Spotlight on practiceThe whiplash shaken infant syndrome: Has Caffey's syndrome changed or have we changed his syndrome?
Abstract
Objective: The aim of this study is to examine the data used by John Caffey in his description of the Whiplash Shaken Infant Syndrome and compare it with recent data in an attempt to determine whether the syndrome that he described has changed, or if we have changed his syndrome into what we now call The Shaken Infant Syndrome.
Method: This study examined recent literature describing the Shaken Infant Syndrome, and compared it to Caffey's descriptions. In addition, a retrospective review of 71 children under the age of 3 years identified as having a subdural hematoma caused by other than accidental means during 54 months was done. This data was compared to data from the 27 case examples offered by Caffey in 1972 and his other descriptions in 1974 and 1946.
Results: A review of recent literature shows that our definition of Shaken Infant Syndrome today includes cases where impact trauma was involved. In contrast to Caffey's descriptions, we found the perpetrator to be more often male, fractures to be more often to ribs rather than long bones, and admissions of shaking and other trauma more often made.
Conclusions: Our findings demonstrate that not only have we changed the diagnostic parameters from Caffey's original Whiplash Shaken Infant Syndrome, but the syndrome has also changed to reflect changes in medical diagnosis and in our society.
Résumé
But: Le but de cette étude est d'examiner les données utilisées par John Caffey dans sa description du “Whiplash Shaken Syndrome” et de les comparer avec des données récentes, afin de déterminer si le syndrome qu'il a décrit a changé ou si nous avons transformé son syndrome en ce que nous appelons aujourd'hui le “Shaken Infant Syndrome” (Le syndrome de l'enfant secoué).
Méthode: Cette étude examine la littérature récente décrivant le “Shaken Infant Syndrome” et la compare aux descriptions de Caffey. En plus une étude rétrospective de 71 enfants de moins de 3 ans, identifiés comme ayant un haematome sous-dural non accidentel a été effectuée pendant 54 mois. Ces données not été comparées aux données des 27 cas décrits par Caffey en 1972 et ses autres descriptions en 1974 et 1946.
Résultats: Une revue récente de la littérature démontre que notre définition du “Shaken Infant Syndrome” inclus aujourd'hui des cas où un traumatisme par impact direct avait eu lieu. contrastant avec les découvertes de Caffey, nous avons trouvé que l'auteur était plus souvent masculin, les fractures le plus souvent des fractures des côtes que des os longs et qu'il y avait plus d'aveux de secouements et autres traumatismes.
Conclusions: Nous n'avons donc pas seulement changé les paramètres diagnostiques depuis l'original “Whiplash Shaken Infant Syndrome” de Caffey, mais le syndrome a aussi évolué et reflete les changements liés au diagnostique médical et à la société.
Resumen
Objetivo: El objetivo de este estudio es examinar los datos utilizados por John Caffey en su descripción del “Whiplash Shaken Infant Syndrome” (Síndrome Infantil por Sacudida de Látigo) y compararlos con datos recientes en un intento por determinar si el síndrome que el describió ha cambiado, o si hemos cambiado su síndrome en lo que ahora llamamos “The Shaken Infant Syndrome: (Síndrome del Niño Sacudido).
Método: Este estudio examinó la literatura reciente que describe el “Síndrome del Niño Sacudido,” y la comparó con las descripciones de Caffey. Además, se realizó una revision retrospective de 71 niños menores de tres años identificados con un hematoma subdural ocasionada de manera no addicental durante 54 meses. Estos datos se compararon con los datos de los 27 casos que como ejemplo ofreció Caffey en 1972 y sus otras descripciones en 1974 y 1946.
Resultados: Una revisión de la literatura reciente demuestra que hoy nuestra definición del “Síndrome del Niño Sacudido” incluye casos de trauma por impacto. Contrario a las descripciones de Caffey, encontramos que el perpetrador era más a menudo varón, las fracturas eran más a menudo en las costillas en lugar de los huesos largos, y las admisiones por sacudidas y otros traumas son más frecuentes.
