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| {{Infobox_Disease | | |||
| {{DiseaseDisorder infobox | | |||
| Name = Shaken baby syndrome | | Name = Shaken baby syndrome | | ||
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Image = | | ||
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Caption = | | ||
| DiseasesDB = | <!-- no direct topic --> | |||
| ICD10 = | <!-- no ICD10 code {{ICD10|ICD10Group|Major|minor|Linkcode|Minorlink}} --> | |||
| ICD9 = {{ICD9|995.55}} | | |||
| ICDO = | | |||
| OMIM = | | |||
| MedlinePlus = 000004 | | |||
| eMedicineSubj = search | | |||
| eMedicineTopic = shaken%20infant%20syndrome | | |||
| MeshID = | | |||
| }} | }} | ||
| '''Shaken baby syndrome''' ('''SBS''') is a form of ] affecting between 1,200 and 1,600 children every year in the USA.<!-- | |||
| --><ref name="NCIPC_factsheet">{{cite web | author=National Center for Injury Prevention and Control | title=Child Maltreatment: Fact Sheet | publisher=] (CDC) | url=http://www.cdc.gov/ncipc/factsheets/cmfacts.htm | date=7th September 2006 | accessdate=2006-10-09}}</ref> | |||
| '''Shaken baby syndrome''' ('''SBS''') is a form of child abuse affecting between 1,200 and 1,600 children every year in the USA. SBS encompasses a variety of outcomes that allegedly may occur as a result of shaking an infant or small child. SBS, which is a theory and is largely circumstantial was initially described in the 1970's by Dr. Caffey, a radiologist. | |||
| SBS encompasses a variety of outcomes that allegedly may occur as a result of shaking an infant or small child. SBS, which is a theory and is largely circumstantial was initially described in the 1970's by Dr. Caffey, a radiologist. <!-- | |||
| --><ref>{{cite journal | author=Caffey J | title=On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation | journal=Amer J Dis Child | year=1972 | volume=124 | pages=161-169 | url=http://archpedi.ama-assn.org/content/vol124/issue2/index.dtl}} - in Archives of Pediatrics & Adolescent Medicine</ref> | |||
| SBS is thought to occur when an abuser violently shakes an infant, creating a ]-type motion that causes ]. SBS is a specific type of ] (physical ]). SBS is often coupled with striking of the infant against a hard object and, in these cases may be known as the '''shaken impact syndrome'''. | SBS is thought to occur when an abuser violently shakes an infant, creating a ]-type motion that causes ]. SBS is a specific type of ] (physical ]). SBS is often coupled with striking of the infant against a hard object and, in these cases may be known as the '''shaken impact syndrome'''. | ||
| ''"Caffey's hypothesis was that the whiplash shaking might be a component of violence and abuse but might also occur during normal childhood handling such as tossing a baby into the air, 'riding the horse' (baby bouncing on knee of parent), swinging a baby in a circle around the parent or 'skinning the cat' (the child is somersaulted forward while being held by the wrists), or even be caused by noise and vibration from dishwashers, vacuum cleaners and televisions."'' <!-- | |||
| --><ref>{{cite journal | author = David T | title = Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy. | journal = J R Soc Med | volume = 92 | issue = 11 | pages = 556-61 | year = 1999 | id = PMID 10703491 | url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=10703491 | format=Scanned image & PDF}}</ref> | |||
| SBS, a major cause of mortality in infants, is often fatal and can produce lifelong disability from ]. About 25% to 30% of infant victims with SBS die from their injuries. Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments. Direct costs (judicial, law enforcement, and health system responses to child maltreatment) are estimated at $24 billion each year. The indirect costs (long-term economic consequences of child maltreatment) exceed an estimated $69 billion annually in the USA. |
SBS, a major cause of mortality in infants, is often fatal and can produce lifelong disability from ]. About 25% to 30% of infant victims with SBS die from their injuries. Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments. Direct costs (judicial, law enforcement, and health system responses to child maltreatment) are estimated at $24 billion each year. The indirect costs (long-term economic consequences of child maltreatment) exceed an estimated $69 billion annually in the USA.<!-- | ||
| --><ref name="NCIPC_factsheet"/> | |||
| ==Signs and symptoms== | ==Signs and symptoms== | ||
| The signs of SBS include retinal hemorrhages, retinal petechiae (small, pinpoint hemorrhages in the retinas at the backs of the eyes), multiple fractures of the long bones, and subdural hemotomas. |
The signs of SBS include retinal hemorrhages, retinal petechiae (small, pinpoint hemorrhages in the retinas at the backs of the eyes), multiple fractures of the long bones, and subdural hemotomas. <!-- | ||
| --><ref name="Clemetson2006">{{cite journal | author=Clemetson C | title=Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome." | journal=J Am Phys Surg | year=2006 | month=Spring | volume=11 | issue=1 | pages=20-1 | url=http://www.jpands.org/vol11no1/clemetson.pdf | format-PDF}}</ref> | |||
| These signs have evolved through the years as the accepted and recognized signs of child abuse and the shaken baby syndrome. Additional signs of SBS are ], ] and ], which can raise ] and damage delicate brain tissue. | |||
| Most victims of SBS are under 1 year old. SBS infants may display irritability, ], alterations in eating patterns, ], ], ]s, bulging or tense ]s, increased size of the head, altered respirations, and dilated ]s (BIAUSA). | Most victims of SBS are under 1 year old. SBS infants may display irritability, ], alterations in eating patterns, ], ], ]s, bulging or tense ]s, increased size of the head, altered respirations, and dilated ]s (BIAUSA). | ||
| Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, ] or ] injuries, subdural hemoatoma, and no history of trauma or a history of trauma that could not have caused injuries as serious as those observed in the child. No condition mimics all of the symptoms of SBS exactly, but those that must be ruled out include ], ] (SIDS), ]s, and ] or ]s like ] and ]s |
Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, ] or ] injuries, subdural hemoatoma, and no history of trauma or a history of trauma that could not have caused injuries as serious as those observed in the child. No condition mimics all of the symptoms of SBS exactly, but those that must be ruled out include ], ] (SIDS), ]s, and ] or ]s like ] and ]s. <!-- | ||
| --><ref name="Oral">{{cite web | author=Oral R | title=Intentional Head Trauma In Infants: Shaken Baby Syndrome | publisher=Virtual Children's Hospital | date=August 2003 | url=http://web.archive.org/web/20050214084615/http://www.vh.org/pediatric/provider/pediatrics/shakenimpactsyndrome/ | format=Archived | accessdate=2006-10-09}}</ref> | |||
| ] and ] may also be associated with SBS. However, several bone disorders may also cause fractures to occur, apparently spontaneously or with normal handling, and unexplained fractures of whose presence the parents were unaware may be found on routine radiology. The principal disorders known to cause unexplained fractures and difficulty in diagnosis are: Osteogenesis imperfecta; Temporary brittle bone disease; Bone disease of prematurity; Rickets due to vitamin D deficiency; Scurvy (vitamin C deficiency); Copper deficiency and Menkes’ syndrome. |
