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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 47-53

Forensic examination of abusive head trauma in child abuse cases

1 Key Laboratory of Evidence Science (China University of Political Science and Law), Ministry of Education; Collaborative Innovation Center of Judicial Civilization, Beijing, China
2 Anshan Public Security Bureau, Anshan, China
3 Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China

Date of Submission30-Jun-2021
Date of Decision30-Jun-2021
Date of Acceptance30-Jun-2021
Date of Web Publication26-Jul-2021

Correspondence Address:
Dong Zhao
Key Laboratory of Evidence Science (China University of Political Science and Law), Ministry of Education, Beijing; Collaborative Innovation Center of Judicial Civilization, NO.25, Xitucheng Road, Haidian District, Beijing
Qi Wang
Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, No. 1023, South Shatai Road, Baiyun District, Guangzhou, Guangdong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfsm.jfsm_44_21

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Abusive head trauma (AHT) in child abuse cases is rarely encountered in the practice of forensic examination in China, and such cases are rarely reported. The authors reviewed a large number of relevant domestic and foreign studies to differentiate between the definitions of AHT and shaken baby syndrome; determine the relationship between the two; and discuss their epidemiology, mechanism, and symptoms. In addition, the main points in forensic examination and strategies for preventing AHT are also summarized to help forensic workers and clinicians identify and prevent such injuries.

Keywords: Abusive head trauma, forensic examination, shaken baby syndrome

How to cite this article:
Zhao D, Cao Z, Wang Q. Forensic examination of abusive head trauma in child abuse cases. J Forensic Sci Med 2021;7:47-53

How to cite this URL:
Zhao D, Cao Z, Wang Q. Forensic examination of abusive head trauma in child abuse cases. J Forensic Sci Med [serial online] 2021 [cited 2022 May 16];7:47-53. Available from: https://www.jfsmonline.com/text.asp?2021/7/2/47/322341

  Introduction Top

Abusive head trauma (AHT) is a dangerous and lethal form of child physical abuse, which could cause disability or even death, permanently changing the situation of the families and abusers related to the victims. Therefore, it is important for forensic and medical experts to effectively prevent, detect, and diagnose cases of child abuse trauma. In many countries and regions, due to the low occurrence of AHT, the public lack the awareness of AHT, and even forensic and medical professionals also lack AHT prevention, identification, diagnosis, and treatment expertise.

  Concept Top

AHT, or shaken baby syndrome, refers to injury of the skull and/or intracranial contents of an infant or a child, usually under the age 5 years, caused by intentional blunt force hitting on the head and/or violent shaking of the body, which in severe cases can lead to death; however, the following situations are not included: unintentional injury, gunshot/stab wound, and penetrating injury due to negligence in supervision.[1],[2],[3] Shaken baby syndrome can lead to head and eye injuries, permanent disabilities, and even death from violent shaking of the shoulders, upper limbs, or lower limbs of an infant, which causes repeated and intense acceleration-deceleration movements of the head.[4],[5]

The concept of shaken baby syndrome was proposed decades ago. However, in recent years, with increased understanding of the injury mechanism and clinical manifestations of AHT, people are gradually realizing that the concept is too narrow, emphasizing only a specific injury mechanism; the concept does not comprehensively describe the various forms of injuries that actually or potentially affect the head (such as inertial injury, impact/contact injury, and ischemic/hypoxic injury) and the consequent clinical manifestations, imaging findings, and sequelae. Shaken baby syndrome, as a concept, is more like the description of a phenomenon, rather than a disease classification. Therefore, many investigators, especially forensic pathologists, are inclined to accept and widely use the concept of AHT in a broad sense.[6],[7],[8],[9] In addition, AHT is recommended by the American Academy of Pediatrics, Centers for Disease Control and Prevention and many investigators for use in medical diagnosis and communication and is also incorporated by the World Health Organization into the International Classification of Diseases.[1],[5],[6],[8] However, many investigators use the concept of shaken baby syndrome because it is easy to understand and well known among the general public.

