Transcript Document

Shaken Baby Syndrome
David R. Kroning, M.D., M.S. FAAP
Chief
Child Protection and Safety Center
St. Joseph’s Children’ Hospital
7/7/2015
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Introduction
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Present an overview of the
problem of the Shaken Baby
Syndrome and the impact it has on
society.
The great importance of the use of
a multidisciplinary approach to the
problem
What exactly is Shaken Baby
Syndrome
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The most common cause of
traumatic death in infants???
Head Injury.
Mechanism: Abuse
AAP: 1993; Cody, Brown,
Montgomery, Flynn, Yetman,
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First described (1974)
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“Whiplash shaken infant
syndrome”
SBS is now widely recognized
diagnosis in the medical literature.
Medical components include:
retinal hemorrhage, subdural or
subarachnoid hemorrhage,
fractures +/- external physical
findings
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Incidence
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???? Hard to ascertain
Perpetrator is reluctant to provide an
accurate history
Most victims are < six months of age
(AAP, 1993 )
Males > Females ( Starling, Holden
Jenny 1995)
Race: Predominance Caucasian,
African-American with fewer Latino and
Asian infants
Effects all racial, ethnic and socioeconomic groups (Riffenburgh 1991)
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RISK Factors
Concept of reversed nurturing needs
Environmental stressors
Children may possess factors which
contribute to their own abuse.
People who have admitted to
shaking a child usually state that
they were not trying to harm the
infant but wanted to:
“ Make the Baby Stop Crying”
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Risk
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Others admit to shaking the infant
during “Vigorous Play” which is
later found to be inconsistent with
the severity of injury (Starling et. al.
1995)
??? 25% - 50% No Idea Shaking
Can Harm A Baby ???
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Mechanism of Injury
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Infants are more susceptible to shaking
injuries. WHY ????
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Factors: Large head, weak neck
muscles, unmyelinated brain, soft
sutures, open fontanelles, and realtively
increased cerebrospinal fluid.
Cerebral bridging veins are more easily
stretched or lacerated with excessive
acceleration, deceleration and rotation of
the brain
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WHY ????
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Ocular injury : Retinal and vitreal
hemorrhage, retinal folds and
retinoschesis.
Results from 1) increased
intracranial pressure, increased
ocular pressure 2) rapid brain
acceleration/deceleration 3) direct
trauma to the retina from being
struck by vitreous moving within
the eye (Coody et al. 1994)
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Can Shaking Alone
Cause All This???
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Duhaime et al.(1987) used laboratory and animal
models and found that some form of impact was
necessary in at least the most severe cases of
SBS.
“ Although shaking may , in fact, be part of the
process, it is more likely that the infants suffer
blunt impact “
Shaking is sufficient to cause serious intracranial
injury or death”
Irrespective of the presence of impact, SBS
injuries occur because of severe
acceleration/deceleration and remain a
significant cause of morbidity and mortality.
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Clinical Presentation
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Can be very non-specific
Child may present with a bulging
fontanelle or with more subtle
signs: Vomiting, irritability,
seizures, poor feeding, failure to
thrive
Bruising is more the exception than
the rule
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Diagnosis
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CT Scan has become the method of
choice for initial imaging of patients with
suspected brain injury
CT Scan identifies lesions requiring
operative intervention (AAP 1993)
MRI has shown to detect 50% more
subdural hemorrhages than CT and
detect smaller injuries missed by CT
However, cost makes it more useful as a
second study
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Diagnosis
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Ophthalmologist
RH has been found in 75-90% of
cases of SBS
External signs usually minimal (this
is one of the hallmarks of shaken
baby syndrome
Bulging fontanelle present in 55%
of infants with subdural (Ludwig)
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Prognosis
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Victims : Significant morbidity and
mortality
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50% morbidity 15% mortality
(Ludwig)
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Prognosis
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Permanent brain damage
Hydrocephalus, developmental
delay, blindness, deafness,
paralysis and mental retardation
Milder forms of SBS might present
with mental retardation and
developmental delay upon
reaching school age
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Prevention
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100% preventable
Medical literature is abundant with
information about SBS
Many pediatricians and health
professional lack the knowledge,
willingness or ability to make the
diagnosis
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Prevention
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More concerning the lack of SBS
knowledge by the general public
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Great example: The nanny case, this
case documented this lack of information
by judges, juries and even the medical
profession
Many confessed perpetrators believed
that shaking an infant for discipline or
during vigorous play could not harm the
child in such a devastating way.
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Historical Perspectives
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1891 German Pathologist, Dohle
Autopsies in children found
subdural hematoma to be a
common finding
396 autopsies of children <1 14%
had subdural children >1 8%
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Historical
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1907 William Preyer published his
text Mental Development of the
Child he described several
potentially harmful practices: “too
vigorous rocking of the cradle”
‘The inexcusable violent rocking in
the cradle which puts the baby into
a dazed condition in order that he
may not trouble that have care of
him is extremely injurious”
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Historical
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1930 David Sherwood’ publication:
Investigation of subdural
hematoma in children, he reported
infants came from dubious
environments made the histories
provided by the parents less
valuable, therefore questioned the
possible head trauma with taking
the final step and suggesting the
possibility of abuse.
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Historical
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Holt’s Diseases of Infants and Children
was a popular pediatric textbook 19301940s
Holt “hemorrhagic pachymeningitis”
etiology unknown.