] and ] may also be associated with SBS. However, several bone disorders may also cause fractures to occur, apparently spontaneously or with normal handling, and unexplained fractures of whose presence the parents were unaware may be found on routine radiology. The principal disorders known to cause unexplained fractures and difficulty in diagnosis are: Osteogenesis imperfecta; <!-- | ||
| --><ref>Osteogenesis Imperfecta Foundation </ref> | |||
| Temporary brittle bone disease; Bone disease of prematurity; Rickets due to vitamin D deficiency; <!-- | |||
| --><ref>Chudgar P. "Radiology In Rickets" Pediatric Oncall - Child Health Care </ref> | |||
| Scurvy (vitamin C deficiency); <!-- | |||
| --><ref>Chudgar P. "Radiology In Scurvy" Pediatric Oncall - Child Health Care </ref> | |||
| Copper deficiency and Menkes’ syndrome. <!-- | |||
| --><ref>Paterson CR. Burns J, McAllion SJ. "Osteogenesis imperfecta: the distinction from child abuse." </ref><!-- | |||
| , | |||
| --><ref>Paterson CR. "Bone diseases that lead to false allegations of non-accidental injury." </ref><!-- | |||
| In addition to scurvy (a vitamin C deficiency) , , a number of medical conditions can mimic SBS, even before birth. Medical experts assert that "no case studies have ever been undertaken to probe even a partial list of possible confounding variables/phenomena, such as the presence of intracranial cysts or fluid collections, hydrocephalus, congenital and inherited diseases, infection, coagulation disorders and venous thrombosis, recent immunizations, medications, birth-related brain injuries, or recent or remote head trauma. Until and unless these and probably many more factors are evaluated, it is inappropriate to select one mechanism only and ignore the rest of the potential causes.” | |||
| --><ref>Paterson CR. "Radiological features of the brittle bone diseases," Cambridge University Press (External link removed)</ref> | |||
| In addition to scurvy (a vitamin C deficiency) <!-- | |||
| --><ref>Rothschild BM, Sebes JI. </ref><!-- | |||
| --><ref>Suman RL, Dabi DR. Scurvy-An Unusual Cause of Proptosis? </ref><!-- | |||
| --><ref>"Sloan B, Kulwin DR, Kersten RC. "Scurvy causing bilateral orbital hemorrhage." </ref> | |||
| a number of medical conditions can mimic SBS, even before birth. Medical experts assert that "no case studies have ever been undertaken to probe even a partial list of possible confounding variables/phenomena, such as the presence of intracranial cysts or fluid collections, hydrocephalus, congenital and inherited diseases, infection, coagulation disorders and venous thrombosis, recent immunizations, medications, birth-related brain injuries, or recent or remote head trauma. Until and unless these and probably many more factors are evaluated, it is inappropriate to select one mechanism only and ignore the rest of the potential causes." <!-- | |||
| --><ref>Leestma, J E. "Shaken Baby Syndrome": Do Confessions by Alleged Perpetrators Validate the Concept?" </ref> | |||
| ==Anatomy and pathophysiology== | ==Anatomy and pathophysiology== | ||
| Several anatomical factors make infants susceptible to brain damage. 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 (Patel and Moorjani, 2005). Infants' brains are not ]ated; myelin sheaths form in childhood and are complete in adolescence. The ] (CSF), or brain water, content is reduced as ]s gain myelin during development, so babies have a greater percentage of CSF than adults (Stock and Singer, 2004). Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury, including the axons of the respiratory control center (Stock and Singer, 2004). Infants also have a larger ] than young adults, and so the veins traversing the space are in greater danger of being torn during violent movement of the head, causing subdural hematoma (Patel and Moorjani, 2005). | Several anatomical factors make infants susceptible to brain damage. 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 (Patel and Moorjani, 2005). Infants' brains are not ]ated; myelin sheaths form in childhood and are complete in adolescence. The ] (CSF), or brain water, content is reduced as ]s gain myelin during development, so babies have a greater percentage of CSF than adults (Stock and Singer, 2004). Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury, including the axons of the respiratory control center (Stock and Singer, 2004). Infants also have a larger ] than young adults, and so the veins traversing the space are in greater danger of being torn during violent movement of the head, causing subdural hematoma (Patel and Moorjani, 2005). | ||
| Rotation injury is especially damaging and likely to occur in shaking trauma |
Rotation injury is especially damaging and likely to occur in shaking trauma. <!-- | ||
| --><ref name="Oral"/> | |||
| The type of injuries caused by shaking injury are usually not caused by falls and impacts from normal play, which are mostly linear forces. <!-- | |||
| --><ref name="Oral"/> | |||
| Rotation injury is also referred to as diffuse axonal injury (DAI). A report in 2001, "reviewed the brains of 37 infants aged 9 months or less, all of whom died from inflicted head injuries, and 14 control infants who died of other causes. Axonal damage was identified using immunohistochemistry for ß-amyloid precursor protein. The observation that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI, can be explained in one of two ways: 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." |
Rotation injury is also referred to as diffuse axonal injury (DAI). A report in 2001, ''"reviewed the brains of 37 infants aged 9 months or less, all of whom died from inflicted head injuries, and 14 control infants who died of other causes. Axonal damage was identified using immunohistochemistry for ß-amyloid precursor protein. The observation that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI, can be explained in one of two ways: 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."'' <!-- | ||
| --><ref>Geddes JF, et al: "Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants" </ref> | |||
| "Apparently a critical point was missed or overlooked in a paper published in 1968 concerning the results of bioengineering study in conjunction with the U.S. Department of Transportation. It is significant to note that whereas this experiment showed, qualitatively, that rotation alone could indeed produce intracranial injury, it was not shown quantitatively that human beings could generate the required rotational acceleration by manual shaking. Nonetheless, this critical omission was not addressed until 19 years later. At that time, it was shown quantitatively that impact was required to generate adequate force. Guthkelch, Caffey, and others either were not aware of, or disregarded, this critical missing piece of information. In the intervening years, and even up to the present, numerous references are made to infants sustaining inflicted brain injury by manual shaking. Yet no laboratory proof of this possibility has ever been put forth. In fact, the available experimental evidence began as far back as 1943, addressed directly in 1987 and reproduced in 2003, seems to indicate the contrary. |
