SBS White Papers: Timing the Injuries
March 2014 draft
AretheSymptomsofSeriousInfantHeadInjuryAlways
Immediate?
(No)
Theearliestpapersproposingshakingasamechanismofinfantbraininjuryaresilenton
thesubjectoftiming,andtheearlystatementsformalizingthediagnosisreportedthatthe
[Link],however,mostexpertshave
adoptedthepositionthatsymptomsareimmediate,andtheformalpositionpapershave
changedwithpopularopinion,butthemedicalliteraturecontainsexamplesofdelayed
symptoms,someofthemdocumentedinmedicalsettings.
[Link] Baby Syndrome: Inflicted Cerebral Trauma, Pediatrics 1993
92(6): 8723.
ThisfirststatementfromtheAmericaAcademyofPediatricsgavethestampof
[Link]
mightnotbeimmediate:
Theinfantmayhaveahistoryofpoorfeeding,vomiting,lethargy,and/or
irritabilityoccurringintermittentlyfordaysorweekspriortothetimeof
[Link]
physiciansorattributedtomildviralillnesses,feedingdysfunction,or
infantcolic.(Idat872)
[Link] H, Ratcliffe J, The shaken infant syndrome: Parents and other
carers need to know of its dangers, British Medical Journal 1995 310:
344
TheBritishequivalent,publishedatthesametimeasagovernmentflieronthesubjet,
[Link]
unusual:
Afteravariabletime,theinfantwilldevelopsignsofcerebralirritation,
cerebraloedema,[Link],
convulsions,orrespiratoryorcirculatoryarrestmayfollow.(Idat344)
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
[Link],WilsonHL,FatalChildAbuse:ThePathologistsPerspective,in
Reece,RM,ed.,ChildAbuse:MedicalDiagnosisandManagement,Lea&Febiger,
1994325357
Inthechildabusetexts,meanwhile,expertswerearguingthatallfatalcasesofchild
abuse,includingabusiveheadinjury,[Link]
camewithnocitationstotheliterature:
Despite its frequency, deaths (sic) related to head trauma in
infancy remain the most difficult to prosecute for two reasons: (1)
lethal head trauma in infants is often produced without external
evidence of injury, leading to speculation about mysterious natural
causes or trivial accidental injury; and (2) many clinicians and
pathologists equivocate about the timing of the lethal event
because they are uncertain of the immediate relationship between
the injury and its effect on the brain. It is best, therefore, to state
immediately two axioms regarding fatal head trauma in infants:
1. Trivial events (i.e., falls from beds, couches, against coffee
tables, etc.) produce trivial injuries; significant events (blows,
shaking, forced impact) produce potentially lethal injuries.
2. Lethal injuries produce progressively more severe
symptoms almost immediately; no significant lucid or
asymptomatic period occurs. (Id at 349350)
Although there is a well-recognized lucid interval in adult head injury,
Kirschner and Wilson argue that differences between the adult and infant
brains make a time lag impossible in infants:
The myelinated brain reacts differently to trauma, swelling more
slowly than the infant brain with its higher water content, and the
greater capacity of the cranial vault accommodates a greater
degree of edema before the development of significant
symptoms. (Id at 350)
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
[Link],ZimmermanR,LeedsNMD,Neurologicalmanifestationsinabusedchildren
whohavebeenshaken,DevelopmentalMedicine&ChildNeurology198527:312
316
Thisarticlefromthe1980s,however,includedthiscasestudy:
L.C., a five-week-old girl, was admitted to hospital in status epilepticus.
