0 Comments
Abstract
Medical personnel who evaluate children for child abuse and neglect (CAN) must be familiar with the many pediatric conditions that resemble CAN in order to avoid over reporting. During a 3-year period, a total of 504 suspected child abuse patients were evaluated by our CAN team. After preliminary evaluation, 264 (52%) of these cases were unsubstantiated. Eighteen of these 264 (7%) were initially considered as cases of CAN but were later proven to be conditions that were misdiagnosed as CAN. Thirteen of the 18 (72%) were readily diagnosed after consultation with a pediatrician or other health care consultant. Investigation of the remaining 5 patients (29%) was more difficult and more extensive, requiring a period of separation from the parents with consequent emotional hardship to the family. These conditions included (1) a patient with osteogenesis imperfecta type IV, (2) a patient with Ehlers-Danlos syndrome, (3) two patients with benign external hydrocephaly of infancy, and (4) a patient with Crohn's disease, who was evaluated for sexual abuse because of chronic abdominal pain. A comprehensive literature review of pediatric conditions that may mimic CAN is presented by diagnostic categories to assist clinicians in differentiating medical conditions that may simulate CAN. Methods to support parents who have been incorrectly reported are discussed. http://www.ncbi.nlm.nih.gov/pubmed/7746427 W. James King and colleagues1 report that bruising was noted on examination for 46% of the children in their study of shaken baby syndrome in Canada. Such a high proportion warrants attention, but we must ensure that the diagnosis is correct.
A few years ago, a mother brought to my office her 31/2-month-old child, who had ecchymosis of the left cheek and left pinna. The mother reported 3 separate episodes of bruising before the presenting episode. She suspected abuse by a babysitter, and the case was reported to the appropriate authorities. The child was investigated for bleeding disorders, but none were found. On the basis of the results of a pediatric examination arranged by social services, the child was removed from the mother's care. Subsequent medical care was provided by the family physician of the child's foster parent. I next saw the child at 10 months of age during a day visit to the birth mother. The presenting problem at that time was described as recurrent impetigo of the left pinna. Infected eczema of the left pinna had been diagnosed on several occasions in the intervening period, and a dermatologist had confirmed the diagnosis of impetigo. This story sounded odd and led me to speculate that the child might have a herpes simplex infection. The dermatologist had taken a sample for culture, and a phone call to the local laboratory confirmed that the viral swab was growing herpes simplex I. In view of this information, I suspected that the episodes of ecchymosis of the left pinna seen in the first few months of life were actually the result of the original herpes infection. After letters and phone calls to the Ministry of Children and Families, the child was finally returned to the birth mother in the second year of life. The lesson to be learned is that in our haste to ensure the safety, welfare and protection of our pediatric patients, we should remember that all that glitters is not gold. A.J. Walter Physician Surrey, BC http://www.ncbi.nlm.nih.gov/pmc/articles/PMC202278/ Abstract
Several medical conditions have been reported to mimic the physical manifestations of child abuse and neglect (CAN). These conditions include genetic, congenital, and other disorders that may result in poor weight gain, bone fracture, or skin lesions that appear to be bruises or burns. Society demands that medical personnel who care for children be aware of the many indicators that suggest CAN. This article is a review of 6 of 18 cases among 264 that were referred to a child abuse team over a 3-year period because of suspected abuse in which medical disorders were initially and erroneously diagnosed as CAN. This report also suggests ways to support aggrieved parents who have been mistakenly reported to be child abusers. http://www.ncbi.nlm.nih.gov/pubmed/7561712 Abstract
Supplemental vitamin K is required for normal hemostasis in infancy. Infants born outside the hospital may not receive prophylactic vitamin K. They may suffer from bleeding into various tissues and are likely to present to the emergency department. This report describes an infant born at home who presented with intracranial bleeding and signs and symptoms consistent with child abuse. Further investigations confirmed the diagnosis of Vitamin K deficiency. Although it is important to consider child abuse when the history and examination are consistent with the diagnosis, it is equally important to consider other potential diagnoses including Vitamin K deficiency. http://www.jem-journal.com/article/S0736-4679%2805%2900156-3/abstract Internationally renowned natural health physician and Mercola.com founder Dr. Joseph Mercola and Dr. F. Edward Yazbak discuss the frequency of accusations of shaken baby syndrome.
