- Email: [email protected]
Shaken babies
CORRESPONDENCE
COMMENTARY
CORRESPONDENCE Shaken babies Sir—Your Aug 1 editorial1 was singularly unhelpful, misrepresented current clinical thinking, and ignored the many publications now available to practitioners. Diagnosis of child abuse is likened to completion of a jigsaw (as is the case in other specialties), with the extra dimension that if abuse is suspected the police and social services are informed. It is the police who investigate and the local social services who have the statutory responsibility to protect the child, once the doctor has given his opinion.2 The clinical picture in shaken baby syndrome is changing,3 which is not unexpected with the availability of computed tomography (CT) and magnetic resonance imaging (MRI) scan is of the head. Diagnosis may now be made earlier and hopefully before development of serious brain and eye damage as well as other injury to the infant’s skeleton and soft tissues as abuse escalates. The diagnosis of shaken baby syndrome is made on the history, examination (bruises, burns, retinal haemorrhages, and other eye injuries), and investigations (usually as a baseline, haemoglobin, blood film, platelet count, clotting screen, skeletal survey, and CT and MRI brain scans). It is usual for the history to be vague and to change, and in many cases there will be multiple injuries. There may be an admission by the carer of shaking. The debate as to shake/impact is largely played out in the courts: clinically a severe shake inevitably leads to a deceleration injury, plus a skull fracture if the child’s head is banged against a hard service, or a minor soft tissue injury if the child is thrust down in a cot. National studies are underway into retinal haemorrhages (by ophthalmologists) and subdural haematoma (British Paediatric Surveillance Unit involving paediatricians, pathologists, and neurosurgeons). David Southall has published widely and is highly respected amongst paediatricians in this topic. Bernard Knight’s research is less well known, although a fellow forensic pathologist, Malcolm Green, who has an acknowledged interest in infant
THE LANCET • Vol 352 • September 5, 1998
deaths, has linked eye and cerebral trauma.4 Your reference to Cleveland is gratuitous and ill-informed. We refer you to the inquiry report.5 *Jane Wynne, Chris Hobbs *Belmont House, Leeds LS2 2JT, UK; and Community Paediatrics, St James’s Hospital, Leeds (e-mail: [email protected]) 1 2
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Editorial. Shaken babies. Lancet 1998; 352: 335. Hobbs CJ, Hanks HIG, Wynne JM. Physical abuse in child abuse and neglect, chapter 4. London: Churchill, Livingstone, 1993. Lazoritz S, Baldwin S, Kini N. The whiplash shaken infant syndrome—has Caffey’s syndrome changed or have we changed his syndrome? Child Abuse and Neglect 1997; 21: 1009–14. Green MA, Lieberman G, Milroy CM, Parsons MA. Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice. Br J Ophthalmol 1996; 50: 282–87. Butler-Sloss E. Report of the injury into child abuse in Cleveland 1987. HMSO, 1998.
Sir—The flurry of media activity surrounding recent highly publicised cases of allegations of shaken baby syndrome has stimulated a useful examination of long-held views of various forms of child abuse (nonaccidental injury). Your editorial1 addresses some of the difficulties with the diagnosis of this syndrome. You credit the first description of the syndrome to Caffey, an American paediatric radiologist.2 His paper was preceded by Guthkelch’s description of whiplash injuries in abused children.3 What does or does not constitute a diagnosis of shaken baby syndrome? Uncertainties are inevitable when a diagnosis denoting a specific mechanism of injury is inferred only from the presence of characteristic clinical and pathological findings. You address the ocular and neurological findings and cite publicised anecdotes in which an incorrect diagnosis was a possibility. You grossly oversimplify the subject by linking the unsupported notion that 5% of subdural haematomas occur with minor falls, with a tendency for overzealous diagnosis of abuse. The customary practice of experienced physicians is to view clinical and imaging findings suspicious of abuse in conjunction with all other imaging data,
clinical findings, and historical information. A worrisome statement is, “No imaging or clinical investigations can differentiate with certainty between accidental and inflicted injury”. As physicians, critical decisions about the welfare of our patients are often based on data providing less than 100% certainty. Over 40 years ago, Caffey4 said that metaphyseal lesions carried a strong association with abuse. These injuries as well as other high specificity indicators provide compelling evidence that abuse has occurred.5 Do you believe that a radiologist would be mistaken in diagnosing abuse in, for example, an otherwise normal infant with an interhemispheric subdural haemorrhage, cerebral swelling, multiple classic metaphyseal lesions, and rib fractures of varying ages? Failure to suspect abuse in the face of strong clinical and radiological indications exposes the physician to the risks of civil and even criminal penalties. Media attention to this subject has provoked useful examination of our ideas about inflicted injuries in childhood and, as you suggest, we should continually scrutinise and refine our definitions. On the other hand, knowledgeable and experienced clinicians and imaging specialists have a remarkable ability to reliably differentiate child abuse from its imitators in most cases. Regretfully, this point is conspicuously absent in your editorial. Paul K Kleinman Department of Radiology, University of Massachusetts Medical Center, Worcester, MA 01655, USA 1 2
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Editorial. Shaken babies. Lancet 1998; 352: 335. Caffey J. On the theory and practice of shaking infants: its potential effects of permanent brain damage and mental retardation. Am J Dis Child 1972; 124: 161–69. Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injury. BMJ 1971; 11: 430–31. Caffey J. Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiological features. Br J Radiol 1957; 30: 225–38. Kleinman PK. Diagnostic imaging of child abuse. St. Louis: Mosby Inc, 1998.
