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Catherine Combee Defends Defendant of Shaken Baby Syndrom

Medical status

Shaken baby syndrome
Other names abusive head trauma, not accidental head injury
CTheatInfantAbusiveheadtrauma.png
An intraparenchymal bleed with overlying skull fracture from shaken infant syndrome
Symptoms Variable[ane]
Complications Seizures, visual impairment, cerebral palsy, cerebral damage[2] [1]
Usual onset Less than v years old[3]
Causes Blunt trauma, vigorous shaking[1]
Diagnostic method CT browse[1]
Prevention Educating new parents[1]
Prognosis Long term health bug common[3]
Frequency 3 per 10,000 babies per twelvemonth (US)[ane]
Deaths ≈25% run a risk of expiry[iii]

Shaken baby syndrome (SBS), also known as abusive head trauma (AHT), is an unproven theory regarding injury to a child's brain caused by someone else.[ane] [4] According to the shaken babe theory, symptoms may range from subtle to obvious.[1] According to the theory, symptoms may include airsickness or a baby that volition not settle.[ane] Often there are no visible signs of trauma.[one] Complications include seizures, visual impairment, cerebral palsy, cognitive impairment and decease.[2] [1]

The cause may be blunt trauma or vigorous shaking.[1] Oft this occurs as a event of a caregiver becoming frustrated due to the child crying.[iii] Diagnosis tin can be hard equally symptoms may be nonspecific.[i] A CT browse of the head is typically recommended if a business organization is present.[1] While retinal bleeding is common, it can as well occur in many other conditions.[1] Abusive caput trauma is a type of child abuse.[5]

Educating new parents appears to be benign in decreasing rates of the condition.[1] Treatment occasionally requires surgery, such as to place a cognitive shunt.[i] SBS is estimated to occur in 3 to 4 per 10,000 babies a year.[one] Information technology occurs most frequently in those less than five years of age.[3] The take a chance of decease is almost 25%.[3] The diagnosis include retinal bleeds, multiple fractures of the long bones, and subdural hematomas (bleeding in the brain).[6] These signs have evolved through the years as the accepted and recognized signs of child abuse. Medical professionals strongly doubtable shaking as the crusade of injuries when a young child presents with retinal bleed, fractures, soft tissue injuries or subdural hematoma, that cannot exist explained by adventitious trauma or other medical conditions.[7]

Retinal bleeds occur in effectually 85% of SBS cases; the type of retinal bleeds are often believed to be particularly characteristic of this condition, making the finding useful in establishing the diagnosis, although this finding is based on round reasoning and other studies have establish that patterns of retinal bleeding cannot exist used to make diagnoses.[8] While there are many other causes of retinal bleeds besides SBS, there are usually additional findings (eyes or systemic) which brand the alternative diagnoses apparent[ citation needed ] although again, this claim is based on circular reasoning.[nine]

Fractures of the vertebrae, long bones, and ribs may also be associated with SBS.[ten] Dr. John Caffey reported in 1972 that metaphyseal avulsions (small-scale fragments of bone torn off where the periosteum roofing the os and the cortical bone are tightly bound together) and "bones on both the proximal and distal sides of a single joint are affected, particularly at the articulatio genus".[eleven]

Infants may brandish irritability, failure to thrive, alterations in eating patterns, lethargy, vomiting, seizures, jutting or tense fontanels (the soft spots on a infant's head), increased size of the head, altered animate, and dilated pupils, although all these atmospheric condition can have alternative causes, and and so cannot be used to brand a diagnosis of corruption.[12]

Risk factors [edit]

Caregivers that are at risk for becoming calumniating often have unrealistic expectations of the kid and may display "role reversal", expecting the child to fulfill the needs of the caregiver.[13] Substance abuse and emotional stress, resulting for case from financial troubles, are other risk factors for aggression and impulsiveness in caregivers.[xiii] Both males and females can cause SBS.[thirteen] Although it had been previously speculated that SBS was an isolated consequence, evidence of prior kid abuse is a common finding.[13] In an estimated 33–40% of cases, evidence of prior head injuries, such as old intracranial bleeds, is nowadays.[13]

Machinery [edit]

Furnishings of SBS are thought to be diffuse axonal injury, oxygen deprivation and swelling of the brain,[xiv] which can enhance pressure within the skull and harm delicate brain tissue, although witnessed shaking events have not lead to such injuries.