''"Apparently a critical point was missed or overlooked in a paper published in 1968 concerning the results of bioengineering study in conjunction with the U.S. Department of Transportation. It is significant to note that whereas this experiment showed, qualitatively, that rotation alone could indeed produce intracranial injury, it was not shown quantitatively that human beings could generate the required rotational acceleration by manual shaking. Nonetheless, this critical omission was not addressed until 19 years later. At that time, it was shown quantitatively that impact was required to generate adequate force. Guthkelch, Caffey, and others either were not aware of, or disregarded, this critical missing piece of information. In the intervening years, and even up to the present, numerous references are made to infants sustaining inflicted brain injury by manual shaking. Yet no laboratory proof of this possibility has ever been put forth. In fact, the available experimental evidence began as far back as 1943, addressed directly in 1987<!-- | ||
| --><ref>Duhaime A, Gennarelli T, Thibault L, et al. "The shaken baby syndrome. A clinical, pathological, and biomechanical study." </ref> | |||
| and reproduced in 2003, <!-- | |||
| --><ref>Prange M., Coats B, Duhaime A., Margulies S. "Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants." | |||
| </ref> | |||
| seems to indicate the contrary."'' <!-- | |||
| --><ref>Uscinski R. "The Shaken Baby Syndrome" </ref><!-- | |||
| --><ref>Ommaya A.K., Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and pediatric head injury, </ref><!-- | |||
| --><ref>Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court </ref> | |||
| "The assessment of the mechanical causation of injury requires training and experience in Injury Biomechanics, a distinct discipline not taught in medical school. Lack of education and experience in Injury Biomechanics, amongst other factors, has led in practice to the proliferation and propagation of inaccurate and sometimes erroneous information on SBS injury mechanisms in the literature." A recent 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. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS. These findings are consistent with the physical laws of injury biomechanics as well as our collective understanding of the fragile infant cervical spine from (1) clinical obstetric experience, (2) automotive medicine and crash safety experience, and (3) common parental experience. We have determined that 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 the SBS. |
''"The assessment of the mechanical causation of injury requires training and experience in Injury Biomechanics, a distinct discipline not taught in medical school. Lack of education and experience in Injury Biomechanics, amongst other factors, has led in practice to the proliferation and propagation of inaccurate and sometimes erroneous information on SBS injury mechanisms in the literature." A recent 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. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS. These findings are consistent with the physical laws of injury biomechanics as well as our collective understanding of the fragile infant cervical spine from (1) clinical obstetric experience, (2) automotive medicine and crash safety experience, and (3) common parental experience. We have determined that 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 the SBS."''<!-- | ||
| --><ref>Bandak FA. "Shaken baby syndrome: a biomechanics analysis of injury mechanisms." </ref> | |||
| The following is part of a letter to the editors in 2006, reponding to criticism of the reported velocity values as being too high, in the previously mentioned biomechanical experiment in 2005. "Since SBS is referred to in the literature as causing |
The following is part of a letter to the editors in 2006, reponding to criticism of the reported velocity values as being too high, in the previously mentioned biomechanical experiment in 2005. ''"Since SBS is referred to in the literature as causing "acceleration/deceleration" brain injury, my approach was to directly analyze these accelerations applied for the time course of shaking. I chose a range that includes the highest values of accelerations reported because had I chosen lower values, the analysis would simply exclude the cornerstone mechanism of SBS and therefore, would be rendered moot. In other words, lower values would not be sufficient to activate the customary mechanism of rupturing bridging veins that SBS solely depends on for producing SDH. This of course, is the mechanism garnered for SBS from experiments where the head of a primate was potted in a metal cylinder constrained for acceleration/deceleration along a prescribed arc in a prescribed time frame."''<!-- | ||
| --><ref>Bandak FA. "Response to the Letter to the Editor" </ref> | |||
| 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); 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 publish in the UK in 2001, which included immunocytochemistry for microscopic damage. | 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); 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. <!-- | ||
| --><ref>"Four types of inflicted brain injury predominate," "Patterns of presentation of the shaken baby syndrome" Case Reports & Letter </ref> | |||
| An earlier detailed neuropathological study was publish in the UK in 2001, which included immunocytochemistry for microscopic damage. <!-- | |||
| --><ref>Geddes JF, et al: "Neuropathology of inflicted head injury in children. I: Patterns of brain damage." </ref> | |||
| ==Prognosis== | ==Prognosis== | ||
| SBS kills about one third of its victims and permanently and severely disables another third |
SBS kills about one third of its victims and permanently and severely disables another third.<!-- | ||
| --><ref name="Oral"/> | |||
| Problems resulting from SBS include learning disabilities, seizure disorders, speech disability, hydrocephalus, ], and visual disorders.<!-- | |||
| --><ref name="Oral"/> | |||
| == Prevention == | == Prevention == | ||
| Prevention is similar to the prevention of ] in general. Crying is a common trigger for creating irritation and frustration in the caregiver. Some experts have advised that caregivers should know that they are not always responsible when babies cry. Parents and caregivers need to acquaint themselves with the different sounds and pitches of crying with an infant and their behavioral signs. Chronic crying in an infant could be the sign of a condition that needs medical attention. A few of the many medical conditions that may cause chronic crying in an infant, may include the following (for information only and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional). | Prevention is similar to the prevention of ] in general. Crying is a common trigger for creating irritation and frustration in the caregiver. Some experts have advised that caregivers should know that they are not always responsible when babies cry. Parents and caregivers need to acquaint themselves with the different sounds and pitches of crying with an infant and their behavioral signs. <!-- | ||
| --><ref>"Crying Baby" Parenting and Child Health, Children, Youth and Women’s Health Service – AU </ref> | |||
| Chronic crying in an infant could be the sign of a condition that needs medical attention. A few of the many medical conditions that may cause chronic crying in an infant, may include the following (for information only and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional). | |||
| Unexplained crying, fussiness and spiting up or vomiting could be the result of colic, |
Unexplained crying, fussiness and spiting up or vomiting could be the result of colic, <!-- | ||
| --><ref>"Baby Colic," Patient UK </ref> | |||