According to her parents' initial history 'she fell off a kitchen table on her
chest', on the day before admission. Later they admitted they had shaken
her 'because she cried'. She had not lost consciousness, but the next day
she was feeding poorly, and then developed 'right-sided movements'. (Id at
313)
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
[Link],DixJF,Thetimeintervalbetweenlethalinfantshakingandonsetof
symptoms:Areviewoftheshakenbabysyndromeliterature,AmericanJournalof
ForensicMedicine&Pathology199516(2):154157
[Link]
concede,Threecasesdonotenableonetodrawsubstantiveconclusions,they
expresstheiropinioninthediscussion:
Intwocases,[Link]
onecase,therewasadelayof4daysbetweenshakingandonsetof
seizuresalthoughthechildhadseveralepisodesofvomitingduringthe
[Link]
beforeonsetofseizureactivity.(Idat157)
[Link],BankDE,SenacM,ChadwickDL,Restrictingthetimeofinjuryinfatal
inflictedheadinjuries,ChildAbuse&Neglect199721(10):929940
Thisstudylookedat95accidentalfatalinjuriesinvolvingbluntheadtraumainpatients
youngerthan16years,[Link]
[Link]
wasunwitnessedandcasesinwhichtherewasnoemergencyresponseteamsentto
[Link],forexample,achildwhohadbeentakento
theemergencyroombyfamilymembers,becausetherewouldbenoavailable
documentationofthechildsprehospitalclinicalcourse.(Idat930
Unlessthemedicalexaminersinvestigationspecifiedanothertimefortheincident,the
authorsstartedtheintervalclockatthetimeofinitialhealthcarecontact,usingthis
definition:
AlucidintervalwasdefinedasatimewhenachildhadaGCS[Glasgow
ComaScore]of1415,orwhenthetermslucidintervalofconscious
wereusedtodescribeapatientsclinicalstate.(Idat931)
Theonlycasesinwhichchildrenseemedtodeteriorateafterreachingthehospital
includedepiduralhematomas,sotheauthorsconcluded:
Unlessanepiduralhematomaispresent,childrenwhodieofblunthead
[Link]
[headinjury]wherethehistoryclaimsthatthechildlookedwellfollowing
theinjuryandonlylaterbegantoactabnormal,thestorymustbe
questionedandnonaccidentaltraumamustbesuspected.(Idat938939)
[Link],TheMortalityofChildhoodFalls,JournalofTrauma198929(9):12731275.
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
Researchersreviewedacountymedicalexaminersrecordsandidentified44pediatric
deathsfromfallsovera4yearperiod,18ofthemfromaheightoflessthan3feet.
Authorsconcludedthattheyoungestchildrenaremorevulnerablethanolderchildren
todeathfromshortfalls,andnoted,onthesubjectoftiming:
Minorfallscanbelethal,especiallyinatoddler,andmustbeevaluated.
Itisratherdisconcerting,however,thatofthefinaltwogroups,42%
sufferedinjuriesthatareusuallyassociatedwithsurvivalhadtheinjuries
beenimmediatelyrecognizedandaggressiveresuscitationanddefinitive
treatmentinitiated.(Idat1274)
[Link],A,NonaccidentalHeadInjuryinInfantsTheShakenBabySyndrome,
NewEnglandJournalofMedicine1998338(25),18221829
ThisisnotaresearchpaperbutaCurrentConceptscolumn,areviewofthetopicby
theauthorofthe1987biomechanicalstudythatcastdoubtonshakingtheoryandher
[Link]
shaking,butargueforimmediatesymptoms,inbothfatalandnonfatalcases.
Regardingfatalcases,theauthorscitetheWillmanpaper,initem6,andtwoothersless
relevant,toconclude:
On the basis of these data, it can be discerned that there is no
evidence of a prolonged interval of lucidity between the injury and
the onset of symptoms in children with acute subdural hematoma
and brain swellingthe injuries also seen in severe cases of the
shaking-impact syndrome (i.e., those associated with coma or
death). Thus, an alert, well-appearing child has not already
sustained a devastating acute injury that will become clinically
obvious hours to days later. (Id at 1825)
Regardingnonfatalcases,theauthorsnote:
The timing of the traumatic event is more difficult to establish in
patients with mild neurologic injuries and is determined on the
basis of general physical and radiologic findings. These methods
can indicate only a general time frame. (Id at 1825)
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
The paper also explicitly rejects the Woodward defense (an old subdural began
rebleeding while the child was in the nannys care), citing whats known about
sports injuries:
This pattern of injury, with a clear time line and rapid, welldescribed acute deterioration, stands in sharp contrast to the vague
histories of previous episodes of trivial trauma that are sometimes
suggested as possibly causative in the shaking-impact syndrome.
