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The Shaken Baby Syndrome University of Pennsylvania ScholarlyCommons Departmental Papers (BE) Department of Bioengineering 3-1987 The hS aken Baby Syndrome: A Clinical, Pathological, and Biomechanical Study Ann-Christine Duhaime Thomas A. Gennarelli Lawrence E. Thibault University of Pennsylvania Derek A. Bruce Susan S. Margulies University of Pennsylvania, [email protected] See next page for additional authors Follow this and additional works at: http://repository.upenn.edu/be_papers Part of the Biomedical Engineering and Bioengineering Commons, and the Social Work Commons Recommended Citation Duhaime, A., Gennarelli, T. A., Thibault, L. E., Bruce, D. A., Margulies, S. S., & Wiser, R. (1987). The hS aken Baby Syndrome: A Clinical, Pathological, and Biomechanical Study. Journal of Neurosurgery, 66 (3), 409-415. http://dx.doi.org/10.3171/ jns.1987.66.3.0409 This paper is posted at ScholarlyCommons. http://repository.upenn.edu/be_papers/210 For more information, please contact [email protected]. The hS aken Baby Syndrome: A Clinical, Pathological, and Biomechanical Study Abstract Because a history of shaking is often lacking in the so-called “shaken baby syndrome,” diagnosis is usually based on a constellation of clinical and radiographic findings. Forty-eight cases of infants and young children with this diagnosis seen between 1978 and 1985 at the Children's Hospital of Philadelphia were reviewed. All patients had a presenting history thought to be suspicious for child abuse, and either retinal hemorrhages with subdural or subarachnoid hemorrhages or a computerized tomography scan showing subdural or subarachnoid hemorrhages with interhemispheric blood. The hp ysical examination and presence of associated trauma were analyzed; autopsy findings for the 13 fatalities were reviewed. All fatal cases had signs of blunt impact to the head, although in more than half of them these findings were noted only at autopsy. All deaths were associated with uncontrollably increased intracranial pressure. Models of 1-month-old infants with various neck and skull parameters were instrumented with accelerometers and shaken and impacted against padded or unpadded surfaces. Angular accelerations for shakes were smaller than those for impacts by a factor of 50. All shakes fell below injury thresholds established for subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural hematoma, and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome. Keywords shaken baby syndrome, head injury, child abuse Disciplines Biomedical Engineering and Bioengineering | Engineering | Social Work Author(s) Ann-Christine Duhaime, Thomas A. Gennarelli, Lawrence E. Thibault, Derek A. Bruce, Susan S. Margulies, and Randall Wiser This journal article is available at ScholarlyCommons: http://repository.upenn.edu/be_papers/210 J Neurosurg 66:409-415, 1987 The shaken baby syndrome A clinical, pathological, and biomechanical study ANN-CHRISTINE DUHAIME, M.D., THOMAS A. GENNARELLI, M.D., LAWRENCE E. THIBAULT, Sc.D., DEREK A. BRUCE, M.D., SUSAN S. MARGULIES, M.S.E., AND RANDALL WISER, M.S.E. Division of Neurosurgery and Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania v- Because a history of shaking is often lacking in the so-called "shaken baby syndrome," diagnosis is usually based on a constellation of clinical and radiographic findings. Forty-eight cases of infants and young children with this diagnosis seen between 1978 and 1985 at the Children's Hospital of Philadelphia were reviewed. All patients had a presenting history thought to be suspicious for child abuse, and either retinal hemorrhages with subdural or subarachnoid hemorrhages or a computerized tomography scan showing subdural or subarachnoid hemorrhages with interhemispheric blood. The physical examination and presence of associated trauma were analyzed; autopsy findings for the 13 fatalities were reviewed. All fatal cases had signs of blunt impact to the head, although in more than half of them these findings were noted only at autopsy. All deaths were associated with uncontrollably increased intracranial pressure. Models of 1-month-old infants with various neck and skull parameters were instrumented with accelerom- eters and shaken and impacted against padded or unpadded surfaces. Angular accelerations for shakes were smaller than those for impacts by a factor of 50. All shakes fell below injury thresholds established for subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural hematoma, and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome. KEY WORDS 9 shaken