shaken baby syndrome
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SHAKEN BABY SYNDROME. Bernadette J. Madrid, M.D. Executive Director Child Protection Unit Network. What is physical abuse?. Acts by a caregiver that cause actual physical harm or have the potential for harm (WHO, 2002) - PowerPoint PPT PresentationTRANSCRIPT
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SHAKEN BABY SHAKEN BABY SYNDROMESYNDROME
Bernadette J. Madrid, M.D.Bernadette J. Madrid, M.D.
Executive DirectorExecutive Director
Child Protection Unit NetworkChild Protection Unit Network
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What is physical abuse?What is physical abuse?
Acts by a caregiver that cause actual Acts by a caregiver that cause actual physical harm or have the potential physical harm or have the potential for harm (WHO, 2002)for harm (WHO, 2002)
Physical injury includes but is not Physical injury includes but is not limited to lacerations, fractured limited to lacerations, fractured bones, burns, internal injury or bones, burns, internal injury or serious bodily harm suffered by the serious bodily harm suffered by the child (R.A. 7610)child (R.A. 7610)
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Head Trauma in Head Trauma in Child AbuseChild Abuse
Most common cause of Most common cause of mortality and morbidity in mortality and morbidity in physical child abusephysical child abuse
33%-56% of brain injuries in 33%-56% of brain injuries in children children < 1 year of age were inflicted.< 1 year of age were inflicted.
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Head Trauma in Head Trauma in Child AbuseChild Abuse
INCIDENCEINCIDENCE
Population-based study in Population-based study in Scotland (Barlow & co-Scotland (Barlow & co-authors, 2000):authors, 2000):
24.6 per 100,00024.6 per 100,000
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Shaken Baby Syndrome Shaken Baby Syndrome (SBS)(SBS)
Violent shaking or shaking plus head Violent shaking or shaking plus head impact against a hard or even soft impact against a hard or even soft surfacesurface
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SBS/SISSBS/SIS
Crying is the usual trigger to shakingCrying is the usual trigger to shaking Infant held by chest, upper arms or neckInfant held by chest, upper arms or neck Variable duration – 4-20 secondsVariable duration – 4-20 seconds 2-4 shakes per second2-4 shakes per second Head rotates in many directions on the Head rotates in many directions on the
axis of the neckaxis of the neck
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Infant Brain vs. Infant Brain vs. Adult BrainAdult Brain
Infant brain has approximately 25% Infant brain has approximately 25% more water than the adult brainmore water than the adult brain
Infant brain has little or no myelinInfant brain has little or no myelin
Result: infant brain is much softer, Result: infant brain is much softer, more gelatinous than adult and thus more gelatinous than adult and thus more fragilemore fragile
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Retinal HemorrhagesRetinal Hemorrhages
Incidence of RHs in SBS: 50% -100%Incidence of RHs in SBS: 50% -100%
Overwhelmingly more common in SBS Overwhelmingly more common in SBS than in accidental head injuriesthan in accidental head injuries
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Signs and Symptoms of Signs and Symptoms of SBS/SISSBS/SIS
Variable, depending on duration and Variable, depending on duration and number of shakes, presence of impactnumber of shakes, presence of impact
Continuum from decreased Continuum from decreased responsiveness, irritability, lethargy, responsiveness, irritability, lethargy, limpness to:limpness to: Seizures, tachypnea, bradycardia, Seizures, tachypnea, bradycardia,
hypothermiahypothermia Coma, deathComa, death
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Associated InjuriesAssociated Injuries
BruisingBruising Abdominal InjuriesAbdominal Injuries Skeletal injuries:Skeletal injuries:
Long bonesLong bones Posterior rib fracturesPosterior rib fractures Classic metaphyseal lesions (CML)Classic metaphyseal lesions (CML)
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Present IllnessPresent Illness
3 most common triggering 3 most common triggering events:events:
Inability to control infant cryingInability to control infant crying
Feeding difficultiesFeeding difficulties
Toileting issuesToileting issues