Traumatic shaking occurs when a kid is shaken in such a way that its head is flung backwards and forwards.[fifteen] In 1971, Guthkelch, a neurosurgeon, hypothesized that such shaking tin result in a subdural hematoma, in the absence of any detectable external signs of injury to the skull.[15] The article describes two cases in which the parents admitted that for diverse reasons they had shaken the child before it became ill.[xv] Moreover, one of the babies had retinal hemorrhages.[15] The clan betwixt traumatic shaking, subdural hematoma and retinal hemorrhages was described in 1972 and referred to as whiplash shaken infant syndrome.[15] The injuries were believed to occur because shaking the child subjected the head to dispatch–deceleration and rotational forces.[15] In 1987, this theory was queried in a biomechanical study which ended that isolated shaking, in the absence of directly violence, is probably not of sufficient force to crusade the injuries described as office of the triad.[15] Information technology has been suggested that the machinery of ocular abnormalities is related to vitreoretinal traction, with motion of the vitreous contributing to development of the characteristic retinal bleeds, although this has been challenged.[xvi] These heart findings correlate well with intracranial abnormalities.[17]

Force [edit]

At that place has been controversy regarding the corporeality of force required to produce the brain harm seen in SBS. In that location is broad understanding, even amongst skeptics, that shaking of a baby is dangerous and tin can be fatal.[xviii] [19] [xx]

A biomechanical analysis published in 2005 reported that "forceful shaking can severely injure or kill an infant, this is because the cervical spine would exist severely injured and non because subdural hematomas would be caused past high caput rotational accelerations... an infant caput subjected to the levels of rotational velocity and dispatch called for in the SBS literature, would feel forces on the babe neck far exceeding the limits for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for SBS."[21] Other authors were disquisitional of the mathematical analysis by Bandak, citing concerns most the calculations the author used terminal "In lite of the numerical errors in Bandak's neck strength estimations, we question the resolute tenor of Bandak's conclusions that cervix injuries would occur in all shaking events."[22] Other authors disquisitional of the model proposed by Bandak terminal "the mechanical analogue proposed in the paper may not be entirely appropriate when used to model the motility of the caput and neck of infants when a baby is shaken."[23] Bandak responded to the criticism in a letter of the alphabet to the editor published in Forensic Scientific discipline International in February 2006.[24]

Diagnosis [edit]

Diagnosis can be hard as symptoms may be nonspecific.[1] A CT scan of the caput is typically recommended if a concern is present.[1] While retinal bleeding is common, it can also occur in other conditions.[ane] It is unclear how useful subdural haematoma, retinal hemorrhages, and encephalopathy are solitary at making the diagnosis.[nine]

Triad [edit]

While the findings of SBS are complex and many,[25] they are often incorrectly referred to as a "triad" for legal proceedings; distilled down to retinal hemorrhages, subdural hematomas, and encephalopathy.[26]

SBS may be misdiagnosed, underdiagnosed, and overdiagnosed,[27] and caregivers may lie or exist unaware of the mechanism of injury.[13] Normally, in that location are no externally visible signs of the condition.[13] Examination by an experienced ophthalmologist is often critical in diagnosing shaken baby syndrome, as particular forms of ocular bleeding take been claimed to be quite characteristic, although the scientific basis for such claims seems weak at all-time.[28] Magnetic resonance imaging may also depict retinal hemorrhaging;[29] this may occasionally exist useful if an ophthalmologist examination is delayed or unavailable.[ citation needed ] Conditions that are ofttimes excluded past clinicians include hydrocephalus, sudden infant decease syndrome (SIDS), seizure disorders, and infectious or congenital diseases like meningitis and metabolic disorders.[30] [31] CT scanning and magnetic resonance imaging are used to diagnose the condition.[13] Atmospheric condition that may accompany SBS include os fractures, injury to the cervical spine (in the cervix), retinal bleeding, cerebral drain or atrophy, hydrocephalus, and papilledema (swelling of the optic disc).[fourteen]

The terms non-accidental head injury or inflicted traumatic brain injury accept been suggested instead of "abusive head trauma" or "SBS".[32]

Classification [edit]

The term abusive head trauma is preferred equally it better represents the broader potential causes. Even so whatever information technology is referred to every bit, when there are no external signs of abuse or witnesses, there is no scientific discipline base for making a diagnosis of abuse based on internal bleeding injuries.[15]

The US Centers for Illness Control and Prevention identifies SBS equally "an injury to the skull or intracranial contents of an babe or young child (< 5 years of age) due to inflicted edgeless bear on and/or violent shaking".[33] In 2009, the American Academy of Pediatrics recommended the utilise of the term abusive head trauma to replace SBS, in part to differentiate injuries arising solely from shaking and injuries arising from shaking every bit well equally trauma to the caput.[34]