In summary, the concepts of AHT and shaken baby syndrome are essentially the same; that is why most people use the terminology of shaking baby syndrome when referring to abusive head injury or one of its forms.[1],[6],[7],[10],[11],[12],[13],[14]

  Epidemiology Top

In the US, an average of 3–4 children suffers from severe or even fatal AHT every day. AHT is the most common cause of death in infantile child abuse cases. Approximately one-third of child abuse-related deaths are caused by AHT.[1],[3],[4],[13],[14] Affected children are usually infants younger than 1 year old, mainly 2–4 (or 3–8) months old, but also those 3–5 years old.[2],[3],[4],[5],[6],[13],[14],[15]

The reasons why infants are vulnerable to AHT are as follows: first, infants have a large head: body ratio; the heaviness of their brain and incomplete development of the neck muscles makes them sensitive to shaking and striking forces and vulnerable to acceleration-deceleration injuries. Second, the cerebral myelin sheath in the brain of an infant is not completely formed and the brain tissue is soft, so the axons are sensitive to shear damage caused by rotational motion. Third, the brain of an infant is rich in water and blood flow, so it is at risk of cerebral edema. Fourth, the external force can be easily transmitted to the brain because the cerebral cranium of an infant is thin and soft. Meanwhile, studies have shown that parents in many countries often shake the bodies of infants under the age of 2 years usually as an impulsive event with some triggers which precipitate the event.[3],[6],[13],[14],[16],[17],[18],[19]

AHT often has poor prognosis. According to the US Centers for Disease Control and Prevention, 25%–30% of the victims of AHT die, and their mortality rate is five times higher than that of victims of accidental head injuries. Nearly two-thirds of survivors end up with a disability, and only 15% have no sequel.[2],[3],[6],[13],[14] Most surviving children experience long-term and irreversible effects on the nervous system and behavioral and cognitive development. At the age of 2–5 years, they could develop disorders involving motor, language, cognitive, and behavior skills, or other sequelae, such as parahypnosis, mental impairment, cerebral palsy, cortical blindness, epilepsy, and learning disabilities.[2],[3],[6],[7],[13],[15]

The abuser causing the AHT is often the biological father, stepfather, or boyfriend of the mother of the infant/toddler.[6],[13],[20] The cries of infants and young children when they feel uncomfortable may drive their guardians to shake them violently. This kind of crying gradually increases in the 1st month after birth reaches a peak at about 2 months and gradually disappears at 3–4 months. The peak of the crying curve coincides with the peak of the incidence of AHT.[2],[3],[4],[6],[13],[14],[20],[21]

  Mechanism of Injury Top

At present, there is still much controversy over the injury mechanism of AHT. There are mainly two proposed mechanisms: shaking injury and striking injury.[3],[4],[13],[16],[17],[18],[19],[20],[21],[22],[23] Some investigators[3],[4],[6],[14],[17],[21],[24],[25],[26],[27] support that shaking the body alone causes severe, even fatal, injury. They suggest that violently shaking an infant's body causes repeated acceleration-deceleration whiplash movement in the anteroposterior direction, during which the brain moves back and forth in the cranial cavity and hits the skull, causing brain contusion, swelling, and bleeding. Violent shaking can lead to rupture of the cortex and tearing of the bridging veins, resulting in a subdural hematoma, subarachnoid hemorrhage, and hydrocephalus. Shaking not only generates shear damage, inducing diffuse cerebral injury, such as cerebral edema and diffuse axonal injury but also causes damage to the eyes, such as retinal and vitreous hemorrhage. Furthermore, squeezing a baby's body can block the venous return and push more blood into the brain, leading to increased pressure in the blood vessels in the brain, increasing the risk of blood vessel rupture and bleeding in the brain.

