Shaken baby syndrome.

PURPOSE: To examine the comprehensive ophthalmologic experience with the shaken baby syndrome at one medical center, including clinical findings, autopsy findings, and the outcome of survivors. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: One hundred twenty-three children admitted from January 1987 through December 1998 for subdural hematomas of the brain secondary to abuse were included. METHODS: Clinical features of eye examinations of the patients during their admission and after discharge and histopathologic observations for patients who died were retrieved from medical records and statistically analyzed. MAIN OUTCOME MEASURES: Visual response and pupillary response on initial examination, fundus findings, final vision, neurologic outcome of survivors, and death. RESULTS: Ninety percent of the patients had ophthalmologic assessments. Retinal hemorrhages were detected in 83% of the examined children. The retinal hemorrhages were bilateral in 85% of affected children and varied in type and location. Nonophthalmologists missed the hemorrhages in 29% of affected patients. Poor visual response, poor pupillary response, and retinal hemorrhage correlated strongly with the demise of the child. One child who died had pigmented retinal scars from previous abuse, a condition not previously observed histopathologically to our knowledge. One fifth of the survivors had poor vision, largely the result of cerebral visual impairment. Severe neurologic impairment correlated highly with loss of vision. CONCLUSIONS: Shaken baby syndrome causes devastating injury to the brain and thus to vision. Retinal hemorrhages are extremely common, but vision loss is most often the result of brain injury. The patient's visual reaction and pupillary response on presentation showed a high correlation with survival. Good initial visual reaction was highly correlated with good final vision and neurologic outcome. According to the literature, when retinal hemorrhages are found in young children, the likelihood that abuse occurred is very high. Nonophthalmologists' difficulty in detecting retinal hemorrhages may be an important limiting factor in identifying shaken babies so they can be protected from further abuse.

Psychosocial aspects of child abuse for primary care pediatricians.

Childhood is an image that advertisers use to conjure up feelings of care-free innocence. Society frequently calls for protecting our children and creating strong, healthy families. Yet thousands of children experience violence on a regular basis, and their lives are irretrievably altered. For these children, the sites of violence and not war-torn villages or crime-ridden streets but their own homes. This article provides primary care physicians with basic information about the psychosocial aspects of recognition and prevention of child abuse.

Evaluation for possible physical or sexual abuse.

In summary, child abuse requires a multidisciplinary approach. The clinician's role in obtaining the history and physical examination demands that one be familiar with interview technique, appropriate developmental milestones, normal genital anatomy, and the use of local community resources. Knowing that there are circumstances when the examination should be deferred to a specialized center or done under anesthesia is critical. Determining that a reasonable suspicion of abuse exists is the job of the clinician. The final determination of abuse is under the purview of the legal system.

The Whiplash Shaken Infant Syndrome: has Caffey's syndrome changed or have we changed his syndrome?

OBJECTIVE: The aim of this study is to examine the data used by John Caffey in his description of the Whiplash Shaken Infant Syndrome and compare it with recent data in an attempt to determine whether the syndrome that he described has changed, or if we have changed his syndrome into what we now call The Shaken Infant Syndrome. METHOD: This study examined recent literature describing the Shaken Infant Syndrome, and compared it to Caffey's descriptions. In addition, a retrospective review of 71 children under the age of 3 years identified as having a subdural hematoma caused by other than accidental means during 54 months was done. This data was compared to data from the 27 case examples offered by Caffey in 1972 and his other descriptions in 1974 and 1946. RESULTS: A review of recent literature shows that our definition of Shaken Infant Syndrome today includes cases where impact trauma was involved. In contrast to Caffey's descriptions, we found the perpetrator to be more often male, fractures to be more often to ribs rather than long bones, and admissions of shaking and other trauma more often made. CONCLUSIONS: Our findings demonstrate that not only have we changed the diagnostic parameters from Caffey's original Whiplash Shaken Infant Syndrome, but the syndrome has also changed to reflect changes in medical diagnosis and in our society.

