has been offered as a basis for criminal defenses, including insanity, unconsciousness, self-defense, diminished capacity, and sentencing mitigation. Examination of case law (e.g., appellate decisions) involving PTSD reveals that when offered as a criminal defense, PTSD has received mixed treatment in the judicial system. Courts have often recognized testimony about PTSD as scientifically reliable. In addition, PTSD has been recognized by appellate courts in U.S. jurisdictions as a valid basis for insanity, unconsciousness, and self-defense. However, the courts have not always found the presentation of PTSD testimony to be relevant, admissible, or compelling in such cases, particularly when expert testimony failed to show how PTSD met the standard for the given defense. In cases that did not meet the standard for one of the complete defenses, PTSD has been presented as a partial defense or mitigating circumstance, again with mixed success.

[Clinical forensic examination findings and legal outcome in cases of suspected physical child abuse]

Clinical forensic examinations performed at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected physical abuse of children were analyzed retrospectively with special emphasis on the legal consequences. Altogether, 192 children (85 girls, 107 boys) with a median age of 4.4 years were examined. In 47 cases (24.5 %), the clinical forensic examination findings were interpreted as accidental injuries, birth traumas or unspecific findings. 29 victims (20.0 %) had suffered a shaken baby syndrome. Only part of the presented cases ended with conviction, which was more likely if the victims were aged between 7 and 11 years. Prison terms of 2 years and more were imposed only if the child suffered potentially or acute life-threatening injuries or if additional anogenital lesions were diagnosed indicating sexual child abuse.

[Diagnostic imaging in cases of suspected child abuse--focus craniocerebral trauma divergent guidelines and resulting problems]

For the clinical diagnosis of non-accidental craniocerebral trauma in children there are different recommendations and guidelines, which are not completely consistent. Depending on the examiner, the focus may be on therapeutic relevance, minimization of the exposure to radiation or potential conclusions as to the course of events. Under certain circumstances it may be difficult for the responsible institution to deal with all three perspectives, as is shown by the presented case. From the authors' point of view it would be desirable to work out a common guideline taking into account paediatric radiological and medicolegal aspects.

Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine

Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.

Evaluation of the siblings of physically abused children: a comparison of child protective services caseworkers and child abuse physicians

Current theories suggest that all children in a home are at risk for physical abuse, when one child is abused. However, little evidence exists to guide decisions regarding the medical management of siblings of physically abused children (contact children [CC]). This study sought to compare child protective services (CPS) caseworkers' and child abuse physicians' (CAP) recommendations regarding the need for medical evaluation of CC in case scenarios of unequivocal physical abuse. In all cases, caseworkers and physicians disagreed on which CC warranted a medical evaluation. In addition, 25% of caseworkers did not think that physicians should make recommendations on the need for medical evaluation of CC. The findings of the authors suggest that the home visit is a critical part of the decision-making process for caseworkers and that it often acts as a substitute for a medical evaluation. Caseworkers indicated that visible injury to the contact child and severity of injury to the index child were among the most important factors in deciding which CC need a medical evaluation. Although caseworkers and physicians disagree on certain issues related to the evaluation of CC, it is clear that limited resources should be directed at CC at highest risk for physical abuse.

Maternal and paternal filicides: a retrospective review of filicides in Finland

The purpose of this retrospective study was to illustrate the differences in maternal and paternal filicides in Finland during a 25-year period. In the sample of 200 filicides [neonaticides (n = 56), filicide-suicides (n = 75), other filicides (n = 69)], the incidence was 5.09 deaths per 100,000 live births: 59 percent of filicides were committed by mothers, 39 percent by fathers, and 2 percent by stepfathers. The mean age of the maternal victims (1.6 y) was significantly lower than that of the paternal victims (5.6 y), but no correlation between the sex of the victim and the sex of the perpetrator was found, and the number of female and male victims was equal. The sample of other filicides (n = 65) was studied more closely by forensic psychiatric examination and review of collateral files. Filicidal mothers showed mental distress and often had psychosocial stressors of marital discord and lack of support. They often killed for altruistic reasons and in association with suicide. Maternal perpetrators also dominated in filicide cases in which death was caused by a single episode or recurrent episodes of battering. Psychosis and psychotic depression were diagnosed in 51 percent of the maternal perpetrators, and 76 percent of the mothers were deemed not responsible for their actions by reason of insanity. Paternal perpetrators, on the other hand, were jealous of their mates, had a personality disorder (67%), abused alcohol (45%), or were violent toward their mates. In 18 percent of the cases, they were not held responsible for their actions by reason of insanity. During childhood, most of the perpetrators had endured emotional abuse from their parents or guardians, some of whom also engaged in alcohol abuse and domestic violence. The purpose of this study was to examine the differences between maternal and paternal filicides in a sample of 200 cases in Finland. This report also provides a psychosocial profile of the perpetrator and victim in 65 filicides and a discussion of the influence of diagnoses on decisions regarding criminal responsibility.