SBS was previously believed to present with constellation of findings (oft referred to as a "triad"): subdural hematoma; retinal bleeding; and encephalon swelling or encephalopathy – which has controversially been used to infer kid abuse acquired by violent shaking or traumatic shaking.[15] The diagnostic accuracy of the triad, linked to episodes of traumatic shaking is controversial with a 2016 systematic review finding limited scientific evidence associating the triad to episodes of traumatic shaking, and insufficient prove for using the triad to identify such episodes.[15] The connectedness is controversial in part post-obit cases where parents of children exhibiting the triad take, in addition to losing custody, been jailed or sentenced to death.[35]

The Crown Prosecution Service for England and Wales recommended in 2011 that the term shaken baby syndrome be avoided and the term non accidental caput injury (NAHI) exist used instead.[36]

Differential diagnosis [edit]

Vitamin C deficiency [edit]

Some authors have suggested that certain cases of suspected shaken baby syndrome may result from vitamin C deficiency.[37] [38] [39] This contested hypothesis is based upon a speculated marginal, virtually scorbutic condition or lack of essential nutrient(s) repletion and a potential elevated histamine level. However, symptoms consistent with increased histamine levels, such as low blood pressure and allergic symptoms, are non commonly associated with scurvy as clinically meaning vitamin C deficiency. A literature review of this hypothesis in the periodical Pediatrics International concluded the post-obit: "From the available information in the literature, concluded that in that location was no convincing show to conclude that vitamin C deficiency can be considered to exist a cause of shaken baby syndrome."[40]

The proponents of such hypotheses often question the capability of nutrient tissue levels, specially vitamin C,[41] [42] for those children currently or recently ill, bacterial infections, those with higher individual requirements, those suffering from environmental challenges (e.g. allergies), and perhaps transient vaccination-related stresses.[43] At the time of this writing, infantile scurvy in the United States is practically nonexistent.[44] No cases of scurvy mimicking SBS or sudden baby decease syndrome have been reported, and scurvy typically occurs afterwards in infancy, rarely causes death or intracranial bleeding, and is accompanied by other changes of the bones and skin and invariably an unusually scarce dietary history.[45] [46]

In ane study vaccination was shown not associated with retinal hemorrhages.[47]

Gestational bug [edit]

Gestational problems affecting both mother and fetus, the birthing process, prematurity and nutritional deficits can advance skeletal and hemorrhagic pathologies that can also mimic SBS, fifty-fifty before nascence.[48] [49] [50] [51] [ verification needed ]

Prevention [edit]

Interventions by neonatal nurses including giving parents information almost calumniating head trauma, normal infant crying and reasons for crying, teaching how to calm an infant, and how to cope if the infant was inconsolable may reduce rates of SBS.[52]

Treatment [edit]

Treatment involves monitoring intracranial pressure level (the pressure level within the skull), draining fluid from the cerebral ventricles, and, if an intracranial hematoma is nowadays, draining the claret collection.[14]

Prognosis [edit]

Prognosis depends on severity and can range from total recovery to severe inability to decease when the injury is severe.[14] One third of these patients dice, ane third survives with a major neurological status, and only one third survives in good condition; therefore shaken baby syndrome puts children at risk of long-term inability.[53] [54] The most frequent neurological impairments are learning disabilities, seizure disorders, speech disabilities, hydrocephalus, cognitive palsy, and visual disorders.[30]

Epidemiology [edit]

Small children are at particularly high risk for the abuse that causes SBS given the large difference in size betwixt the small kid and an adult.[13] SBS usually occurs in children under the age of two but may occur in those up to age v.[13]

History [edit]

In 1971, Norman Guthkelch proposed that whiplash injury acquired subdural bleeding in infants by tearing the veins in the subdural infinite.[55] [56] The term "whiplash shaken baby syndrome" was introduced by Dr. John Caffey, a pediatric radiologist, in 1973,[57] describing a set of symptoms establish with picayune or no external evidence of head trauma, including retinal bleeds and intracranial bleeds with subdural or subarachnoid bleeding or both.[11] Development of computed tomography and magnetic resonance imaging techniques in the 1970s and 1980s avant-garde the ability to diagnose the syndrome.[13]

Legal issues [edit]