| gastroesophageal reflux<!-- | |||
| --><ref>"Gastroesophageal Reflux in Infants," National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH) USA </ref><!-- | |||
| --><ref>"Lactose Intolerance," Better Health Channel, Victorian Government, Australia </ref> | |||
| Irritability and inconsolable crying can also be caused by an ear infection that causes pain in the infant. While there are different types of ear infections, the most common is called otitis media, which means an inflammation and infection of the middle ear. The term "acute" refers to a short and painful episode. An ear infection that lasts a long time or comes and goes is called chronic otitis media. |
Irritability and inconsolable crying can also be caused by an ear infection that causes pain in the infant. While there are different types of ear infections, the most common is called otitis media, which means an inflammation and infection of the middle ear. The term "acute" refers to a short and painful episode. An ear infection that lasts a long time or comes and goes is called chronic otitis media. <!-- | ||
| --><ref>"Ear infection – acute," Medical Encyclopedia, U.S. National Library of Medicine and the National Institutes of Health (NIH) USA </ref> | |||
| ''"Protracted inconsolable crying and screaming can also be caused by immunization and appears to be a reaction to vaccination. The obvious clinical presentation of crying, its timing, and the duration of persistent crying and high-pitched crying indicate that the exposure truly preceded the onset of the condition. It is reasonable to conclude that crying and screaming can occur in response to the pain, local reaction, and fever often observed after receipt of DPT vaccine. "''<!-- | |||
| --><ref>"Adverse Effects of Pertussis and Rubella Vaccines," Institute of Medicine, "The National Academies Press, page 165 (1991) </ref> | |||
| ''"Persistent crying in newborns and infants may also be caused by serious or even life-threatening conditions. Sepsis should also be considered in the differential diagnosis of acute unexplained crying in infants."''<!-- | |||
| --><ref>Ruiz-Contreras J, Urquia L, Bastero R. "Persistent crying as predominant manifestation of sepsis in infants and newborns." </ref> | |||
| “Sepsis is a serious but rare infection that is usually caused by bacteria. It occurs when bacteria, which can originate in a child's lungs, intestines, urinary tract, or gallbladder, make toxins that cause the body's immune system to attack the body's own organs and tissues. Because symptoms of sepsis can be vague in infants, laboratory tests play a crucial role in confirming or ruling out sepsis.” | |||
| ''"Sepsis is a serious but rare infection that is usually caused by bacteria. It occurs when bacteria, which can originate in a child's lungs, intestines, urinary tract, or gallbladder, make toxins that cause the body's immune system to attack the body's own organs and tissues. Because symptoms of sepsis can be vague in infants, laboratory tests play a crucial role in confirming or ruling out sepsis."''<!-- | |||
| --><ref>"Sepsis – Pregnancy and Newborns," Rainbow Babies & Children's Hospital, University Hospitals of Cleveland | |||
| </ref> | |||
| Another cause of fussiness and crying could be meningitis. |
Another cause of fussiness and crying could be meningitis. ''"Meningitis is an infection that causes inflammation of the three thin layers of tissue, known as meninges, that cover the brain and spinal cord. The two most common types of meningitis are bacterial and viral, and although they have similar symptoms (viral meningitis symptoms may be milder), the two diseases are quite different and require different treatment."''<!-- | ||
| --><ref>Harper M, Goldmann D. "What is bacterial meningitis vs. viral meningitis?" Children’s Hospital Boston </ref> | |||
| == SBS as a medical/legal concept == | == SBS as a medical/legal concept == | ||
| Since the inception of "whiplash shaking" evolving into SBS, the concept has been the subject of criticism by some scientists and jurists for years. | Since the inception of "whiplash shaking" evolving into SBS, the concept has been the subject of criticism by some scientists and jurists for years. | ||
| 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. Expert testimony and evidence was present for the Daubert hearing by Dr. Ronald H. Uscinski. M.D., FACS. for the defense and Dr. Betty S. Spivack represented the prosecution. | 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. <!-- | ||
| --><ref>Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court </ref> | |||
| 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. Expert testimony and evidence was present for the Daubert hearing by Dr. Ronald H. Uscinski. M.D., FACS. for the defense and Dr. Betty S. Spivack represented the prosecution. | |||
| The Court after hearing the expert testimony and reviewing the evidence, issued the following conclusion and opinion: | The Court after hearing the expert testimony and reviewing the evidence, issued the following conclusion and opinion: | ||
| ''"The Court can further conclude that based on the medical signs and symptoms, 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. Therefore, the Court finds that because the Daubert test has not been met, neither party can call a witness to give an expert opinion as to whether a child's head injury is due to a shaken baby syndrome when only the child exhibits a subdural hematoma and bilateral ocular bleeding. Either party can call a witness to give an expert opinion as to the cause of the injury being due to shaken baby syndrome, if and only, the child exhibits a subdural hematoma and bilateral ocular bleeding, and any other indicia of abuse present such as long-bone injuries, a fractured skull, bruising, or other indications that abuse has occurred."'' | |||
| In July of 2005, the Court of Appeals |
In July of 2005, the Court of Appeals in the ] reversed or reduced three convictions of SBS, finding 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. <!-- | ||
| --><ref>"Shaken baby convictions overturned" "Special Report Child Protection" "Guardian Unlimited" Thursday July 21, 2005 UK </ref> | |||
| In their ruling, they upheld the clinical concept of SBS but dismissed two cases and reduced the sentence on a third based on their individual merits. In their words: ''"Whilst a strong pointer to NAHI 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 term ''"non-accidental trauma'"'' was suggested instead of "SBS" in the March 27, 2004 BMJ<!-- | |||
| --> - see case reports and letter | |||
| These references, along with further BMJ articles in 2005, validated the concept of SBS within the clinical spectrum of non-accidental trauma and documented the wide variety of radiologic and pathologic findings in child abuse. | |||
| ==Nutriture hypothesis== | ==Nutriture hypothesis== | ||
| There is an underlying scientific and medical condition that may be the cause for a majority of SBS cases and infant death cases that are prosecuted. An alternative explanation suggests that scurvy or subclinical scurvy, a vitamin C deficiency plays a role in SBS. Citing that the current SBS pathology is only based only on a theory that may be seriously flawed or incomplete. The bleeding of scurvy is due to a weakness or fragility of the capillaries and small veins, resulting from a very high blood histamine level. Such a weakness in the walls of the bridging veins between the brain and the skull can cause bleeding on the brain, even with the very gentlest of handling. |
