Developmental Delays of a Child With Shaken Baby Syndrome
Christopher R. Stelton, MD, K. David Epley, M.D., Felix Y. Chau, MD, Donny W. Suh, Dr., FAAP, MBA, FACS, Mary Elizabeth Hartnett, MD, Jennifer I Lim MD
Assigned status Upwardly to Appointment
past Mary Elizabeth Hartnett, Doc on January three, 2022.
Shaken Infant Syndrome or Non Adventitious Trauma
Overview:
Child corruption is a significant social problem which is associated with a loftier morbidity and mortality. "Shaken Babe Syndrome" (SBS) is one form of physical child corruption, a not-accidental traumatic (NAT) brain injury. It is included in abusive head trauma classification. [ane]. In 6% of reported cases of child abuse, an ophthalmologist is responsible for initially recognizing the abuse[2]. Shaken Baby Syndrome (SBS) affects an estimated 1400 children/year in the United states [3] and it is thought an astounding 2 million children are abused each yr in the US solitary. Retinal findings may be the only manifestation of this corruption. Information technology is a diagnosis that has important medical-legal implications and one that cannot exist disregarded every bit a child's safety may very well exist at stake.
Detailed Clarification:
The ocular manifestations of kid abuse are numerous. There may be signs of periorbital trauma (i.e. ecchymosis, lid edema, orbital fractures), anterior segment trauma (i.e. hyphema, iris prolapse, corneal laceration, cataract), or posterior segment trauma (i.eastward. vitreous hemorrhage, retinal detachment, optic nerve avulsion)[4]. There may be associated encephalon injury resulting in nystagmus, cortical blindness, encephalopathy, or cranial nervus palsies[4]. Intracranial bleeding may be associated with SBS[4] - most unremarkably subdural hemorrhage.
Retinal hemorrhages are the cardinal manifestation of SBS. The incidence of retinal hemorrhages in SBS is approximately 85%[five]. Classically, children with SBS have retinal hemorrhages which are multilayered – preretinal, intraretinal, and subretinal. They are usually too numerous to count and extend out to the retinal periphery (i.e. not just confined to the posterior pole). Macular retinoschisis (splitting of the retinal layers) may too be associated with SBS[vi]. As retinal hemorrhages may subside over fourth dimension, prompt retinal photography is recommended at the time of discovery of retinal hemorrhages on dilated funduscopic exam to document findings as a baseline for hereafter comparison. If possible, extended ophthalmoscopy with examination of the entire retina with scleral low is recommended to likewise evaluate for peripheral nonperfusion (from retinal vascular disruptions) and neovascularization too as for peripheral retinal tears, hemorrhages, and other pathology. If possible, broad sweeping photographs and fluorescein angiography are recommended every bit soon equally the discovery of retinal hemorrhages from SBS / NAT are discovered. Examination under anesthesia may exist required to obtain imaging besides equally administer handling.
Epidemiology/Run a risk Factors:
Mayhap the greatest diagnostic clue is a detailed history that is incompatible with the extent and severity of the injuries found on dilated fundus test. Suspected abusers may confess to investigators in upward to 47% of cases[7]. A kid with classic evidence supporting physical abuse (i.e. onetime fractures, bruises of varying ages, signs of neglect, new sleep or behavioral issues) should alert the clinician to request a dilated fundus exam looking for SBS. The actual crusade of retinal hemorrhages is still being studied experimentally.
Etiology/Pathophysiology:
Several mechanisms for the retinal hemorrhages have been postulated and recently been the subject of some debate (generally in the courts). One likely hypothesis implicates repetitive acceleration-deceleration forces which cause damage via vitreomacular traction[8]. Other possible mechanisms include blunt head impact, increased intracranial force per unit area, increased intrathoracic pressure, hypoxia, sodium imbalance, or coagulopathies. Vascular disruption may also lead to peripheral nonperfusion which subsequently may result in neovascularization, vitreous hemorrhage, and tractional or combined tractional / rhegmatogenous retinal disengagement. Models of the eye and orbit are beingness used to sympathize better the causes of pathology seen in NAT.
