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Shaken impact syndrome
(‘/Jr/d IlWW & Ac:@/n!. Vol. 14. pp 603-605. Pnnlcd ,n Ihc ll.S.4. All nghls rcscrvcd.
1990 CopyrIght
0
0145.?134/90 $3.00 + 00 1990 Pergamon Press plc
LETTERS TO THE EDITOR
SHAKEN
IMPACT SYNDROME
Sir:
In the January 1990 issue of American Jownal of Diseases qf Children, Alexander and colleagues ( 1990) describe the high incidence of serial abuse in children who have suffered from the shaken baby syndrome. This syndrome of intracranial hemorrhages, typically associated with retinal hemo~hages, has been attributed to violent and repetitive shaking. The term, “shaken impact syndrome,” has also been used (Bruce & Zimmerman, 1989) to call attention to the causative role of a relatively minor impact upon the release from shaking. This release impact (even if against a soft surface such as a mattress) may generate sudden deceleration forces much greater than shaking alone (Duhaime, et al., 1987); the result is serious intracranial injuries in the absence of external signs of trauma. The diagnosis of intracranial hemorrhage in an infant must raise the extreme suspicion of child abuse. An exceptional case is described below, wherein accidental head trauma mimics child abuse.
Patient
Rqmrt
A 5-month-old infant with a previous history ofjejunal atresia repair as a neonate was evaluated following one day of non-bilious vomiting and fussiness. His abdomen was soft, without distention or tenderness, and he had no fever and no diarrhea. Physical examination was normal except for irritability. mild lethargy, and mild dehydration: the anterior fontanelle was flat. He was admitted for dehydration and initial glycosuria. Suspected diabetes mellitus was excluded when glycosuria and mild hyperglycemia resolved spontaneously. (The patient’s hyperglycemia was later attributed to a nonspecific stress response.) Following admission. the infant developed abdominal distention and bilious vomiting. Abdominal radiographs showed dilated small bowel loops. but intestinal ileus eventually resolved without evidence of obstruction. A barium enema and upper gastrointestinal series radiographs were normal. The patient’s lethargy continued, however. and on the third hospital day he experienced a generalized tonic-clonic seizure. A drop in serum sodium from I34 mEq/ I to 124 mEq/ I was initially considered to be a possible cause. An electroencephalogram was normal, but his lethargy showed only gradual improvement. A complete neurologic examination revealed no focal findings. but a computerized tomographic scan ofthe head on the seventh hospital day showed bilateral tempero-frontal subdural effusions, consistent with a subdural hemorrhage at least one week old. When confronted with this finding, the parents denied any abusive events or shaking of the infant. The mother did report. however, that 36 hours prior to the initial evaluation a shaking/impact event may have occurred in a borrowed automobile. The mother apparently attempted to drive a stick-shift manual transmission vehicle. but being unfamiliar with the automobile’s clutch, she caused the car to jerk forward several times in rapid succession. The event was severe enough that she and the other passengers agreed that another driver should be chosen immediately. The infant was appropriately restrained in an approved car seat in the vehicle at the time of this event, and in all likelihood his occiput struck against the car seat suddenly, but he did not appear to have suffered any harm at the time. it is postulated that the event resulted in a gradually progressive subdural hemorrhage. presumably from the tearing of bridging veins.