Some investigators believe that violent shaking of a child's body will not cause severe injury, and the majority of the AHT cases involve hitting with blunt force on the head, which is a necessary condition for the formation of characteristic intracranial injuries.[7],[10],[16],[17],[18] Duhaime found that it is difficult or impossible to achieve a peak value of acceleration by shaking alone that causes an observable intracranial injury. Duhaime found that shaking a 1-month-old infant model produced an acceleration of no more than 10 G while hitting the head produced an acceleration of more than 300 G, which is sufficient to cause loss of consciousness, subdural hematoma, and direct damage to the brain tissue.[16],[17] Moreover, in their experiment, Gennarelli and Duhaime found that the force exerted on the brain by striking was 50 times greater than that exerted by shaking; the average time taken for shaking was 106 msonds, while hitting took only 20 msonds.[16],[19],[23] Thibault performed experiments on primates and found that the angular acceleration generated by a shaking motion was lower than that required to cause contusion, subdural hematoma, or diffuse axonal injury and that it was possible for hitting to cause such injuries.[19] Duhaime et al. reported 48 cases of shaken baby syndrome, 13 of which showed evidence of blunt head trauma on autopsy.[19],[23] Howard et al. studied 28 cases of subdural hematoma in infants under 18 months, and the medical histories of all the cases were more in line with hitting than shaking.[16] Many investigators believe that striking the head and face with a blunt object with a wide contact area or against a soft surface, or striking a face that is not cut open during routine dissection, will show no specific signs on autopsy.[16],[17],[18],[19] In fact, until now, all models and proposed mechanisms have limitations, and many clinicians, forensic experts, and researchers acknowledge that their understanding of the exact mechanism of AHT is still incomplete.[7]

  Signs of Injury Top

Mild AHT is not associated with specific clinical manifestations but with nonspecific symptoms of vomiting, excitement, and sleepiness. If the symptoms are mild, trauma is often confused with viral infection and gastrointestinal discomfort and is easily missed or misdiagnosed. According to statistical data, 31% of the cases are missed or misdiagnosed. Devastating AHT can cause severe neurological symptoms, such as seizures, apnea, or coma.[3],[6],[9],[13],[14],[20],[21],[22] Seizures and attentional deficits are the most common neurological symptoms but not in all cases. Some investigators suggest that an expanded fontanelle, excessive tension, and increase in head circumference may be indications of intracranial injury in a baby.[9],[20],[28]

Most investigators believe that “the triad” – subdural hemorrhage, retinal hemorrhage, and diffuse brain injury – is the differential pathological response to AHT. Rib fractures and metaphyseal injuries to the long bones can be associated with AHT.[3],[5],[10],[13],[17],[21],[22],[23],[28],[29] However, the “triad” is not a definitive sign of abusive trauma. The triad should be combined with clinical history and other conclusive evidence to rule out other causes and make a comprehensive diagnosis.[13],[22],[23],[27],[30]

Subdural hemorrhage

Subdural hematoma in infants and toddlers primarily results from AHT, and it is the main sequelae of AHT in 83%–90% of the cases. In the case of infants and toddlers with subdural hematoma, there is a high possibility of abuse.[3],[17],[26],[31]

Manifestation of injury

Conventionally, it is considered that subdural hemorrhage in infants is a result of the tearing of the bridging veins in the head by repeated shaking or violent impact.[20],[21],[26],[31] Some studies show that subdural hematoma does not result from traumatic rupture of the bridging veins but from blood vessel rupture caused by ischemic-hypoxic injuries, cerebral edema, increased intracranial pressure, and hemodynamic disorders.[10],[21],[22],[26],[27]

Subdural hemorrhage caused by AHT is often distributed on both sides of a hematoma can be unilateral or bilateral, have a bleeding volume of <10 mL, have no obvious space-occupying effect, is located in the cerebral hemisphere that is convex, and could spread to the posterior cerebral longitudinal fissure; these are the signs of injury due to shaking trauma and shear forces.[10],[17],[21],[23],[32],[33] Some investigators suggest that if there is no obvious accidental injury, subdural hemorrhage in the posterior cerebral longitudinal fissure would be, in most cases, the indication of AHT.[17],[23],[34] Mortality is not usually caused by subdural hemorrhage and space-occupying lesions but by craniocerebral injury, which results from diffuse axonal injury, cerebral edema, and postcirculation disorder.[16]

Differential diagnosis

Besides abusive head injuries, many nonabusive head injuries and nontraumatic conditions could lead to subdural hemorrhage. Therefore, subdural hemorrhage, as a single symptom, is only moderately specific in the diagnosis of AHT.[21] About 46% of healthy newborns, delivered by spontaneous delivery, assisted labor, or cesarean section, in the postnatal stage, could present with subdural hemorrhage as incidental findings when studies are done to detect them or for unrelated reasons, and the hemorrhage is generally absorbed in a month after birth.[6],[20],[21],[23]

