abusive head trauma: an overview and review of the

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Abusive Head Trauma: An Overview and Review of the

Literature

Learner Course Guide

DOH Mandatory Training FY 2013-2014


Abusive Head Trauma


DOH CMS Training

FY 2015-2016

Abusive Head Trauma - Learner Course Guide

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Table of Contents

SLIDE NUMBER - TITLE PAGE

Slide 1 – Abusive Head Trauma: An Overview Review of the Literature 1

Slide 2 – Abusive Head Trauma – Objectives 1

Slide 3 – Abusive Head Trauma – Why Does It Happen? 2

Slide 4 – Abusive Head Trauma - Perpetrators 3

Slide 5 – Head Injuries – Anatomy of the Skull 4

Slide 6 – Abusive Head Trauma – Medical Terms 4

Slide 7 – Meninges and Cerebrospinal Fluid 6

Slide 8 – Abusive Head Trauma – Factors Contributing to Brain Damage and Death 7

Slide 9 – Subdural Hematoma – Common Finding in Head-Injured Children 8

Slide 10 – Non-Accidental Head Trauma – Where Exactly Is the Subdural Space? 8


Slide 12 – Meninges and Cerebrospinal Fluid 9


Slide 14 – Abusive Head Trauma – Possible Associated Findings 9

Slide 15 – Retinal Hemorrhages: Other Causes – A Variety of Readily Apparent Conditions

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Slide 16 – Can CPR Cause Retinal Hemorrhages? – Very Rarely and They’re Different 11

Slide 17 – Coagulopathy in Abusive Head Trauma – The Result, Not the Cause of the Injury

12

Slide 18 – Bleeding Studies of ICH – Different from Those to Evaluate Bruising 12

Slide 19 – Abusive Head Trauma – A Range of Outcomes 13

Slide 20 – Abusive Head Trauma – Late Consequences 14

Slide 21 – Abusive Head Trauma – A Bad Outcome 14

Slide 22– Abusive Head Trauma – A Bad Outcome 15

Slide 23 – The Whiplash Shaken Infant Syndrome – The Original Description 15

Slide 24 – Some Claim It’s Impossible to Shake a Baby to Death 16

Slide 25 – Duhaime’s Biomechanics Study – Questionable Assumptions 17

Slide 26 – Biomechanical Studies – Attempts to measure the Forces Involved 18

Slide 27 – Abusive Head Trauma – Is Impact Necessary 18

Slide 28 – Skull fractures: Complex Fractures Indicate Great Force 18

Slide 29 – Physical Evidence of Impact Trauma – Sometimes Obvious 19

Slide 30 – Physical Evidence of Impact Trauma – Sometimes Less Obvious 19

Slide 31 – Physical Evidence of Impact Trauma – Sometime Subtle 19


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Slide 32 – Physical Evidence of Impact Trauma – Sometimes Hidden 20

Slide 33 – Physical Evidence of Impact Trauma – Sometimes Hidden 20

Slide 34 – Physical Evidence of Impact Trauma – Sometimes Absent 20

Slide 35 – Yes, It Is Possible to Shake a Baby to Death 21

Slide 36 – Perpetrator Confessions to Shaking – Some But Not All Also Impact 21

Slide 37 – Shaking Injuries – Is There and Upper Age Limit? 22

Slide 38 – Abusive Head Trauma in Infants and Children – Recent American Academy of Pediatrics Statement

23

Slide 39 – Dating Subdural hematomas – Age Can Not Be Reliably Determined 24

Slide 40 – Mixed-Density Subdurals – Not Necessarily Different Ages 25

Slide 41 – Fatally injured Children – They Don’t Behave Normally 25

Slide 42 – The Classic Abusive Head Trauma – Multiple Injuries, Near Death 26

Slide 43 – The less Classic Abusive Head Trauma – Infants with Less Severe Injury Harder to Recognize

27

Slide 44 – Shaken baby Syndrome – Missed Cases 27

Slide 45 – Time of Onset of Head Injury Symptoms – Sometimes Not Possible to Say 28

Slide 46 – Injuries Resulting from Short Vertical Falls – Rarely Life-Threatening 28



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Slide 50 – Injuries Resulting from falling Down Stairs – Rarely Life-Threatening 29

Slide 51 – Falls in Infant Walkers – Real Potential for Serious Injury 30

Slide 52 - Serious Head injuries – The Short fall defense 30

Slide 53 – The Leading Current Proponent 31

Slide 54 – Plunkett’s case 5 Chart 31

Slide 55 – Plunkett’s Short Fall Defense – Characteristics of Cited Cases 32

Slide 56 – Actual Risk of Death from Short Falls – Best Estimates 33

Slide 57 – Epidural Hematomas – The Exception to the Rules 33

Slide 58 - Epidural Hematomas – The Exception to the Rules 33

Slide 59 – The “Au Pair Case” – Flawed Defense Offered 34

Slide 60 – Re-Bleeding – The Reality 34

Slide 61 – “Temporary Brittle Bone Disease” – Paterson Now Relates It to Subdurals 35

Slide 62 – “The Geddes Hypothesis” – Hypoxia as Cause of SDH and RH 36

Slide 63 – Geddes Disavows Her Hypothesis – Says It Was Not Meant to Be Taken As fact

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Slide 64 – Overcoming False Defenses – A Valuable Resource 37

Slide 65 – Abusive head Trauma - Summary 38

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Slide 1

Abusive Head Trauma:

An Overview and

Review of the Literature

Bruce J. McIntosh, M.D.Co-Interim Statewide Medical Director

Child Protection Team System

Hello, I'm Dr. Bruce McIntosh. I am

Co-Interim Statewide Medical Director

of Florida's Child Protection Team

System. I'm here to talk with you about

abusive head trauma. This is one of the

most serious, and often fatal forms of

child abuse. A form of child abuse that

we are, to a very great extent, trying to

prevent when we intervene in cases of

children who have bruises, bumps and

less severe forms of abuse.

Slide 2

Abusive Head TraumaObjectives

Review the basic anatomy of the skull, brain and supporting membranes

Review the mechanisms of injury and clinical findings in Abusive Head Trauma

Discuss the reasons why the term “Abusive Head Trauma” is replacing the term “Shaken Baby Syndrome”

Discuss the scientific basis on which the diagnosis of Abusive Head Trauma can be made, issues of timing addresse, and exceptions to the rules

Review flawed literature and arguments often proffered by defense experts to explain away abusive head injuries

What we're going to be talking about

today is working our way through a

review of the basic anatomy of the

skull, the brain, and the membranes

that support them and the blood vessels

that supply them. We're going to

review the mechanism of injury and

clinical findings that we see in abusive

head trauma. We'll talk about why the

term "abusive head trauma" is

replacing the term "shaken baby

syndrome" which was around for many

years. And we'll talk about the

scientific basis on which the diagnosis

of abusive head trauma can be made,

address the issue of timing and

exceptions to the general rules about

abusive head trauma. We'll also talk

about the flawed literature often offered

by defense and family attorneys as they

tried to explain away abusive injuries

because it's important for us to know

what that literature is and who the

people are who make those arguments

so that we can help our colleagues and

children's legal services in the state

attorney's office counter those

arguments when they arise.

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Slide 3 Abusive Head TraumaWhy Does It Happen?

Now, abusive head trauma. Why does

it happen? Just pause for a minute and

think, why in particular---let's talk

about young babies, why does abusive

head trauma happen? What do you

think? Well many of you are saying

crying and that is the most common

reason in infants. You have a baby

who's crying and the caretaker's trying

to take care of the baby, trying to make

the baby happy trying to figure out

what the baby wants but the baby

continues to cry. As they continue to

work with the baby and the baby

continues to cry and cry and cry until

finally there's really nothing in that

caretaker's world except the crying

baby who has been going on now for

perhaps an hour or two, perhaps in the

middle of the afternoon, perhaps at

night and just in anger and frustration

with this crying baby they lose their

temper and either violently shake the

baby or violently slam the baby, or

shake and slam the baby to shut it up.

It's important to notice that it's not the

caretaker's intent to kill the baby or put

the baby in the intensive care unit; it's

their intent to shut the baby up, to make

the baby stop crying. But they do

intend to shake it, they do intend to

slam it, and they are therefore

responsible for the effects that that

damaging behavior has on the baby. So

typically it's crying in younger babies.

In older kids, once they start creeping,

cruising, crawling about nine months it

may be because they're getting into

things, breaking things, making a mess.

As they approach two it may be

because of toilet training trouble; that's

a common reason for abusive head

trauma in children whose parents are

trying to toilet train them. Older kids, it

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may be because they're talking back or

not doing their chores. There are

different things that make kids get

abused at different ages, but the

commonality is an adult who can't

control their angry impulses towards

the child.

Slide 4

Father of Child

Mother's Boyfriend

Female Baby-Sitter

Mother

Other

Step-Father

Male Baby-Sitter

Abusive Head TraumaPerpetrators – Can Be “Nice People”

Starling SP et al. Abusive Head Trauma: The

Relationship of Perpetrators to Their Victims. Pediatrics

95:259, 1995.

