In the JournalsPerspective

Clinicians validate shaken baby syndrome, abusive head trauma as medical diagnoses

Shaken baby syndrome and abusive head trauma are acceptable medical diagnoses for child head trauma, according to multidisciplinary physician opinion.

“The truth is that this is a manufactured controversy — invented by a few authors, primarily so they can be used as expert witnesses,” Daniel Lindberg, MD, associated professor of emergency medicine and pediatrics at the University of Colorado School of Medicine, said in a press release. “Doctors who actually care for children are nearly unanimous in their agreement that shaking and abuse can clearly cause the findings that have been used to diagnose abusive head trauma.”

Daniel Lindberg, MD
Daniel Lindberg

In recent general periodical literature and a U.S. Supreme Court case, “shaken baby syndrome” (SBS) and “abusive head trauma” (AHT) had been questioned as valid reasons for subdural hematoma, coma or death in injured children. Lindberg, along with Sandeep K. Narang, MD, JD, of Lurie Children’s Hospital, and colleagues conducted an email survey between March and October 2015 to assess clinicians’ acceptability of shaking and other mechanisms of injury as medical diagnoses for severe retinal hemorrhages, subdural hematoma, coma or death. The survey was sent electronically to 1,378 physicians — including those in emergency medicine, critical care, pediatric neurosurgery and child abuse pediatrics — at 10 leading children’s hospitals nationwide who frequently saw and evaluated children with head trauma.

Among the 628 clinicians whose responses were included, 96.7% remarked that SBS (n = 88%) and AHT (n = 93%) were valid medical diagnoses. They indicated that shaking a child with or without impact would likely result in subdural hematoma, severe retinal hemorrhages, coma or death. Of those who responded that SBS or AHT was an acceptable diagnosis, 89.7% reported that scientific literature and their own clinical experiences helped form the opinion, 8% remarked their own clinical experiences informed them, and 1.8% used only scientific literature to form their opinion.

“It is critically important to dispel the myth that there is controversy about the harm resulting from abusive head trauma and shaken baby syndrome,” Lindberg said in the release. “The life and health of children are at stake here. There should be no confusion that these diagnoses are widely recognized and accepted among a range of physicians who provide care to these children.” – by Kate Sherrer

Disclosure: The researchers report no relevant financial disclosures.

Shaken baby syndrome and abusive head trauma are acceptable medical diagnoses for child head trauma, according to multidisciplinary physician opinion.

“The truth is that this is a manufactured controversy — invented by a few authors, primarily so they can be used as expert witnesses,” Daniel Lindberg, MD, associated professor of emergency medicine and pediatrics at the University of Colorado School of Medicine, said in a press release. “Doctors who actually care for children are nearly unanimous in their agreement that shaking and abuse can clearly cause the findings that have been used to diagnose abusive head trauma.”

Daniel Lindberg, MD
Daniel Lindberg

In recent general periodical literature and a U.S. Supreme Court case, “shaken baby syndrome” (SBS) and “abusive head trauma” (AHT) had been questioned as valid reasons for subdural hematoma, coma or death in injured children. Lindberg, along with Sandeep K. Narang, MD, JD, of Lurie Children’s Hospital, and colleagues conducted an email survey between March and October 2015 to assess clinicians’ acceptability of shaking and other mechanisms of injury as medical diagnoses for severe retinal hemorrhages, subdural hematoma, coma or death. The survey was sent electronically to 1,378 physicians — including those in emergency medicine, critical care, pediatric neurosurgery and child abuse pediatrics — at 10 leading children’s hospitals nationwide who frequently saw and evaluated children with head trauma.

Among the 628 clinicians whose responses were included, 96.7% remarked that SBS (n = 88%) and AHT (n = 93%) were valid medical diagnoses. They indicated that shaking a child with or without impact would likely result in subdural hematoma, severe retinal hemorrhages, coma or death. Of those who responded that SBS or AHT was an acceptable diagnosis, 89.7% reported that scientific literature and their own clinical experiences helped form the opinion, 8% remarked their own clinical experiences informed them, and 1.8% used only scientific literature to form their opinion.

“It is critically important to dispel the myth that there is controversy about the harm resulting from abusive head trauma and shaken baby syndrome,” Lindberg said in the release. “The life and health of children are at stake here. There should be no confusion that these diagnoses are widely recognized and accepted among a range of physicians who provide care to these children.” – by Kate Sherrer

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Lori D. Frasier

    Lori D. Frasier

    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.