PubMed · 10236307
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J C Kelleher. Nursing.. https://pubmed.ncbi.nlm.nih.gov/10236307/
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OBJECTIVE: To study ocular and nonocular signs of patients diagnosed as having "shaken baby syndrome" and determine prognostic indicators for vision and mortality. METHODS: Medical records of child abuse cases involving bilateral retinal hemorrhages were reviewed. Particular attention was paid to visual function and pupillary light reaction at the time of admission as well as the location of retinal hemorrhages, neuroimaging findings, ventilatory requirement, and associated skeletal injuries. These findings were correlated with visual prognosis and mortality. RESULTS: Thirty consecutive cases met the criteria for review. At the initial visit, mean age of the children was 9.3 months (range, 1-39 months) and 12 children (40%) had at least fix-and-follow vision. Preretinal and intraretinal hemorrhages (93% [n = 28] and 100% [n = 30]) were more common than vitreous hemorrhage (10% [n = 3]). Subdural hematomas were detected in 21 patients (70%). Twenty children (67%) had seizures and 16 (53%) required ventilatory support; bruises and long bone fractures were seen in 14 (47%) and 4 (13%) children, respectively. Eight patients died. All patients with nonreactive pupils on presentation died, while all patients with a pupillary light reaction lived (P<.001). Six (86%) of 7 patients with midline shift died, whereas 21 (91%) of 23 with no midline shift lived (P<.001). At follow-up, retinal hemorrhages had resolved in nearly all children by 4 months, and 16 children (73%) had at least fix-and-follow vision. Ventilatory requirement was associated with poorer vision (P<.01). CONCLUSIONS: Nonreactive pupils and midline shift of the brain structures correlate highly with mortality. Ventilatory requirement, but not visual acuity on presentation, predicts visual outcome.
OBJECTIVE: Advances in radiologic technique have increased the recognition of subdural hematoma. No study to date has addressed the role of child protective investigation into the cause and management of subdural hematoma in children who lack other indicators of abuse. METHODS: Medical records, radiology studies, and social service notes for all infants and children referred for child abuse investigation who had any form of intracranial hemorrhage were reviewed. The study covered the 12 months of 1997. All referrals were to the Suncoast Child Protection Team (St Petersburg, FL). RESULTS: There were 19 investigations because of subdural hematoma. Eight children had retinal hemorrhage as well as other major findings of trauma, such as bruises and/or fractures; all 8 were victims of child abuse. Two infants had tiny subdurals adjacent to accidental linear skull fractures. Nine infants were investigated for the possibility of abuse that had no findings of trauma apart from the subdural hematoma. These 9 cases form the basis for this study. The age range was 11 days to 15 months. Inflicted cerebral trauma was the medical diagnosis in 8 of the 9 cases; 1 case had a final diagnosis of possible inflicted injury in a high-risk setting. CONCLUSIONS: Infants with subdural hematoma but no other findings of abuse present a difficult challenge to child protection workers. Investigation by a medically oriented team can uncover the circumstances of the trauma in most instances and can usefully direct protective efforts. The high incidence of severe sequelae in infants with inflicted cerebral trauma warrants a vigorous approach.
In the context of chronic physical child abuse, two entities have been described based on macroscopical and radiological criteria: the battered baby syndrome and the shaken baby syndrome. However, in some autopsy cases, clinico-radiological information may not be available. In these cases, histological examinations are necessary to look for sequelae of repeated haemorrhages, particularly in organs likely to have suffered traumatisms such as the lungs, or in organs belonging to the mononucleated macrophage resorption system, such as the liver and the spleen. We examined a series of 15 young children who died from proven chronic child abuse and compared them with 15 sex and age-matched control subjects who died from natural causes with no history of child abuse. Using Perl's stain for iron, we identified haemosiderin deposits in pulmonary, hepatic and splenic samples and the deposits were evaluated qualitatively and quantitatively. Haemosiderin deposits were significantly (P < 0.001) more abundant in the lungs and liver of the chronic abuse victims than in those of the control subjects. However, they were not significantly more abundant in the spleens of child abuse victims than in controls. We conclude that haemosiderin deposits in lungs and liver could be proposed as a marker for chronic physical child abuse. This study stresses the importance of systematic histological examination to look for pulmonary and hepatic haemosiderin deposits in cases in which chronic child abuse is suspected.