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Shaken baby syndrome (SBS) or Battered Baby Syndrome is a form of child abuse that occurs when an abuser violently shakes an infant or small child, creating a whiplash-type motion that causes acceleration-deceleration injuries. The injury is estimated to affect between 1,200 and 1,600 children every year in the USA. It is common for there to be no external evidence of trauma.

The concept of SBS was initially described by Dr. John Caffey, a radiologist.

SBS is often fatal and can cause severe brain damage, resulting in lifelong disability. Estimated death rates (mortality) among infants with SBS range from 15 to 38%; the median is 20–25%. Up to half of deaths related to child abuse are reportedly due to shaken baby syndrome. Nonfatal consequences of SBS include varying degrees of visual impairment (including blindness), motor impairment (e.g. cerebral palsy) and cognitive impairment.

Signs and symptoms

SBS is accompanied by a variety of signs, which range from mild to severe and nonspecific to obviously head trauma related. There is no single symptom that defines SBS. The characteristic injuries associated with SBS include retinal hemorrhages, multiple fractures of the long bones, and subdural hematomas (bleeding in the brain). These signs have evolved through the years as the accepted and recognized signs of child abuse and the shaken baby syndrome. Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, fractures, soft tissue injuries or subdural hematoma, that cannot be explained by accidental trauma or other medical conditions. About three quarters of cases involve retinal hemorrhaging. Additional effects of SBS are diffuse axonal injury, oxygen deprivation and swelling of the brain, which can raise intracranial pressure and damage delicate brain tissue.

Victims of SBS may display irritability, failure to thrive, alterations in eating patterns, lethargy, vomiting, seizures, bulging or tense fontanels (the soft spots on an infant's head), increased size of the head, altered breathing, and dilated pupils.

Fractures of the vertebrae, long bones, and ribs may also be associated with SBS. Dr. John Caffey reported in 1972 that metaphyseal avulsions (small fragments of bone had been torn off where the periosteum covering the bone and the cortical bone are tightly bound together) and "bones on both the proximal and distal sides of a single joint are effected, especially at the knee".

Anatomy and pathophysiology

Children under the age of three years are especially susceptible to brain damage from shaking. This is due to several anatomical factors. Their heads are bigger and weigh more with respect to their bodies than adults' heads, and their neck muscles are weak and cannot prevent violent motions. Infants' brains are not fully myelinated; myelin sheaths form in childhood and are complete in adolescence. The water content of the brain is reduced as neurons gain myelin during development, so babies have a greater percentage of brain water than adults do. Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury.

The underlying injury in SBS is typically diffuse axonal injury.

In 2004, a Scottish database collected data for five years on cases of suspected non-accidental head injury diagnosed after a multiagency assessment and included cases with uncoerced confessions of perpetrators and criminal convictions. Several patterns appeared allowing the categorization of the cases into four predominant types: Hyperacute encephalopathy (6% of all cases); Acute encephalopathy (53% of cases (SBS)); Subacute non-encephalopathic presentation (19% of cases); Chronic extracerebral presentation (22% of cases). Infants can be traumatically injured in many ways, and many instances are unwitnessed. Thus the generic term non-accidental head injury or inflicted traumatic brain injury is occasionally used in preference to shaken baby syndrome, which implies a specific mechanism of injury.An earlier detailed neuropathological study was published in the UK in 2001, which included immunocytochemistry for microscopic damage.

Mechanism

SBS results from rotational acceleration of the head. Rotational injury is especially damaging and likely to occur in shaking trauma.The type of injuries caused by shaking injury are usually not caused by falls and impacts from normal play, which are mostly linear forces. The type of shaking that is necessary to cause SBS is very violent and would be clearly recognizable to an observer as dangerous and potentially deadly.

Prevention

Prevention is similar to the prevention of child abuse in general. New parents, babysitters, and other caregivers can be warned about the dangers of shaking infants. A child's crying and irritation are common triggers for the frustration that can lead to violence in the caregiver. Some experts offer caregivers strategies to cope with their own frustrations; for example, they may be reminded that they are not always responsible when babies cry.