It is impossible to know with complete certainty that this child had not been abused. However, a wealth of supporting evidence suggests that no abuse occurred. The family was well known to the attending private pediatrician; the father (a graduate student) and the mother had both been present at every well-baby visit, and their interactions with the infant were always loving and gentle. The child had never been left with any caretaker other than the parents. The event in the car seat occurred in the presence of both parents and their neighbors, all of whom reported the event to be a rather violent series of jerking motions. The event occurred at a point in time consistent with the subsequent radiographic 603
604
Letters to the Editor
studies, as well as consistent with the clinical progression of vomiting, lethargy, and seizure activity. There were no external signs of trauma, and a fundoscopic examination was without evidence of retinal
hemorrhages. A magnetic resonance imaging study sub~quently showed evidence of only this single central nervous system hemorrhage event. A skeletal survey revealed no evidence of old or new fractures. Additional studies excluded the possibility of a bleeding diathesis. Lastly, the infant has been followed into the second year of life with no evidence of sequelae and continuing evidence of appropriate parenting. The shaken impact syndrome of child abuse will in ail likelihood never be witnessed by health professionals. It is therefore a matter of speculation as to what degree of violence is required to produce serious sequeiae such as intracranial hemorrhages. Although models have been used to measure the relative force generated during severe shaking and the impact produced by a release from shaking (Duhaime et al., 1987). it is difficult to visualize these forces in terms of life experiences. The case described above, however, allows one to imagine an approximation of the forces involved, since most adults have experienced a similar episode of “clutch-release impact syndrome” sometime during their years of driving automobiles. Lastly, this unusual case should not lower the suspicion of child abuse in any young child with an intracranial hemorrhage. Rather, the case illustrates an unusual exception where accidental trauma may imitate nonaccidental trauma. The report also allows an appreciation of the approximate forces involved in the shaken impact syndrome. Albert L. Mehl Colorado Permanente Medical Group Boulder, Colorado
REFERENCES Alexander R.. Crabbe, L., Sate, Y., Smith, W., Bennett, T. ( 1990).Serial abuse in children who are shaken. Americnn Journal of Diseases qf Children, 144, 58-60. Bruce, D. A., & Zimmerman, R. A. (1989).Shaken impact syndrome. Pediatric Annals, 18,482-494. Duhaime. A. C.. Gennarelli, T. A., Thibault, L. E., Bruce, D. A., Margulies, S. S., & Wiser, R. (1987). The shaken baby syndrome: A clinical, pathological, and biom~hanical study. Journal ~r~et~r~sur~er.~,66,409-415.
Response to Commentary by N. Fost on Ethical Considerations in Testing Victims of Sexual Abuse for HIV Infection Sir: We read with some concern Dr. Fost’s commentary on our paper, “Developing Guidelines for HIV Antibody Testing Among Victims of Pediatric Sexual Abuse,” which recently appeared in this Journal (Fost, 1990; Gellert, Durfee. & Berkowitz, 1990). As Dr. Fost writes, “Good ethics starts with good facts.” It is surprising to us, therefore, that he should so inapprop~ately misuse the findings and misinterpret the objectives of our paper. First, as pointed out repeatedly in the paper, this study represents a preliminary effort to explore an almost entirely neglected area which is nonetheless of frequent concern to clinicians involved with the diagnosis and care of sexually abused children. Thus the use of the words “Developing Guidelines . . .” in the title. As Dr. Fost himself cites, we caution against use of any guidelines prior to the completion of prospective studies to generate much needed data on actual seroconversion rates under specific circumstances of pediatric sexual abuse. Unfo~unately, in the real world, such research is not yet occurring despite its need. Our research was an effort to provide some guidance in the interim, as is clearly pointed out in the paper. Dr. Fost has grossly misunderstood the study’s intention, which was to delimit and focus rather than expand HIV antibody testing of sexually
605
Letters to the Editor
abused children. He then proceeds to perform a cost-benefit analysis on our 2/1000 rate of detected seropositives from the survey. This is a flawed and meaningless analysis because, as we describe in our methods, the study does not survey a representative population from which to derive denominator data. Furthermore, these two cases were not even detected using the interim guidelines we propose. However it is Dr. Fost’s ethical comments that most concern us by disparaging the concept of testing these children and by discouraging clinicians to test cautiously as we recommend. Dr. Fost should review current clinical practice and research in AIDS before he concludes that there is no compensating benefit to HIV antibody testing. Zidovudine will soon be prescribed to HIV infected individuals who suffer from neither ARC nor AIDS because of its potential to prevent or delay onset of disease (Volberding. et al., 1990). Clinical trials are being implemented around the nation utilizing zidovudine in infants during the perinatal period before disease onset (AIDS Clinical Trial Group Protocol 076). Prophylactic treatment with zidovudine or other agents after sexual assault of children is foreseeable in settings where the assailant’s HIV positive serostatus is known. Recommendations already exist for prophylactic zidovudine treatment of occupational exposure to HIV (Public Health Service statement, 1990). Studies have also indicated good potential for topical application of nonoxynol-9 for rape and abuse victims, which inhibits HIV in vitro (Foster & Bartlett, 1989; Hicks, et al., 1985; Murphy, Kitchen, Harris, & Forster, 1989). Before widespread implementation of such a practice, studies of seroconversion rates among victims may be necessary. We believe our paper provides a useful preliminary contribution to discussion and research in the area of HIV antibody testing of sexually abused children. In conclusion, primum no nocere implies getting one’s facts straight and placing them in appropriate context in ethical as well as epidemiological analyses.