[Clinical assessment of suspected child physical abuse]

Violence against children has many faces. Child physical abuse, neglect, sexual abuse and interparental violence can cause acute and permanent damage and affect children's development and their life plans in the long term. In industrialized nations almost 1 child in 10 is affected. Up to 10% of child physical abuse cases involve the central nervous system with 80% of these cases occurring during the first year of life. Worldwide more than 50,000 children die as a result of violence, abuse and neglect every year, according to the United Nations Children's Fund UNICEF. In Germany, there are about 120 cases of non-accidental head injury per year. In addition to the officially known cases there is a large grey area for all forms of violence. Recognition of these cases and the provision of help for the victims require an appropriate suspicion and understanding of the pertinent pathophysiology. Suspicion must be based on a well-documented medical history and multidisciplinary diagnostic assessment. Medical confidentiality prevents the disclosure of such information making early detection networks and guidelines for collaboration absolutely indispensable.

[Non-accidental trauma in children. Case report]

The aim of this study is to analyze the problem of child abuse. Non-accidental injuries of young children constitute a very important diagnostic issue, which continues to be faced by both clinicians and forensic medicine specialists. This report presents an extremely interesting case of a young boy, in which a very detailed assessment of the files allowed for determining the circumstances of his sustaining injuries.

Coagulation testing in the evaluation of suspected child abuse

Every year in Germany nearly 3000 cases of child abuse were reported. When children are presented at emergency units with suspicious injuries and bruises a detailed documentation an evaluation is necessary after emergency treatment. As differential diagnosis inherited or acquired bleeding disorders should be excluded. In addition to a detailed evaluation of personal and family history and a physical evaluation different coagulation test to exclude defects of primary and secondary hemostasis should be performed. Clinician must know the limitations of these tests and keep in mind that an abnormal coagulation test does not exclude child abuse. Coagulation defects may be the consequence of child abuse and neglect or the two conditions may coexist.

Bruises, blood coagulation tests and the battered child syndrome

Cutaneous bruises are a common symptom and a sign of injury and blood coagulation disorders in childhood. A carefully-taken history, coupled with a thorough physical examination, would lead to the diagnosis, or guide the clinician to the necessary laboratory investigations. Most children suffering from non-accidental injury can have their diagnosis established on clinical grounds alone and do not require laboratory investigation. An initial screening with full blood counts, prothrombin time and activated partial thromboplastin time will be adequate in most cases if laboratory investigation is indicated, but the clinician must be aware of the limitations of these tests. The finding of an abnormal coagulation test does not exclude child abuse as it can be a consequence of maltreatment, or the two conditions may coexist. Whenever necessary, the opinion of a haematologist should be sought in order to obtain an accurate diagnosis, which is essential for subsequent management and the prevention of further injury in the case of child abuse.

[Atypical staphylococcal scalded skin syndrome: it could be battered child syndrome]

A case of pseudo staphylococcal scalded skin syndrome is presented and discussed within the clinical spectrum of the battered child syndrome. The authors underline the behavior of the parents in this setting, which can mislead the physician in charge. Dermatologic symptoms are important to make a diagnosis of the battered child syndrome.