Diagnosis

SBS may be misdiagnosed and underdiagnosed, and caregivers may lie or be unaware of the mechanism of injury. Commonly, there are no externally visible signs of the condition, and there is no established set of symptoms that indicate it. Examination by an experienced ophthalmologist is often critical in diagnosing shaken baby syndrome, as particular forms of ocular bleeding are quite characteristic. No alternative condition mimics all of the symptoms of SBS exactly, but those that must be ruled out include hydrocephalus, sudden infant death syndrome (SIDS), seizure disorders, and infectious or congenital diseases like meningitis and metabolic disorders. CT scanning and magnetic resonance imaging are used to diagnose the condition. Conditions that may accompany SBS include bone fractures, injury to the cervical spine (in the neck), hemorrhaging of the retina (in the eye), cerebral hemorrhage or atrophy, hydrocephalus, and papilledema (swelling of the optic disc).

Treatment

Treatment involves monitoring of intracranial pressure (the pressure within the skull), draining of fluid from the cerebral ventricles, and, if an intracranial hematoma is present, draining of the hematoma.

Prognosis

Prognosis depends on severity and can range from total recovery to severe disability to death when the injury is severe.SBS kills about one third of its victims and permanently and severely disables another third. Problems resulting from SBS include learning disabilities, seizure disorders, speech disability, hydrocephalus, behavioral problems, cerebral palsy, and visual disorders.

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. SBS usually occurs in children under the age of two but may occur in those up to age five. In 2001, 903,000 children suffered from SBS and an additional 1,300 died from it.

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. Substance abuse and emotional stress, resulting for example from financial troubles, are other risk factors for aggression and impulsiveness in caregivers. Both males and females can inflict SBS, but the abusers are more often male. Although it had been previously speculated that SBS was an isolated event, a history of prior child abuse is a common finding in cases of SBS. In an estimated 33–40% of cases, evidence of prior head injuries, such as old intracranial bleeds, is present.
  • Even such a triviality as irritation over childs crying may trigger the abuse. [48210] In fact it is so common it constitute one of the most prevalent factors behind the shaken child syndrom.


History

In 1946, the concept of SBS and the term "whiplash shaken baby syndrome" was introduced by Dr. John Caffey, a pediatric radiologist. The term described a set of symptoms found with little or no external evidence of head trauma, including retinal hemorrhages and intracranial hemorrhages with subdural or subarachnoid bleeding or both. In 1971, Guthkelch proposed that whiplash injury caused subdural hemorrhage in infants by tearing the veins in the subdural space. Development of computed tomography and magnetic resonance imaging techniques in the 1970s and 1980s advanced the ability to diagnose the syndrome.

Legal issues

"Shaken Baby Syndrome (SBS) is, in essence, a medical diagnosis of murder, one based solely on the presence of a diagnostic triad: retinal bleeding, bleeding in the protective layer of the brain, and brain swelling."

In April 2006, a Daubert hearing (a mini-trial within a trial, conducted before the judge only, not the jury, over the validity and admissibility of expert opinion testimony) was conducted concerning the admissibility of proposed medical and scientific evidence in a Kentucky Circuit Court case.A Grand Jury had indicted the defendant of first-degree criminal abuse by violently shaking a child. The Defendant alleges that the child's medical records indicate that the only significant injury for the victim was a subdural hematoma and retinal hemorrhaging and there was no significant bruising, fractures, or evidence of impact. The Commonwealth's case was based upon the theory of shaken baby syndrome. The Court concluded that "the clinical medical and scientific research communities are in disagreement as to whether it is possible to determine if a given head injury is due to an accident or abuse." The trial court's ruling is not considered binding legal precedent. The Commonwealth of Kentucky appealed the ruling to the commonwealth's intermediate appellate court. On June 13, 2008, the Kentucky Court of Appeals ruled in favor of allowing the commonwealth's expert witness to testify as to shaken baby syndrome.

In July 2005, the Court of Appeals in the United Kingdommarker heard four appeals of SBS convictions: one case was dropped, the sentence was reduced for one, and two convictions were upheld. The court found that the classic triad of retinal hemorrhage, 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. 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." .