So who does it? As you can see from

this pie graph, the child's natural father

is the most common perpetrator with

mother's boyfriend being number two. I

always say that the most dangerous

night of a baby's life is the first night he

or she spends with mother's new

boyfriend. You can say stepfathers and

male baby sitters also enter into the

picture. Women can do it. You'll notice

that the female babysitter in the gray

pie piece is the natural mother. Women

can do it and you can find studies in

which women actually are

predominate. You may have people

arguing that women don't have the

upper body strength to do it. Yes, yes

they do. Women can definitely inflict

abusive head trauma. So, typically

because of crying, more commonly

men do it. But women are certainly

capable of doing it. They can also be

nice people. We very commonly, when

women work with these cases will

encounter DCF law enforcement

nursing staff will say, "These are such

nice people. They are at the baby’s

bedside the whole time. There's no way

they could have done this." What we

have to remember and what we have to

help educate our community partners

about is that the way they are in the

hospital when they are genuinely

concerned about their injured baby is

very different from what it was at two

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o'clock in the morning when the baby

had been crying for two hours. When

they were sleep-deprived, tired, angry,

and frustrated, things happen in the

middle of the night that would not

happen in the light of day with other

company around. So we have to accept

the fact that otherwise nice people do

lose control when they're angry and

frustrated.

Slide 5 Head InjuriesAnatomy of the Skull

Now, the nature of the baby's skull is a

little different from the adult skull. The

skull of the adult is rigid boned. The

sutures or growth lines are fixed and

firm so there's very little flexibility in

the adult skull. It's also thicker boned.

The baby's skull is more flexible.

People use the term, "plastic". That

doesn't mean it's literally plastic, just

that it's very flexible in the sutures, that

the connections between the different

bones in the skull are very soft and

flexible so that a baby's skull can be

kind of partially crushed and bounce

back. The underlying brain would be

damaged by that, but you might not

always get a skull fracture even with

the significant blow to a baby's head.

The bone may be thinner, but it's more

flexible. Now, to go over some medical

terms that you will see in medical

reports.

Slide 6 Abusive Head TraumaMedical Terms

Contusion = Bruise (Bleeding into

soft tissues)

Cerebral Contusion = Bruise of

the brain

Cephalhematoma = Collection of

blood under the scalp (outside

the skull)

Subdural Hematoma = Blood

from torn veins over the surface

of the brain (inside the skull)

Epidural Hematoma = Blood from

a torn artery over the surface of

the brain (inside the skull)

Contusion is another fancy word for

bruise. And when we talked about

bruises, bruises are the result of

bleeding into the soft tissues under the

skin. So a contusion is a bruise like we

see in this child's forehead. You can

also have contusions of the brain, what

we call cerebral contusions. You see

the white mark there just inside the

skull is an area bleeding into the

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substance of the brain, a cerebral

contusion. A Cephalhematoma is a

collection of blood on the outside of the

skull under the scalp. This is a big lump

that appears on a child's head with a

skull fracture. You may or not be able

to appreciate under that swollen area

there where the red arrow is. There's

also a thin line through the skull. That's

the skull fracture. We often see these in

toddlers who may go into the next

room, climb up on the bed or couch,

fall off, fracture their skull. That's a

situation where family may not know

exactly what happened because it

happened in another room. So they can

get the skull fracture falling off a bed

or a couch, but they don't get a brain

injury from that. Subdural blood is a

kind of blood that we see in babies who

are victims of abusive head trauma. It

can happen in motor vehicle accidents

and falls from great heights, yes, but

we very often see it in child abuse

cases. Here we have white blood at the

back and we have a darker blood up in

the front. We'll talk more about what

can be said about that later. But this is

blood that comes from torn veins inside

the skull. We will talk about how those

veins get torn in a moment. One other

term, well, okay, first we have another

example here of subdural hematomas

where we have blood layered out over

the surface of the brain. And do notice

that it is layered out. Then the Epidural

hematoma is a lens shaped collection of

blood inside the skull that comes from

torn arteries. Epidural hematomas,

which we will talk about that in more

detail later, are a very different animal.

They look very different, they're not

going to be confused with the kind of

subdurals we see with child abuse.

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They are often Epidural hematomas are

often the result of accidents.

Slide 7 Meninges and Cerebrospinal Fluid

Gray H. Anatomy of the Human Body. Lea & Feiger, Philadelphia,

1966, page 887.

So here we have a picture the meninges

and spinal fluid. And what we have

here....what we had, the skull would be

out here, the black part here is the dura,

a tough membrane that covers the

surface of the brain. Beneath the dura is

the subarachnoid space filled with

spinal fluid and these are veins that go

from the inside of the skull in the dura

across to the brain. They carry blood

from the brain back to the veins and

down to the general circulation. These

veins are called bridging veins because

they bridge the gap between the inner

surface of the skull and the surface of

the brain. So they're called bridging

veins. Now, when an infant is violently

shaken or slammed, the brain is able to

move back and forth a little bit within

the skull. So as the brain moves back

and forth in the spinal fluid, these

bridging veins are stretched and torn

leading to bleeding the subdural

hematoma that we've been talking

about. Now, if they actually tore here,

the blood would go in spinal fluid and

you would have what we call a

subarachnoid hemorrhage. They

actually tear up here within the dura

and we will talk more about that in a

moment. Thing to emphasize though

about this is that a subdural hematomas

are easy to see, so they're the marker

for the kind of trauma that the baby's

head has been subjected to. But they

are not really why the baby gets quiet,

they're not why the baby stops crying,

they're not why the baby lapses into a

comma, goes to sleep, or why the

baby's badly damaged. The reason for

that is what goes on down in the

substance of the brain. Down in the

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substance of the brain....down here in

the substance of the brain as the brain

moves around, nerve fibers are

stretched and torn. A process that we

call diffuse axonal injury. It's that

damage to the nerves fibers in the

substance of the brain that make the

baby lose consciousness, stop crying,

and sometimes even stop breathing. So

we can see the blood on the CT scan

easily. That tells us that the baby had a

head trauma, but the thing that makes

him go quiet is what goes on down here

in the substance of the brain with the

nerve fibers.

Slide 8 Abusive Head TraumaFactors Contributing to Brain Damage and Death

Impact trauma

Hemorrhage

Diffuse axonal injury

Lack of oxygen

Cerebral edema

So when we look at what goes on we

often have impact trauma from the

baby being slammed, we have

bleeding, we have the diffuse axonal

injury that we talked about, the nerve

fibers being stretched and torn. These

things often make the baby stop

breathing which results in a lack of

oxygen in the blood going to the brain.

And the damaged brain then swells.

And as the brain swells inside the skull,

that makes high pressure inside the

skull. So it is much harder for the heart

to pump blood up to the brain so then

there's even less circulation and less

oxygen getting to the brain creating a

vicious cycle that can result ultimately

in serious brain injury or even death.

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Slide 9 Subdural HematomaCommon Finding in Head-Injured Children

This shows what a subdural hematoma

looks like. And again, we have ...we

have a subdural hematoma here. And

on this line drawing, we can see that

this is where it is. Out here, we have

scalp, here we have skull, and this is

the subdural hematoma within the

substance overlying the substance of

the brain. Now, this is an autopsy

picture. Just be warned, this is what a

subdural hematoma looks like. You can

see that big blood clot lying over the

surface of the brain.

Slide 10 Non-Accidental Head TraumaWhere Exactly Is the Subdural Space?

Haines DE. On the Question of a

Subdural Space. The Anatomical

Record 230:3-21, 1991.

Subarachnoid Space

Now, I mentioned earlier that if the

bridging vessels were torn there in the

subarachnoid space, you would have

blood spreading all over the surface of

the brain and the spinal fluid. As it

happens, there is a very weak cell layer.

This whole thing is Dura. We have the

skull out here. This is dura, this is a

subarachnoid space with a spinal fluid

is and there is a weak cell layer here, so

that when the bridging veins break, this

is the layer in which they break, the

blood then dissects along that cell layer

in it. That's why it stays in a thin layer

over the surface of the brain. It's

contained within the dura. So by

convention, we call them subdurals.

They're actually interim dura or within

the dura.

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Impact trauma

Hemorrhage


Lack of oxygen

Cerebral edema

This is a picture that shows a torn nerve

fiber. You can appreciate that long

curvy thing in the middle there. It's a

never fiber that's been broken by being

stretched and torn as the brain rattled

around within the skull. That's the kind

of thing that makes the baby go quiet

and maybe stop breathing.

Slide 12 Meninges and Cerebrospinal Fluid

Gray H. Anatomy of the Human Body. Lea & Feiger, Philadelphia,

1966, page 887.

And that's the area again down low on

the surface the brain where these nerve

fibers are torn resulting in the loss of

consciousness. The abrupt loss of

consciousness, change in level of

consciousness that results immediately

after a baby has been subjected to

violent head trauma.