There is an underlying scientific and medical condition that may be the cause for a majority of SBS cases and infant death cases that are prosecuted. An alternative explanation suggests that scurvy or subclinical scurvy, a vitamin C deficiency plays a role in SBS. Citing that the current SBS pathology is only based only on a theory that may be seriously flawed or incomplete. The bleeding of scurvy is due to a weakness or fragility of the capillaries and small veins, resulting from a very high blood histamine level. Such a weakness in the walls of the bridging veins between the brain and the skull can cause bleeding on the brain, even with the very gentlest of handling. <!-- | ||
| --><ref name="Clemetson2004">{{cite journal | author=Clemetson C | title=Was it "shaken baby" or a variant of Barlow's disease? | journal=J Am Phys Surg" | year=2004 | volume=9 | pages=78-80 | url=http://www.jpands.org/vol9no3/clemetson.pdf | format=PDF}}</ref><!-- | |||
| --> <ref>Suman RL, Dabi DR. Scurvy-An Unusual Cause of Proptosis? </ref> | |||
| In 2006, a case review of Caffey’s six original cases from 1946 was published finding that "the word scurvy was mentioned in the differential diagnosis of each of the original six cases." <!-- | |||
| --><ref name="Clemetson2006"/> | |||
| Health officials and medical professionals do not recognize that scurvy, a vitamin C deficiency or Barlow's Disease could possibly occur today or be responsible for a majority of these deaths or child abuse cases. Currently, mandatory routine laboratory examinations of blood plasma ascorbic acid (vitamin C) or whole blood histamine are not preformed in SBS cases. These two laboratory tests could determine if a underlying scientific and medical condition such as scurvy existed or if acutal physical abuse occured. However, very few laboratories are adequately equipped and trained to carry out such analyses. | |||
| Health officials and medical professionals do not recognize that scurvy, a vitamin C deficiency or Barlow's Disease<!-- | |||
| --><ref>Möller-Barlow Disease, </ref><!-- | |||
| --><ref name="Clemetson2004"/> | |||
| could possibly occur today or be responsible for a majority of these deaths or child abuse cases. Currently, mandatory routine laboratory examinations of blood plasma ascorbic acid (vitamin C) or whole blood histamine are not preformed in SBS cases. These two laboratory tests could determine if a underlying scientific and medical condition such as scurvy existed or if acutal physical abuse occured. However, very few laboratories are adequately equipped and trained to carry out such analyses. | |||
| ==See also== | ==See also== | ||
| Line 79: | Line 150: | ||
| * ] | * ] | ||
| == |
==Footnotes== | ||
| <div class="references-small"><references/></div> | |||
| # "Child Maltreatment: Fact Sheet," National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Department of Health and Human Services Administration | |||
| # Caffey J. On the theory and practice of shaking infants. "Amer J Dis Child" 1972; 124:161-169. | |||
| # David T J "Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy." | |||
| # "Child Maltreatment: Fact Sheet," National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Department of Health and Human Services Administration | |||
| # Clemetson, CAB "Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome.” | |||
| # Osteogenesis Imperfecta Foundation | |||
| # Chudgar P. "Radiology In Rickets" Pediatric Oncall - Child Health Care | |||
| # Chudgar P. "Radiology In Scurvy" Pediatric Oncall - Child Health Care | |||
| # Paterson CR. Burns J, McAllion SJ. "Osteogenesis imperfecta: the distinction from child abuse." | |||
| # Paterson CR. "Bone diseases that lead to false allegations of non-accidental injury." | |||
| # Paterson CR. "Radiological features of the brittle bone diseases," Cambridge University Press (External link removed) | |||
| # Rothschild BM, Sebes JI. | |||
| # Suman RL, Dabi DR. Scurvy-An Unusual Cause of Proptosis? | |||
| # "Sloan B, Kulwin DR, Kersten RC. "Scurvy causing bilateral orbital hemorrhage." | |||
| # Leestma, J E. “Shaken Baby Syndrome”: Do Confessions by Alleged Perpetrators Validate the Concept?" | |||
| #Geddes JF, et al: "Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants" | |||
| # Duhaime A, Gennarelli T, Thibault L, et al. "The shaken baby syndrome. A clinical, pathological, and biomechanical study." | |||
| # Prange M., Coats B, Duhaime A., Margulies S. "Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants." | |||
| # Uscinski R. "The Shaken Baby Syndrome" | |||
| #Ommaya A.K., Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and pediatric head injury, | |||
| # Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court | |||
| # Bandak FA. "Shaken baby syndrome: a biomechanics analysis of injury mechanisms." | |||
| # Bandak FA. “Response to the Letter to the Editor” | |||
| # "Four types of inflicted brain injury predominate," "Patterns of presentation of the shaken baby syndrome" Case Reports & Letter | |||
| #Geddes JF, et al: "Neuropathology of inflicted head injury in children. I: Patterns of brain damage." | |||
| # “Crying Baby” Parenting and Child Health, Children, Youth and Women’s Health Service – AU | |||
| # “Baby Colic,” Patient UK | |||
| # “Gastroesophageal Reflux in Infants,” National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH) USA | |||
| # “Lactose Intolerance,” Better Health Channel, Victorian Government, Australia | |||
| # “Ear infection – acute,” Medical Encyclopedia, U.S. National Library of Medicine and the National Institutes of Health (NIH) USA | |||
| # “Adverse Effects of Pertussis and Rubella Vaccines,” Institute of Medicine, “The National Academies Press, page 165 (1991) | |||
| # Ruiz-Contreras J, Urquia L, Bastero R. “Persistent crying as predominant manifestation of sepsis in infants and newborns.” | |||
| # “Sepsis – Pregnancy and Newborns,” Rainbow Babies & Children's Hospital, University Hospitals of Cleveland | |||
| # Harper M, Goldmann D. “What is bacterial meningitis vs. viral meningitis?” Children’s Hospital Boston | |||
| # Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court | |||
| # "Shaken baby convictions overturned" "Special Report Child Protection" "Guardian Unlimited" Thursday July 21, 2005 UK | |||
| # C. Alan B. Clemetson, M.D. "Was it “shaken baby” or a variant of Barlow’s disease?". | |||
| # Suman RL, Dabi DR. Scurvy-An Unusual Cause of Proptosis? | |||
| # Clemetson CAB, "Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome.” | |||
| # Möller-Barlow Disease, | |||
| # Clemetson CAB. Was it “shaken baby” or a variant of Barlow’s disease? | |||
| ==External links== | ==External links== | ||
| Line 129: | Line 160: | ||
| * Brain Injury Association of America (BIAUSA) | * Brain Injury Association of America (BIAUSA) | ||
| * - Pataki signs shaken baby law | * - Pataki signs shaken baby law | ||
| * (Oral 2003) Virtual Children's Hospital | |||
| ===Video=== | ===Video=== | ||
Revision as of 22:59, 9 October 2006
Medical condition| Shaken baby syndrome |
|---|
Shaken baby syndrome (SBS) is a form of child abuse affecting between 1,200 and 1,600 children every year in the USA. SBS encompasses a variety of outcomes that allegedly may occur as a result of shaking an infant or small child. SBS, which is a theory and is largely circumstantial was initially described in the 1970's by Dr. Caffey, a radiologist.
