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Shaken baby syndrome is a less widely recognized form of physical child abuse. It is defined as vigorous manual shaking of an infant who is being held by the extremities or shoulders, leading to whiplash-induced intracranial and intraocular bleeding and no external signs of head trauma; often identifying shaken baby syndrome is difficult because of the lack of obvious external signs. Shaken baby syndrome should be considered in infants with seizures, failure to thrive, vomiting associated with lethargy or drowsiness, respiratory irregularities, coma, or death. With the increased awareness of child abuse, more attention has been focused on morbidity and death caused by the violent shaking of infants. This article describes the clinical findings of shaken baby syndrome, explores the characteristics of families at risk for abuse, and discusses implications for nurse practitioners.
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PMID:Shaken baby syndrome: identification and prevention for nurse practitioners. 815 88

This review of diagnostic imaging in cases of suspected child abuse characterizes the significant differences between bone scintigraphy and x-ray evaluation, describes the advantages and disadvantages of each modality, postulates on the specific mechanisms of injury that produce the characteristic scintigraphic findings, and emphasizes the influences that scintigraphic studies have on the medical, social, and legal aspects of child abuse. The major advantages of bone scintigraphy are its increased sensitivity (25% to 50%) in detecting evidence of soft tissue as well as bone trauma in child abuse. Furthermore, it is postulated that the specific mechanisms of inflicting the trauma relate to the patient's size and are characterized by bone scintigraphy. During fits of anger or frustration, the perpetrator of child abuse grasps the small infant or child by the thorax during the shaking activity. This produces characteristic rib injuries. The older and heavier child is more likely to be grabbed by the extremities, which produces periosteal injuries manifested as characteristic abnormal localizations in the diaphyses of the extremities. The roentgenograms of these injuries are frequently normal. The importance of bone scintigraphy is its complementary nature in defining and characterizing the extent and severity of trauma from child abuse. Such findings have direct bearing on the medical, social, and legal outcomes for the abused child. The quality of scintigraphic imaging is important, requiring the use of magnification techniques in the infant. The interpretation of the scintigraphic images depends on an understanding of the mechanisms by which the radionuclide localizes in bone. The same traumatic incident can lead to decreased, normal, or increased localization at the trauma site. Radionuclide scintigraphy is a complementary rather than competitive imaging modality to X-ray evaluation in the diagnosis and management of physical child abuse.
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PMID:The role of bone scintigraphy in detecting child abuse. 825 39

Five hundred twenty seven parents and tutors from three schools of Santiago were surveyed, using anonymous inquiry, to know behaviors and opinions towards child abuse. Sixty three percent of the sample judged physical punishment useless as an educational tool. However, 75% tacitly admitted to hit children, when they were asked a question about the ways they used to punish them. This question was answered by a significantly higher proportion of women. The principal reasons to use physical punishments were defying attitudes, lack of study and running away from home. The principal ways of physical punishment were hand blows (49%), lashes with belts (13%) and shaking (19%). The principal punitive restrictions were restrains from going out of home (70%) or watching television (46%) and not talking to children (14%). Sixty six percent of parents reminded physical punishments during their childhood. This background was associated with a higher frequency of actual battering. It is concluded that there is incoherence between real behavior and opinions towards child battering among parents and that the magnitude of this problem precludes its short term eradication.
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PMID:[Physical punishment in children: opinions and behaviors of adults]. 827 42

Strangulation has been postulated as one cause of cerebral hypoxia in child abuse. This report describes the finding of necklace calcification in an infant with rib fractures and a metaphyseal fracture and an admission of a shaking injury. The calcification is likely to represent fat necrosis as the result of strangulation.
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PMID:Case report: child abuse--necklace calcification--a sign of strangulation. 806 15

Head injuries are the leading cause of death in infants younger than 1 year old, and many of these injuries are the result of child abuse. Violent shaking is a form of child abuse that can cause severe head trauma, particularly to infants. This pattern of injuries is known as shaken baby syndrome (SBS). Although SBS can cause serious injuries such as retinal hemorrhage or subdural hematoma, it is difficult to diagnose because SBS often leaves no external evidence of abuse. This article reviews the most common cranial injuries associated with SBS, describes the mechanism of each injury and presents clinical signs and symptoms. It also investigates the use of computed tomography and magnetic resonance imaging to diagnose head trauma associated with SBS.
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PMID:The shaken baby syndrome: diagnosis using CT and MRI. 882 18

A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least one eye could be found ranging between a maximum value of 19.2 and 73.2% of the entire retinal area. In contrast, only two cases of the control group (severe head injury with skull fractures and intracranial bleeding following traffic accident or fall) showed slight hemorrhages of 3.33 or 1.18% of the retinal area but only in one eye. Therefore, the results provide evidence that massive intraretinal hemorrhages indicate violent shaking -- in particular in association with other signs of physical child abuse.
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PMID:Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome. 894 34