Evaluating child sexual abuse in the emergency department: clinical and behavioral indicators.

Child sexual abuse is an increasingly common problem. This article reviews the current clinical and behavioral indicators that will aid the emergency physician when evaluating and managing this condition. The most common differential diagnoses are described and a general approach to this diagnosis is suggested. Adopting a multidisciplinary method when evaluating this problem will lessen the anxiety facing the examining physician and provide a better outcome for the child, parents, and community.

Whatever happened to Mary Ellen?

It is well recognized that the organized response to child abuse in the United States began with the rescue of a little girl named Mary Ellen from the abuse inflicted upon her by her stepmother. It is often forgotten, however, that Mary Ellen was, indeed, a real child who survived her horrendous start in life and went on to have a meaningful and productive life and raise children of her own.

Otitis media and language development.

Otitis media can be a vexing, recurrent problem. An episode is often treated with antibiotics, followed by reevaluation at two weeks. The complete resolution of effusion, however, may never be documented. Impairments in children's speech, language and cognition have been related to chronic and continuous middle ear disease. Responses to antibiotic regimens must be carefully monitored. Follow-up is essential.

Evaluation of system providing feedback to students on videotaped patient encounters.

A technique in which feedback is provided on videotaped performances to teach interview and examination skills in a pediatric clerkship was evaluated with a single-blind, controlled study. At the beginning of the pediatric ambulatory rotation, each of 105 third-year medical students received verbal and written instruction in conducting pediatric patient interviews and examinations. Then an encounter between each student and a patient was videotaped using a stationary camera mounted in an examination room. The students were randomly assigned to one of three groups: to receive critiques of their performances on the videotaped encounters by their preceptors; to critique their own recorded performances themselves using a written checklist; and to have no critiques. At the end of the clerkship, a second patient encounter was videotaped and was rated and scored by three faculty pediatricians who were unaware of the students' group assignments. Students who received critiques from their preceptors performed significantly better on the second recorded interview and examination (p less than 0.001) than did those who had self-guided critiques or those in the control group that received no critiques.

Interobserver and method variability in tuberculin skin testing.

Accurate measurement and interpretation of tuberculin skin tests is essential both to avoid unnecessary prophylactic treatment with potentially hepatotoxic drugs and to ensure the proper institution of therapy in tuberculin-positive individuals. Although two methods are currently used for reading tuberculin skin tests, palpation and ballpoint, the optimal technique has not been established. We compared measurements obtained by each method on 101 patients tested with intermediate tuberculin purified protein derivative. Fifty-eight of these patients were also tested using Mono-Vacc. Excellent interobserver agreement among the five raters was demonstrated for both the palpation and ballpoint techniques. There was no significant difference between the two methods for any reader using the normal 10-mm cutoff point for a positive intermediate tuberculin purified protein derivative test. For any individual observer the decision as to whether the test was positive or negative was unaffected by the method in at least 93% of readings. We conclude that readings by physicians using palpation and ballpoint methods are comparable for clinical decision making.

Management of acute epiglottitis.

Airway obstruction secondary to acute epiglottitis is a dramatic, life-threatening emergency. Early diagnosis and provision of an adequate artificial airway are critical in the management of these patients. Tracheostomy has been the traditional method of securing the airway in acute epiglottitis, but more recently, endotracheal intubation has been advocated. Whichever method of airway management is preferred, it is imperative that every hospital have a protocol for the management of acute epiglottitis so that immediate action can be taken.

Depressed skull fracture in the neonate. Report of three cases.

The authors describe three cases of neonatal depressed skull fracture that were elevated by means of an obstetrical vacuum extractor. In one case, a transparent breast pump shield replaced the metal vacuum extractor cup, permitting direct observation as the depression was elevated. Neonatal depressed skull fractures not associated with neurological signs may be safely elevated without surgery using the obstetrical vacuum extractor.