The frequency with which the condition is
encountered in foundlings, illegitimate
children and those in institutions have
often been commented on” “ Breast-fed
infants are notoriously immune from this
disorder”
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Historical
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Greatest advances: 1940-1950s
Emergence of radiology as a medical
specialty
John Caffey: 1946 Published the
landmark article “multiple fractures in the
long bones of infants suffering from
chronic subdural hematoma”
John Caffey: “On the theory and practice
of shaking infants (1972) Whiplash
Shaken Infant Syndrome”
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Historical
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Caffey: Case: 15 patients and their
injuries occurred while in the care of
Virginia Jaspers, who was employed to
care for infants. Newsweek Magazine
1956
Quote: “ That evening Abby, 11 days old,
didn’t want to take her formula. The
nurse picked her up and gave her a good
shaking. It was all uncontrollable I don’t
know why I did it”
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The Perpetrator
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Males 60-70%
Mother boyfriends 34%, also found to be
the most common perpetrators in cases
of severe or fatal cases
One study Boyfriend perpetrator in 64%
of cases (Margolin)
(Starling) men 2.2 times more likely the
perpetrators in cases of abusive head
trauma
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Perpetrators
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Baby sitters (4-30%) (Kunz, Bahr)
With more than 60% of mother
working outside of home (Starling)
Mother (6.5%) Most likely
perpetrators during the first week
of life and often the father or
stepfather after week of life
(Duhaime)
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The Victim
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Relative risk for males compared
to females ( 4 ) ( “Harm Standard”)
Under 1 year of age with the mean
age between five and six months
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Presenting Symptoms
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Frequently non-specific
URI, Vomiting or Irritability (23%)
Diarrhea, Poor Feeding, Lethargy,
Apnea, Seizure, History of minor trauma
Most missed cases: (age) younger than
180 days (race) white children, (family
composition) both parents lived with the
child and (severity of symptoms) at the
initial visit
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Symptoms
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History must match Physical
findings
High index of suspicion when nonspecific symptoms and history are
at odds
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Differential Diagnosis
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Coagulopathy, Osteogenesis
Imperfecta, Glutaric Aciduria type 1
(GA-1)
Familial or acquired coagulation
disorders generally present with
vaible bruises, petechia and
mucosal bleeding in addition to
intracranial bleeding
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DDx
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Osteogenesis Imperfecta: blue
sclerae, joint hypermobility, hearing
deficits, inadequate mineralization
and dental defects
GA-1: Developmental delay,
disorders of tone and movement
as well as evidence of cerebral
atrophy
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Long Term Medical
Burden
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Reports estimate that SBS
accounted for 10% to 12% of all
child maltreatment related deaths
Approximately 25% of all shaken
baby syndrome victims will die as a
result of their injury (Jason)
Who survive: Neurologic
complication could affect as many
as 57% (Goldstein et al.)
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The Cost of SBS
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SBS cost the State of Michigan an
estimate of $ 92 Million Dollars in
1994 (Caldwell)
Impossible to measure the worth of
human life
Medical care, juvenile justice
system, child protection system,
foster care placement,
psychological care, special
education
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Prevention
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Education
Awareness programs
Places like St. Joseph’s Children’s
Hospital
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Review Physical and
Radiographic Findings
The Brain:
Subural Hemorrhage
Subarachnoid Hemorrhage
Diffuse Axonal Injury
Edema/infarction
Parenchymal laceration/contusion
Parenchymal Hemorrhage
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Continue
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The Eye:
Retinal Hemorrhages
Vitreous Hemorrhages
Retinoschisis
Papilledema
Retinal Detachment
Disruption of eye contents
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Continue
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The Bones
Rib fractures
Skull fractures
Long bone injuries periosteal
stripping, metaphyseal fractures,
shaft fractures
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How can all this
happen???
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Violent, sustained accelerationdeceleration +/- blunt head trauma
Shake time 2-3 seconds, head
movement approximately 3-4X per
sec
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Short Falls do not kill
children
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Shaking is often accompanied by
impact
Impact is not required for serious
injury
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Conclusion
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Help us in the prevention of SBS
and all forms of abuse. We at
SJHRMC, Children Hospital are
involved in a statewide prevention
initiative to initiated “Mandatory
Statewide Program” in which
parents would be given information
on the dangers of shaking a baby.
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The Turrell Fund
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The Positive Pathways to
Parenting
A program of The Child Protection
Center
Goal: Providing education to all
Patients and families (care-givers)
who deliver their baby’s at SJRMC.
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Providing What
Education????
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DVD presentation
Handouts and other take home
gifts
Finally a certificate given to caregivers of baby
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How to Capture Your
Caretaker???
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While still in the Hospital, Materials
given Education initiated,
questions answered
Our plan and our proposal to you!!!
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Shaken Baby
Legislation
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Take it to the Capitol
Assemblyman Steele,
Assemblywomen Pou and Senator
Girgenti have all agreed to sponsor
a bill
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The Bill
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Require all hospitals in New Jersey
to educate their parents on Shaken
Baby Syndrome
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Help Us Make It Happen
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Two states currently have
legislation: Utah and New York
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St. Joseph’s Children’s
Hospital
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Our Patients Our Nursery Our
Babies 100% compliance all who
enter our nursery will leave with
the knowledge and awareness of
the risk of not only shaking their
baby but also with tips on how to
handle those periods of “Purple
Crying”
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