The President'south Quango of Advisers on Science and Engineering (PCAST) noted in its September 2016 report that there are concerns regarding the scientific validity of forensic evidence of abusive head trauma that "require urgent attending".[58] Similarly, the Maguire model, suggested in 2011 as a potential statistical model for determining the probability that a child's trauma was caused past abuse, has been questioned.[59] A proposed clinical prediction dominion with loftier sensitivity and low specificity, to rule out Abusive Head Trauma, has been published.[60]

In July 2005, the Court of Appeals in the United Kingdom heard four appeals of SBS convictions: one case was dropped, the sentence was reduced for i, and two convictions were upheld.[61] The court establish that the classic triad of retinal bleeding, subdural hematoma, and acute encephalopathy are not 100% diagnostic of SBS and that clinical history is likewise important. In the Court'south ruling, they upheld the clinical concept of SBS merely dismissed one case and reduced some other from murder to manslaughter.[61] In their words: "Whilst a stiff pointer to NAHI [not-accidental head injury] on its own we practise not think it possible to discover that it must automatically and necessarily lead to a diagnosis of NAHI. All the circumstances, including the clinical picture, must be taken into account."[62]

The courtroom invalidated the "unified hypothesis", proposed by British dr. J. F. Geddes and colleagues, equally an alternative machinery for the subdural and retinal bleeding plant in suspected cases of SBS.[61] The unified hypothesis proposed that the bleeding was not caused by shearing of subdural and retinal veins but rather by cognitive hypoxia, increased intracranial pressure, and increased pressure in the brain's blood vessels.[61] The court reported that "the unified hypothesis [could] no longer be regarded equally a credible or alternative cause of the triad of injuries": subdural bleeding, retinal bleeding and encephalopathy due to hypoxemia (low claret oxygen) institute in suspected SBS.[61]

On Jan 31, 2008, the Wisconsin Court of Appeals granted Audrey A. Edmunds a new trial based on "competing credible medical opinions in determining whether in that location is a reasonable doubt as to Edmunds's guilt." Specifically, the appeals court institute that "Edmunds presented testify that was not discovered until later on her confidence, in the form of skilful medical testimony, that a significant and legitimate argue in the medical community has developed in the past ten years over whether infants can be fatally injured through shaking alone, whether an babe may suffer head trauma and nevertheless experience a significant lucid interval prior to expiry, and whether other causes may mimic the symptoms traditionally viewed every bit indicating shaken infant or shaken impact syndrome."[63] [64]

In 2012, A. Norman Guthkelch, the neurosurgeon often credited with "discovering" the diagnosis of SBS,[65] published an article "after 40 years of consideration," which is harshly critical of shaken baby prosecutions based solely on the triad of injuries.[66] Once more, in 2012, Dr. Guthkelch stated in an interview, "I remember we demand to go dorsum to the drawing board and make a more thorough assessment of these fatal cases, and I am going to bet . . . that nosotros are going to find in every - or at least the large majority of cases, the child had another astringent disease of some sort which was missed until likewise belatedly."[67] Furthermore, in 2015, Dr. Guthkelch went so far every bit to say, "I was against defining this matter equally a syndrome in the offset instance. To become on and say every time you see it, it's a crime...It became an easy way to go into jail."[68]

On the other hand, Teri Covington, who runs the National Center for Kid Death Review Policy and Practice, worries that such caution has led to a growing number of cases of child abuse in which the abuser is not punished.[65]

In March 2016, Waney Squier, a paediatric neuropathologist who has served equally an expert witness in many shaken baby trials, was struck off the medical register for misconduct.[69] Soon after her confidence, Dr. Squier was given the "champion of justice" award by the International Innocence Network for her efforts to costless those wrongfully convicted of shaken baby syndrome.[70]

Squier denied the allegations and appealed the decision to strike her off the medical register.[71] Equally her case was heard by the Loftier Court of England and Wales in October 2016, an open letter to the British Medical Journal questioning the decision to strike off Dr. Squier, was signed past 350 doctors, scientists, and attorneys.[72] On 3 November 2016, the court published a judgment which concluded that "the determination of the MPT is in many significant respects flawed".[73] The approximate institute that she had committed serious professional misconduct but was non quack. She was reinstated to the medical register but prohibited from giving expert evidence in court for the next iii years.[74]

The Louise Woodward example relied on the "shaken babe syndrome".

References [edit]

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External links [edit]

  • Centers for Illness Control and Prevention - Abusive caput trauma

woodalver1998.blogspot.com

Source: https://en.wikipedia.org/wiki/Shaken_baby_syndrome

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