Impact trauma

Hemorrhage


Lack of oxygen

Cerebral edema

So these are the things that all work

together to create the spectrum of

abusive head trauma that we see:

impact, bleeding, nerve damage, lack

of oxygen, and brain swelling.

Slide 14 Abusive Head TraumaPossible Associated Findings

Retinal hemorrhages

Posterior rib fractures

Metaphyseal chip fractures

Bruises on the chest or upper arms

Now, there are things that you may see

associated with abusive head trauma.

Not always, these are things you might

possibly see: retinal Hemorrhages,

posterior rib fractures, attached to your

chip fractures, and bruises on the chest

or arms. Just to address the bottom one

first, in the time I have been doing this,

I think I have maybe seen two or three

babies who had bruises on the arms and

chest. Defense attorneys would often

say, "Well gee, if he grabbed him and

shook him so hard that he caused brain

damage, surely that mostly bruises on

the arms and chest." Well, no, in fact it

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doesn't. You don't have to explain it,

it's simply an empiric observed fact.

We talked at another presentation on

fractures about the emphasis about the

importance of metaphyseal chip

fractures and posterior rib fractures. So

let's talk right now about retinal

hemorrhages. Retinal hemorrhages are

not specific for abusive head trauma.

They do occur in other circumstances.

They have occurred in a lot of newborn

babies. They typically go away, says

here ten days, can be two weeks maybe

as long as three weeks. But if you're

looking at a one-month-old with retinal

hemorrhages, they're not from birth.

Retinal hemorrhages cannot be dated.

Just as bruises on the skin cannot be

dated, Retinal hemorrhages cannot be

dated. You do see retinal hemorrhages

in other circumstances like motor

vehicle accidents, falls from great

heights, and so forth. They can also be

seen in kids who are in the intensive

care unit with high blood pressure and

other blood clotting problems and that

kind of thing. But otherwise, well

babies don't go to bed well and wake

up with retinal hemorrhages in a coma

without someone doing something bad

to their heads. So, if you don't have a

clear reason for retinal hemorrhages in

a baby with brain injury, it's going to

be child abuse.

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Slide 15 Retinal Hemorrhages: Other CausesA Variety of Readily Apparent Conditions

Occur in 20-49% of normal newborns, but usually resolve with in 10 days.

May occur in serious accidents resulting in head injury, e.g. automobile accidents and falls from great heights.

May result from severe high blood pressure, severe infections, blood clotting abnormalities and conditions causing inflammation of small blood vessels.

Eisenbrey, Arthur. Retinal Hemorrhages in the Battered Child.

Child’s Brain 5:40, 1979.

These are in the inner surface of the

eye, these are not ones that you're

going to see if you just look at the

baby. These require an ophthalmologist

to look into the eye with those of us

who are child abuse specialists also

look into the eyes, but we defer to the

ophthalmologist who gets photos and

get so much more detailed exam using

his specialized equipment than we can

get. So these retinal hemorrhages are

inside at the back of the eye.

Slide 16 Can CPR Cause Retinal Hemorrhages?Very Rarely, and They’re Different

Kanter evaluated 54 patients for

retinal hemorrhages following

CPR.

Nine patients were victims of

trauma, and 45 had no preceding

history of trauma.

Five of the nine victims of trauma

had retinal hemorrhages,

including 4 due to abuse.

Only one (2%) had retinal

hemorrhages following CPR for

non-traumatic events.

Kanter. Retinal Hemorrhages After CPR or Child Abuse. J Peds

108:430, 1986.

Now, it will often be claimed that the

baby choked on his formula and

stopped breathing, someone gave CPR,

and that's why they got retinal

hemorrhages. So people have looked at

the issue of whether or not CPR

cardiopulmonary resuscitation causes

retinal hemorrhages. Extremely rarely

and they are different. Several people

have looked at this and if you look at

large numbers of babies who have

undergone CPR for reasons other than

abuse, you'll find the occasional baby

had a few little hemorrhages back in

what we call the posterior pole in the

very back in the eye. Whereas the

retinal hemorrhages that we see and

abuse victims are more widespread and

extend out to what's called the “Ora

Serrata” out at the very edges of the

retina. So they're more severe, more

extreme, not just a few little ones in the

back. It's worth noting accidentally,

that retinal hemorrhages don't always

happen with abusive head trauma. You

can have abusive head trauma without

retinal hemorrhages, you can have

abusive head trauma with retinal

hemorrhaging in one eye, and not the

other. Seems strange, but it's an

observed fact.

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Slide 17 Coagulopathy in Abusive Head TraumaThe Result, Not the Cause, of the Injury

Tissue factors released from

damaged brain cells activate

the coagulation system and

can produce DIC

Mortality rate higher in those

with evidence of activated

coagulation

Presence of coagulopathy

(prolonged PT and PTT) in

infant with CNS hemorrhage

does not necessarily indicate a

preexisting abnormality

Hymel, KP et al. Pediatrics 99:371, 3 March 1997.

Now, babies with severe abusive head

trauma will often have blood clotting

problems. And it will often be claimed

by defense that the reason the baby

blend into his head was that his blood

doesn't clot properly. He has what we

call a coagulopathy or an abnormal

blood clotting mechanism. The fact is

that when you have severe brain

trauma, you develop a coagulopathy.

That is bits of brain tissue perhaps leak

into the blood stream or whatever, they

trigger the coagulation cascade and all

those things that normally help blood

clot kind of used up so that ultimately

they're all gone and then you start to

bleed. So that you can get prolonged

PT and PTT, those are blood clotting

studies in babies who had abusive head

trauma. But the abnormal blood

clotting study isn't what caused the

bleeding in the brain, the brain damage

is what caused the blood clotting

studies to be abnormal. This is an

important article to have available if

you might be dealing with that defense.

At this point in fact, let me pause and

urge you to download the handout out

that goes with this presentation so that

you can have these references at your

fingertips should you need them.

Slide 18 Bleeding Studies for ICH

• May not be needed if:

• Independently witnessed trauma, abusive or otherwise

• Other medical findings consistent with abuse

• If needed, initial recommended testing panel:

• CBC with differential and platelet count

• PT and PTT

• Factor VIII level

• Factor IX level

• DIC panel (d-dimer and fibrinogen)

Different from Those to Evaluate Bruising

AAP Section on Hematology/Oncology and Committee on Child Abuse

and Neglect. Evaluation for Bleeding Disorders in Suspected Child Abuse.

Pediatrics 2013: 131; e1314, March 25, 2013.

If you do have a baby with intracranial

hemorrhage, these are studies that a

recommended by the American

Academy of Pediatrics section on

hematology and evaluating bleeding

disorders and suspected child abuse.

You may not need extensive studies if

it was witnessed abuse, If you had a

confession, if you have a range of

retinal hemorrhages, intracranial

hemorrhage, metaphyseal chip

fractures, and so forth, you may not

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need extensive studies. Although, it's

always good to get some because there

will be a defense somewhere along the

line that may be simply bled into his

head. And you can see the studies that

are needed: The CBC platelet count, PT

and PTT, factor levels, and

disseminated a DIC level panel that's a

disseminated intravascular coagulation

panel that's to look for signs of what I

said earlier, that the coagulation

problem is not primary, but it is rather

secondary to the brain injury.

Slide 19 Abusive Head TraumaA Range of Outcomes

Now, as far as outcomes for abusive

head trauma there's a whole spectrum.

Some babies are dead on arrival. We

see that not uncommonly, others will

come in, linger on a ventilator for some

time and then have a delayed death,

you have some babies who with

modern intensive care will pull through

but be profoundly handicapped with

cerebral palsy type pictures, blindness,

we have some who survived with

relatively mild deficits, and you have

some who appear grossly normal. Now,

I have normal in quotes because you

never know how much potential the

child has lost when these nerve fibers

in the substance of the brain were

damage. But the thing to keep in mind

when you look at this spectrum is that

again the person who's lost their temper

with a crying baby doesn't intend to put

them in the hospital, they intend to shut

them up. They intend to shake them

and some people get very good at

shaking babies just enough to

essentially give them a concussion so

that they go unconscious, stop crying,

and are easy to put down in the crib so

that the adult can get a good night's

sleep.

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Slide 20 Abusive Head TraumaLate Consequences

Partial or total blindness

Developmental delays

Mental retardation

Seizures

Paralysis

Cerebral palsy

Hearing loss

Florida Hospital Association. Children’s Network

Special Report, January 1998.

Late consequences of abusive head

trauma include blindness. Now, this

can be because of the retinal

hemorrhages damaging the part of the

eye where you have your best vision, or

it can be due to damage to the part of

the brain where you see because part of

the brain is like the screen on which

your vision is projected and if you

damage that part of the brain, it is like

you don't have any screen to see with.

Developmental delays, mental

retardation, convulsions, paralysis, or

partial paralysis of a part of the body, a

cerebral palsy like picture which is

spasticity or a loss of tone, and hearing

loss. All of these things can be

consequences which can be just

devastating to the survivors.