Motor vehicle accidents and injuries due to falls can also cause subdural hemorrhage.[19] Subdural hemorrhage is the result of several trauma and not accidents related to daily activities. Statistical data indicate that death by falling or injuries is extremely rare; the risk of death from falling from a height of <4.9 feet (1.5 meters) is <1 in a million. Some investigators have even argued that death due to a fall from <4 ft should be treated with suspicion, as it is often an evidence of abuse.[6],[13],[20],[31],[35]

Many diseases can cause subdural hemorrhage, such as cerebral aneurysm, arteriovenous malformation, meningitis, coagulation disorder, acute nonlymphocytic leukemia, sickle-cell anemia, disseminated intravascular coagulation, hemophilia, idiopathic thrombocytopenic purpura, and metabolic diseases.[6],[17],[21],[20] These diseases are easily diagnosed according to clinical symptoms and laboratory test results. Repeated bleeding from a chronic subdural hematoma also indicates abusive head injury, as such bleeding is usually observed in children with brain atrophy or postoperative hydrocephalus shunt.[17]

Retinal hemorrhage

Retinal hemorrhage is an important hallmark of AHT, which can be seen in 50%–100% of the cases. Most cases of retinal hemorrhage in children are caused by AHT, especially in children under 3 years.[11],[15],[28],[29],[32],[36],[37],[38]

Manifestations of injury

Retinal hemorrhage caused by AHT commonly occurs near the serrate edge, retrobulbar optic disc, and macula lutea where the vitreous adheres to the retina. In AHT, the child's head is shaken violently and or beaten; this results in repeated and rapid acceleration-deceleration motion, causing lens and retina dyssynchrony. The activities above exert a shearing force on the junction of the lens and retina, ultimately resulting in a retinal tear. At the same time, this external force can also cause intraorbital injuries, such as optic hemorrhage, intraorbital fat hematoma, and external muscle bleeding.[11],[20],[26],[29],[32],[36],[37],[38],[39] Intracranial hypertension, cerebral anoxia, artery hypertension, retinal occlusion, and central retinal vein hypertension are considered some of the mechanisms of retinal hemorrhage, but this is debated.[17],[21],[22],[26],[27],[30],[39]

AHT often causes retinal hemorrhage in multiple layers of the retina, spreading from the postretinal layer to the peripheral serrated edges; flame-shaped hemorrhage is the most common type, especially with retinal lamination or plaque, which is of diagnostic significance.[6],[11],[15],[28],[29],[32],[36],[37],[40],[41],[42]

Sometimes, retinal bleeding in both eyes may be asymmetrical, with unilateral retinal bleeding and laminar detachment; lack of retinal bleeding or mild bleeding confined to the area around the optic nerve does not rule out the possibility of abusive head injury.[20],[26],[29],[30],[36],[37] Retina hemorrhage due to AHT is often absorbed in days or weeks, while preretinal and vitreous hemorrhage can remain for weeks or months.[13],[37],[43]

Differential diagnosis

In an appropriate clinical situation, retinal hemorrhage is an important hallmark of child abuse; however, retinal hemorrhage has a moderate level of specificity in the diagnosis of abuse injury.[12],[15],[21],[38]

Head trauma due to fatal accidents causes retinal hemorrhage, e.g., traffic accidents with repeated acceleration-deceleration movements (such as rolling), fatal crash, or fall from a height. Retinal hemorrhage is mild, unilateral, and mostly located in the postretinal and inner retinal areas and infrequently in the subretinal retina, but severe damage can lead to retinal hemorrhage in multiple layers, from the postretinal to peripheral layer, even accompanied by retinal lamination or plaque. Mild accidental head trauma, falling from a low height, and normal playing do not contribute to retinal hemorrhage.[15],[19],[29],[32],[37],[38],[39],[44] Peripheral retinal hemorrhage indicates repeated acceleration-deceleration injuries, more common in abuse than in accidents, and can be used to distinguish between the two. In one study, peripheral retinal hemorrhage was reported in 27% of AHT cases and not in accidental head injury cases.[15],[32],[35]