SBS is thought to occur when an abuser violently shakes an infant, creating a whiplash-type motion that causes acceleration-deceleration injuries. SBS is a specific type of non-accidental trauma (physical child abuse). SBS is often coupled with striking of the infant against a hard object and, in these cases may be known as the shaken impact syndrome.
"Caffey's hypothesis was that the whiplash shaking might be a component of violence and abuse but might also occur during normal childhood handling such as tossing a baby into the air, 'riding the horse' (baby bouncing on knee of parent), swinging a baby in a circle around the parent or 'skinning the cat' (the child is somersaulted forward while being held by the wrists), or even be caused by noise and vibration from dishwashers, vacuum cleaners and televisions."
SBS, a major cause of mortality in infants, is often fatal and can produce lifelong disability from neurological damage. About 25% to 30% of infant victims with SBS die from their injuries. Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments. Direct costs (judicial, law enforcement, and health system responses to child maltreatment) are estimated at $24 billion each year. The indirect costs (long-term economic consequences of child maltreatment) exceed an estimated $69 billion annually in the USA.
Signs and symptoms
The signs of SBS include retinal hemorrhages, retinal petechiae (small, pinpoint hemorrhages in the retinas at the backs of the eyes), multiple fractures of the long bones, and subdural hemotomas. These signs have evolved through the years as the accepted and recognized signs of child abuse and the shaken baby syndrome. Additional signs of SBS are diffuse axonal injury, oxygen deprivation and swelling of the brain, which can raise intracranial pressure and damage delicate brain tissue.
Most victims of SBS are under 1 year old. SBS infants may display irritability, failure to thrive, alterations in eating patterns, lethargy, vomiting, seizures, bulging or tense fontanels, increased size of the head, altered respirations, and dilated pupils (BIAUSA).
Medical professionals strongly suspect shaking as the cause of injuries when a baby or small child presents with retinal hemorrhage, fractures or soft tissue injuries, subdural hemoatoma, and no history of trauma or a history of trauma that could not have caused injuries as serious as those observed in the child. No 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.
Fractures in the vertebrae and ribs may also be associated with SBS. However, several bone disorders may also cause fractures to occur, apparently spontaneously or with normal handling, and unexplained fractures of whose presence the parents were unaware may be found on routine radiology. The principal disorders known to cause unexplained fractures and difficulty in diagnosis are: Osteogenesis imperfecta; Temporary brittle bone disease; Bone disease of prematurity; Rickets due to vitamin D deficiency; Scurvy (vitamin C deficiency); Copper deficiency and Menkes’ syndrome. In addition to scurvy (a vitamin C deficiency) a number of medical conditions can mimic SBS, even before birth. Medical experts assert that "no case studies have ever been undertaken to probe even a partial list of possible confounding variables/phenomena, such as the presence of intracranial cysts or fluid collections, hydrocephalus, congenital and inherited diseases, infection, coagulation disorders and venous thrombosis, recent immunizations, medications, birth-related brain injuries, or recent or remote head trauma. Until and unless these and probably many more factors are evaluated, it is inappropriate to select one mechanism only and ignore the rest of the potential causes."
Anatomy and pathophysiology
Several anatomical factors make infants susceptible to brain damage. 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 (Patel and Moorjani, 2005). Infants' brains are not myelinated; myelin sheaths form in childhood and are complete in adolescence. The cerebrospinal fluid (CSF), or brain water, content is reduced as neurons gain myelin during development, so babies have a greater percentage of CSF than adults (Stock and Singer, 2004). Because of this higher water content, children's brains are softer and are much more susceptible to acceleration-deceleration injuries and diffuse axonal injury, including the axons of the respiratory control center (Stock and Singer, 2004). Infants also have a larger subarachnoid space than young adults, and so the veins traversing the space are in greater danger of being torn during violent movement of the head, causing subdural hematoma (Patel and Moorjani, 2005).
Rotation 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.
Rotation injury is also referred to as diffuse axonal injury (DAI). A report in 2001, "reviewed the brains of 37 infants aged 9 months or less, all of whom died from inflicted head injuries, and 14 control infants who died of other causes. Axonal damage was identified using immunohistochemistry for ß-amyloid precursor protein. The observation that the predominant histological abnormality in cases of inflicted head injury in the very young is diffuse hypoxic brain damage, not DAI, can be explained in one of two ways: 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."
"Apparently a critical point was missed or overlooked in a paper published in 1968 concerning the results of bioengineering study in conjunction with the U.S. Department of Transportation. It is significant to note that whereas this experiment showed, qualitatively, that rotation alone could indeed produce intracranial injury, it was not shown quantitatively that human beings could generate the required rotational acceleration by manual shaking. Nonetheless, this critical omission was not addressed until 19 years later. At that time, it was shown quantitatively that impact was required to generate adequate force. Guthkelch, Caffey, and others either were not aware of, or disregarded, this critical missing piece of information. In the intervening years, and even up to the present, numerous references are made to infants sustaining inflicted brain injury by manual shaking. Yet no laboratory proof of this possibility has ever been put forth. In fact, the available experimental evidence began as far back as 1943, addressed directly in 1987 and reproduced in 2003, seems to indicate the contrary."