Forensic pathologists are frequently asked to describe the interval between injury and the onset of symptoms in child abuse head injury deaths. A prospective, postmortem study examined the interval between injury and onset of symptoms in 76 head injury deaths in which this information was available. The head injury deaths were divided by mechanism of injury. The mechanisms were shake (no impact), combined shake and blunt impact, and blunt impact (no history of shaking). The interval was less than 24 hours in 80% of shakes, 71.9% of combined, and 69.2% of blunt injuries. The interval was greater than 24 hours in more than 25% of each of these latter groups and was more than 72 hours in four children. The variable intervals between injury and severe symptoms warrant circumspection in describing the interval for investigators or triers of fact. It should be noted that in all of the cases where information was supplied by someone other than the perpetrator, the child was not normal during the interval.
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PMID:Interval duration between injury and severe symptoms in nonaccidental head trauma in infants and young children. 960 15

Shaken baby syndrome is a serious form of physical child abuse, which is frequently overlooked. It should be suspected in all children younger than one year of age, who present with drowsiness, coma, seizures or apnoea. A combination of subdural haematomas and retinal haemorrhages with minimal or no trauma and no coagulopathy is almost pathognomonic of the syndrome. The findings are caused by shaking with or without impact. Physical signs of violence are often absent and the syndrome may easily be mistaken for serious infection or seizure disorder. Many cases are fatal or lead to severe disability including blindness, cerebral palsy, mental retardation or epilepsy in about 60% of the children. There are many unresolved problems regarding diagnosis, pathophysiology, treatment, prognosis, prophylaxis and legal actions. We discuss these problems and in addition present eleven children with shaken baby syndrome.
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PMID:[Shaken baby syndrome]. 982 79

More than 3 million children are abused and/or neglected each year in the United States. Unfortunately, a significant percentage of these cases result in homicide by child abuse or child neglect. Causes of death range from blunt force trauma and shaking to asphyxia to immolation. We retrospectively reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over the past 10 years, from January 1986 to December 1995. Of these, we looked only at children < or =5 years of age. The majority (342 cases, 69%) of these deaths were classified as natural, 96 (19%) as accident, and 60 (12%) as homicide. Of the homicides, we examined the cause of death; age, gender, and race of the victim; relationship to the perpetrator; time interval between injury and death; and the initial history given as to the cause of the injury. The cause of death fell into nine categories, the number one category being head trauma. Forty-five percent of the homicides were by head trauma, 12% by abdominal or body trauma, 25% by asphyxia (with half of these due to drowning), 10% by carbon monoxide poisoning or thermal injury, and the remaining 8% involving cases of neglect, stabbing, and poisoning. The majority of the homicide victims were male (67%) and black (67%). Forty-six percent were < or =1 year of age. Approximately 25% of the homicide cases were designated as shaken baby syndrome (SBS). In 97% of the cases, the assailant was known to the victim and was a family relative in 77%. Sixty-three percent of the assailants were female and 45% of the assailants were male; in 12%, the assailants were both parents, and in 1 case, the assailant remains unknown. Of the asphyxia deaths, 87% of the assailants were female. The time interval between injury and death ranged from minutes to hours in most cases to months in cases of repeated abuse and chronic injury and sequelae. The time interval between injury and the onset of symptoms remains unknown in most cases due to inconsistencies in the history and lack of credibility of the caretaker. The most common initial history given was "a fall" (20%). We report our findings of a decade of pediatric homicides to increase awareness of the common scenarios and case histories, demographics of the victims, causes of death, and perpetrators of pediatric homicide.
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PMID:A decade of pediatric homicide: a retrospective study at the Medical University of South Carolina. 1041 59

Much important information can be obtained at necropsy by the pathological examination of the eye and its adnexal structures in adults and children. This information may be related to the cause of death (for example, violent shaking trauma in physical child abuse), or may pertain to disease processes affecting the eye, the orbit, and surrounding structures outside the orbit. This article reviews the technical methods used to remove the following: the vitreous (for example, for biochemistry); the eye itself (anterior approach); the eye and orbital contents (posterior approach); the eye, orbit and orbital walls; and the eye, orbital walls, and surrounding structures. The removal of the eye and adnexal ocular structures must be recognised as a "culturally sensitive" issue, which must be approached cautiously. It should only be undertaken for sound scientific reasons, with the fully informed consent of the relatives and/or the coroner (or equivalent authority), and with properly agreed procedures for the eventual retention or disposal of the ocular tissues. For this reason, this article reviews not only the scientific indications and methods for the removal of such tissues, but also the legal and ethical issues that must underpin this pathology "best practice".
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PMID:ACP Best Practice No 164: Necropsy techniques in ophthalmic pathology. 1137 13


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