Conclusiones: Nuestros hallazgos demuestran que no solo hemos cambiado los parámetros del diagnóstico original del “Síndrome Infantil por Sacudida de Látigo,” sino que el síndrome también ha cambiado reflejando cambios en el diagnóstico médico y en nuestra sociedad.
References (9)
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The whiplash shaken infant syndrome: What has been learned?
Child Abuse & Neglect
(1986) - A.L. Mehl
Shaken impact syndrome
Child Abuse & Neglect
(1990) - D.A. Bruce et al.
Shaken impact syndrome
Pediatric Annals
(1989) - J. Caffey
Multiple fractures in the long bones of infants suffering from chronic subdural hematoma
American Journal of Roentgenology
(1946)
Cited by (46)
Pediatric Major Head Injury: Not a Minor Problem
2018, Emergency Medicine Clinics of North AmericaCitation Excerpt :For this reason, a thorough physical examination may still not be enough in younger children. Nearly 20% to 50% of children with AHT were found to have axial or appendicular fracture as well, so a skeletal survey and dilated retinal examination performed by an ophthalmologist is recommended by the American Academy of Pediatrics for all such patients.4,87–91 Management of these patients is similar to that of accidental trauma with life-threatening issues addressed first and prevention of secondary injury second.
Nuances in pediatric trauma
2013, Emergency Medicine Clinics of North AmericaCitation Excerpt :Classically, the injury pattern associated with nonaccidental head trauma includes subdural hemorrhages, retinal hemorrhages, and diffuse brain injury.27,28 The provider must be judicious and search for other injuries in a child with suspected NAT, because approximately 20% to 50% of children with abusive head trauma have extracranial skeletal fractures.29–34 The American Academy of Pediatrics recommends a full skeletal survey in any child less than 2 years of age with suspected NAT.
Shaken baby syndrome consists of intracranial and intraocular hemorrhages in young children in the absence of signs of direct head trauma. Because it has major medicolegal implications, it must be distinguished from accidental trauma. This study aimed to determine the ophthalmologic manifestations and their natural course in child abuse victims and whether ophthalmologic examination can help to distinguish shaken babies from children with accidental impact head trauma.
Prospective comparative observational case series.
A prospective study was conducted from January 1996 to September 2001 on 241 consecutive infants hospitalized for a subdural hematoma to determine the frequency and the type of ocular abnormalities encountered. At admission, 186 children were highly presumed to have been shaken (group 1), 38 children had signs of direct head trauma without any relevant history of trauma (group 2), some of them having been possibly shaken, whereas 7 children had proven severe accidental head trauma (group 3).
Intraocular hemorrhages were the main finding. Their shape, laterality, and size were not significantly different in groups 1 and 2. However they were significantly more frequent in nonaccidental head trauma than in infants with head impact (77.5% versus 20%). None of the group 3 children had intraocular hemorrhage. Eighty-two percent of intraocular hemorrhages resolved within 4 weeks.
Intraocular hemorrhages are frequent in shaken babies but not specific of this syndrome. When associated with a subdural hematoma, they are strongly suggestive of shaken neglect. They are rare in pediatric accidental head trauma.
Abusive head trauma in Maine infants: Medical, child protective, and law enforcement analysis
2003, Child Abuse and NeglectObjective: To collect and compare the results of medical, child protective, and law enforcement evaluation of a sample of Maine children who were victims of abusive head trauma (AHT) in order to describe the clinical and evaluative characteristics as they relate to victims, families and perpetrators of such trauma and to improve the professional response to AHT in Maine.
Method: Retrospective chart review of medical, child protective, and law enforcement records of all AHT victims admitted to two tertiary care hospitals in Maine or seen by the state medical examiner from 1991 to 1994.
