Abusive head trauma ( AHT ), commonly known as shaken baby syndrome ( SBS ), is an injury to the child's head caused by others. Symptoms can range from smooth to clear. Symptoms may include vomiting or a baby that will not settle. Often there are no signs of visible trauma. Complications include seizures, impaired vision, cerebral palsy, and cognitive impairment.
The cause may be blunt trauma or strong tremors. Often this happens as a result of caregivers becoming frustrated because the child is crying. Diagnosis can be difficult because symptoms may not be specific. A CT scan of the head is usually recommended if there are concerns. While retinal hemorrhage is common, it can also occur in other conditions. Rough head trauma is a type of child abuse.
Educating new parents seems to be beneficial in reducing the level of conditions. Treatment sometimes requires surgery, such as to place cerebral shunt. AHT is estimated to occur at 3 to 4 per 10,000 babies per year. This is most common in those less than five years old. The risk of death is about 25%. Diagnosis can also bring legal consequences for parents.
Video Abusive head trauma
Signs and symptoms
The characteristic injuries associated with AHT include retinal hemorrhage, multiple long bones, and subdural hematoma (cerebral hemorrhage). These signs have evolved over the years as signs of child abuse are recognized and acknowledged. Medical professionals strongly suspect shocks as a cause of injury when a child has retinal hemorrhage, fractures, soft tissue injury or subdural hematoma, which can not be explained by accidental trauma or other medical conditions.
Retinal hemorrhage occurs in approximately 85% of cases of AHT; the type of retinal hemorrhage is very typical of this condition, making this finding useful in making the diagnosis. Although there are many other causes of retinal hemorrhage other than AHT, there is usually an additional (eye or systemic) finding that makes the alternative diagnosis apparent.
Spine fractures, long bones, and ribs can also be associated with AHT. Dr. John Caffey reported in 1972 that the metaphyseal avulsion (a small fragment of bone had been torn where the periosteum covered the bone and the cortical bones were tightly bound) and the "bone on both sides of the proximal and distal joints would be affected, especially on the knee."
People after AHT can show irritability, failure to develop, changes in diet, fatigue, vomiting, seizures, prominent or tense protrudes (soft spots in the baby's head), increased head size, variable breathing, and growing pupils.
Maps Abusive head trauma
Risk factors
Risk-averse caregivers often have unrealistic expectations of children and may indicate "role reversal," expecting children to meet caregiver needs. Substance abuse and emotional distress, generated for example from financial problems, are other risk factors for aggression and impulsivity on caregivers. Men and women can cause AHT. Although it has previously been speculated that AHT is a separate event, evidence of previous child abuse was a common finding. An estimated 33-40% of cases, evidence of previous head injury, such as prolonged intracranial hemorrhage, is present.
Mechanism
The effects of AHT are diffuse axonal injury, oxygen deprivation and brain swelling, which can increase pressure inside the skull and damage delicate brain tissue.
Traumatic tremors occur when a child is shaken in such a way that the head is thrown backwards and forwards. In 1971, Guthkelch, a neurosurgeon, hypothesized that such vibrations can cause subdural hematoma, in the absence of any external signs that can be detected from an injury to the skull. The article describes two cases in which parents acknowledge that for various reasons they have shaken a child before illness. In addition, one baby has retinal hemorrhage. The relationship between traumatic tremor, subdural hematoma and retinal hemorrhage was described in 1972 and referred to as whiplash whipped baby syndrome. The injury is believed to occur due to wagging a child who bows his head to accelerations and rotational forces. In 1987, this theory was questioned in biomechanical research which concluded that isolated shaking, in the absence of direct violence, may not be sufficient to cause the injury described as part of the triad. It has been suggested that the mechanism of ocular disorders is associated with vitreoretinal traction, with a vitreous movement that contributes to the development of characteristic retinal bleeding, although this has been contested. These eye findings correlate well with intracranial abnormalities.
Forced
There is controversy about the amount of power needed to produce the brain damage seen in AHT. There is widespread agreement, even among skeptics, that shaking the baby is dangerous and can be fatal.
A biomechanical analysis published in 2005 reported that "strong shocks can greatly injure or kill babies, this is because the cervical spine will be severely injured and not because subdural hematoma will be caused by high head rotation acceleration... infant heads experiencing levels the speed of rotation and acceleration mentioned in the SBS literature, will experience strength in the baby's neck far beyond the limit of structural failure of the cervical spine. Furthermore, tremor cervical bone injury may occur at much lower head-speed and acceleration rates than reported for SBS. "Another writer is critical of mathematical analysis by Bandak, citing concerns about the calculations used by the authors concluding" Given the numerical error in Bandak neck force estimates, we are questioning the exact determination of Bandak's conclusion that neck injuries will occur in all shaking events. "Other authors critical of the model proposed by Bandak conclude" the proposed mechanical analogs in the paper may not be entirely appropriate when used to model head and neck movements of babies when the baby is shaken. " Bandak responded to criticism in a letter to an editor published in Forensic Science International in February 2006.