Slide 21 Abusive Head TraumaA Bad Outcome

Normal Infant CT Head Trauma: Result

This is just one example of a really bad

outcome. On the left, you see a normal

CT, and on the right you can see the

CT scan of a baby with abusive head

trauma. You can see here some bright

white areas. We don't actually have a

lot of subdural blood, they're not blood

layered up, but with these white areas

or areas of cerebral contusion leading

in the substance of the brain and you'll

notice here on the normal side how

there is this spinal fluid. The black is

spinal fluid over the surface of the

brain. Notice over here, there is no such

space. This brain is swollen up tight

against the inside of skull. There's no

space for spinal fluid and you notice

where...here's a good example of the

normal brain, you can see the white

areas which are nerve cells and the dark

areas which are nerve fibers. Over here,

you have kind of a grayish area. This is

what we call loss of gray-white

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differentiation. This is a sign of

cerebral edema or fluid in the substance

of the brain leaking from damaged

blood vessels. So, while we don't have

a big subdural in this case, we do have

cerebral contusions and cerebral

edema. A sign of a very bad outcome.

And this is what that maybe looked like

about a month later. What you can see,

those big black cystic areas, this baby's

brain has simply degenerated into

cysts. Very little actual brain substance

left. You can see how much space there

is over the substance of the brain that's

being filled with spinal fluid, the

ventricles, the normal hollow spot

within the substance brain are now very

large. This baby has virtually no brain

substance left.

Slide 22 Abusive Head TraumaA Bad Outcome

This is that baby with the bad outcome,

this is that baby a short time later and

what I want to draw your attention to is

up here at the fontanel, the normal soft

spot at the top of the head. It's just

sucking in because the baby's brain is

simply shriveled up and the fontanel

has collapsed inward.

Slide 23

Caffey, John. The Whiplash

Shaken Infant Syndrome: Manual

Shaking by the Extremities with Whiplash-

Induced Intracranial and Intraocular

Bleedings, Linked with Residual

Permanent Brain Damage and Mental

Retardation. Pediatrics 54:396, 1974.

The Whiplash Shaken Infant SyndromeThe Original Description

Now, this sort of abuse of head trauma

was originally described back in 1974

by Dr. John Caffey. Dr. Guthkelch in

England actually published a year

before in Lancet. But most people give

Caffey the credit for describing it

because his article was bigger and

verackily read in the states. But the title

of this article was "The Whiplash

Shaken Infant Syndrome: Manual

shaking by the extremities with

whiplash induced intracranial and

intraocular bleedings linked with

residual permanent brain damage and

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mental retardation." I think that's

probably the longest title of any

medical article I know of, but he

described the whole thing in the title

and written in a day before CT scans,

he described very accurately much if

not most of what we now know about

abusive head trauma. We subsequently

lost the word whiplash because that

was not considered necessary.

Slide 24 Some Claim It’s Impossible

to Shake a Baby to Death

Duhaime found evidence of blunt impact trauma at autopsy in all of 13 fatal cases of supposed shaken baby syndrome

In a study in which adults shook and/or slammed life-like dolls to measure the forces that could be generated, results suggested that shaking alone could not produce forces necessary to produce damage

Author proposes that the injuries attributed to shaking are in fact due to impact, hence the term “Shaken Impact Syndrome”

Duhaime AC, et al. The Shaken Baby Syndrome. Journal of

Neurosurgery 66:409-415, March 1987.

It's important to know if you haven't

already heard that there are some

people who claim that he was wrong

about this. There are some people who

claim that it's not possible to shake a

baby to death or to shake a baby such

that the brain is injured. One researcher

who was quoted often on this is Dr.

Ann Duhaime. Now people actually get

her purpose wrong when they quote her

in this context. Duhaime was involved

in thirteen cases of fatal head trauma

that presented initially as supposed

shaken baby syndrome, but in autopsy,

they found evidence of the impact that

is bruises on the head, bruises on the

surface of the skull and so forth. Well,

it was common at this time back in the

eighties for people to say as a defense

that the baby stopped and he choked on

his formula, and he stopped breathing,

and I shook him to revive him. The so-

called shook to revive defense. Well

when Duhaime found evidence of

impact she said, "Ah ha! These people

are lying. They didn't panic and shake

the baby, they slammed the baby." And

she set out to prove that by doing a

study where she had volunteers shake

dolls that had instruments in their head

measure how fast their heads would

move. And she claimed to prove that it

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was not possible to shake a baby so

hard that they would cause brain

damage, but that it was easy to slam

them hard enough. So, you'll hear

people say that it's been proven that

you can't shake a baby to death. Well,

it's not true, there are many flaws with

their study.

Slide 25 Duhaime’s Biomechanics StudyQuestionable Assumptions

That mature and immature primate brains have identical biomechanical properties

That repetitive shakes will produce injuries at the same thresholds as single shakes

That the model used is sufficiently true-to-life that it accurately reflects what happens when a real infant is shaken

That shaking is performed in a uniform and predictable manner and that potential variations in technique are not important

Spivak B. “Biomechanics” p. 40 in Frasier L, Rauth-Farley K,

Alexander R and Parrish R. Abusive Head Trauma in Infants and

Children. G.W. Medical Publishing, St. Lewis, 2006.

For instance the studies that evaluated

the force, clearly, nobody's ever done a

study measuring the force it takes to

shake a baby to death, but people have

done studies with monkeys. So,

Duhaime assumed that mature monkey

brains were the same as baby human

brains which was a leap of faith. She

had her volunteer shake the dolls one

time whereas people who were angry

with the baby shake it multiple times.

The models that used were not good,

true-to-life examples of how babies

would behave. And she had all the

people who shook the dolls shake them

one time in the same way but people

who are angry with baby shake them in

lots of ways. So, it's pretty much

agreed by everybody who thinks hard

on the subject that Duhaime's study did

not in fact prove that it's impossible to

shake babies to death.

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Slide 26 Biomechanical StudiesAttempts to Measure the Forces Involved

Use dolls and models in an attempt

to reproduce and measure the

effects of accidental and non-

accidental trauma

Purport to prove that it is not

possible to shake a baby to death

Purport to prove that it should be

common for children to be killed

falling out of bed

All present models too seriously

flawed to be considered scientifically

valid

These so-called biomechanical studies

that are often cited in defense of people

who have killed their children, they

used dolls and models in an effort to

reproduce the forces involved in

accidental and non-accidental trauma.

They claim to prove that it's not

possible to shake a baby to death. They

claim to prove that it's very easy for a

baby to kill himself falling out of bed.

Well, we know babies don't kill

themselves falling out of bed and we

know that people can shake babies to

death. So, we don't really have a

biomechanical models at present that

are reliable and scientifically valid.

Slide 27 Abusive Head TraumaIs Impact Necessary?

But we do need to ask ourselves, "Is

shaking sufficient? Or is impact really

necessary?" Well, sometimes you have

obvious signs of impact in these cases.

Slide 28 Skull FracturesComplex Fractures Indicate Great Force

This is a baby whose skull has been

shattered like an eggshell. So this is a

case in which we have obvious signs of

impact.

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Slide 29 Physical Evidence of Impact TraumaSometimes Obvious

Here's a case where there are fairly

obvious signs of impact. Not as

obviously as a skull fracture, but this is

the hand slap to the face. A little

bleeding on surface of the eye. This is

clear evidence of impact trauma with a

hand in this case to a baby's head. Here

is another sign of impact trauma to a

baby's head. Another slap mark to the

face. Here are signs of impact trauma

multiple bruises about a child's head.

Slide 30 Physical Evidence of Impact TraumaSometimes Less Obvious

Here's side of impact trauma not quite

as obvious. We can see here swelling

on the left side of the baby's head and

we can see a little bit of hemorrhage in

the white of the baby's eye. These are

all the same case just different lighting

techniques. But less obvious signs of

impact. And here on CT scan you can

see some swelling on the left side of

baby's head.

Slide 31 Physical Evidence of Impact TraumaSometimes Subtle

Sometimes it can be fairly subtle, this

you may or may not be able to

appreciate there's a little linear bruise

on the lower part of the baby's cheek

there fairly obvious intracranial

hemorrhage but the bruising is very

subtle compared to the intracranial

bleeding. Sometimes...oh, this baby

also had three broken posterior ribs

healing fractures.

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Slide 32 Physical Evidence of Impact TraumaSometimes Hidden

Sometimes the evidence of impact

trauma is hidden. This is an autopsy

photo. What the medical examiner does

an autopsies is make an incision around

the back and neck and peel the scalp

forward over the child's face. If you're

squeamish, don't look at this.

Slide 33 Physical Evidence of Impact TraumaSometimes Hidden

Ok what we have here, the baby's nose

is to your left under the scalp. Each of

those red spots is an impact site where

the baby's head was struck. There may

or may not be any evidence of bruising

on the surface of the skull. If the child

died quickly, blood may not have made

its way to the surface of the skin. But

we do see these impacts sites. But in

babies who survive, they cannot have a

bad brain injury and survive. If you

don't do an autopsy and peel back the

scalp, you don't see this. So, it can be

hidden.