Risikoeinschätzung bei Vernachlässigung und Kindeswohlgefährdung im Säuglings- und Kleinkindalter - Chancen früher beziehungsorientierter Diagnostik

The German child protection system lacks of interdisciplinary and standardized procedures for screening and diagnosing child maltreatment as well as for service delivery. Evidence based assessments of risk-screening in combination with consensus-based models for risk-judgement seem to predict the best possible results. A central part of determining whether an infant is at risk is to evaluate various domains of parental competencies and skills. In particular assessment procedures based on attachment research have proven to be practically and methodologically relevant. These include interactive and video-based observational methods as well as parental representations as sources of information for risk assessment. Attachment based intervention and treatment programs are effective, especially with regard to enhancing paternal sensitive behavior. However, these programs need to be adapted to delivery for specific risk groups. Overall an interdisciplinary approach with regard to the programs as well as to the training of the professionals has to be taken into account.

Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse

BACKGROUND AND PURPOSE

Patients who have benign enlargement of the subarachnoid spaces (BESS) have long been suspected of having an increased propensity for subdural hematomas either spontaneously or as a result of accidental injury. Subdural hematomas in infants are often equated with nonaccidental trauma (NAT). A better understanding of the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental trauma may help distinguish this group of patients from those who suffer subdural hematomas as a result of NAT. The purpose of this study is to describe the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental injury in infants with BESS.

METHODS

We conducted a retrospective review of all patients with BESS complicated by subdural hematomas evaluated at a single institution from 1998 to 2004. Data concerning the patient's clinical presentation, physical findings, imaging, and management are described.

RESULTS

During the study period, 7 patients with BESS complicated by subdural hematoma were identified. Their mean age at identification of the subdural hematoma was 7.4 months of age. In 5 cases, there was no recognized trauma before identification of the subdural hematoma. In 3 cases, baseline CT or MR imaging was available, showing prominent subarachnoid spaces without any evidence of subdural hemorrhage.

CONCLUSION

Although suspicious for NAT, subdural hematomas can occur in children either spontaneously or as a result of accidental trauma. Caution must be exercised when investigating for NAT based on the sole presence of subdural hematomas, especially in children who are otherwise well and who have BESS.

Nonaccidental head trauma as a cause of childhood death

OBJECT

The authors present the demographic and clinical information in 36 children who died as a result of abusive head trauma at a Level 1 pediatric trauma center between January 1, 1997, and January 1, 2004.

METHODS

Abusive head trauma was defined as radiographic evidence of intracranial injury and documentation from a multidisciplinary child protection team that the injury was nonaccidental. There was no sex bias for the children in the 1st year of life (nine girls, nine boys). In children older than 1 year of age, boys were much more likely to be victims (14 boys, four girls). At the time of admission, every child exhibited a seriously impaired level of consciousness and 81% had retinal hemorrhages. Injuries to other organ systems were rare (17%). The most common abnormality found on neuroimaging studies was subdural hematoma. Six children underwent craniotomy for extraaxial hematomas. Death occurred within 24 hours after hospital admission in one half of the cases.

CONCLUSIONS

Abusive head trauma was the cause of death in 36 (86%) of the 42 children whose deaths were classified as nonaccidental at the Children's Hospital in Denver between 1997 and 2003. The authors were unable to identify anything that could have been done from a medical or neurosurgical viewpoint to prevent the deaths of these children after they came to medical attention.

The work of Ambroise Tardieu: the first definitive description of child abuse

The first important monograph describing the battered child syndrome was written in 1860 by Ambroise Tardieu, a French forensic physician. Here is a translation of his article, published in the Annales d'hygiene publique et de medecine legale, with the title "Etude medico-legale sur les sevices et mauvais traitements exerces sur des enfants." The first part of his article is entirely translated. A brief summary of the 32 cases report described by Tardieu in the second part of his article is presented.

Isolated subconjunctival hemorrhages in nonaccidental trauma

PURPOSE

To establish child abuse as part of the differential diagnosis of isolated bilateral subconjunctival hemorrhages in infants.

METHODS

To review three cases of nonaccident trauma initially presenting with isolated bilateral subconjunctival hemorrhages as the only significant clinical finding.

RESULTS

Ophthalmic examination in cases 1 and 2 were entirely normal except for the large bilateral subconjunctival hemorrhages. Hematological parameters were normal in all three infants. Initial radiological findings were normal in case 1 but multiple healing rib fractures were identified when the chest X-ray was repeated 3 weeks later. Case 2 had skin and skeletal X-ray findings compatible with abuse at time of presentation to the ophthalmologist. Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae.