Harvard
Institute
George A. Gellert for International Development Harvard University
Michael J. Durfee Child Abuse Prevention Program Los Angeles County Department of Health Services Carol D. Berkowitz UCLA School of Medicine and Harbor/UCLA Medical Center
REFERENCES AIDS Clinical Trial Group Protocol 076. A multi-center Phase B randomized trial to evaluate the efficacy, safety and tolerance of oral zidovudine in infants with perinatal HIV exposure. Fost, N. (1990). Ethical considerations in testing victimsofsexual abuse for HIV infection. ChildAbuse& Neglect, 14, 5-7.
Foster, I. M., & Bartlett, J. (1989). Anti-HIV substances for rape victims. Journal of the American Medical Association, 261, 3407. Gellert. G. A., Durfee, M. J., & Berkowitz, C. D. (1990). Developing guidelines for HIV antibody testing among victims of pediatric sexual abuse. Child Abuse & Neglect, 14, 9-17.
Hicks, D. R., Martin, L. S., Getchell, J. P., Heath, J. L., Francis, D. P., McDougal, J. S., Curran, J. W., & Voeller, B. (1985). Inactivation of HTLV-III/LAV-infected cultures of normal human lymphocytes by nonoxynol-9 in vitro. The Lancer, 2, 1422-1423.
Murphy, S., Kitchen, V., Harris, J. R. W., Forster, S. M. (1989). Rape and subsequent seroconversion to HIV. British Medical Journal, 299, 7 18.
Public Health Service statement on management of occupational exposure to HIV, including considerations regarding zidovudine post-exposure use. ( 1990). Morbidity & Mortality Weekly Report, 39. Volberding, P. A., Lagakos, S. W., Koch, M. A., Pettinelli, C., Myers, M. W., Booth, D. K., Balfour, H. H., Jr., Reichman, R. C., Bartlett, J. A., Hirsch, M. S., Murphy, R. L., Hardy, W. D., Soeiro, R., Fischl, M. A., Bartlett, J. G., Merigan, T. G., Hyslop, N. E., Richman, D. D., Valentine, F. T., Corey, L., & AIDS Clinical Trials Group of the National Institute of Allergy and Infectious Diseases. ( 1990). Zidovudine in asymptomatic human immunodeficiency virus infection: A controlled trial in persons with fewer than 500 CD4 + cells per cubic millimeter. New England Journal of Medicine, 322, 94 1-949.
1990 CopyrIght
0
0145.?134/90 $3.00 + 00 1990 Pergamon Press plc
LETTERS TO THE EDITOR
SHAKEN
IMPACT SYNDROME
Sir:
In the January 1990 issue of American Jownal of Diseases qf Children, Alexander and colleagues ( 1990) describe the high incidence of serial abuse in children who have suffered from the shaken baby syndrome. This syndrome of intracranial hemorrhages, typically associated with retinal hemo~hages, has been attributed to violent and repetitive shaking. The term, “shaken impact syndrome,” has also been used (Bruce & Zimmerman, 1989) to call attention to the causative role of a relatively minor impact upon the release from shaking. This release impact (even if against a soft surface such as a mattress) may generate sudden deceleration forces much greater than shaking alone (Duhaime, et al., 1987); the result is serious intracranial injuries in the absence of external signs of trauma. The diagnosis of intracranial hemorrhage in an infant must raise the extreme suspicion of child abuse. An exceptional case is described below, wherein accidental head trauma mimics child abuse.
Patient
Rqmrt
A 5-month-old infant with a previous history ofjejunal atresia repair as a neonate was evaluated following one day of non-bilious vomiting and fussiness. His abdomen was soft, without distention or tenderness, and he had no fever and no diarrhea. Physical examination was normal except for irritability. mild lethargy, and mild dehydration: the anterior fontanelle was flat. He was admitted for dehydration and initial glycosuria. Suspected diabetes mellitus was excluded when glycosuria and mild hyperglycemia resolved spontaneously. (The patient’s hyperglycemia was later attributed to a nonspecific stress response.) Following admission. the infant developed abdominal distention and bilious vomiting. Abdominal radiographs showed dilated small bowel loops. but intestinal ileus eventually resolved without evidence of obstruction. A barium enema and upper gastrointestinal series radiographs were normal. The patient’s lethargy continued, however. and on the third hospital day he experienced a generalized tonic-clonic seizure. A drop in serum sodium from I34 mEq/ I to 124 mEq/ I was initially considered to be a possible cause. An electroencephalogram was normal, but his lethargy showed only gradual improvement. A complete neurologic examination revealed no focal findings. but a computerized tomographic scan ofthe head on the seventh hospital day showed bilateral tempero-frontal subdural effusions, consistent with a subdural hemorrhage at least one week old. When confronted with this finding, the parents denied any abusive events or shaking of the infant. The mother did report. however, that 36 hours prior to the initial evaluation a shaking/impact event may have occurred in a borrowed automobile. The mother apparently attempted to drive a stick-shift manual transmission vehicle. but being unfamiliar with the automobile’s clutch, she caused the car to jerk forward several times in rapid succession. The event was severe enough that she and the other passengers agreed that another driver should be chosen immediately. The infant was appropriately restrained in an approved car seat in the vehicle at the time of this event, and in all likelihood his occiput struck against the car seat suddenly, but he did not appear to have suffered any harm at the time. it is postulated that the event resulted in a gradually progressive subdural hemorrhage. presumably from the tearing of bridging veins.