The court invalidated a "unified hypothesis" proposed by Geddes and colleagues as an alternative mechanism for the subdural and retinal hemorrhage found in suspected cases of SBS. The unified hypothesis proposed that the hemorrhage was not caused by shearing of subdural and retinal veins but rather by cerebral hypoxia, increased intracranial pressure, and increased pressure in the brain's blood vessels. The court reported that "the unified hypothesis [could] no longer be regarded as a credible or alternative cause of the triad of injuries": subdural haemorrhage, retinal bleeding and encephalopathy due to hypoxemia (low blood oxygen) found in suspected SBS.

On January 31st, 2008, the Wisconsin Court of Appeals granted Audrey A. Edmonds 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."

The term non-accidental trauma has been suggested instead of "SBS".

Controversies and alternative hypotheses

Whether sbs exists at all as presently defined and understood hitherto (that three types of bodily changes found together inevitably point to external blunt violence being exerted on an infant and constitute a syndrome) has become controversial since the advent of Magnetic Resonance Imaging (MRI) that produces images of the inside of the body that are far sharper and have greater resolution that previous methods. Findings such as internal bleeding (in medical parlance haemorrhaging) can be dated more exactly as their visual appearance on the MRI changes over time. In their discussion of the syndrome, forensic pathologists Vincent and Dominick DiMaio quoted Lewis Caroll's Alice's Adventures in Wonderland: "If any one of them can explain it," said Alice, "I'll give him sixpence. I don't believe there is an atom of meaning in it."Jane M. Orient writes: "In a prosecution paradigm without precedent, expert medical testimony is used to establish that a crime occurred, that the defendant caused the infant’s death by shaking, and that the shaking was sufficiently forceful to constitute depraved indifference to human life. Shaken Baby Syndrome (SBS) is, in essence, a medical diagnosis of murder, one based solely on the presence of a diagnostic triad: retinal bleeding, bleeding in the protective layer of the brain, and brain swelling."

"There are no studies that substantiate that shaking and shaking only produces this triad of injuries," Dr. Patrick Barnes, a pediatric neuroradiologist at Stanford University, has said. [48211]

Vitamin C deficiency

Some authors have suggested that certain cases of suspected shaken baby syndrome may result from vitamin C deficiency. 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. A review of this hypothesis in the journal Pediatrics International concluded that there was "no convincing evidence to conclude that vitamin C deficiency can be considered to be a cause of shaken baby syndrome", but recommended that further research be conducted, to thoroughly test the hypothesis.

The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C, for those children currently or recently ill, bacterial infections, those with higher individual requirements, those suffering from environmental challenges (e.g. allergies), and perhaps transient vaccination-related stresses. However, no cases of scurvy mimicking SBS or crib death have been reported, and scurvy typically occurs later in infancy, rarely causes death or intracranial bleeding, and is accompanied by other changes of the bones and skin and invariably an unusually deficient dietary history.

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. These views are not widely known, utilized or explored in conventional medicine.

Diffuse injury

A 2001 study reported that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI .and suggested two possible explanations: either the unmyelinated axon of the immature cerebral hemispheres is relatively resistant to traumatic damage, or in shaking-type injuries the brain is not exposed to the forces necessary to produce DAI.

Force

There has been controversy regarding the amount of force required to produce the brain damage seen in shaken baby syndrome. A biomechanical experiment in 2005 demonstrated 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." The validity of calculations performed in that study were challenged. A detailed explanation of the calculations was provided in a "Letter To The Editors" in February 2006. which refers to


The BBC has made a documentary in 3 parts that covers arguments for and against the diagnosis of SBS.

See also

  • Louise Woodward case - was famously convicted of killing Matthew Eappen in 1997 by shaking him.
  • Alan Yurko - sentenced to life in prison + 10 years (1998) without parole for the murder of his son, due to shaken baby syndrome. Later released after appeal.
  • C. Alan B. Clemetson


Footnotes

Further reading

  • This American legal review contains an extensive examination of the divergent views of the scientific literature, in addition to examining the divergent views of the legal parameters involving a trial.


External links




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