Forced suffocation of infants with baby wipes: a previously undescribed form of child abuse.

BACKGROUND: Foreign body aspiration in children is commonly seen in emergency departments and carries a significant mortality. Abusive foreign body suffocation is not well described. METHODS: We present a case-series of four infants who presented with aspiration of a baby wipe. RESULTS: Each child was found to be a victim of child physical abuse with substantial morbidity and mortality associated with the aspiration of the wipe and associated injuries. CONCLUSIONS: We recommend that infants who present with a baby wipe aspiration should be considered as likely victims of child abuse and physicians should evaluate each infant for associated injuries of the oropharynx, skin, skeleton, and head.

Nonaccidental head trauma in infants.

BACKGROUND: Nonaccidental head trauma in infants is the leading cause of infant death from injury. RESULTS AND DISCUSSION: Clinical features that suggest inflicted head trauma include the triad of the so-called shaken baby syndrome, consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Studies have shown that, in general, the average short fall in the home is extremely unlikely to produce either subdural or retinal hemorrhage, although focal injuries such as skull fractures and epidural hemorrhage may be seen. Acceleration/deceleration, especially of the rotational type, is believed to be the most probable mechanism of injury in cases of nonaccidental head trauma. Damage to the cervicomedullary junction and the respiratory centers, with subsequent hypoxia and intracerebral edema, has also been implicated. After the initial trauma and hemorrhage, loss of cerebral autoregulation, breakdown of the blood-brain barrier, and disruption of ionic homeostasis occur, leading to brain edema and cytotoxicity. Cellular damage can involve large volumes of tissue, without respecting vascular territories. CONCLUSION: Overall, a satisfactory biomechanical model is lacking, and the criminal nature of abusive injury makes it difficult to perform systematic, controlled studies. Unfortunately, outcomes are poor, and the rate of repeated abusive episodes is high. Future research should focus on the development of a satisfactory research model and on prevention strategies.

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.