"The assessment of the mechanical causation of injury requires training and experience in Injury Biomechanics, a distinct discipline not taught in medical school. Lack of education and experience in Injury Biomechanics, amongst other factors, has led in practice to the proliferation and propagation of inaccurate and sometimes erroneous information on SBS injury mechanisms in the literature." A recent 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. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for the SBS. These findings are consistent with the physical laws of injury biomechanics as well as our collective understanding of the fragile infant cervical spine from (1) clinical obstetric experience, (2) automotive medicine and crash safety experience, and (3) common parental experience. We have determined that 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 the SBS."
The following is part of a letter to the editors in 2006, reponding to criticism of the reported velocity values as being too high, in the previously mentioned biomechanical experiment in 2005. "Since SBS is referred to in the literature as causing "acceleration/deceleration" brain injury, my approach was to directly analyze these accelerations applied for the time course of shaking. I chose a range that includes the highest values of accelerations reported because had I chosen lower values, the analysis would simply exclude the cornerstone mechanism of SBS and therefore, would be rendered moot. In other words, lower values would not be sufficient to activate the customary mechanism of rupturing bridging veins that SBS solely depends on for producing SDH. This of course, is the mechanism garnered for SBS from experiments where the head of a primate was potted in a metal cylinder constrained for acceleration/deceleration along a prescribed arc in a prescribed time frame."
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); 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 publish in the UK in 2001, which included immunocytochemistry for microscopic damage.
Prognosis
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, cerebral palsy, and visual disorders.
Prevention
Prevention is similar to the prevention of child abuse in general. Crying is a common trigger for creating irritation and frustration in the caregiver. Some experts have advised that caregivers should know that they are not always responsible when babies cry. Parents and caregivers need to acquaint themselves with the different sounds and pitches of crying with an infant and their behavioral signs. Chronic crying in an infant could be the sign of a condition that needs medical attention. A few of the many medical conditions that may cause chronic crying in an infant, may include the following (for information only and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional).
Unexplained crying, fussiness and spiting up or vomiting could be the result of colic, gastroesophageal reflux
Irritability and inconsolable crying can also be caused by an ear infection that causes pain in the infant. While there are different types of ear infections, the most common is called otitis media, which means an inflammation and infection of the middle ear. The term "acute" refers to a short and painful episode. An ear infection that lasts a long time or comes and goes is called chronic otitis media.
"Protracted inconsolable crying and screaming can also be caused by immunization and appears to be a reaction to vaccination. The obvious clinical presentation of crying, its timing, and the duration of persistent crying and high-pitched crying indicate that the exposure truly preceded the onset of the condition. It is reasonable to conclude that crying and screaming can occur in response to the pain, local reaction, and fever often observed after receipt of DPT vaccine. "
"Persistent crying in newborns and infants may also be caused by serious or even life-threatening conditions. Sepsis should also be considered in the differential diagnosis of acute unexplained crying in infants." "Sepsis is a serious but rare infection that is usually caused by bacteria. It occurs when bacteria, which can originate in a child's lungs, intestines, urinary tract, or gallbladder, make toxins that cause the body's immune system to attack the body's own organs and tissues. Because symptoms of sepsis can be vague in infants, laboratory tests play a crucial role in confirming or ruling out sepsis."
Another cause of fussiness and crying could be meningitis. "Meningitis is an infection that causes inflammation of the three thin layers of tissue, known as meninges, that cover the brain and spinal cord. The two most common types of meningitis are bacterial and viral, and although they have similar symptoms (viral meningitis symptoms may be milder), the two diseases are quite different and require different treatment."
SBS as a medical/legal concept
Since the inception of "whiplash shaking" evolving into SBS, the concept has been the subject of criticism by some scientists and jurists for years.
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. Expert testimony and evidence was present for the Daubert hearing by Dr. Ronald H. Uscinski. M.D., FACS. for the defense and Dr. Betty S. Spivack represented the prosecution.
The Court after hearing the expert testimony and reviewing the evidence, issued the following conclusion and opinion: "The Court can further conclude that based on the medical signs and symptoms, 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. Therefore, the Court finds that because the Daubert test has not been met, neither party can call a witness to give an expert opinion as to whether a child's head injury is due to a shaken baby syndrome when only the child exhibits a subdural hematoma and bilateral ocular bleeding. Either party can call a witness to give an expert opinion as to the cause of the injury being due to shaken baby syndrome, if and only, the child exhibits a subdural hematoma and bilateral ocular bleeding, and any other indicia of abuse present such as long-bone injuries, a fractured skull, bruising, or other indications that abuse has occurred."
In July of 2005, the Court of Appeals in the United Kingdom reversed or reduced three convictions of SBS, finding 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 their ruling, they upheld the clinical concept of SBS but dismissed two cases and reduced the sentence on a third based on their individual merits. In their words: "Whilst a strong pointer to NAHI 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 term "non-accidental trauma'" was suggested instead of "SBS" in the March 27, 2004 BMJ - see case reports and letter These references, along with further BMJ articles in 2005, validated the concept of SBS within the clinical spectrum of non-accidental trauma and documented the wide variety of radiologic and pathologic findings in child abuse.
Nutriture hypothesis
There is an underlying scientific and medical condition that may be the cause for a majority of SBS cases and infant death cases that are prosecuted. An alternative explanation suggests that scurvy or subclinical scurvy, a vitamin C deficiency plays a role in SBS. Citing that the current SBS pathology is only based only on a theory that may be seriously flawed or incomplete. The bleeding of scurvy is due to a weakness or fragility of the capillaries and small veins, resulting from a very high blood histamine level. Such a weakness in the walls of the bridging veins between the brain and the skull can cause bleeding on the brain, even with the very gentlest of handling. In 2006, a case review of Caffey’s six original cases from 1946 was published finding that "the word scurvy was mentioned in the differential diagnosis of each of the original six cases."
Health officials and medical professionals do not recognize that scurvy, a vitamin C deficiency or Barlow's Disease could possibly occur today or be responsible for a majority of these deaths or child abuse cases. Currently, mandatory routine laboratory examinations of blood plasma ascorbic acid (vitamin C) or whole blood histamine are not preformed in SBS cases. These two laboratory tests could determine if a underlying scientific and medical condition such as scurvy existed or if acutal physical abuse occured. However, very few laboratories are adequately equipped and trained to carry out such analyses.