Studies have shown that a significant proportion of newborns experience retinal hemorrhage after normal vaginal delivery, generally bilateral and inside the retina, confined to the postretinal area, rarely found in preretinal or subretinal areas, with no retinal laminar detachment or retinal plaque. The risk of retinal hemorrhage is high in cases of long labor, use of forceps, and advanced maternal age. In 2 weeks, 85% of the bleeding is absorbed, and in 4 weeks, it is completely absorbed. Retinal hemorrhage in neonates may be related to increased intracranial pressure due to the pressure exerted by the birth canal on the head during labor, eye compression and decompression, perinatal hemodynamic changes, and release of prostaglandins in fetal blood.[11],[15],[17],[32],[36],[37],[38],[39]

Some investigators believe that cardiopulmonary resuscitation unlikely to lead to retinal hemorrhage, and if there is a small amount of bleeding, it is limited to the posterior pole; however, this remains controversial.[15],[16],[29],[32],[37],[38],[39]

In addition, spontaneous subarachnoid hemorrhage, hemorrhagic diseases, pernicious anemia, iron-deficiency anemia, sickle-cell disease, thrombocytopenia, hyperviscosity, nonleukemia, meningitis, increased intracranial pressure, and systemic infection can also lead to nontraumatic retinal hemorrhage, which is usually mild. Therefore, the finding of retinal hemorrhage should be combined with medical history, ophthalmological and clinical examination results, anatomical assessments, and a case and scene investigation for a comprehensive analysis.[17],[29],[32],[36],[37],[38],[40]

Persistent cough, severe vomiting, and increased intrathoracic pressure during epileptic seizures do not lead to retinal hemorrhage in children nor do vaccination. Some investigators suggest that hypoxia alone can trigger intracranial hemorrhage and retinal hemorrhage, but there is no clinical or anatomical evidence to support this theory.[15],[27],[29],[32],[35],[39]

Eye injuries

Besides retinal hemorrhage, abusive head injuries can also cause vitreous hemorrhage, optic nerve hemorrhage, crystal dislocation, cataracts, and optic nerve atrophy.[17],[38] Vitreous hemorrhage, although rare, has particular diagnostic significance and is associated with child abuse. Vitreous hemorrhage has not been observed in accidental head injury.[15],[38]

Optic hemorrhage is also an important hallmark of severe head trauma. Optic nerve sheath hemorrhage accompanied by retinal hemorrhage occurs in 70% of abusive head injuries. Optic sheath hemorrhage has a higher correlation with abuse-related injury than retinal hemorrhage.[17],[18],[29],[38]

Shaking-related injuries to the optic nerve occur at the junction area, such as the optic nerve's connection to the eye and the orbital apex, where the optic nerve is tightly attached to the optic canal of the sclera or bone and suffers the greatest shearing force when the eyeballs press into intraorbital space due to deceleration forces.[17],[29],[36],[37],[39] The optic nerve is long, allowing the eye and orbital contents to move. However, if optic nerve hemorrhage is observed, it must be noted that, occasionally, traumatic or spontaneous intracranial hemorrhage may diffuse into the subdural and subarachnoid spaces of the optic nerve sheath.[17],[18],[29],[36]

Orbital content bleeding is rare in accidental head injuries and is often associated with direct orbital damage or repeated acceleration-deceleration head injuries. Therefore, if a child presents with changes in extraocular muscles, orbital fat, and hemorrhage without orbital fracture, abusive head injury should be highly suspected.[29],[36],[39]

Diffuse cerebral injuries

The most common brain injuries in AHT are brain swelling and ischemic hypoxic brain injury.[10],[17],[21],[22],[23] The mechanism of cerebral-parenchymal lesion formation in AHT is not fully understood and may be the result of multiple factors. Brain swelling is usually caused by brain edema, and children often develop diffuse brain swelling on both sides of the cerebral hemisphere but rarely have a hernia. Cerebral hypoxia may be the result of cerebral edema; damage to the brain stem and/or axonal cords at the medulla oblongata can lead to apnea and hypoxia. Ischemic brain changes in infants are common in the periventricular white matter areas most sensitive to ischemia and hypoxia.[16],[17],[18],[22] Diffuse traumatic axonal injuries are uncommon in abusive head injuries and are confined to specific areas of the brain stem or upper cervical spinal cord.[10],[17],[23]

Cerebral lesions due to abusive head injuries are nonspecific; only subdural hemorrhage, retinal hemorrhage, craniocervical junction injuries, and diffuse cerebral-parenchymal lesions are related to AHT.