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Past HistoryPast History
AccidentsAccidents Previous seizure episodesPrevious seizure episodes Previous hospitalizationPrevious hospitalization
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Suspicious Stories* – Suspicious Stories* – Fatal CasesFatal Cases
1.1. Child fell from low heightChild fell from low height
2.2. Child fell onto furniture, floor, objectChild fell onto furniture, floor, object
3.3. Unexpectedly found deadUnexpectedly found dead
4.4. Child choked, shaken to dislodge Child choked, shaken to dislodge objectobject
5.5. Child turned blue, shaken to reviveChild turned blue, shaken to revive
6.6. Sudden seizure activitySudden seizure activity
*Kirschner*Kirschner
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7.7. Resuscitation efforts caused Resuscitation efforts caused injuriesinjuries
8.8. Traumatic event a day or so agoTraumatic event a day or so ago
9.9. Tripped or slipped carrying childTripped or slipped carrying child
10.10. Sibling did itSibling did it
11.11. Child left alone for short timeChild left alone for short time
12.12. Child fell down stairsChild fell down stairs
Common Suspicious Common Suspicious StoriesStories
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Outcomes of SBSOutcomes of SBS
Long-term morbidity high Long-term morbidity high amongst survivors – 90% amongst survivors – 90% affectedaffected
Mortality rate approximately Mortality rate approximately 20%20%
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Sequelae of SBSSequelae of SBS
Tetraplegia, hemiplegia, Tetraplegia, hemiplegia, hemiparesishemiparesis
Mental RetardationMental Retardation BlindnessBlindness Learning DisabilitiesLearning Disabilities Cerebral PalsyCerebral Palsy
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Issues when child is in the Issues when child is in the hospitalhospital
Protective CustodyProtective Custody Consent for proceduresConsent for procedures ““Bantay” in the hospitalBantay” in the hospital
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Sec. 9 IRR of RA 7610Sec. 9 IRR of RA 7610
Protective Custody. Protective Custody. If the investigation If the investigation discloses sexual abuse, serious physical discloses sexual abuse, serious physical injury or life-threatening neglect of the injury or life-threatening neglect of the child, the duly authorized officer or child, the duly authorized officer or social worker of the Department shall social worker of the Department shall immediately remove the child from his immediately remove the child from his home or the establishment where he home or the establishment where he was found and place him under was found and place him under protective custody ensure his safety.protective custody ensure his safety.
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Patient comes to MD
Determine nature of injuries
Intentional/Neglect/Physical abuse
Child at risk
Report to LGU or DSWD field office
PROTECTIVE CUSTODY
INVESTIGATIONS:
Family
Crime Scene
Community
Involuntary commitment Criminal Case filed
MD
LGU DSWD
LGU DSWD
PNP
LGU DSWD
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Issues if the child diesIssues if the child dies
Consent for autopsyConsent for autopsy No ComplainantNo Complainant Can we prove who inflicted Can we prove who inflicted
these injuries?these injuries? What is the charge?What is the charge?
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DOJ circular No. 55 (Sept. 11, DOJ circular No. 55 (Sept. 11, 2002)2002)
Authorizing all Provincial and City Prosecutors to make an order for the performance of an autopsy on the
body of child-victims, upon the request of any interested party, and upon proper showing that the child
may have died under suspicious or abuse-related circumstances, there being no external signs to readily conclude that the child died as a result of violence or
crime.
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DOJ circular No. 55 (Sept. 11, DOJ circular No. 55 (Sept. 11, 2002)2002)
“Any interested party”
Shall include but be not limited to a law enforcementOfficer, parent or legal guardian, or authorized physicians of the UP-PGH Child Protection Unit and other government hospitals.
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Common DefensesCommon Defenses
Alibi, character and other Alibi, character and other defense witnessesdefense witnesses
Medical Witnesses for the Medical Witnesses for the defensedefense