Results: Nineteen children (age range 2 weeks to 17 months) were identified as victims of AHT (out of a total of 94 head trauma admissions) accounting for 20 hospitalizations during the study period. There was a history of prior injury in 30%, history of prior medical evaluations for possibly abuse related problems in 65%, while, on presentation, 75% had evidence or history of prior injury. The hospitals notified child protective services (CPS) in all 20 cases and correctly identified abuse in 18 (90%). Parental risk factors for abuse identified in CPS records included substance abuse (53%), domestic violence (42%), criminal history (32%), unrealistic expectations (42%), and attachment problems (32%). However, risk factors were inadequately assessed in 53% of homes. Law enforcement identified a likely perpetrator in 79% of cases and in the majority the identified suspect was the father. In the 15 cases where a perpetrator was identified by law enforcement, that person was alone with the child at symptom onset in 14 (93%).
Conclusions: The medical response, at least at the inpatient level, was generally well done with regard to suspicion and reporting. Cases are possibly being missed at the outpatient level. Child protective risk assessment was limited overall yet in a third of the homes where AHT occurred, few if any risk factors were present to aid in identification and prevention. Law enforcement results suggest that a primary suspect for AHT is the caretaker alone with the child at the time of symptom onset.
Objectif: Réunir et comparer les résultats de l’évaluation des aspects de l’intervention médicale, de l’intervention de protection des enfants et de l’intervention judiciaire pour un échantillon d’enfants maltraités victimes de traumatisme crânien (AHT) afin de décrire les caractéristiques cliniques et évaluatives relatives aux victimes, aux familles, aux auteurs de tels traumatismes. Le but poursuivi concerne également l’amélioration de la réponse des professionnels au AHT dans le Maine.
Méthode: On a mis en tableaux les dossiers médicaux, de protection de l’enfance et d’intervention judiciaire de toutes les victimes admises dans deux hopitaux tertiaires du Maine ou examinés par l’expert de l’Etat entre 1991 et 1994.
Résultats: 19 enfants (entre 2 semaines et 17 mois) ont été identifiés comme victimes de traumatisme crânien (sur un total de 94 admissions pour ce traumatisme) ceci ayant amené 20 hospitalisations pendant la durée de l’étude. Il était fait état de blessure antérieure dans 30% des cas, d’examen médical pour des problèmes qui auraient pu être liés à des mauvais traitements dans 65% des cas, alors que, au moment de leur présentation 75% avaient des signes évidents de mauvais traitement. Les hopitaux ont avertiles Services de Protection de l’Enfance (CPS) pour les 20 cas et correctement identifié les mauvais traitements pour 18 d’entre eux (90%). Les risques parentaux identifiés dans les dossiers des CPS concernaient: la toxicomanie (53%), la violence domestique (42%), des antécédants criminels (32%), des attentes démesurées (42%) ainsi que des problèmes d’attachement (32%). Toutefois les facteurs de risques avaient été évalués de façon inadéquate dans 53% des foyers. L’intervention judiciaire avait identifié un auteur présumé dans 70% des cas et dans la majorité de ceux-ci le suspect était le père. Parmi les 15 cas où un suspect fut identifié par l’intervention judiciaire, cette personne était seule avec l’enfant dans 14 cas (93%).
Conclusions: La réponse médicale, au moins lors de l’hospitalisation, a été correctement apportée en ce qui concerne la présomption et le signalement. Certains cas ont pu être méconnus au niveau de consultations externes. L’évaluation du risque pour la protection de l’enfant a été limitée dans l’ensemble, alors que dans le tiers des foyers où un traumatisme crânien a eu lieu, seulement un petit nombre de facteurs de risque ont pu être epérés pour aider à l’identification et à la prévention du problème. Les résultats de l’intervention judiciaire a suggéré que le premier suspect concernant un traumatisme crânien serait la personne s’occupant seule d’un enfant au moment où le symptôme est apparu.
Objetivo: Recoger y comparar los resultados de las evaluaciones médica, de protección infantil y legal, de una muestra de niños de Maine que fueron vı́ctimas de trauma abusivo de la cabeza (AHT) para describir las caracterı́sticas clı́nicas y evaluativas relacionadas con las vı́ctimas, las familias, y los perpetradores de estos traumas, y para mejorar la respuesta profesional a los AHT en Maine.
Método: Revisión retrospectiva del record médico, de protección infantil, y legal de todas las vı́ctimas de AHT admitidas a dos hospitales de cuidado terciario en Maine o vistos por el examinador médico estatal de 1991–1994.