See also
Footnotes
- ^ National Center for Injury Prevention and Control (7th September 2006). "Child Maltreatment: Fact Sheet". Centers for Disease Control and Prevention (CDC). Retrieved 2006-10-09.
{{cite web}}: Check date values in:|date=(help) - Caffey J (1972). "On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation". Amer J Dis Child. 124: 161–169. - in Archives of Pediatrics & Adolescent Medicine
- David T (1999). "Shaken baby (shaken impact) syndrome: non-accidental head injury in infancy" (Scanned image & PDF). J R Soc Med. 92 (11): 556–61. PMID 10703491.
- ^ Clemetson C (2006). "Caffey Revisited: A Commentary on the Origin of "Shaken Baby Syndrome."" (PDF). J Am Phys Surg. 11 (1): 20–1.
{{cite journal}}: Text "format-PDF" ignored (help) - ^ Oral R (August 2003). "Intentional Head Trauma In Infants: Shaken Baby Syndrome" (Archived). Virtual Children's Hospital. Retrieved 2006-10-09.
- Osteogenesis Imperfecta Foundation "Fast Facts on Osteogenesis Imperfecta"
- Chudgar P. "Radiology In Rickets" Pediatric Oncall - Child Health Care "Radiology In Rickets"
- Chudgar P. "Radiology In Scurvy" Pediatric Oncall - Child Health Care "Radiology In Scurvy"
- Paterson CR. Burns J, McAllion SJ. "Osteogenesis imperfecta: the distinction from child abuse." "Am J Med Genet" 1993; 45:187-192
- Paterson CR. "Bone diseases that lead to false allegations of non-accidental injury." NCHR Symposium June 2004
- Paterson CR. "Radiological features of the brittle bone diseases," "Journal of Diagnostic Radiography and Imaging" 2003 5, 39–45 (pdf) Cambridge University Press (External link removed)
- Rothschild BM, Sebes JI. "Scurvy" Emedicine.com
- Suman RL, Dabi DR. Scurvy-An Unusual Cause of Proptosis? "Indian Pediatrics" 1998; 35:915-916 Editorial
- "Sloan B, Kulwin DR, Kersten RC. "Scurvy causing bilateral orbital hemorrhage." "Arch Ophthalmol." 1999; Jun;117(6):842-3
- Leestma, J E. "Shaken Baby Syndrome": Do Confessions by Alleged Perpetrators Validate the Concept?" "J Am Phys Surg" 2006; 11: 14-16
- Geddes JF, et al: "Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants" "Brain" Vol. 124, No. 7, 1299-1306, July 2001
- Duhaime A, Gennarelli T, Thibault L, et al. "The shaken baby syndrome. A clinical, pathological, and biomechanical study." "J Neurosurg" 1987; 66:409-415 Abstract
- Prange M., Coats B, Duhaime A., Margulies S. "Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants." "J Neurosurg" 2003; 99:143-150
- Uscinski R. "The Shaken Baby Syndrome" "J Am Phys Surg" 2004; 3: 76-77 PDF
- Ommaya A.K., Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and pediatric head injury, "Brit J Neurosurg" 2002; 16(3): 220-242 Abstract
- Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court CASE NO.04-CR 205
- Bandak FA. "Shaken baby syndrome: a biomechanics analysis of injury mechanisms." "Forensic Sci Int" 2005 Jun 30; 151(1): 71-9
- Bandak FA. "Response to the Letter to the Editor" "Forensic Sci Int." V 157, Issue 1, (10 February 2006)
- "Four types of inflicted brain injury predominate," "Patterns of presentation of the shaken baby syndrome" Case Reports & Letter "BMJ" 2004;328:766 (27 March)
- Geddes JF, et al: "Neuropathology of inflicted head injury in children. I: Patterns of brain damage." "Brain" 2001:124;1290-1298
- "Crying Baby" Parenting and Child Health, Children, Youth and Women’s Health Service – AU "Crying Baby"
- "Baby Colic," Patient UK "Baby Colic"
- "Gastroesophageal Reflux in Infants," National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH) USA "Gastroesophageal Reflux in Infants"
- "Lactose Intolerance," Better Health Channel, Victorian Government, Australia "Lactose Intolerance"
- "Ear infection – acute," Medical Encyclopedia, U.S. National Library of Medicine and the National Institutes of Health (NIH) USA "Ear infection – acute"
- "Adverse Effects of Pertussis and Rubella Vaccines," Institute of Medicine, "The National Academies Press, page 165 (1991) "Adverse Effects of Pertussis and Rubella Vaccines"
- Ruiz-Contreras J, Urquia L, Bastero R. "Persistent crying as predominant manifestation of sepsis in infants and newborns." "Pediatr Emerg Care". 1999 Apr;15(2):113-5Abstract
- "Sepsis – Pregnancy and Newborns," Rainbow Babies & Children's Hospital, University Hospitals of Cleveland "Sepsis – Pregnancy and Newborns"
- Harper M, Goldmann D. "What is bacterial meningitis vs. viral meningitis?" Children’s Hospital Boston "What is bacterial meningitis vs. viral meningitis?"
- Commonwealth Of Kentucky VS. Christopher A. Davis, Greenup Circuit Court CASE NO.04-CR 205
- "Shaken baby convictions overturned" "Special Report Child Protection" "Guardian Unlimited" Thursday July 21, 2005 UK "Shaken baby convictions overturned"
- ^ Clemetson C (2004). "Was it "shaken baby" or a variant of Barlow's disease?" (PDF). J Am Phys Surg". 9: 78–80.
- Suman RL, Dabi DR. Scurvy-An Unusual Cause of Proptosis? "Indian Pediatrics" 1998; 35:915-916 Editorial
- Möller-Barlow Disease, Who Named It?
External links
- National Child Abuse Defense & Resource Center.org - National Child Abuse Defense & Resource Center
- DontShake.com - The National Center on Shaken Baby Syndrome
- SBSDefense.com - Shaken Baby Syndrome Defense
- ShakenBaby.com - The Shaken Baby Alliance
- "Types of Brain Injury." Brain Injury Association of America (BIAUSA)
- The Journal News - Pataki signs shaken baby law
Video
- ExpertDigital.com - Graphic Demonstration (QuickTime)