Normal computerized tomography of brain in children with shaken baby syndrome.

OBJECTIVE: To characterize the clinical presentation and clinical course of shaken baby syndrome (SBS) with normal cranial computerized tomography (CT) on admission and to suggest further diagnostic procedures in such circumstances. METHODS: Using a worldwide listserv designed to facilitate discussion in the field of child abuse and neglect, we solicited case information for children hospitalized in different medical centers, who were diagnosed with SBS and had a normal CT scan on admission. RESULTS: Nine cases were identified. While all children had an abnormal neurologic examination on admission, eight had a normal CT, and one had "widening of cranial sutures." In four cases, subdural hemorrhage was diagnosed on magnetic resonance imaging (MRI) 3 to 7 days after admission. Five children had bone fractures. The neurological outcome was normal in four of nine cases. Five children had long-term neurologic damage. The diagnosis of SBS was supported by either perpetrator confession, characteristic evolution of brain abnormalities on CT or MRI, inconsistent or absent explanatory history, and/or other social risk factors. CONCLUSION: The diagnosis of SBS can be established even when brain CT is normal on admission. The documentation of retinal hemorrhages is of primary importance in establishing the diagnosis of SBS in these cases.

Into hot water head first: distribution of intentional and unintentional immersion burns.

INTRODUCTION: Experience with several, previously unreported, intentional face-first immersion burns led us to evaluate the distribution of inflicted and unintentional immersion scald burns in a hospital series. SETTING: (1) Authors' clinical and legal practices; (2) Burn center at regional Level 1 trauma hospital. SUBJECTS: : (1) Case series of face-first, inflicted immersion burn victims; (2) Consecutive hospitalized scald burn victims younger than 5 years old, 1/3/1996 to 3/25/2000. METHODS: (1) Individual case reports; (2) Retrospective records review. Simple descriptive statistics, Fisher Exact test and t test. RESULTS: (1) Six cases of inflicted head and neck immersion injury are described. Four were tap water and 2 food/drink scalds. (2) 22/195 hospitalized victims had sustained immersion burns, 13 from tap water and 9 from other fluids. Six (46%) tap water immersions and no (0%) other immersions had inflicted injuries (P = 0.05). Two of the tap water immersions and one other source immersion included burning of the head and neck. Of these, one tap water immersion, but no other immersion, was inflicted. In no patients were head and neck injuries the sole or predominant site of scalding. In all, 9 children sustained inflicted scalds. Bilateral lower extremity tap water immersion scalds occurred in 100% (6/6) of abusive and 29% (2/7) of unintentional injuries (P = 0.02). Buttock and perineal injuries occurred in 67% (4/6) inflicted versus 29% (2/7) unintentional tap water immersion scalds (P = 0.28). Other fluids caused bilateral lower extremity immersion burns in 3/9 (33 %) unintentionally injured patients, but no abused children (NS). CONCLUSIONS: Craniofacial immersion injury, although seen by the authors in legal cases, is infrequent. It was present incidentally in one inflicted tap water burn in the consecutive hospital series. This series affirms the predominance of bilateral lower extremity burns in inflicted tap water immersions. Buttock/perineal immersions were more common with abuse than with unintentional injury.