There is no evidence that traumatic acute subdural hematoma,
particularly that leading to death, occurs in otherwise healthy
infants in an occult or sublinical manner. (Id at 1825)
[Link],ShakenBabySyndrome:Rotational
CranialInjuriesTechnicalReport,Pediatrics2001108(1):206209
The2001updateoftheAAPstatementonSBSintroducedimmediatesymptomsby
addingasentencesayingthatparentsshouldnoticeanimmediatechange,butseeming
toleaveroomforambiguity:
A victim of sublethal shaking may have a history of poor feeding,
vomiting, lethargy, and/or irritability occurring for days or weeks.
These clinical signs of shaken baby syndrome are immediate and
identifiable as problematic, even to parents who are not medically
knowledgeable.19 However, depending on the severity of clinical
signs, this may or may not result in caretakers seeking medical
attention. These nonspecific signs are often minimized by
physicians or attributed to viral illness, feeding dysfunction, or
colic. (Id at 207)
[Link],PositionPaperonFatalAbusiveHeadInjuriesinInfantsandYoung
Children,AmericanJournalofForensicMedicine&Pathology,200122(2):112122
TheNationalAssociationofMedicalExaminerspublishedapositionstatementthathas
[Link]
syndrome,arguingthataxonsarestretchedbeyondtheirlimitsduringtheshaking
episode,leadingtoimmediatesymptoms:
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
Recognition of the underlying mechanism of the rotational brain or
shearing injury is important to an understanding of the clinical course of
these children, particularly with respect to the decrease in the level of
consciousness and respiratory distress demonstrated after injury. (Id at 112)
The position paper also cited both Duhaime 1998 and Willman in support of this
conclusion on timing:
Studies in children dying of accidental head injuries indicate that children
with diffuse injury show an immediate decrease in the level of
consciousness (15, 16). (Id at 118)
[Link],SymptomsFollowingHeadInjury(letter),AmericanJournalof
ForensicMedicineandPathology,2002vol.23,no.1,p.105
[Link]
performedtheautopsyonatoddlerwhohadbeenbroughttothehospitalinthe
[Link]
[Link]
gaspingforair,[Link]:
Mypointisthatthechilddidhavesomesymptoms,butclearlythesevere
intracranialinjurysymptoms,whichwereconfirmedonrepeatcomputer
tomographyandautopsy,weredelayedforseveralhours,duringwhich
timeshewasunderourviewandreviewinthehospital.(Idat105)
[Link],AuthorsResponse,AmericanJournalofforensicMedicineandPathology,
2002vol.23,no.1,pp.105106
Theleadauthorrespondedthatthechildhadshownsymptoms,astheposition
statementpredicted:
When a child has suffered a serious acceleration injury to the brain that
will result in long-term neurologic impairment or cause death, the socalled lucid interval is a fiction. The change from fine to not fine may
be lethargy or it may be unresponsiveness, but it is a neurologic change,
and it occurs at the time of injury (Id. at 106)
Sue Luttner
SBS White Papers: Timing the Injuries
March 2014 draft
[Link],MileusnicD,DelayedSuddenDeathinanInfantFollowinganAccidental
Fall:ACaseReportWithReviewoftheLiterature,AmericanJournalofforensic
MedicineandPathology,vol.24,no.4,pp.371376
Apairofphysiciansreportedfromthefieldontheirexperiencewithanapparentcase
ofdelayedsymptomsfollowinga30inchfallfromabed.The9montholdwas
observedintheinterimbyhisgrandmother,hismother,andhisbabysitter,whoall
knewofthefallandwerewatchingforinjuriesbutsawnothingalarmingfortwodays.
Approximately72hoursafterthefallfromthebed,thechildwasfoundcoldand
[Link].
Althoughthisisararepresentationofatraumaticbraininjurybasedon
recentadvancesintraumaticneuropathologyitisconceivable,asinthis
case,thatadelayedasymptomaticdeteriorationtodeathcanoccur.(Idat
375)
Sue Luttner