Resultados: Diecinueve niños (las edades van desde 2 semanas a 17 meses) identificados como vı́ctimas de AHT (de un total de 94 admisiones por trauma de cabeza) corresponden a 20 hospitalizaciones en el perı́odo de estudio. El 30% tenı́a una historia de lesión anterior; 65% tenı́an una historia de evaluaciones médicas anteriores por problemas relacionados con sospecha de abuso; mientras que en la presentación, el 75% tenı́a evidencia o historia de lesiones anteriores. Los hospitales notificaron a los Servicios de Protección Infantil (CPS) en los 20 casos e identificaron correctamente el abuso en 18 (90%). Los factores de riesgo parental para el abuso identificado en los registros de los Servicios de Protección Infantil incluyeron abuso de sustancias (53%), violencia doméstica (42%), historia criminal (32%), expectativas irreales (42%), y problemas de apego (32%). Sin embargo, los factores de riesgo fueron inadecuadamente evaluados en 53% de los hogares. El departamento legal identificó un posible perpetrador en 70% de los casos y en la mayorı́a de estos el sospechoso identificado era el padre. En los 15 casos en que el perpetrador fue identificado por el departamento legal, esa persona estaba sola con el niño al aparecer el sı́ntoma en 14 (93%) de los casos.
Conclusiones: La respuesta médica, por lo menos en la etapa del registro del paciente y relacionada con la sospecha y el reporte, estuvo generalmente bien hecha. Los casos posiblemente se escapan en la etapa ambulatoria. La evaluación de riesgo de Protección Infantil fue en general limitada; sin embargo en un tercio de los hogares donde ocurrió AHT, pocos o ninguno de los factores de riesgo estuvieron presente para ayudar en la identificación y la prevención. Los resultados del departamento legal sugieren que un sospechoso primario de AHT es el cuidador solo con el niño en el momento de inicio del sı́ntoma.
Do educational materials change knowledge and behaviour about crying and shaken baby syndrome? A randomized controlled trial
2009, CMAJ. Canadian Medical Association JournalShaken baby syndrome often occurs after shaking in response to crying bouts. We questioned whether the use of the educational materials from the Period of PURPLE Crying program would change maternal knowledge and behaviour related to shaking.
We performed a randomized controlled trial in which 1279 mothers received materials from the Period of PURPLE Crying program or control materials during a home visit by a nurse by 2 weeks after the birth of their child. At 5 weeks, the mothers completed a diary to record their behaviour and their infants' behaviour. Two months after giving birth, the mothers completed a telephone survey to assess their knowledge and behaviour.
The mean score (range 0–100 points) for knowledge about infant crying was greater among mothers who received the PURPLE materials (63.8 points) than among mothers who received the control materials (58.4 points) (difference 5.4 points, 95% confidence interval [CI] 4.1 to 6.5 points). The mean scores were similar for both groups for shaking knowledge and reported maternal responses to crying, inconsolable crying and self-talk responses. Compared with mothers who received control materials, mothers who received the PURPLE materials reported sharing information about walking away if frustrated more often (51.5% v. 38.5%, difference 13.0%, 95% CI 6.9% to 19.2%), the dangers of shaking (49.3% v. 36.4%, difference 12.9%, 95% CI 6.8% to 19.0%), and infant crying (67.6% v. 60.0%, difference 7.6%, 95% CI 1.7% to 13.5%). Walking away during inconsolable crying was significantly higher among mothers who received the PURPLE materials than among those who received control materials (0.067 v. 0.039 events per day, rate ratio 1.7, 95% CI 1.1 to 2.6).
The receipt of the Period of PURPLE Crying materials led to higher maternal scores for knowledge about infant crying and for some behaviours considered to be important for the prevention of shaking. (ClinicalTrials.gov trial register no. NCT00175422.)
Une version française de ce résumé est disponible à l'adresse www.cmaj.ca/cgi/content/full/180/7/727/DC1
CMAJ 2009; 180(7):727-33
A case of shaken baby syndrome after discharge from the newborn intensive care unit
2005, Advances in Neonatal Care