CONCLUSION

Nonaccidental trauma should be considered in the differential diagnosis of bilateral isolated subconjunctival hemorrhages in infants especially if associated with facial petechiae. These isolated subconjunctival hemorrhages may be part of the traumatic asphyxia syndrome caused by severe, prolonged compression of the child's chest and upper abdomen. Appropriate assessment includes a complete ophthalmic and pediatric examination as well as hematological testing and imaging studies. If the coagulation profile and initial imaging studies are normal yet there remains a high suspicion of abuse, an immediate nuclear scan or a repeat skeletal survey or chest film 2 weeks later is indicated.

Shaken baby syndrome

Shaken baby syndrome (SBS) is a violent act of abuse that can cause myriad neurologic, cognitive, and other functional deficits. In the most serious cases, death can result. Health care practitioners, child care providers, and parents must be educated on the signs of SBS. Cases should be thoroughly reviewed and prevention strategies developed to prevent future incidents.

What is the significance of haemosiderin in the lungs of deceased infants?

In infants, pulmonary haemosiderin has been put forward as a marker of previous asphyxic abuse and possible grounds for suspicion of homicide. Review of the available literature does not provide a strong enough evidence base to support this claim. Further research is needed before instigation of criminal proceedings can be justified on this pathological finding.

Understanding shaken baby syndrome

Health care professionals involved in the care of infants are in an ideal position to identify and to educate families, the public, and other health care professionals about the risk factors, dangers, and consequences of infant shaking. The purpose of this article is to review the incidence, biomechanics, risk factors, clinical presentation, diagnosis, and prognosis of shaken baby syndrome (SBS), as well as to encourage involvement in SBS prevention through the use of a family teaching tool. Education is essential to decrease the incidence, morbidity, and mortality of SBS.

[Difficulties in diagnosis of battered child syndrome in infant]

The diagnosis of battered child syndrome in infants was reached on the basis of the risk factors appraisal in social and family history, combined with clinical and roentgenographic examinations; the difficulties in establishing the diagnosis are presented. Long hospitalisation also revealed that the observed injuries are due to child abuse. The interdisciplinary approach is needed when non-accidental injuries are considered.

[Child abuse syndrome]

The aggrievement of children is not only a present day problem. The term: child abuse has appeared in the literature in the mid XIX century. In this paper an attempt has been made to reference this phenomenon in region of Bydgoszcz. There were 2889 cases of children with bodily injuries requiring hospital treatment in the years 1992-1996. 10 cases were victims of long lasting violence in their homes. This paper also presented the basic regulations and pays attention to the requirement of greater engagement of the whole society. A restrictive system of child protection can contribute to a significant decrease in the scale of this phenomenon. Scandinavian countries can be used as an example of such an approach.

Childhood multifocal skeletal non-Hodgkin lymphoma is a differential diagnosis of battered child syndrome

Skeletal lesions observed in battered children include fractures, subperiostal new bone formation, irregular metaphyses, and cone-shaped epiphyses. A 4-year-old girl presented with bone pain. Radiographs revealed multiple fractures and epiphyseal and metaphyseal lesions highly significant for battered child syndrome. Six weeks later the authors diagnosed primary multifocal skeletal non-Hodgkin lymphoma. This case report illustrates that multifocal skeletal non-Hodgkin lymphoma is a differential diagnosis of battered child syndrome.

[Diagnostic imaging in non-accidental brain injuries]

Diagnosis of nonaccidental injury (child abuse) may be difficult because most infants present with non-specific clinical findings and without external signs of trauma. Brain lesions severely disproportionate to the history of trauma, retinal hemorrhages and characteristic fractures or fractures of varying age are key indicators to child abuse when encountered in an infant. It is therefore incumbent upon the radiologist to recognize the radiologic findings of the various forms of nonaccidental injury and to correlate them with the physical findings in order to render a more accurate opinion. Craniocerebral injuries are not uncommon in infants who are physically abused and have a worse long-term outcome than accidental injuries. The particularities of the infant's skull and its content and the pathophysiology of cerebral nonaccidental injuries are remembered. The imaging findings in infants with blunt impact, shaken- and whiplash shaken-injuries are emphasized. The combination of edema, malignant hyperaemic cerebral swelling, hypoxic-ischemic brain injury, diffuse axonal injuries, and bilateral and/or interhemispheric subdural hematomas is almost typical of a shaken infant. MRI, with its multiplanar capability and its sensitivity to cytotoxic edema and to degraded hemoglobin, is the modality of choice for detecting cerebral lesions in nonaccidental injury.