Slide 34 Physical Evidence of Impact TraumaSometimes Absent

And sometimes evidence of impact

trauma is actually absent. This is a

case, an example of good detective

work. This young man was caring for a

baby about a year previously who had

died in his care. The baby had an

autopsy, absolutely no findings and

nothing at all on the autopsy. But the

detective involved in the case was

suspicious. He built a positive

relationship with the man, invited him

to come back and talk whenever he felt

like it and after about a year, the man

came back and said, "I've got to get it

off my chest." And he confessed that he

had been wanting to watch TV that

night and the baby had been crying and

would not stop until finally he pressed

the baby's face into his chest and hit it

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with his hand until it got quiet. There

were no findings at autopsy, so

sometimes evidence of impact trauma

is subtle or hidden or absent so when

we have children who don't die they

may have been impacted and we just

may not be able to tell.

Slide 35 Yes, It Is Possible Shake

a Baby to Death

Alexander prospectively examined 24 infants

diagnosed with SBS looking carefully for signs of

impact trauma

Nine infants died and were autopsied

No evidence of impact trauma was found in 12

infants, including 5 of those autopsied

The death rate and spectrum of intracranial injuries

noted was the same in those with and without

evidence of impact

Alexander R, et al. Incidence of Impact Trauma with Cranial

Injuries Ascribed to Shaking. AJDC 144:724-726, 1990.

Likewise, we do have confessions that

some people do just shake babies. This

was an article by Dr. Randall

Alexander when he looked at a number

of fatal head injuries and found that

some did have signs of impact but

some did not have any signs of impact.

Slide 36 Perpetrator Confessions to Shaking Some But Not All Also Impact

Study of 81 cases of Abusive Head Trauma over a

20-year period in which perpetrators admitted to their actions

65% boys, 35% girls

Ages 2 weeks to 15 months

Actions described: 71% included shaking

46% shaking alone

29% impact only

25% shaking and impact

None of the children were described as behaving normally after

the event.

Starling SP et. al. Analysis of Perpetrator Admissions to Inflicted

Traumatic Brain Injury in Children. Arch Ped Adolesc Med 158: 454-

8, May 2004.

There are a number of articles dealing

with confessions. And we're not talking

about bright light, hot light, lead pipe

confessions. We're talking about

spontaneous confessions. I've seen

examples of many of them where

people with true remorse described

what they did with their baby would

not stop crying when they lost control

and violently shook them. This is a set

of confessions in which forty-six

percent admitted shaking, along

twenty-nine said impact alone, and

twenty-five percent included shaking

and impact. And it's not surprising that

there's a lot of impact because if you

think about it, if you're if you're

standing at the crib with a baby that

won't stop crying, you can just shake

them, but it's also very easy as you

stand there to go, "Wham! Wham!

Wham!" on the crib mattress. That's an

impact, but crib mattresses is not going

to leave a bruise, a crib mattress is not

going to cause a fracture. So if you hit

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the baby on the wall, or a table, or the

door, you can have bruises and

fractures, but if you're slamming him

on the crib mattress or sofa cushion,

there's impact, there won't be bruising.

So because of this, we understand that

it's hard to tell the difference between

babies who have only been shaken and

babies who have only been impacted

and babies who've been impacted and

shaken. Important point, in these

confessions where people were talking

about what they did. None of them,

eighty-one cases, none of them said the

baby acted normal after the event.

That's really important in determining

in other cases where people don't

confess in determining who's

responsible because it will often be

claimed that the baby suffered the

serious head injury in one person's care

and then collapsed in my poor clients

care. But we know from cases like this

confessions and other studies that

babies who have suffered serious life-

threatening head injury don't act

normal.

Slide 37 Shaking InjuriesIs There and Upper Age Limit?

30 year old Palestinian man died under interrogation by Israeli security forces. Autopsy revealed acute subdural hemorrhage, diffuse axonal injury and retinal hemorrhages.

Carrigan TD et al. Domestic Violence: The Shaken Adult

Syndrome. Journal of Accidental and Emergency Medicine

17:138, 2000.

34 year old woman was treated for retinal hemorrhages, subdural

hemorrhage and linear bruises on both upper arms due to domestic

violence.

Pounder DJ. Shaken Adult Syndrome. American Journal of

Forensic Medicine 18:321, 1997.

So is there an upper age limit? I

remember seeing an expert opinion in

an abusive head trauma case that said,

"The child was two years old, it's not

possible to shake a two-year-old.

Maybe you can shake a two-month-old,

but you can't shake a two-year-old

together." Well no, you can. This is a

well-documented case of a thirty year

old man who was being interrogated by

security forces over the course of a

couple of a days. He was repeatedly

shaken violently and at death, at

autopsy had excellent injury retinal

hemorrhages and subdural hemorrhage.

Also, a case of domestic violence, a

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woman who survived. So we're finding.

So yes there are even shaken adults.

There are no upper limit, if you have a

big enough adult, you can shake a five-

year-old to death.

Slide 38 Abusive Head Trauma in Infants and ChildrenRecent American Academy of Pediatrics Statement

“Although shaking an infant has the potential to cause

neurologic injury, blunt impact or a combination of shaking

and blunt impact cause injury as well.”

“Pediatricians should use the term ‘Abusive Head Trauma’

rather than a term that implies a single injury mechanism,

such as shaken baby syndrome in their diagnosis and

medical communication.”

“Shaken Baby Syndrome is a subset of AHT.”

“The goal of this policy statement is not to detract from

shaking as a mechanism of AHT . . .”

AAP Committee on Child Abuse and Neglect. Abusive Head Trauma

in Infants and Children. Pediatrics 123:1409, May 2009.

Now because of this controversy over

shaking, slamming, shaking and

slamming, the American Academy of

Pediatrics now recommends that the

preferable term is abusive head trauma

abusive. Head trauma is a generic term

that takes into account the possibility of

shaking and slamming. My typical

report in one of these cases will say,

"Diagnosis - abusive head trauma: the

mechanism of injury would have

included some combination of violent

shaking and or blunt force trauma to

the head." That's how I describe it.

Now, you will sometimes have defense

experts or attorneys say, "Oh, you

know doctors aren't sure what they're

talking about. I mean, the American

Academy of Pediatrics has now

decided there's no such thing as shaken

baby syndrome." You'll hear them say

that. That's not true the statement here

from the American Academy of

Pediatrics doubles down on the concept

of shaken baby syndrome. I think it's

the lower right-hand column of the text

where they say that, "The shaken baby

syndrome is a subset of abusive head

trauma." So, shaking is still a

mechanism of injury for the brains and

children. The American Academy of

Pediatrics has not backed away from

the concept, it is simply expanded the

concept to include blunt force head

trauma. So, in my reports I never use

the term "Shaken Baby Syndrome". If I

use that diagnosis I invite the defense at

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trial to put the concept of shaken baby

on trial. I don't need to have that

argument, I'm going to call it abusive

head trauma and allow from the outset

that maybe the baby's only shaken,

maybe the baby was slammed, maybe

the baby was shaken and slammed. But

don't let them put the concept on trial

because that will simply confuse the

jury.

Slide 39 Dating Subdural HematomasAge Can Not Be Reliably Determined

Result of a systematic of 22 published studies describing

973 SDHs on CT and 4 studies describing 83 SDHs on MRI:

“Most time intervals of the different appearances of SDHs onCT and

MRI are broad and overlapping. Therefore CT or MRI findings cannot

be used to accurately date SDHs.”

Sieswerda-Hoogendoorn T, et.al. Age Determination of Subdural Hematomas

with DT and MRI: A Systematic Review. Eur J Radiol 83:1257-68, July 2014.

Result of survey of current practice among radiologists in the Netherlands

regarding the dating of subdural hematomas in children:

“The results demonstrate that there is a considerable practice

variation among . . . Radiologists regarding the age determination of

subdural hematomas. This implicates that dating of subdural

hematomas is not suitable to use in court, as no uniformity among

experts exists.”

Postema FA, et. al. Age Determination of Subdural Hematomas: Survey Among

Radiologists. Emerg Radiol 21:349-58, August 2014.

Now, can subdurals be reliably dated?

Now I know this is something that over

a course of time, people have often

done, they've often looked at blood that

was grayish and looked at whitish

blood and said that was acute and

grayish blood was older. There is now

general agreement among experts in the

field who think hard about it that you

cannot reliably date subdural

hematomas. There are several reasons

for that. One as described in these two

studies different radiologists have

different standards so what one person

says six days, another person's going to

say ten days, and someone else's going

to say two weeks. So, if you can't get

the experts to agree, that means you

probably should not go there. Now

having said that if you have a

radiologist who feels completely

comfortable dating one, well that says

opinion, but I would encourage you not

to get involved in giving your opinion

on the dating of a subdural hematoma.

That holds true also for what are called

"Mixed density Subdurals".