It is impossible to know with complete certainty that this child had not been abused. However, a wealth of supporting evidence suggests that no abuse occurred. The family was well known to the attending private pediatrician; the father (a graduate student) and the mother had both been present at every well-baby visit, and their interactions with the infant were always loving and gentle. The child had never been left with any caretaker other than the parents. The event in the car seat occurred in the presence of both parents and their neighbors, all of whom reported the event to be a rather violent series of jerking motions. The event occurred at a point in time consistent with the subsequent radiographic 603
604
Letters to the Editor
studies, as well as consistent with the clinical progression of vomiting, lethargy, and seizure activity. There were no external signs of trauma, and a fundoscopic examination was without evidence of retinal
hemorrhages. A magnetic resonance imaging study sub~quently showed evidence of only this single central nervous system hemorrhage event. A skeletal survey revealed no evidence of old or new fractures. Additional studies excluded the possibility of a bleeding diathesis. Lastly, the infant has been followed into the second year of life with no evidence of sequelae and continuing evidence of appropriate parenting. The shaken impact syndrome of child abuse will in ail likelihood never be witnessed by health professionals. It is therefore a matter of speculation as to what degree of violence is required to produce serious sequeiae such as intracranial hemorrhages. Although models have been used to measure the relative force generated during severe shaking and the impact produced by a release from shaking (Duhaime et al., 1987). it is difficult to visualize these forces in terms of life experiences. The case described above, however, allows one to imagine an approximation of the forces involved, since most adults have experienced a similar episode of “clutch-release impact syndrome” sometime during their years of driving automobiles. Lastly, this unusual case should not lower the suspicion of child abuse in any young child with an intracranial hemorrhage. Rather, the case illustrates an unusual exception where accidental trauma may imitate nonaccidental trauma. The report also allows an appreciation of the approximate forces involved in the shaken impact syndrome. Albert L. Mehl Colorado Permanente Medical Group Boulder, Colorado
REFERENCES Alexander R.. Crabbe, L., Sate, Y., Smith, W., Bennett, T. ( 1990).Serial abuse in children who are shaken. Americnn Journal of Diseases qf Children, 144, 58-60. Bruce, D. A., & Zimmerman, R. A. (1989).Shaken impact syndrome. Pediatric Annals, 18,482-494. Duhaime. A. C.. Gennarelli, T. A., Thibault, L. E., Bruce, D. A., Margulies, S. S., & Wiser, R. (1987). The shaken baby syndrome: A clinical, pathological, and biom~hanical study. Journal ~r~et~r~sur~er.~,66,409-415.
