The study by Narang and colleagues was designed to answer a common legal challenge in cases of shaken baby syndrome (SBS) or abusive head trauma (AHT). That challenge presents in the form of either a legal motion for a Frye or Daubert hearing and seeks to inform the court as to whether a scientific theory is generally accepted.
Defense witnesses often raise the challenge that neither SBS nor AHT are generally accepted by the medical community, whether resulting from shaking, or shaking with impact. If the court rules that there is no general acceptance that shaking or shaking with impact, causes subdural hematomas, retinal hemorrhages or brain injuries, the prosecution’s expert will be disallowed from using AHT or SBS as an explanation for the child’s injuries. The prosecution is left with the almost impossible task of describing injuries and mechanisms without being able to use terms such as shaking or AHT.
The study is important because it serves to support a legal standard of “general acceptance.” AHT/SBS are overwhelmingly accepted by the pediatric medical professionals. For physicians who evaluate pediatric head trauma and rarely find themselves in a courtroom defending their diagnosis of AHT/SBS, the paper may seem unnecessary. The majority of specialty training programs in pediatrics and associated trauma services continue to evaluate, diagnose, and treat such patients. There has been no compelling, well-done studies that have caused a change in the medical acceptance of this diagnosis. However, for physicians who regularly testify in legal proceedings, the paper is important and pertinent. It is those who provide testimony for the defense that have perpetuated the false concept that AHT/SBS is no longer a generally accepted concept in the medical community.
AHT is a leading cause of morbidity and mortality due to child abuse and affects the youngest and smallest patients. Epidemiologic studies suggest a prevalence of around 20/100,000 children are diagnosed with AHT in the first year of life. Mortality is high in the acute period, around 25% with 50% or more of survivors suffering lifelong disabilities. Pediatricians, PCPs and ED physicians should consider that an infant or young child has suffered a possible head injury if they present with neurological symptoms, vomiting, enlarging head circumference or unexplained bruising.
Up to 30% of AHT victims are missed on initial presentation, because of lack of accurate history of trauma, or failure of providers to consider abuse, and pursue the appropriate assessment. A non-contrast head CT in concerning cases is often the first line of assessment and is preferable to a cranial ultrasound. A skeletal survey, according to ACR standards, may also be considered. Dilated funduscopic evaluation only, without neuroimaging, as a screening tool for AHT should be discouraged and will miss up to 25% of children who have suffered AHT. Consultation with a child abuse pediatrician or other medical professional who has training and experience in the evaluation and diagnosis of AHT should be weighed when this diagnosis is considered; if intracranial injuries are suspected or revealed on CT scan transfer to a pediatric trauma center is mandatory.
Lori D. Frasier, MD
Chief, Division of Child Abuse Pediatrics
Penn State Hershey Children’s Hospital
Chairperson, National Center on Shaken Baby Syndrome
Disclosures: Frasier reported no relevant financial disclosures.