Factor XIII deficiency mistaken for battered child syndrome: case of "correct" test ordering negated by a commonly accepted qualitative test with limited negative predictive value

We report herein a case of Factor XIII deficiency that remained undiagnosed until 2 years of age. Part of the delay in diagnosis was a consequence of testing that was performed on a blood sample obtained after plasma transfusion therapy for a life-threatening bleeding episode. Due to insufficient family follow-up after discharge from the hospital, the diagnosis was delayed 1 year until the child was rehospitalized and a pre-transfusion plasma sample was tested. The commonly accepted approach of using only a qualitative test for the diagnosis of factor XIII deficiency is challenged by this case report.

[Child abuse--undiagnosed]

We present the case of a 2 1/2 year old child brought to the emergency room by his mother, a nurse at that hospital, and her companion, because of a fractured clavicle. Over the next 14 days the child was seen by a variety of physicians in different sites (3 different emergency rooms, pediatricians' offices, orthopedic clinics) for various injuries. Each individual injury was treated separately, and the diagnosis of a battered child syndrome was not entertained. The child was not undressed completely and numerous clues to the diagnosis went undetected. A greater sensitivity to the diagnosis of child abuse is essential. More careful history-taking, more thorough physical examination and better interinstitutional communication are essential if child abuse is to be detected in its earliest phases.

Planning and Development Committee of Japanese Society of Legal Medicine. [Forensic autopsy cases of battered children in Japan (1990-1999)]

The investigation committee of Japanese Society of Legal Medicine has investigated 459 forensic autopsy cases of battered children from 1990-1999. The age range was 0-4 years of 381 cases (83%). Of them, the age less than 1 year was high as 161 cases (35.1%). The cause of death including head injury was 161 cases (35.1%), suffocation caused by nasal blockages 37 cases (8.1%), strangulation 32 cases (7.0%), and drowning 30 cases (6.5%) was revealed. In case of assailant, own mother was 226 cases (49.2%), own father was 73 cases (15.9%) and stepfather 46 cases (10.0%) were reported. The intention of cruelty was that the body was positively assaulted (84.3%) and duration was less than 2 months in 136 cases (67%). The nature of cruelty was that beating by other hands (16.8%) in 77 cases and pushed away and threw (1.7%) in 8 cases and those complex (7.8%) in 36 cases. The motive of cruelty when he assailant was own mother (209 cases) was as fellow: 1. Mentally abnormal (15.3%), 2. Irresponsibility (14.4%), 3. Victim cries (5.7%). When the assailant was own father (63%), the motive of cruelty was as 1. Victim cries (12.7%), 2. Lack of love (7.9%), 3. Reassisted attitude (6.3%). Reported death in high temperature was in 29 cases (6.3%) and strangulation was in 27 cases (5.9%). The homicide was 13% and neither care nor protection (neglect) was 2.7%. The physical conditions of battered children were emaciated and stunted growth in 128 cases (31.2%). The past history of medical consultation to the medical hospital was 32 cases (17.8%). Among the injuries, external findings consist of abrasions and bruises were 147 cases (32%) and internal findings were 70 cases (16.7%) mainly numerous gastro-intestinal tract injuries than liver and lungs. In addition, lung edema (16.8%) in 68 cases, thymus atrophy (12.6%) in 51 cases and amalgamation (4.5%) in 18 cases were reported. The injury around the anus and genitalia were 13 cases (3.2%). The bone fracture was not observed in 368 cases (80.2%) out of 459. Among the intracranial injuries, subdural haemastoma or amalgamation were 31.6% (145 cases) out of 459.

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.