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COMMENTARY
CORRESPONDENCE Shaken babies Sir—Your Aug 1 editorial1 was singularly unhelpful, misrepresented current clinical thinking, and ignored the many publications now available to practitioners. Diagnosis of child abuse is likened to completion of a jigsaw (as is the case in other specialties), with the extra dimension that if abuse is suspected the police and social services are informed. It is the police who investigate and the local social services who have the statutory responsibility to protect the child, once the doctor has given his opinion.2 The clinical picture in shaken baby syndrome is changing,3 which is not unexpected with the availability of computed tomography (CT) and magnetic resonance imaging (MRI) scan is of the head. Diagnosis may now be made earlier and hopefully before development of serious brain and eye damage as well as other injury to the infant’s skeleton and soft tissues as abuse escalates. The diagnosis of shaken baby syndrome is made on the history, examination (bruises, burns, retinal haemorrhages, and other eye injuries), and investigations (usually as a baseline, haemoglobin, blood film, platelet count, clotting screen, skeletal survey, and CT and MRI brain scans). It is usual for the history to be vague and to change, and in many cases there will be multiple injuries. There may be an admission by the carer of shaking. The debate as to shake/impact is largely played out in the courts: clinically a severe shake inevitably leads to a deceleration injury, plus a skull fracture if the child’s head is banged against a hard service, or a minor soft tissue injury if the child is thrust down in a cot. National studies are underway into retinal haemorrhages (by ophthalmologists) and subdural haematoma (British Paediatric Surveillance Unit involving paediatricians, pathologists, and neurosurgeons). David Southall has published widely and is highly respected amongst paediatricians in this topic. Bernard Knight’s research is less well known, although a fellow forensic pathologist, Malcolm Green, who has an acknowledged interest in infant
THE LANCET • Vol 352 • September 5, 1998
deaths, has linked eye and cerebral trauma.4 Your reference to Cleveland is gratuitous and ill-informed. We refer you to the inquiry report.5 *Jane Wynne, Chris Hobbs *Belmont House, Leeds LS2 2JT, UK; and Community Paediatrics, St James’s Hospital, Leeds (e-mail: [email protected]) 1 2
3
4
5
Editorial. Shaken babies. Lancet 1998; 352: 335. Hobbs CJ, Hanks HIG, Wynne JM. Physical abuse in child abuse and neglect, chapter 4. London: Churchill, Livingstone, 1993. Lazoritz S, Baldwin S, Kini N. The whiplash shaken infant syndrome—has Caffey’s syndrome changed or have we changed his syndrome? Child Abuse and Neglect 1997; 21: 1009–14. Green MA, Lieberman G, Milroy CM, Parsons MA. Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice. Br J Ophthalmol 1996; 50: 282–87. Butler-Sloss E. Report of the injury into child abuse in Cleveland 1987. HMSO, 1998.
Sir—The flurry of media activity surrounding recent highly publicised cases of allegations of shaken baby syndrome has stimulated a useful examination of long-held views of various forms of child abuse (nonaccidental injury). Your editorial1 addresses some of the difficulties with the diagnosis of this syndrome. You credit the first description of the syndrome to Caffey, an American paediatric radiologist.2 His paper was preceded by Guthkelch’s description of whiplash injuries in abused children.3 What does or does not constitute a diagnosis of shaken baby syndrome? Uncertainties are inevitable when a diagnosis denoting a specific mechanism of injury is inferred only from the presence of characteristic clinical and pathological findings. You address the ocular and neurological findings and cite publicised anecdotes in which an incorrect diagnosis was a possibility. You grossly oversimplify the subject by linking the unsupported notion that 5% of subdural haematomas occur with minor falls, with a tendency for overzealous diagnosis of abuse. The customary practice of experienced physicians is to view clinical and imaging findings suspicious of abuse in conjunction with all other imaging data,
clinical findings, and historical information. A worrisome statement is, “No imaging or clinical investigations can differentiate with certainty between accidental and inflicted injury”. As physicians, critical decisions about the welfare of our patients are often based on data providing less than 100% certainty. Over 40 years ago, Caffey4 said that metaphyseal lesions carried a strong association with abuse. These injuries as well as other high specificity indicators provide compelling evidence that abuse has occurred.5 Do you believe that a radiologist would be mistaken in diagnosing abuse in, for example, an otherwise normal infant with an interhemispheric subdural haemorrhage, cerebral swelling, multiple classic metaphyseal lesions, and rib fractures of varying ages? Failure to suspect abuse in the face of strong clinical and radiological indications exposes the physician to the risks of civil and even criminal penalties. Media attention to this subject has provoked useful examination of our ideas about inflicted injuries in childhood and, as you suggest, we should continually scrutinise and refine our definitions. On the other hand, knowledgeable and experienced clinicians and imaging specialists have a remarkable ability to reliably differentiate child abuse from its imitators in most cases. Regretfully, this point is conspicuously absent in your editorial. Paul K Kleinman Department of Radiology, University of Massachusetts Medical Center, Worcester, MA 01655, USA 1 2
3
4
5
Editorial. Shaken babies. Lancet 1998; 352: 335. Caffey J. On the theory and practice of shaking infants: its potential effects of permanent brain damage and mental retardation. Am J Dis Child 1972; 124: 161–69. Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injury. BMJ 1971; 11: 430–31. Caffey J. Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiological features. Br J Radiol 1957; 30: 225–38. Kleinman PK. Diagnostic imaging of child abuse. St. Louis: Mosby Inc, 1998.
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