Spinal injuries

In child abuse cases, obvious spinal injuries are not common. There have been reports of spinal injuries from abusive head injuries, most commonly in infants younger than 6 months of age. Hence, AHT should be suspected in cases of inexplainable cervical spine lesions.

In cases of suspected child abuse, forensic experts incise the back of the neck, especially the craniocervical junction, to inspect the neck muscles and check for ligament hematoma and cervical spinous fracture. The spinal cavity is opened to check for epidural/subepidural hematoma due to cervical spinal cord fracture, nerve root contusion, spinal cord parenchymal contusion, and hemorrhage. Sometimes, spinal injuries can reach as far as the lumbar spine. Systematic examination of the spine can help uncover the mechanism of abusive head injury.[13],[17],[18],[21],[26],[45] It is also important to recognize that the pathologist doing the autopsy should review all the medical records as well as the imaging studies. Sometimes, hemorrhage may be noted around the spinal cord without any external evidence.

The spine of infants and toddlers is cartilaginous, with high elasticity. The vertebrae can be deformed and temporarily displaced since the spinal ligaments and muscles are not completely developed. At the same time, the neck ligaments and dura mater are more tolerant to external mechanical forces than the spinal cord. The spine may be deformed (with dislocation) at the site of spinal cord compression/injury but not endure vertebral fracture and ligament rupture.[17],[18],[45] Therefore, vertebral fracture is not common in infants and toddlers who experience AHT.

Subdural hemorrhage around the spinal cord in the cervical segment does not always indicate neck injury but may be due to the posterior fossa subdural hematoma leaking into the spinal canal, as far as the dorsal side of the thoracic and lumbar segments, showing a gravitational distribution.[17],[23] In one study, 19 cadavers of infants who died of natural diseases or sudden infant death syndrome were autopsied; different degrees of spinal epidural hemorrhage were reported in 18, suggesting that the spinal epidural hemorrhage is correlated with hemodynamics not trauma.[19],[23],[45] Some investigators stated that spinal epidural hemorrhage is a response to intracranial pressure due to various causes. Others claimed that it may be an artificial illusion. Therefore, if there is no evidence of intracranial injury or no evidence to support the antemortem injuries, spinal epidural hemorrhage should not be overinterpreted as proof of child abuse.[19],[23],[45]

  Clinical Diagnosis and Forensic Identification Top

If exterior signs of head injury are not visible, it becomes difficult to diagnose AHT. Pediatricians must be aware that serious injuries, especially fatal cases, are rarely the result of accidental causes, except in the cases of motor vehicle accidents or falls.[34] Therefore, if a child below the age of 5 years is suspected of having endured AHT, head, neck, and spinal exam must be performed along with fundoscopy, systemic skeletal examination, and EEG.[15],[28],[33],[36],[40],[41],[45],[46]

After receiving emergency medical care, fundoscopy should be conducted within 24 h and no later than 72 h; in some cases, even after 72 h, fundoscopy is necessary. After mydriasis, fundoscopy is the gold standard for detecting retinal hemorrhage.[13],[36],[41] Abusive head injuries are often concomitant with bone injuries, including metaphyseal injuries to the tibia, femur, and humerus and posterior rib fracture, but the absence of fractures does not rule out abusive head injuries.[20],[33]

Some investigators[28] believe that an abusive head injury can only be diagnosed when at least two of the following four criteria are present: (1) intracranial abnormalities on computed tomography or magnetic resonance imaging; (2) rib fracture or epiphyseal injury/fracture of the long bones; (3) intraocular injury, retinal hemorrhage, vitreous hemorrhage, macular retinal lamination, and macular hole; and (4) loss of consciousness and seizure. Others[22] proposed that the diagnosis must be based on clinical symptoms, imaging findings, and lack of reasonable explanation for the above criteria.

