The Swedish Agency for health technology-report about traumatic shaking: much ado about nothing?

The 2016 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) systematic review deals with the role of the 'triad' (subdural hematoma, retinal hemorrhages, and various forms of brain symptoms) in the medical investigation of suspected traumatic shaking. In this commentary we will not discuss the methodological shortcomings of the SBU-review but will concentrate on the effects of the review on the daily practice of protecting children and families in court procedures. In our opinion the report did not add anything to what was already known in clinical and forensic medicine. The SBU-review confirmed that shaking can cause the 'triad' and that there are other explanations for the 'triad' and its components. The report however did not provide a realistic list of these other explanations. The review reduced the discussion about inflicted head injury in young children to a discussion about the 'triad' and traumatic shaking, ignoring the fact that 'diagnosing' inflicted head injury concerns a complete clinical and forensic evaluation of all individual and combined findings, of which for example the presence of bruising or fractures, were excluded by the SBU-panel.

Nonaccidental trauma: clinical aspects and epidemiology of child abuse.

Radiologists play a key role in the recognition of child abuse. In the last century, radiologists pioneered the identification of nonaccidental injuries, including fractures and brain injury, and together with colleagues in paediatrics advocated the protection of children from abuse. Prevalence studies in many countries have revealed the widespread and hidden nature of child maltreatment. New and complex forms of abuse, e.g. fabricated or induced illness, have been recognized. Physical abuse affects 7-9% of children in the UK, although fewer suffer the severe or life-threatening injuries seen by radiologists. A high index of suspicion of nonaccidental trauma is required where known patterns of injury or inconsistencies of presentation and history are detected. In many cases the diagnosis is readily made, although some cases remain contentious or controversial and consume much clinical time and energy. Differences of view between doctors are tested in the courts. Adverse publicity has made this work unpopular in the UK. Knowledge of the differential diagnosis of unexplained or apparent injury is essential for accurate diagnosis, vital where errors in either direction can be disastrous. New UK radiological guidelines will assist radiologists in achieving best evidence-based practice.