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Slide 40 Mixed-DensitySubduralsNot Necessarily Different Ages

Haines DE. On the Question of a Subdural Space. The Anatomical Record 230:3-21, 1991.

Subarachnoid Space

Skull

You can see in the CT scan up there

that there's a subdural that has some

white blood and then some grayish

blood above, some people would say

traditionally that this represents

subdurals of two different ages.

Modern thought on the subject is that

you cannot say that. We saw this slide

earlier where I showed the blood

dissecting through the layers of the

dura above the subdural space. Now

that layer of cells is only a couple of

layers of dura between the subdural

hematoma and the subarachnoid space,

it's only a couple of cells thick. And it's

easy sometimes for that layer of cells to

get torn, in which case you will have

subarachnoid spinal fluid get in and

mixed with the fresh blood so that you

can get diluted acute blood, you can get

mixed density blood. So because of that

possibility of mixing of spinal fluid

with subdural blood. Most experts in

this field are now reluctant to try to

date subdurals or to try to claim that

you have more than one age because of

differences in density.

Slide 41 Fatally Injured ChildrenThey Don’t Behave Normally

Willman, et. al. reviewed 138 accidental fatalities involving

head injuries

With the exception of one acute epidural hematoma, no

child with a fatal head injury acted normal after the injury

When infants suffer life-threatening head injuries, it may be

presumed that:

The injury occurred after they were last seen

appearing well

The injury was inflicted by the person caring for them at

the time they became symptomatic

Willman KY, et. al. Restricting the Time of Injury in Fatal Inflicted

Head Injuries. Child Abuse & Neglect 24:929-939, 1997.

Now, as we begin to draw towards a

close here, let's talk about how we

know who is responsible for the injury.

I showed you a slide earlier of

confessions in which in over eighty

cases, the perpetrators who confessed

to shaking and slamming their babies,

none of them said their baby acted

normal after it happened. This is

another study that I often cite, woman

in child abuse and neglect, nineteen

ninety-seven, they described one

hundred and thirty-eight accidental

fatalities where people knew exactly

what happened, when, where, and how,

and with the exception of one epidural

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hematoma, which is a different beast

we will talk about a minute, none of the

children acted normal after the injury.

They might had not been completely

unconscious, but they weren't normal

either. People knew something was

wrong. So, what this means for us is

that when a child has a life-threatening

head injury, we can say the injury

occurred after they were last appearing

well. So, important point here, when

you're doing a head injury case you

need to really nail down the time line

of who last saw the baby well. So I

remember a case for instance the father

dropped the baby off at the babysitter

he could testify credibly that the baby

smiled, threw him a kiss, said, "Bye

daddy", and then two hours later the

babysitter calls and says, "Hey, your

baby's not breathing". Then you know

that the injury happened in the care of

the babysitter. So, nail down the

timeline of when the baby last acted

fine. And be specific. The word fine is

pretty general to a lot of people. So, did

he take a full bottle? Did he spit up?

Did he feed well? Did he smile? Was

he playing? Did he wave? All the

things that are age appropriate that the

baby did or didn't do can help you nail

down the time of the injury.

Slide 42 The Classic Abusive Head Trauma Multiple Injuries, Near Death

This is what I'd call the classic abuse of

head trauma case. Baby is near death

on a ventilator with subdural

hematomas, retinal hemorrhages, and

metaphyseal chip fractures. This is the

image that we typically have babies

with abusive head trauma, but they

don't all look like that.

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Slide 43 The Less Classic Abusive Head Trauma Infants with Less Severe Injury Harder to Recognize

Seven-month-old infant brought to ED having a seizure

CT scan obtained and revealed fresh subdural hemorrhage

Dad questioned and admitted shaking infant

Photograph taken just four hours after presentation. Infant appears well.

This is the baby that I saw in the

emergency room at a local hospital

some years ago. He came in, seven

months old, came in having a seizure.

They stopped the seizure, sent him to

CT scan, found a small subdural

hematoma, they went to the father and

said, "Hey, the baby was blood in his

head. What happened?” And the father

admitted in the emergency room that he

had lost his temper and shaken the

baby. I wish I could show you the

baby’s eyes. I can't for obvious reasons,

but this baby is looking right at the

camera. He is bright eyed, bushy-tailed

as normal looking a baby as you would

want. Which brings us back to the point

that people who shake babies don't

mean to put them in intensive care unit,

they just mean to shut them up. And

some get pretty good just giving them

concussions. So many babies that we

see with abusive head trauma had been

shaken repeatedly before they get the

one bad shape that puts them in the

hospital.

Slide 44 Shaken Baby SyndromeMissed Cases

Earlier chances to diagnosis SBS

had been missed in fifty-four

(31.2%) of 173 abused infants with

head injuries

Children with missed abusive head

trauma more likely to be less than

six months old, white, and living with

two parents

Fifteen (27.8%) of missed cases

were re-injured, five fatally, before

correct diagnosis was made

Jenny C et al. Analysis of Missed Cases

of Abusive head Trauma. JAMA

281:621, 1999.

There was a study done by Carole

Jenny some years ago where they

looked at cases that came in with

abusive head trauma and then looked at

their medical records going back the

last few weeks and found that many of

them had been in for injuries that in

retrospect were abusive injuries but had

not been detected because the babies

weren't hurt so badly that anybody

recognized.

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Slide 45 Time of Onset of Head injury Symptoms Sometimes Not Possible to Say

Neurological injuries resulting from

shaking/impact trauma represent a

spectrum of severity

Less severely injured infants may have a

more poorly defined time of symptom

onset

Identifying the perpetrator in cases with

the gradual onset of milder symptoms

may be difficult

So sometimes it's not possible to say

"whodunit". The milder injuries...there

are cases where the baby comes in sick

enough to get a CT scan, there's some

blood but he's not life-threatening ill.

And as you get the history, try to

construct the timeline. They say, "Well,

you know, he wasn't all that well

yesterday. He didn't feed well". And

somebody else says, "Well, he threw up

the day before." "Well, we thought he

had a bug three days ago." So you can't

pinpoint when the baby went bad. In

those cases, you sometimes just aren't

going to be able to tell who did it.

Slide 46 Injuries Resulting from Short Vertical Falls

Rarely Life-Threatening

Series of 246 children age 5 or less who had suffered falls

from a height of 60 inches or less

161 had fallen from beds or sofas at home

85 had fallen from beds or stretchers in the hospital

Results:

80% suffered no injury

17 % suffered bumps and bruises

There were 3 fractured clavicles, 1 fractured humerus

and 2 simple linear skull fractures

No child suffered a severe head or CNS injury

Helfer RE et al. Injuries Resulting When Small Children

Fall Out of Bed. Pediatrics 60:533-535. October 1977.

Now people often claim that babies

suffer these injuries in common

household falls. This is a study done by

Ray Helfer back in 1977 where they

looked at babies who fell from beds

and couches. Yes, there were some

simple skull fractures, but no baby

suffered a severe life-threatening

injury.



Series of 106 children with history of falls witnessed

by a second person other than the caretaker

No injuries in 15, including 7 who fell more than 10 feet

Bruises, abrasions and simple fractures in 77, including

43 who fell more than 10 feet

Severe injuries (intracranial hemorrhages, cerebral

edema, etc.) in 14 who fell between 5 and 40 feet

No life-threatening injuries in the 3 who fell less than 10

feet

Only death in series was a child who fell from 70 feet

Williams RA. Injuries in Infants and Small Children

Resulting from Witnessed and Corroborated Free Falls. J.

Trauma 31:1350-1352, 1991.

Study was repeated in 1991 by

Williams. Again, no life-threatening

injuries. The only death in this case

was a child who fell from 70 feet.

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Series of 207 children less than 6 years of age who fell out

of cribs and beds in the hospital

25 inches from beds

41 inches when climbed over bed rails to fall

32 inches from cribs

54 inches when climbed over crib rails

No injury: 86%

Mild injury: 14%, including one linear skull fracture and one

fractured clavicle

No serious, multiple, visceral or life-threatening injuries

Lyons TJ and Oates RK. Falling Out of Bed: A Relatively

Benign Ocurrence. Pediatrics 92:125,1993.

Lyons repeated it in nineteen ninety-

three, no life-threatening injuries, no

visceral, no ruptured sprains, head

injuries.

Slide 49

Series of 167 children less than 10 months old who fell from heights of < 48 inches

Results

85% suffered minor or no injury

15% suffered long bone or skull fractures

The only 2 infants with intracranial hemorrhage were discovered to be victims of abuse

No child suffered an intracranial hemorrhage from falling off a bed or being dropped

Tarantino CA et. al. Short Vertical Falls in Infants. Pediatric

Emergency Care 15:5, 1999.

Injuries Resulting from Short Vertical Falls


And again in nineteen ninety-nine,

Tarantino did it. People keep doing the

study, they keep getting the same

response, about eighty percent aren't

hurt, fifteen to twenty percent have

some injury including a fracture, but

none of these babies have fatal injuries,

are life-threatening injuries unless they

had been abused. Kids don't get fatally

injured, or life-threateningly injured

falling off beds or being dropped.