Response to Commentary by N. Fost on Ethical Considerations in Testing Victims of Sexual Abuse for HIV Infection Sir: We read with some concern Dr. Fost’s commentary on our paper, “Developing Guidelines for HIV Antibody Testing Among Victims of Pediatric Sexual Abuse,” which recently appeared in this Journal (Fost, 1990; Gellert, Durfee. & Berkowitz, 1990). As Dr. Fost writes, “Good ethics starts with good facts.” It is surprising to us, therefore, that he should so inapprop~ately misuse the findings and misinterpret the objectives of our paper. First, as pointed out repeatedly in the paper, this study represents a preliminary effort to explore an almost entirely neglected area which is nonetheless of frequent concern to clinicians involved with the diagnosis and care of sexually abused children. Thus the use of the words “Developing Guidelines . . .” in the title. As Dr. Fost himself cites, we caution against use of any guidelines prior to the completion of prospective studies to generate much needed data on actual seroconversion rates under specific circumstances of pediatric sexual abuse. Unfo~unately, in the real world, such research is not yet occurring despite its need. Our research was an effort to provide some guidance in the interim, as is clearly pointed out in the paper. Dr. Fost has grossly misunderstood the study’s intention, which was to delimit and focus rather than expand HIV antibody testing of sexually
605
Letters to the Editor
abused children. He then proceeds to perform a cost-benefit analysis on our 2/1000 rate of detected seropositives from the survey. This is a flawed and meaningless analysis because, as we describe in our methods, the study does not survey a representative population from which to derive denominator data. Furthermore, these two cases were not even detected using the interim guidelines we propose. However it is Dr. Fost’s ethical comments that most concern us by disparaging the concept of testing these children and by discouraging clinicians to test cautiously as we recommend. Dr. Fost should review current clinical practice and research in AIDS before he concludes that there is no compensating benefit to HIV antibody testing. Zidovudine will soon be prescribed to HIV infected individuals who suffer from neither ARC nor AIDS because of its potential to prevent or delay onset of disease (Volberding. et al., 1990). Clinical trials are being implemented around the nation utilizing zidovudine in infants during the perinatal period before disease onset (AIDS Clinical Trial Group Protocol 076). Prophylactic treatment with zidovudine or other agents after sexual assault of children is foreseeable in settings where the assailant’s HIV positive serostatus is known. Recommendations already exist for prophylactic zidovudine treatment of occupational exposure to HIV (Public Health Service statement, 1990). Studies have also indicated good potential for topical application of nonoxynol-9 for rape and abuse victims, which inhibits HIV in vitro (Foster & Bartlett, 1989; Hicks, et al., 1985; Murphy, Kitchen, Harris, & Forster, 1989). Before widespread implementation of such a practice, studies of seroconversion rates among victims may be necessary. We believe our paper provides a useful preliminary contribution to discussion and research in the area of HIV antibody testing of sexually abused children. In conclusion, primum no nocere implies getting one’s facts straight and placing them in appropriate context in ethical as well as epidemiological analyses.
Harvard
Institute
George A. Gellert for International Development Harvard University
Michael J. Durfee Child Abuse Prevention Program Los Angeles County Department of Health Services Carol D. Berkowitz UCLA School of Medicine and Harbor/UCLA Medical Center
REFERENCES AIDS Clinical Trial Group Protocol 076. A multi-center Phase B randomized trial to evaluate the efficacy, safety and tolerance of oral zidovudine in infants with perinatal HIV exposure. Fost, N. (1990). Ethical considerations in testing victimsofsexual abuse for HIV infection. ChildAbuse& Neglect, 14, 5-7.
Foster, I. M., & Bartlett, J. (1989). Anti-HIV substances for rape victims. Journal of the American Medical Association, 261, 3407. Gellert. G. A., Durfee, M. J., & Berkowitz, C. D. (1990). Developing guidelines for HIV antibody testing among victims of pediatric sexual abuse. Child Abuse & Neglect, 14, 9-17.
Hicks, D. R., Martin, L. S., Getchell, J. P., Heath, J. L., Francis, D. P., McDougal, J. S., Curran, J. W., & Voeller, B. (1985). Inactivation of HTLV-III/LAV-infected cultures of normal human lymphocytes by nonoxynol-9 in vitro. The Lancer, 2, 1422-1423.
Murphy, S., Kitchen, V., Harris, J. R. W., Forster, S. M. (1989). Rape and subsequent seroconversion to HIV. British Medical Journal, 299, 7 18.
Public Health Service statement on management of occupational exposure to HIV, including considerations regarding zidovudine post-exposure use. ( 1990). Morbidity & Mortality Weekly Report, 39. Volberding, P. A., Lagakos, S. W., Koch, M. A., Pettinelli, C., Myers, M. W., Booth, D. K., Balfour, H. H., Jr., Reichman, R. C., Bartlett, J. A., Hirsch, M. S., Murphy, R. L., Hardy, W. D., Soeiro, R., Fischl, M. A., Bartlett, J. G., Merigan, T. G., Hyslop, N. E., Richman, D. D., Valentine, F. T., Corey, L., & AIDS Clinical Trials Group of the National Institute of Allergy and Infectious Diseases. ( 1990). Zidovudine in asymptomatic human immunodeficiency virus infection: A controlled trial in persons with fewer than 500 CD4 + cells per cubic millimeter. New England Journal of Medicine, 322, 94 1-949.