By Robert Sanders, Media Relations
Berkeley - Mechanical engineer Werner Goldsmith of the University of California, Berkeley, is on a mission to reform the way doctors and prosecutors view the thousands of suspected cases of shaken baby syndrome each year.An often fatal set of symptoms caused by violent shaking of an infant or young child, shaken baby syndrome can be difficult to diagnose because frequently there are no external signs of abuse. Most of the damage is in the brain. Backed by decades of research on the effects of head impacts, and as author of the only book on the subject of impacts, Goldsmith nevertheless sees a rush by pediatricians, social workers and prosecutors to brand many parents and caregivers as child abusers when the injuries were more likely caused by a fall. "Anyone who abuses a child deserves the full fury of the law," said Goldsmith, a professor of the graduate school at UC Berkeley. "But people should know the truth. The brain injuries that lead many prosecutors to file charges of child abuse can also be caused by falls or even result from chronic bleeding in the brain." To get his message out, Goldsmith is traveling around the country educating the medical community as well as lawyers and child welfare caseworkers about the complexities of establishing a cause of child brain damage. He also counsels numerous lawyers and testifies as an expert on head impacts at trials, where he sees first-hand the rush to judgement. "A child in someone's care dies by natural causes or accident and the district attorney files charges claiming shaken baby syndrome," he said. "Suddenly, the caregiver is faced with life in prison." His message to doctors and lawyers is not to assume that a child with bleeding in the brain and the eye is automatically the victim of child abuse. Doctors typically look for these symptoms, called subdural hematoma and retinal hemorrhage, respectively, plus brain swelling or edema. Such symptoms could result from an accident or, under certain circumstances, from a chronic condition. Doctors and medical examines need to look for other signs of abuse, in particular, neck damage, he argues. "I am absolutely convinced that in order to do serious or fatal damage to an infant by shaking you have to have soft tissue neck damage," Goldsmith said. "Yet, in 95 percent of cases, medical examiners do not look at the neck in autopsy. They look at the stomach, the abdomen, the head, but the neck is neglected." The main problem is that very little research has been done on the effects of head impacts in infants and small children. Goldsmith, whose 1960 book, "Impact: The theory and physical behaviour of colliding solids," will be reissued next month by Dover Publishers, has written more than 50 papers on the biomechanics of head and neck injury. Yet, though he pioneered the application of biomechanics to head injury, he has conducted no studies of infants. Only one such study has been done, in 1987, and that employed a doll whose head was stuffed with wet rags. To remedy this lack of basic data, within a few months he plans to embark on a preliminary study with UCSF neurosurgeon Geoffrey Manley, MD, PhD, using professional crash test dummies instrumented with devices to measure the types of forces an infant would sustain during shaking and other types of abuse. "I have a very strong feeling that, given how little we really know about the mechanical issues involved in head injury, there may be people who are convicted of crimes they are not guilty of," said Manley, chief of neurotrauma at UCSF. For now, Goldsmith hopes to make an impact on the overly aggressive approach of many pediatricians to suspected shaken baby syndrome. Though most doctors look for brain edema, subdural hematoma and retinal hemorrhaging, many other types of trauma produce similar symptoms, he said. In fact, bleeding in the brain normally increases pressure, leading to swelling and retinal bleeding. So anything that causes intracranial bleeding, in particular falls, can display this trio of symptoms. A fall backwards from three feet onto a hard surface, like concrete, can produce nearly 180 Gs of acceleration - 180 times the force of Earth's gravity - enough to cause a subdural hematoma, Goldsmith calculated. Shaking a child once a second through a range of one foot produces only 11 Gs, at the most. "There is an order of magnitude difference between shaking and falling," Goldsmith said. "From the point of view of the brain, shaking is a much, much milder form of braking than a fall." One dogma often espoused by doctors is that short distance falls do not cause serious harm. However, videotapes demonstrate that falls from as little as 32 inches can cause fatal brain damage in infants and toddlers. To complicate matters, between 5 and 10 percent of children are born with undiagnosed subdural hematomas, and 30 percent are born with retinal bleeding, Goldsmith said. "If you get a rebleed, you may get something that looks like shaken baby syndrome," he said. Because of such uncertainties, Goldsmith urges physicians and prosecutors to look for more certain evidence of shaking, specifically damage to the neck. "You should be able to show neck damage to prove shaken baby syndrome," he said. Goldsmith also urges doctors to talk to biomechanical engineers to get an understanding of the forces involved in accidental falls versus child abuse. The ultimate goal of Goldsmith and Manley is to build a sufficiently lifelike baby dummy containing a skull, dura (a tough membrane that lines the skull and envelops the brain) and brain whose properties are very similar to the real thing. The dummy studies planned for January will provide some of the data they need, and help them apply for a grant from the National Institutes of Health for further studies. "The infant neck, particularly before the age of one, is dramatically different from the neck of, say, you or me," Manley said. "The same is true of the head, which in infants is soft and compliant - they haven't formed sutures yet. "We don't believe that these crash test dummies are sufficient to represent the actual biology of the infant head and neck, so we are going to use the preliminary data to write a grant to develop a much more realistic model." In addition, Goldsmith and graduate student Ken Monson are working with Manley to obtain fresh cerebral arteries and veins from surgery patients for measurement of their mechanical properties. Despite the fact that arteries and veins are embedded in the brain like a net, no one has considered them in models of how the brain responds to impact. In the late 1960s, Goldsmith was chair of a committee at NIH, the Head Injury Model Construction Committee, that for four years oversaw research to construct a model of the adult head and brain. Unfortunately, funding dried up in the 1970s, and the research project was dropped. "Well over 50,000 people die from head injuries each year. Finding out the causes and procedures is very difficult, but essential," he said. Visit http://johncaputo.com/aop/head-trauma… injuries can occur in many different ways. Obviously, trauma can cause a brain injury. Some of these are the result of carelessness causing direct traumatic contact to the brain by an outside object or force. Others are caused by the brain literally striking the inside of the skull in what is caused a closed head injury. Closed head injuries can result in fluid collection called hydrocephalus, bleeding of the tissues which is a hemorrhage, and sometimes a herniation of the brain from the fluid or blood which is a destructive movement of the brain from the force of the fluid or blood collection.
Yet, the brain is sometimes injured very seriously without a fluid or blood collection. A serious concussion or bruise of the brain can injure the connecting fibers of the brain and damage the electrical system. This can cause what is known as cognitive changes such as loss or deterioration of memory, difficulties in reasoning and thinking, speech and learning abilities. There are occasions where a problem with breathing caused by an arrest, by shock, stroke or from a deficiency in the lung whereby blood is not oxygenated sufficiently can cause temporary anoxia, (the lack of oxygen), or persistent hypoxia, (a lowered amount of oxygen to the brain) which damages the tissue resulting in severe motor and mental function deficits. Fore more information on brain injures caused by delayed diagnosis, click here. At our law firm, we have had the experience in pursuing many cases for injured citizens which have occurred in all of the above ways. |