Slide 50 Injuries Resulting from Falling Down Stairs


Joffe and Ludwig reviewed 363

consecutive pediatric patients

seen in the ED who had fallen

down stairs

Most injuries were minor

Only 3% were injured sufficiently

to be admitted to the hospital

No patient had life-threatening

injuries, and none required

intensive care

Joffe M and Ludwig S. Stairway Injuries in Children. Pediatrics

82:457, 1988.

Same holds true for falls downstairs.

This is a study the authors repeated

again a few days later, excuse me, a

few years later with the same result.

The thing to point out is that a fall

down a twenty-foot flight of stairs is

not a twenty foot fall, it's twenty one

foot falls. So they go "bump bump

bump" down the stairs and get bumps

and bruises but they don't kill

themselves falling down stairs. Again,

adults may be different.

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Slide 51 Falls in Infant WalkersReal Potential for Serious Injury

Reider MJ et al. Patterns of Walker Use and Walker Injury.

Pediatrics 78:488, 1986.

Also different is the story with walkers.

This is one of the reasons why the

American Academy of Pediatrics

discourages walkers. Kids who go

downstairs in walkers do suffer serious

head injuries because of the weight of

the Walker added to their own weight a

landing on top of them as they hit their

head.

Slide 52 Serious Head InjuriesThe Short Fall Defense

Aoki reported a series of 26 infants who suffered acute subdural hematomas following minor head trauma in household falls

Most patients presented with seizures

Retinal hemorrhages were present in all patients

Most common mechanism of injury was a fall backward while sitting or standing with the head hitting a soft item such as a tatami mat

Aoki N and Masuzawa H. Infantile Acute Subdural Hematoma.

Journal of Neurosurgery 61:273-280, August 1984.

Now when people want to defend those

who have seriously injured their babies

there are a number of articles that are

often brought up and these are articles

that those who work in this field need

to be aware of. Aoki was a Japanese

neurosurgeon who reported a series of

twenty-six babies back in nineteen

eighty-four in Japan who suffered acute

subdural hematomas with seizures and

retinal hemorrhages after simply falling

over backwards from sitting position

and my wife and I spent three years in

Japan. Typically, they live on tatami

mats, woven straw mats, very soft. So

this is really kind of absurd. When this

article was published people didn't say,

"Oh, Japanese babies are fragile." What

people said is, "Oh...Japan doesn't

know it has a problem child abuse.”

which was the fact. So after this

Japanese researchers started looking

into it and yes, in fact, they do have a

problem with child abuse. But Aoki

continues to stick to his guns in saying,

"American families may shake their

babies, Japanese families don't. Their

babies simply bleed easily into their

head when they fall over backwards."

So if you hear Aoki quoted as

indicating that children get subdural

hematomas falling over backwards,

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don't believe it.

Slide 53 The Short Fall DefenseThe Current Leading Proponent

Review of 1988-1999 U.S. Consumer Product Safety

Commission data base for head injuries associated with use of

playground equipment

Identified 18 fall-related deaths due to head injury

Ages: 12 months - 13 years

Heights: 2 - 10 feet

Twelve of 18 witnessed by non-caretakers

Twelve had lucid intervals

Four of 16 examined had bilateral retinal hemorrhages

Plunkett J. Fatal Pediatric Head Injuries Caused by Short-Distance

Falls. American Journal of Forensic Medicine and Pathology 22:1-

12, 2001.

The leading proponent of the shortfall

defense these days in the United States

is a Dr. John Plunkett who makes a six-

figure living traveling around the

country testifying in these cases. To

bolster his own testimony, he published

an article back in two thousand one

titled "Fatal pediatric head injuries

caused by a short distance falls." He

went to the Consumer Product Safety

Commission data base and collected

stories of fatal falls from playground

equipment. None of these kids were

said to fall off beds or couches, it was

playground equipment. Notice the age

range, twelve months to thirteen years.

None of these kids were less than a

year old which is when we see most of

our shaken babies. He says the height

was two feet to ten feet. We'll talk

more about that in a minute. Some of

them had lucid intervals and so forth.

So, he claimed to show this.

Slide 54

Plunkett J. Fatal Pediatric Head Injuries Caused by Short-Distance Falls.

American Journal of Forensic Medicine and Pathology 22:1-12, 2001.

27”

Now this is a table chart from his

article. Yes, it just outlines all the

cases. What I want to talk to you about

is case number five. Plunkett's case five

where he says the child was twenty-

three months old and fell from a height

of two point three feet. Two point three

feet and had a lucid interval. As it

happens, this child's grandmother was

videotaping the fall. I have seen the

videotape, I have a copy of it. The two

point three feet was the height of a

platform of the play gym in the garage.

The child is actually sitting up on the

wall around the top of the platform so

that her head was actually five or

almost six feet above the concrete

floor. So, when you see this child,

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when you watch this video and see the

child filed, you're not surprised that she

was killed. It was a violent fall onto a

concrete floor with a thin carpet pad

over it. And while they may say she

had a lucid interval, you can see the

family rushed to her and rushed her

straight to the hospital. They knew she

wasn't right after this fall. My point in

telling you this is that I would submit

that Plunkett consciously

misrepresented the facts of this case

when he says this child died from a fall

of two feet. Her head traveled from a

height of six feet. So Plunkett's article

is not good scientific literature and if

you ever come up against Plunkett, be

aware that his article is...well, I'm

searching for polite language to

describe it, let's just say that it's not

worth reading. Except that you do need

to know about it. These are the

dynamics of the child's actual fall.

That's the twenty-seven inches he

describes, but the child had actually fell

from a height of closer to six feet.

Slide 55 Plunkett’s Short Fall DefenseCharacteristics of Cited Cases

History of significant fall from playground

equipment

Death resulting from effects of mass

lesions

Vascular accidents

Abnormalities of blood coagulation system

Uncorroborated history

Plunkett J. Fatal Pediatric Head Injuries Caused by Short-

Distance Falls. American Journal of Forensic Medicine and

Pathology 22:1-12, 2001.

When you look at his other cases, there

were significant falls. Children who fell

out at the height of the arc of a swing.

A vascular accident, one child fell on a

stick and tore his carotid artery stroke.

That's not like falling off a bed. One

child had an ITP, a blood clotting

problem with a very low platelet count.

Kids with that we know they bleed

spontaneously into their heads. Didn't

belong in a series like this. And then

the uncorroborated histories where he

simply accepted it face value a story

that something happened. So again,

Plunkett's article is not valid scientific

literature. Don't be overcome by

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someone who tells you that it has been

proven that kids die in short distance

falls.

Slide 56 Actual Risk of Death from Short FallsBest Estimates

Authors reviewed multiple sources of data related to deaths from short

distance falls (less than 4.7 feet) in young children

Review of death certificates from cases identified in the State of

California Epidemiology and Prevention for Injury Control Branch

database yielded an incidence of 0.48 cases per 1 million children per

year.

Data from the CDC database concerning children less than 4 years

old indicated an “all fall” (not stratified by height) incidence of 3 cases

per 1 million children per year.

The National Consumer Product Safety Commission database

indicated an incidence of 0.625 cases per 1 million children per year.

The best estimate for risk of death in an infant or young child from a short

fall is less than one in a million young children per year.

Chadwick DL, et. al. Annual Risk of Death from Short Falls Among

Young Children. Pediatrics 121:1213, 2008.

One researcher, a respected researcher

in contrast to Plunkett, a Dr. Chadwick

did analyze several databases for the

incidence of actual deaths from short

distance fall and came up with a

number of something like one in a

million a year or thereabouts. So it

occasionally happens with freak

accidents, but it's exceedingly rare.

Slide 57 Epidural HematomaThe Exception to the Rules

Middle Meningeal

Artery

Epidural hematomas with the exception

to the rule, we've eluded to this before.

Epidural hematomas come from when

you get a skull fracture, simple layer

skull fracture the tears the meningeal

artery that runs in a groove in the inner

surface of the skull. You get pumping

blood with arterial pressure and this

can lead to lucid interval where they

seem to be ok for a while and

ultimately can be fatal if it doesn't get

corrected surgically.

Slide 58 Epidural HematomaThe Exception to the Rules

Epidural hematomas

May be fatal

May result from household falls

May have a “lucid interval”

Shugerman et. al. reviewed 93 cases of intracranial hemorrhage in infants and children age 3 and younger

Abuse was diagnosed in 52% (28 of 59) with subdural hematomas but only 6% (2 of 34) with epidural hematomas

Shugerman RP, et al. Epidural Hemorrhage: Is It Abuse?

Pediatrics 97:664-668, 1996.

So that's the exception to several of our

rules. But there's no confusing epidural

hematomas with abusive head trauma,

shaken baby syndrome, or subdural

hematomas.