baby syndrome 9 head injury 9 child abuse HE term "whiplash shaken baby syndrome" was particularly in the posterior interhemispheric fissure. ~7 coined by Galley 3 to describe a clinicopatho- Because of the ambiguous circumstances of such in- T logical entity occurring in infants characterized juries, medicolegal questions are particularly trouble- by retinal hemorrhages, subdural and/or subarachnoid some, and the neurosurgeon is often consulted to give hemorrhages, and minimal or absent signs of external an opinion as to whether the findings are consistent trauma. Because a nursemaid admitted that she had with child abuse or accidental injury. held several such children by the arms or trunk and This paper reviews all cases of the shaken baby shaken them, the mechanism of injury was presumed syndrome seen at the Children's Hospital of Philadel- to be a whiplash-type motion of the head, resulting in phia (CHOP) between January, 1978, and March, 1985. tearing of the bridging veins. Such an injury was be- To better study the mechanism of injury, autopsy re- lieved to be frequently associated with fatalities in in- sults in all fatal cases were reviewed, and the biome- fantile child abuse and has been postulated as a cause chanics of this injury were studied in a series of infant of developmental delay in survivors. 4'~5 models. Based on these observations, we believe that While the term "shaken baby syndrome" has become shaking alone does not produce the shaken baby syn- wetl entrenched in the literature of child abuse, it is drome. characteristic of the syndrome that a history of shak- Clinical Studies ing in such cases is usually lacking. ~2 Shaking is often assumed, therefore, on the basis of a constellation of Clinical Material and Methods clinical findings and on the computerized tomography All reports submitted to the Suspected Child Abuse (CT) picture of subarachnoid and subdural hematomas, and Neglect team were reviewed. Since house officers J. Neurosurg. / Volume 66/March, 1987 409 A. C. Duhaime, et al. TABLE 1 TABLE 2 Initial clinical criteria for diagnosis of shaken baby syndrome Best history in 48 cases of shaken baby syndrome Cases No. of Cases Etiology Diagnosis* No. Percent Deaths No. Percent retinal hemorrhage + SAH or SDH 29 60 5 shaking only I 2 retinal hemorrhage + SAH & SDH 10 21 5 fall or accidental blunt trauma 15 31 bilateral chronic SDH 3 6 0 strike or fall plus shaking 10 21 SAH &/or SDH & interhemispheric 6 13 3 strike only 3 6 blood on CT trauma or shaking denied, caretakers 8 17 total 48 100 13 in attendance history unknown, caretakers not in 10 21 * SAH = subarachnoid hemorrhage; SDH = subdural hemorrhage; attendance CT = computerized tomography. cardiopulmonary resuscitation 1 2 and emergency room personnel are well trained in recognizing the clinical manifestations associated with TABLE 3 this syndrome, it is considered that essentially all cases Trauma associated with shaken baby syndrome in 48 cases seen at CHOP are reported to this group. Suspicion of shaking was based on history, clinical Cases Associated Trauma findings, and CT data. All subjects met the following No. Percent criteria: presence of retinal hemorrhages with subdural no evidence of blunt impact to head 18 37.5 and/or subarachnoid hemorrhages, bilateral chronic no extracranial trauma 12 25.0 subdural hematomas, or a CT scan showing subdural additional extracranial trauma 6 12.5 or subarachnoid hemorrhages with interhemispheric acute 3 6.25 blood. In addition, all patients were judged to have his- old trauma only 3 6.25 evidence of blunt impact to head 30 62.5 tories suggestive of child abuse or neglect; well-docu- skull fractures 12 25.0 mented, witnessed accidental trauma was excluded. cranial soft-tissue contusions 18 37.5 Histories were obtained from several interviews with additional extracranial trauma 18 37.5 caretakers by physicians, social workers, and in some acute 15 31.25 old trauma only 3 6.25 cases law enforcement agents. Caretakers were routine- ly asked specifically about shaking. Associated trauma data were obtained from physical examination, skull radiographs, CT scans, and skeletal with a babysitter. There were two cases (4%) with no surveys. All fatal cases were examined by the Philadel- history to explain the present findings, but both children phia Medical Examiner, and pathology data were ob- were known to have been abused previously or subse- tained from that office. quently. One case was associated with cardiopulmonary resuscitation (2%). In only one case was a history of Results
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