Correspondence
The “Shaken-Baby Syndrome”
N Engl J Med 1998; 339:1329-1330October 29, 1998
- Article
To the Editor:
Duhaime et al. (June 18 issue)1 skirt the fact that there is no objective evidence that the entity called the “shaken-baby syndrome” exists. This is not just my opinion as a forensic pathologist with 30 years of experience but also the opinion of many of my colleagues, and if one reads the article by Duhaime et al. carefully, it is their opinion by implication. In the second paragraph, they note that “it is the sudden deceleration associated with the forceful striking of the head against a surface that is responsible for most, if not all, severe, inflicted brain injuries.” That it is widely recognized that the head injuries in this syndrome are due to impact and not shaking is reflected by the use of the term “shaking–impact syndrome.”
If one has proof of impact, why hypothesize that the child was shaken? There are no lesions to prove the child was shaken. You cannot base such a judgment on self-serving statements by the person who inflicted the injuries. Adding the word “impact” to the term “shaken-baby syndrome” does not prove the existence of the entity or justify the retention of this term. Let us simply drop both the term and the concept of the shaken baby and face the fact that the injuries are due to the impact of being slammed, swung, or thrown against a hard surface, such as a wall, the floor, or furniture.
1 ReferencesVincent J.M. Di Maio, M.D.
Bexar County Forensic Science Center, San Antonio, TX 78229-45651
Duhaime A-C ,Christian CW ,Rorke LB ,Zimmerman RA . Nonaccidental head injury in infants -- the “shaken-baby syndrome.“ N Engl J Med 1998;338:1822-1829
Full Text | Web of Science | Medline
To the Editor:
The presenting symptoms of the shaken-baby syndrome, as described by Duhaime et al., bear a remarkable resemblance to another problem of infancy, known as an apparent life-threatening event.1 This term is used in the case of an infant, usually less than 12 months old, who is found in an unresponsive, apneic, cyanotic, or limp state but who recovers spontaneously or is successfully resuscitated, a situation that has led to the use of the term “near-miss sudden infant death syndrome.”2 Because of the similarity in the presentations of these two entities, and because the cause of an apparent life-threatening event remains unknown in many cases,1 we began considering the possibility that some apparent life-threatening events of unknown cause may actually be occult cases of the shaken-baby syndrome.
We began performing funduscopic examinations of dilated eyes to look for retinal hemorrhages in infants admitted to our hospital after an apparent life-threatening event of unknown cause. Retinal hemorrhage is one of the key findings associated with the shaken-baby syndrome. In 1995, approximately 75 infants were admitted to the Children's Hospital at Westchester Medical Center for evaluation of an apparent life-threatening event, and 5 infants under one year of age were discharged with a final diagnosis of the shaken-baby syndrome. The initial history and physical examination on admission revealed no apparent cause, but examination of dilated eyes in four of the infants revealed retinal hemorrhages. Subsequent imaging studies of the head demonstrated subdural hemorrhages in all four cases. In the fifth patient, a computed tomographic scan of the head, obtained because of focal seizures, revealed subdural hemorrhages. In this patient, the retinal examination showed no abnormalities, but the skeletal survey showed evidence of an unexplained, healing femoral fracture, a finding that strongly suggested the diagnosis of child abuse.
Most clinicians do not usually consider the shaken-baby syndrome in the differential diagnosis when evaluating an infant who appears to be well for a recent apparent life-threatening event. If there is a link between these two entities, physicians will need to consider the shaken-baby syndrome in evaluating infants with an apparent life-threatening event of unknown cause.
2 ReferencesRobin L. Altman, M.D.
Martin L. Kutscher, M.D.
Donald A. Brand, Ph.D.
New York Medical College, Valhalla, NY 105951
Kahn A ,Montauk L ,Blum D . Diagnostic categories in infants referred for an acute event suggesting near-miss SIDS. Eur J Pediatr 1987;146:458-460
CrossRef | Web of Science | Medline2
Dunne K ,Matthews T . Near-miss sudden infant death syndrome: clinical findings and management. Pediatrics 1987;79:889-893
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Di Maio makes an important point, with which we agree: the evidence of an impact is clearly more objectively verifiable than the evidence of shaking, which is based largely on the clinical history. As Dr. Di Maio notes, many children with this syndrome have histories and findings consistent with an impact alone. Although the terminology and mechanisms may be debated, the entity that has been known as the shaken-baby syndrome clearly exists as a useful diagnostic paradigm. Many clinicians, pathologists, and child advocates are convinced that shaking is a part of this syndrome because of their collective experience with histories and confessions in which shaking was described. The possible causative relation between shaking and findings that include retinal hemorrhages, skeletal injuries, and trauma to the cervical spinal cord resulting in respiratory compromise require further research.
Ideally, the terminology for inflicted injuries would be independent of the purported mechanisms, since they remain controversial and inherently difficult to study. Our use of the term “shaking–impact syndrome” is meant to be inclusive of impact-related deceleration until more suitable terminology evolves and our understanding of mechanisms improves.
Dr. Altman and colleagues point out an association between apparent life-threatening events and inflicted head injury. We agree that some infants with life-threatening events are unidentified victims of child abuse. Early detection of the shaking–impact syndrome is improved by routine ophthalmologic examination as well as careful attention when there is blood in the cerebrospinal fluid. The possibility of child abuse needs to be included in the differential diagnosis for all infants with altered mental status, subtle neurologic signs, and unexplained apnea or vomiting.
Ann-Christine Duhaime, M.D.
Cindy W. Christian, M.D.
Lucy B. Rorke, M.D.
Children's Hospital of Philadelphia, Philadelphia, PA 19104- Citing Articles (4)
Citing Articles
1
Gil Binenbaum, Naureen Mirza-George, Cindy W. Christian, Brian J. Forbes. (2009) Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. Journal of American Association for Pediatric Ophthalmology and Strabismus 13:3, 268-272
CrossRef2
Brian J. Forbes, Matthew Cox, Cindy W. Christian. (2008) Retinal hemorrhages in patients with epidural hematomas. Journal of American Association for Pediatric Ophthalmology and Strabismus 12:2, 177-180
CrossRef3
Seema Shah, Ghazala Q Sharieff. (2007) An update on the approach to apparent life-threatening events. Current Opinion in Pediatrics 19:3, 288-294
CrossRef4
Celso Agner, Spencer G. Weig. (2005) Arterial dissection and stroke following child abuse: case report and review of the literature. Child's Nervous System 21:5, 416-420
CrossRef