The clinical diagnosis of abusive head injuries is best performed by a team of experts, including pediatric imaging specialists, pediatric neurosurgical specialists, ophthalmologists, pediatric maltreatment specialists with extensive experience in child abuse, judicial personnel, and child protection personnel.[20],[34]

If child abuse is suspected, vitreous fluids should not be extracted before autopsy to prevent the risk of misdiagnosis. The chemical analysis of vitreous fluids is essential for the diagnosis of dehydration, but in child abuse cases, retinal examination is important.[17],[18] For cases of suspected abusive head injury or unexplainable/sudden death, extracting the orbital contents and eyeballs as a whole is recommended. The process of extraction is as follows: remove the brain and tear off the dura, then remove the orbital apex from the back and examine the eyeball and optic bundle in situ; after removing the orbital apex, strip the orbital fat away to expose the optic nerve and eyeball, cutoff the periocular muscles and connective tissue, and extract the eyeball and orbital contents. Then, fix the eyeball with 10% formalin for 24 h; next, cut horizontally through the optic nerve on both sides of the eyeball.[17],[29]

  Prevention Strategies Top

AHT is a preventable problem which is also a major societal challenge. Prevention of AHT should focus on reducing child abuse and maltreatment. AHT has an obviously dangerous behavior (shaking) and significantly dependencies prestimulation factor (crying) that makes the preventive measures more objective and targeted. AHT can be effectively prevented by educating parents.[3],[13],[14] This education should focus on family resource centers and home visit programs, particularly in those of high-risk homes (e.g., younger parents living in poverty). These programs should include mental, as well as social services. Before discharge from the hospital, the parents should be instructed in the danger of shaking their baby. Health-care providers in pediatric offices, as well as in the emergency department, should receive systematic training and learn to identify parents at high risk of infant abuse. Parents should also be taught coping skills to deal with crying, and they are supposed to know the danger of shaking a baby with an undeveloped brain.[47]

In the United States, a tertiary prevention system guided by educational strategies has been established for the general public and for children who are at risk of child abuse and families with a history of child abuse, plans such as “family visit program” and “no shaking baby program” have been established. In many states, it is mandatory for new parents and guardians to be educated by pediatricians and nurses about shaken baby syndrome; dangers of shaking, hitting, and striking the baby; changes in crying patterns; handling the baby; managing a crying baby; emotional control; and so on before discharge. New parents are also followed up 6–7 months later. In addition, government authorities and relevant organizations educate the medical personnel, the public, and even students about the dangers of shaking babies through various means such as campaigns, brochures, and posters.[4],[7],[12],[13],[14],[31],[34],[48] Although the interventions of relevant institutions and personnel are unlikely to significantly improve the prognosis of severe craniocerebral injury, early identification and treatment can prevent secondary ischemic hypoxic injury in cases of minor injuries and prevent children from suffering more serious injuries in the future.[14] Behavioral parent training programs such as Parent-Child Interaction Therapy (PCIT) demonstrate success in preventing recidivism for abuse in families with substantiated cases of child abuse and neglect and in reducing child abuse and neglect risk factors in high-risk families.[49],[50],[51],[52],[53],[54] Physically abusive parents in the child welfare system who participated in PCIT had significantly fewer re-reports of physical abuse than parents who participated in services as usual (19% vs. 49%).[49] In a study of families with chronic and severe neglect and/or physical abuse histories, PCIT plus a motivational enhancement was effective in reducing future child welfare reports, with a stronger effect observed when children were returned to the home sooner rather than later.[50]

In Japan, the Child Abuse Prevention Law was enforced in November 2000.[55] In October 2004, the above-mentioned law as well as the Child Welfare Law were revised for the purpose of extending the obligation of notification to child guidance centers and promulgating the Regional Council of Countermeasures for Children Requiring Aid (a regional network for protecting children). In April 2008, a regional network for protecting children has been improved so that the on-site inspection to confirm the safety of children was reinforced. Meanwhile, the information regarding high-risk children who had medical problems during the perinatal period and who were difficult to raise came to be shared throughout a certain region.

The purpose of this study is to review and publicize AHT knowledge to professionals and enhance their expertise, hoping to promote the establishment of institutions and systems in relevant countries and regions, and finally contribute to the protection of children from abuse.


This study was supported by Beijing Natural Science Foundation (7192121), National Natural Science Foundation of China (81971796), and CAE Advisory Project: “The strategic research on forensic science and legalization of social governance” (2019-XZ-31).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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