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SHAKEN BABY SHAKEN BABY SYNDROMESYNDROME

Bernadette J. Madrid, M.D.Bernadette J. Madrid, M.D.

Executive DirectorExecutive Director

Child Protection Unit NetworkChild Protection Unit Network

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What is physical abuse?What is physical abuse?

Acts by a caregiver that cause actual Acts by a caregiver that cause actual physical harm or have the potential physical harm or have the potential for harm (WHO, 2002)for harm (WHO, 2002)

Physical injury includes but is not Physical injury includes but is not limited to lacerations, fractured limited to lacerations, fractured bones, burns, internal injury or bones, burns, internal injury or serious bodily harm suffered by the serious bodily harm suffered by the child (R.A. 7610)child (R.A. 7610)

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Head Trauma in Head Trauma in Child AbuseChild Abuse

Most common cause of Most common cause of mortality and morbidity in mortality and morbidity in physical child abusephysical child abuse

33%-56% of brain injuries in 33%-56% of brain injuries in children children < 1 year of age were inflicted.< 1 year of age were inflicted.

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Head Trauma in Head Trauma in Child AbuseChild Abuse

INCIDENCEINCIDENCE

Population-based study in Population-based study in Scotland (Barlow & co-Scotland (Barlow & co-authors, 2000):authors, 2000):

24.6 per 100,00024.6 per 100,000

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Shaken Baby Syndrome Shaken Baby Syndrome (SBS)(SBS)

Violent shaking or shaking plus head Violent shaking or shaking plus head impact against a hard or even soft impact against a hard or even soft surfacesurface

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SBS/SISSBS/SIS

Crying is the usual trigger to shakingCrying is the usual trigger to shaking Infant held by chest, upper arms or neckInfant held by chest, upper arms or neck Variable duration – 4-20 secondsVariable duration – 4-20 seconds 2-4 shakes per second2-4 shakes per second Head rotates in many directions on the Head rotates in many directions on the

axis of the neckaxis of the neck

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Infant Brain vs. Infant Brain vs. Adult BrainAdult Brain

Infant brain has approximately 25% Infant brain has approximately 25% more water than the adult brainmore water than the adult brain

Infant brain has little or no myelinInfant brain has little or no myelin

Result: infant brain is much softer, Result: infant brain is much softer, more gelatinous than adult and thus more gelatinous than adult and thus more fragilemore fragile

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Retinal HemorrhagesRetinal Hemorrhages

Incidence of RHs in SBS: 50% -100%Incidence of RHs in SBS: 50% -100%

Overwhelmingly more common in SBS Overwhelmingly more common in SBS than in accidental head injuriesthan in accidental head injuries

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Signs and Symptoms of Signs and Symptoms of SBS/SISSBS/SIS

Variable, depending on duration and Variable, depending on duration and number of shakes, presence of impactnumber of shakes, presence of impact

Continuum from decreased Continuum from decreased responsiveness, irritability, lethargy, responsiveness, irritability, lethargy, limpness to:limpness to: Seizures, tachypnea, bradycardia, Seizures, tachypnea, bradycardia,

hypothermiahypothermia Coma, deathComa, death

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Associated InjuriesAssociated Injuries

BruisingBruising Abdominal InjuriesAbdominal Injuries Skeletal injuries:Skeletal injuries:

Long bonesLong bones Posterior rib fracturesPosterior rib fractures Classic metaphyseal lesions (CML)Classic metaphyseal lesions (CML)

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Present IllnessPresent Illness

3 most common triggering 3 most common triggering events:events:

Inability to control infant cryingInability to control infant crying

Feeding difficultiesFeeding difficulties

Toileting issuesToileting issues

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Past HistoryPast History

AccidentsAccidents Previous seizure episodesPrevious seizure episodes Previous hospitalizationPrevious hospitalization

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Suspicious Stories* – Suspicious Stories* – Fatal CasesFatal Cases

1.1. Child fell from low heightChild fell from low height

2.2. Child fell onto furniture, floor, objectChild fell onto furniture, floor, object

3.3. Unexpectedly found deadUnexpectedly found dead

4.4. Child choked, shaken to dislodge Child choked, shaken to dislodge objectobject

5.5. Child turned blue, shaken to reviveChild turned blue, shaken to revive

6.6. Sudden seizure activitySudden seizure activity

*Kirschner*Kirschner

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7.7. Resuscitation efforts caused Resuscitation efforts caused injuriesinjuries

8.8. Traumatic event a day or so agoTraumatic event a day or so ago

9.9. Tripped or slipped carrying childTripped or slipped carrying child

10.10. Sibling did itSibling did it

11.11. Child left alone for short timeChild left alone for short time

12.12. Child fell down stairsChild fell down stairs

Common Suspicious Common Suspicious StoriesStories

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Outcomes of SBSOutcomes of SBS

Long-term morbidity high Long-term morbidity high amongst survivors – 90% amongst survivors – 90% affectedaffected

Mortality rate approximately Mortality rate approximately 20%20%

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Sequelae of SBSSequelae of SBS

Tetraplegia, hemiplegia, Tetraplegia, hemiplegia, hemiparesishemiparesis

Mental RetardationMental Retardation BlindnessBlindness Learning DisabilitiesLearning Disabilities Cerebral PalsyCerebral Palsy

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Issues when child is in the Issues when child is in the hospitalhospital

Protective CustodyProtective Custody Consent for proceduresConsent for procedures ““Bantay” in the hospitalBantay” in the hospital

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Sec. 9 IRR of RA 7610Sec. 9 IRR of RA 7610

Protective Custody. Protective Custody. If the investigation If the investigation discloses sexual abuse, serious physical discloses sexual abuse, serious physical injury or life-threatening neglect of the injury or life-threatening neglect of the child, the duly authorized officer or child, the duly authorized officer or social worker of the Department shall social worker of the Department shall immediately remove the child from his immediately remove the child from his home or the establishment where he home or the establishment where he was found and place him under was found and place him under protective custody ensure his safety.protective custody ensure his safety.

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Patient comes to MD

Determine nature of injuries

Intentional/Neglect/Physical abuse

Child at risk

Report to LGU or DSWD field office

PROTECTIVE CUSTODY

INVESTIGATIONS:

Family

Crime Scene

Community

Involuntary commitment Criminal Case filed

MD

LGU DSWD

LGU DSWD

PNP

LGU DSWD

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Issues if the child diesIssues if the child dies

Consent for autopsyConsent for autopsy No ComplainantNo Complainant Can we prove who inflicted Can we prove who inflicted

these injuries?these injuries? What is the charge?What is the charge?

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DOJ circular No. 55 (Sept. 11, DOJ circular No. 55 (Sept. 11, 2002)2002)

Authorizing all Provincial and City Prosecutors to make an order for the performance of an autopsy on the

body of child-victims, upon the request of any interested party, and upon proper showing that the child

may have died under suspicious or abuse-related circumstances, there being no external signs to readily conclude that the child died as a result of violence or

crime.

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DOJ circular No. 55 (Sept. 11, DOJ circular No. 55 (Sept. 11, 2002)2002)

“Any interested party”

Shall include but be not limited to a law enforcementOfficer, parent or legal guardian, or authorized physicians of the UP-PGH Child Protection Unit and other government hospitals.

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Common DefensesCommon Defenses

Alibi, character and other Alibi, character and other defense witnessesdefense witnesses

Medical Witnesses for the Medical Witnesses for the defensedefense