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Slide 59 The “Au Pair Case”Flawed Defenses Offered

The “SODDI Defense”

Child is injured by one person but continues to act well

Suddenly decompensates while with another caretaker

The “Bleed/Re-Bleed” Defense

Minor head injury causes subdural hematoma

Pseudomembrane forms with neovascularization

Second, relatively minor head injury causes more serious bleeding

One other defense that will sometimes

come up is, well it's been referred to as

the "SODDI" defense. Some other dude

done it. Also, the bleed/re-bleed

scenario. This was offered in the so-

called "Au Pair" case up in Boston

where a child died while in the care of

a baby sitter...or "Au Pair". It was

alleged in the babysitters defense that

the parents had fatally injured the child

days or weeks before, but she had

continued to act normal and only

collapsed in the care of the babysitter.

That of course is not a valid argument.

Slide 60 Re-BleedingThe Reality

Small blood vessels (neo-vascularization) develop in the septations or membranes that form within chronic subdural hematomas

May re-bleed with little or no additional trauma

May result in mixed attenuation collections

Such episodes of re-bleeding will be asymptomatic and will not result in acute deterioration of the child’s neurological status

Bleeding will not occur at sites remote from the original subdural or in the subarachnoid space

Frasier L, Rauth-Farley K, Alexander R and Parrish R. Abusive

Head Trauma in Infants and Children. G.W. Medical Publishing, St.

Lewis, 2006.

There's a discussion to this point in the

book edited by Dr. Alexander that talks

about what does happen with

subdurals. They do get tiny blood

vessels what's called "Neo-

vascularization" around them. And

these can bleed tiny little amounts, but

it's not the abrupt huge hemorrhage that

would cause an abrupt change in level

of consciousness. These little leaks of

blood from these tiny blood vessels are

clinically not evident. Someone has

made the analogy that say that the child

suffers a mild head injury with a bleed

that nobody's even aware of and then

later bleeds fatally into that old bleed.

It's like saying that you have scratched

your finger and you pick off the scab

and bleed to death. So this "bleed/re-

bleed" scenario does not hold any

water.

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Slide 61 “Temporary Brittle Bone Disease”Paterson Now Relates It to Subdurals

Dr. Paterson and Monk (of the University of Dundee School of

Business) report 20 infants with multiple fractures, subdural

hematomas and retinal hemorrhages that they believe are due to

“Temporary Brittle Bone Disease.”

They believe the findings are unlikely to be due to abuse because:

There was no “clinical evidence of injury commensurate with the

fracture”, i.e., no bruising

“Metaphyseal fractures, when present, were often symmetrical.”

Subdural hemorrhages were accepted as being due to falls or

birth injury

Included cases in which courts removed children from the parents’

care and/or a parent was convicted in criminal proceedings for

charges including murder.

Paterson CR, Monk EA. Temporary Brittle Bone Disease: Association

with Intracranial Bleeding. J Pediatr Endocr Met 2013, pp. 1-10.

One last argument to deflate is the

temporary brittle bone disease. We

talked about this in conjunction with

evaluating children with multiple

fractures. A Dr. Paterson, whose name

is spelled with a "t" and Monk, who is

not even a doctor, published this. They

claim that babies who have temporary

brittle bone disease, which is a non-

existent disease, spontaneously bleed

into their heads. There are reasons for

thinking that the cases they were

involved with were not abuse. There

was no evidence commensurate of

injury, commensurate with the fracture

that is no visible bruising. Well most of

the fractures I see don't have bruising

associated. They say metaphyseal

fractures, which are highly specific for

abuse when present, were often

symmetrical. Well yeah, people jerk

both arms, jerk both legs. And they

accepted at face value people stories

that subdurals hemorrhages were due to

birth injuries or falls. And in fact, all of

these cases in court, the children were

removed by defensory actions and

parents were criminally prosecuted. So

temporary brittle bone disease does not

explain either multiple fractures or

intracranial hemorrhage.

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Slide 62

Geddes proposed that craniocervical trauma

occurring “without impact or considerable force”

could cause apnea, resulting in hypoxia and

cerebral edema

Increased central venous pressure would then

cause blood to leak from intracranial and retinal

veins

Subdural hematomas and retinal hemorrhages

could therefore be a “phenomenon of immaturity,”

not abuse

“The Geddes Hypothesis”Hypoxia as Cause of SDH and RH

Geddes Jf et al. Neuropathol Appl Neurobiol 2003 Feb: 29(1):14-22.

I promised you the last ones the last,

this one I think is. But you need to

know about it. The "Geddes

Hypothesis" or "Geddes Universal

Hypothesis". Geddes wrote an article in

which he proposed, she did not

research, did not prove, she speculated,

that minor injuries in the cervical area,

even without impact or considerable

force might cause the baby stopped

breathing, that would cause the baby to

have "Hypoxia" or low blood in the,

low oxygen in the blood, and cerebral

Edema. And that then would lead the

baby to bleed into the head and into the

back of the eyes. In other words, stop

breathing, low-oxygen, bleeding into

the head and eyes. She says that this

was just because they were immature.

Slide 63

Geddes called to testify in Court of Appeals in London

in June 2005

Testified her hypothesis was speculative, meant to

stimulate debate and not to be taken as fact

Judges found “unified hypothesis can no longer be

regarded as a credible or alternative cause of the triad

of injuries” of SBS but “excessive trauma” needed

Appeals in four cases then considered in light to these

findings

Geddes Disavows Her HypothesisSays It Was Not Meant to Be Taken As Fact

Richards PG et al. Shaken Baby Syndrome: Before the

Court of Appeal. Arch Dis Child 2006;91, 205-206.

Well after she published this article,

this speculation in a British Medical

Journal where she practices, several

cases several convictions of abusive

head trauma were appealed on the basis

of her argument that said, "Hey!

Geddis has proved that we didn't abuse

our children. They just bled into their

heads because their brains were

immature." So again, as was called into

the appeals court in London to explain

herself. And she said in court, "You

know I never claimed this was real. It

was an idea. I suggested that it was a

possibility that we ought to talk about

it, that we ought to look into it, but no I

didn’t mean people to take this as

accepted fact. So in court in England,

the judges ruled that her Geddes

universal hypothesis could no longer be

regarded as such, as credible science,

and would have to explain the injuries.

So then they went on to evaluate the

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appeals in the light of that. So having

said that, there are people in the United

States who will go into court and claim

that it's been proven that babies bleed

into their heads if they stopped

breathing briefly from a choking

episode. So if you're in a case where it's

being claimed that lack of oxygen,

Hypoxia, cessation of breathing,

whatever, caused the baby to bleed into

his head and eyes, you're looking at

some version of Geddes universal

hypothesis and again, don't have polite

language to describe that. Just don't

believe it, don't be taken into it. And

educate your partners in the legal

community about how that is no longer

believed by anyone who thinks hard

about it.

Slide 64 Overcoming False DefensesA Valuable Resource

National District

Attorneys Association:

ndaa.org/pdf/Abusive

Head Trauma

There are a lot of false defense

theories. And this is a reference that

medical people would enjoy going

over, but it's something that I would

encourage you to tell if they don't

already know about it. Tell your state

attorney about this reference. It's titled,

"Overcoming Defense Expert

Testimony in Abusive Head Trauma

Cases". It's put out by the National

District Attorneys Association. You'd

like to think that all know about it, but

you may be working with the district

attorney who's doing his very first

abusive head trauma case. He may not

know about this. So put them onto this

reference. They can download it for

free and it goes into all those false there

is that I've described and others

including the claim that immunizations

cause it, or low vitamin C caused it.

Endless spate of false statements that

this can help them put aside.

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Slide 65 Abusive Head TraumaSummary

Abusive Head Trauma is a common cause of serious and fatal injury to infants and young children.

It is very rare for infants and children to suffer life-threatening head injuries in household falls.

Medical providers need to know about false explanations commonly offered by the defense explain serious head injuries.

The term “Abusive Head Trauma” is replacing the term “Shaken Baby Syndrome” since it can sometimes be difficult to determine which infants have only been shaken and which have been shaken and slammed.

Infants do not behave normally after life-threatening head injuries have been inflicted. This is useful in determining who is responsible for the injury.

So as we close here, we have to

acknowledge that unfortunately abusive

head trauma is a common cause of

serious and often fatal injury in infants

and young children. It's fortunately

very uncommon for children to suffer

life-threatening injuries in household

falls. We need, those of us who work in

this field need to know about the

common false explanations that are

offered to explain away these injuries,

and we need to know that the term

abusive head trauma is replacing the

older term "Shaken Baby Syndrome"

because it includes the possibility of

impact as well as shaking and avoids

the problem of having to explain the

whole issue of shaking and an impact

to a jury. And also very importantly

with regard to holding people

responsible for what they've done, we

need to be strong in educating our

community partners especially in the

legal and DCF systems that infants who

suffered serious life-threatening

injuries don't act normal. And that can

be helpful in determining who needs to

be held responsible for the injury and

protecting the child. So it's been a long

trip, but thank you for your attention. I

appreciate your working in this field

and I look forward to talking to you

again in the near future on another

subject related to child abuse. Thank

you.

abusive head trauma: an overview and review of the

Documents