Diagnosis
Diagnosis can be difficult because symptoms may not be specific. A CT scan of the head is usually recommended if there are concerns. While retinal hemorrhage is common, it can also occur in other conditions.
Triad
While the AHT findings are very complex and numerous, they are often referred to as "triads".
SBS can be misdiagnosed, underdiagnosed, and overdiagnosed, and the caregiver may be lying or unaware of the mechanism of the injury. Generally, there are no visible signs externally from this condition. Experienced eye examinations are often important in diagnosing a shuffled baby syndrome, because the particular form of eye bleeding is quite distinctive. Magnetic resonance imaging may also describe retinal hemorrhage; this is sometimes useful if the optometrist examination is delayed or unavailable. Conditions to be excluded include hydrocephalus, sudden infant death syndrome (SIDS), seizure disorders, and infectious or congenital diseases such as meningitis and metabolic disorders. CT scan and magnetic resonance imaging are used to diagnose the condition. Conditions that may accompany SBS include fractures, injuries to the cervical spine (in the neck), retinal hemorrhage, cerebral or atrophic hemorrhage, hydrocephalus, and papilledema (swelling of the optical disc).
The term accidental head injury or resulted in traumatic brain injury has been suggested in place of "SBS".
The connection of the triads to the traumatic traumatic episode controversially with a systematic review of 2016 found limited scientific evidence linking the triads to traumatic trembling episodes, and sufficient evidence to use triads to identify the episode. This relationship is controversial in part because of cases in which the parents of children who show triads have, in addition to losing custody, are imprisoned or sentenced to death.
Classification
The term coarse head trauma is preferred because it better represents a wider potential cause.
The US Centers for Disease Control and Prevention identifies SBS as "injury to the cranial or intracranial contents of infants or young children (& lt; 5 years) due to the impact of blunt and/or severe shocks". In 2009, the American Academy of Pediatrics recommended the use of a crude head injury term to replace SBS, partly to distinguish injuries arising from trembling and injury resulting from tremor and head trauma.
SBS was previously believed to be present with a constellation of findings (often referred to as "triads"): subdural hematoma; retinal hemorrhage; and swelling of the brain or encephalopathy - which has been controversially used to infer child abuse caused by traumatic violence or traumatic tremor. The diagnostic accuracy of the trias, related to the episode of controversial traumatic shocks with systematic review 2016, found limited scientific evidence linking triads with traumatic trembling episodes, and sufficient evidence to use triads to identify the episode. This relationship is controversial in part because of cases in which the parents of children who show triads have, in addition to losing custody, are imprisoned or sentenced to death.
The Crown Prosecution Service for England and Wales recommended in 2011 that the term "shaken baby syndrome" would be avoided and the term accidental head injury used instead.
Differential diagnosis
Vitamin C deficiency
Several authors have suggested that certain cases of suspected shocked baby syndrome may occur as a result of vitamin C deficiency. This contested hypothesis is based on conditions of marginal spectrum, near scorbutic or lack of essential nutritional content and potential for increased histamine. However, symptoms consistent with elevated levels of histamine, such as low blood pressure and allergy symptoms, are generally not associated with scabies as a clinically significant vitamin C deficiency. A literature review of this hypothesis in the journal Pediatrics International concludes as follows: "From the information available in the literature, it is concluded that there is no convincing evidence to conclude that vitamin C deficiency can be thought of as the cause of the shaken baby syndrome. "
The proponents of the hypothesis often question the adequacy of nutritional tissue levels, especially vitamin C, for current or sick children, bacterial infections, those with higher individual requirements, those who suffer environmental challenges (eg allergies), and possibly transient vaccination-related pressure. At the time of writing, childhood infantic scabies are practically nonexistent. No scurvy cases mimicking SBS or sudden infant death syndrome have been reported, and scurvy usually occurs later in infancy, rarely causing death or intracranial bleeding, and is accompanied by other changes in bone and skin and is always a very unusual dietary history.
In one study vaccination was shown not to be associated with retinal hemorrhage.
Atmosphere issues
Pregnancy problems that affect the mother and fetus, the birth process, the prematurity and nutritional deficits can accelerate the skeletal and hemorrhagic pathology that can also mimic SBS, even before birth.
Prevention
Interventions by neonatal nurses include giving parents information about rough head trauma, normal baby crying and reasons for crying, teaching how to calm the baby, and how to cope if a baby is not consoled can reduce AHT levels.
Treatment
Treatment involves monitoring intracranial pressure (pressure inside the skull), draining fluid from the cerebral ventricle, and, if the intracranial hematoma is present, depletes the collection of blood.
Prognosis
The prognosis depends on the severity and can range from total recovery to severe disability to death when seriously injured. One-third of these patients died, one-third survived the major neurological condition, and only one-third survived in good condition. The most common neurological damage is learning disabilities, seizure disorders, speech defects, hydrocephalus, cerebral palsy, and visual impairment.
