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Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome

A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least one eye could be found ranging between a maximum value of 19.2 and 73.2% of the entire retinal area. In contrast, only two cases of the control group (severe head injury with skull fractures and intracranial bleeding following traffic accident or fall) showed slight hemorrhages of 3.33 or 1.18% of the retinal area but only in one eye. Therefore, the results provide evidence that massive intraretinal hemorrhages indicate violent shaking — in particular in association with other signs of physical child abuse.     

The eyes of child abuse victims: autopsy findings.

The authors studied 77 pairs of eyes removed from children who had died of suspected child abuse. Forty-seven of the cases had retinal hemorrhages. Those showing retinal hemorrhages were younger children and had fewer other stigmata of child abuse. Hemorrhages are more likely to occur in cases where the child was shaken or swung than in those with severe direct head trauma. The authors recommend that examination of the eyes be included in the autopsies of all small children who died without an obvious cause of death. Experience in both processing and reading of ocular material is necessary for reliable results.     

Retinal hemorrhage in an infant after cardiopulmonary resuscitation

Unexplained retinal hemorrhages in infants are usually indicative of child abuse. We present the case of an infant with retinal hemorrhages following cardiopulmonary resuscitation, who had not been abused. Cardiopulmonary resuscitation should be added to the list of causes of retinal hemorrhages in infants and children.     

Are Peripapillary Intrascleral Hemorrhages Pathognomonic for Abusive Head Trauma?*

Abstract: The American Academy of Pediatrics’ Committee on Child Abuse and Neglect, Section on Ophthalmology, acknowledges that searching for retinal hemorrhages (RHs) in infants only in cases of suspected of abuse creates selection bias. However, they also recommend that postmortem eye removal might not be indicated “in children who have clearly died from witnessed severe accidental head trauma or otherwise readily diagnosed systemic medical conditions.” Although infrequently described in the child abuse literature, peripapillary intrascleral hemorrhages (bleeding in the sclera at the optic nerve insertion)—putatively from severe repetitive acceleration/deceleration forces with or without blunt head trauma—have been considered essentially pathognomonic for abusive head trauma (shaken baby syndrome). We present two neonates who sustained accidental, severe in utero head injuries and had associated extensive RHs and optic nerve sheath hemorrhages with peripapillary intrascleral hemorrhages detected at autopsy. Neither neonate had a documented clinical fundal examination in the intensive care unit.     

Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries.     

Asphyxia protracted after shaking trauma

A case of "shaken baby syndrome" (SBS) is reported. A 3 1/2 months old female baby has been found by his mother death in bed. The circumstances predicted a case of Sudden Infant Death Syndrome (SIDS), but the father, a disc-jockey, who had to look for the baby, had left a notice: "Gitti--i didn't want it, I don't know what had happened, I'm sorry!". The corpse of the baby had no external signs of violence. At the medicolegal examination we found small subarachnoidal and subdural hemorrhage from ruptured bridge veins and signs of prolonged asphyxia. Few hours later the father could be arrested. He told that he had shaken the baby, because she didn't stop crying. The infant lost conscious and he layed him down to the bed with his face below. Then he looked TV for at least a few minutes. After insufficient reanimation he had left the house. The court found the man to be guilty of fatal infant child abuse and convicted him to detention of 8 months. The main signs of SBS are discussed (subarachnoidal and subdural hemorrhage, intraretinal and periretinal hemorrhages, brain edema). Especially in the german speaking Europe many medical examiners are not familiar with this form of infant child abuse.     

Histologic evidence of repetitive blunt force abdominal trauma in four pediatric fatalities

In cases of acute fatal child abuse, certain injuries, including cutaneous blunt force trauma, skull fractures, subdural hematomas, intra-abdominal hemorrhage, and retinal hemorrhages are common and well described in the pediatric and forensic literature. These gross findings at autopsy, when taken into consideration with scene investigation and interviews with caregivers, may indicate both a clear manner and cause of death. In such cases, the discovery of additional pathologic changes attributable to older abusive injuries helps support a conclusion of death due to inflicted trauma. We discuss four cases of fatal child abuse in which acute blunt force abdominal trauma was the cause of death. In each of these cases, careful examination with proper sectioning and microscopy of select abdominal tissues revealed that the acute tissue trauma was superimposed on a background of older, healing injury. This older trauma was characterized by classic histologic elements of tissue repair, including fibroblast proliferation, early scar formation, increased vascularity, and hemosiderin-laden macrophages. Iron and trichrome stains were used to confirm the presence of hemosiderin and fibrosis in all four cases, but the recognition of fibroblast proliferation and a reactive vascular pattern was best seen on routine hematoxylin and eosin stains. The gross and microscopic autopsy findings, along with available investigative information, established the diagnosis of chronic physical abuse.     

Spouse Abuse and Child Abuse by Army Soldiers

This study analyzed data collected by the U.S. Army’s Family Advocacy Program, the group primarily responsible for family violence prevention, identification, evaluation, treatment, and follow-up on Army installations. Patterns of spouse abuse and child abuse perpetrated within a five year period (2000–2004) were examined in a sample of 10,864 Army Soldiers who were substantiated for family violence offenses. Three groups of family violence offenders were compared: (1) those who perpetrated spouse offenses only; (2) those who perpetrated child offenses only; and (3) those who perpetrated both spouse and child offenses. Results showed that the majority of substantiated family violence offenders were spouse offenders who had not committed child abuse (61%), followed by child offenders who had not committed spouse abuse (27%), and finally those who committed both spouse and child offenses (12%). The three groups of family violence offenders differed in terms of the types of abuse they perpetrated (neglect of children, emotional abuse, physical abuse, and sexual abuse), their experiences of being a spouse abuse victim, and sociodemographic characteristics. Twelve percent of all spouse abusers committed multiple spouse abuse incidents, and 10% of all child abusers committed multiple child abuse incidents.     

Emotion Regulation Mediates the Relationship between a History of Child Abuse and Current PTSD/Depression Severity in Adolescent Females

Although experiencing child abuse (i.e., physical abuse, sexual abuse, exposure to violence) is associated with a variety of mental health difficulties, simple exposure to abuse does not produce symptoms in every individual. The current study explored emotion regulation as a mediator in the relationship between a history of child abuse and symptoms of posttraumatic stress and depression. Adolescent females (ages 11–17 years) were asked to retrospectively report on their exposure to child abuse, current symptoms of PTSD/depression, and emotion regulation abilities. Caregiver report of adolescent emotional difficulties was also obtained. Analyses revealed that child abuse-exposed females, when compared to females without a trauma history, had worse emotion regulation abilities and increased mental health difficulties. Moreover, emotion regulation significantly mediated the relationship between child abuse and all assessed mental health symptoms. These findings extend previous work from adult samples, underscoring the importance of assessing emotion regulation abilities in abuse-exposed youth.     

Ophthalmologic Concerns in Abusive Head Trauma

When Abusive Head Trauma (AHT) is suspected in a child, a dilated eye examination by an ophthalmologist is an essential part of the medical workup, as the presence and pattern of retinal hemorrhages can have a high positive predictive rate for abusive head injury. This article proposes to review the clinical presentation, pathophysiology, natural history, sequelae, and differential diagnosis of retinal hemorrhages and other ocular lesions associated with AHT.