Histopathology:
Pathology may reveal findings detailed to a higher place (east.yard. retinal hemorrhages at multiple levels, nervus avulsion). Perimacular folds and hemorrhagic macular retinoschisis may be found on histopathologic exam and may non be well appreciated on dilated fundus exam if the view is obstructed past vitreous hemorrhage.
Differential Diagnosis:
- Accidental Head Trauma
- Purtscher'south retinopathy: associated with blunt thoracic trauma
- Terson Syndrome: intraocular hemorrhage associated with intracranial hemorrhage
- Normal Nativity
- Anemia
- Blunt ocular trauma
- Coagulopathy
Direction/Treatment:
Overall, prevention is the best therapy. Many hospitals and healthcare centers offer classes and education on how to cope with the stresses of parenthood. Unfortunately, some children will require treatment for amblyopia or strabismus. Patching therapy and spectacles may be needed to treat the amblyopia induced by the ocular trauma.
Surgical vitrectomy may rarely be needed for nonclearing vitreous hemorrhage, macular hole, or retinal detachment. Frequently, the prognosis can vary significantly for victims of SBS depending on the severity of the trauma. Conscientious physician documentation of findings and fundus photography (if available) tin can prove very helpful especially in a courtroom of police force. Child protective services and local law enforcement should immediately be alerted in all cases of abuse or suspected corruption.
Retina photographs with broad sweeping fluorescein angiography is recommended to document baseline intraretinal hemorrhages and other pathologic changes as described above as well equally to evaluate for peripheral nonperfusion and possible neovascularization development. Peripheral nonperfusion may lead to development of neovascular tissue that after may contribute to vitreous hemorrhage and tractional or circuitous tractional / rhegmatogenous retinal detachment. If significant peripheral nonperfusion is detected, peripheral besprinkle light amplification by stimulated emission of radiation to all regions of nonperfusion may be considered to reduce the risk of neovascularization and subsequent retinal disengagement.
Prognosis:
Poor. Cortical incomprehension occurs in up to fifteen%. Victims suffer from high incidences of behavioral, social, motor, and visual problems.
References:
- ↑ Caputo G. and Wu Wei-Chi. Nonoaccidental Head Trauma. In Pediatric Retina, third edition. Hartnett, ME Editor-in-Chief. Wolters Kluwer Philadelpha PA 2021.
- ↑ Friendly DS. Ocular manifestations of concrete child corruption. Trans Am Acad Ophthalmol Otolaryngol 1971; 75: 318-332.
- ↑ Newton AW, Vandeven AM. Update on kid maltreatment with a special focus on shaken baby syndrome. Curr Opin Pediatr 2005; 17: 246-251.
- ↑ 4.0 4.one 4.2 Sternberg P Jr. Trauma: principles and techniques of treatment. In: Ryan SJ, ed. Retina, 2ndedn, vol. 3. St. Louis: Mosby; 1994: 2351-2378.
- ↑ Kivlin J, Simons Yard, Lazoritz S, Ruttum M. Shaken baby syndrome. Ophthalmology. 2000; 107(7): 1245-1254.
- ↑ Greenwald, Weiss, Oestrerle, Friendly. Traumatic retinoschisis in battered babies. Ophthalmology. 1986; 93(v): 618-625.
- ↑ Jenny, Hymel, Ritzen, et al. Assay of missed cases of abusive head trauma. JAMA 1999; 281: 621-626.
- ↑ Levin, Alex. Retinal Hemorrhage in Abusive Head Trauma. Pediatrics 2010; 126; 961.
- Caffey J. On the theory and practice of shaking infants: its potential remainder effects of permanent encephalon impairment and mental retardation. Am J Dis Child 1972; 124: 161-169.
Source: https://eyewiki.org/Shaken_Baby_Syndrome
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