Epidemiology
Young children are at very high risk for abuse that causes SBS to be given a huge difference in size between small children and adults. SBS usually occurs in children under the age of two but can occur to them until the age of five.
History
In 1971, Norman Guthkelch proposed that whiplash injury causes subdural hemorrhage in infants by tearing blood vessels in subdural spaces. The term "whiplash shaken baby syndrome" was introduced by Dr. John Caffey, a pediatric radiologist, in 1973, described a series of symptoms found with little or no external evidence of head trauma, including retinal hemorrhage and intracranial hemorrhage with subdural or subarachnoid hemorrhage. or both. The development of computed tomography and magnetic resonance imaging techniques in the 1970s and 1980s led to the ability to diagnose the syndrome.
Legal issues
The Presidential Advisory Council on Science and Technology (PCAST) noted in a report in September 2016 that there is concern about the scientific validity of forensic evidence of rough head trauma that "needs immediate attention.". Similarly, the Maguire model, suggested in 2011 as a potential statistical model to determine the probability that child trauma is caused by abuse, has been questioned. The proposed clinical prediction rule with high sensitivity and low specificity, to rule out Abusive Head Trauma, has been published.
In July 2005, the Court of Appeals in the United Kingdom heard four appeals from SBS's conviction: one case was dropped, sentence was reduced to one, and two decisions were dropped. The court found that the classic triads of retinal hemorrhage, subdural hematoma, and acute encephalopathy are not 100% SBS diagnostic and clinical history is also important. In the Court's decision, they uphold the clinical concept of SBS but reject one case and subtract one case from murder to premeditated murder. In their words: "While a strong pointer to NAHI [unintentional head injury] itself we do not think it's possible to find that it should automatically and need to lead to the diagnosis of NAHI.All circumstances, including the clinical picture, should be taken into account."
The court overturned the "unified hypothesis", filed by British physician J. F. Geddes and colleagues, as an alternative mechanism for subdural and retinal hemorrhages found in suspected cases of SBS. The integrated hypothesis states that bleeding is not caused by subdural veins and retinal veins, but rather because of cerebral hypoxia, increased intracranial pressure, and increased pressure in the cerebral blood vessels. The court reported that "unified hypothesis [could] be no longer considered a credible or alternative cause of the injury triad": subdural hemorrhage, retinal hemorrhage and encephalopathy due to hypoxemia (low blood oxygen) found on Suspected SBS.
On January 31, 2008, the Wisconsin High Court granted a new trial of Audrey A. Edmunds based on "competing credible medical opinion in determining whether there is reasonable doubt about the errors of Edmunds." In particular, the appeals court found that "Edmunds presented evidence not found until after his conviction, in the form of expert medical testimony, that a significant and legitimate debate within the medical community has evolved over the past decade as to whether a baby can become seriously injured through a self-shock , whether an infant can suffer head trauma and have not experienced significant clear intervals before death, and whether other causes can mimic symptoms traditionally seen as an indication of a shocked baby or a shaky break-even syndrome. "
In 2012, A. Norman Guthkelch, a neurosurgeon is often credited with "discovering" the diagnosis of SBS, publishing an article "after 40 years of consideration," which is very critical of infant prosecution shaken solely on the basis of a triad of injuries. Once again, in 2012, Dr. Guthkelch stated in an interview, "I think we need to go back to the drawing board and make a more thorough assessment of these fatal cases, and I'll bet... that we'll find in every- or at least most cases, it suffered another severe illness that was missed until it was too late. "Additionally, by 2015, Dr. Guthkelch even said, "I am opposed to defining this as a syndrome in the first example.To go on and say every time you see it, it's a crime... It's an easy way to go to jail."
On the other hand, Teri Covington, who runs the National Center for Child Mortality Review and Practice Policy, fears that such caution has led to an increasing number of child abuse cases where perpetrators are not punished.
In March 2016, Waney Squier, a pediatric neuropathy expert who has been an expert witness in many staggered baby trials, was struck from the medical checklist by mistake. Shortly after his conviction, Dr. Squier was awarded the "champion of justice" by the International Innocence Network for his efforts to free those who were wrongly convicted of shaking the baby syndrome.
Squier denied the allegations and appealed the decision to strike him from the medical list. When the case was heard by the High Court of England and Wales in October 2016, an open letter to the British Medical Journal questioned the decision to attack Dr. Squier, signed by 350 doctors, scientists, and lawyers. On 3 November 2016, the court issued a ruling that concluded that "the determination of MPT is in many ways significantly defective". The judge found that he had committed a serious professional error but was dishonest. He was reinstated to a medical list but was not allowed to provide courtroom expert evidence for three years.
References
External links
- Centers for Disease Control and Prevention - Rough head trauma
Source of the article : Wikipedia
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