On retinal hemorrhages in general:
"The cause is most likely VENOUS CONGESTION. The fetal head is compressed two to four times more forcefully than other fetal parts during the second stage of labor. Retinal hemorrhage is more common in promiparus deliveries and after forceps or vacuum extraction; it is rare after cesarean section. It may occur in normal deliveries."
 

http://www.sciencedaily.com/releases/2006/02/
060226114611.htm

Researchers Say Criterion For Diagnosing Child Abuse Not Always Accurate
ScienceDaily (Feb. 26, 2006) — When it comes to looking for damage to the eyes to prove child abuse, new research shows that things aren't always as they seem, according to Patrick Lantz, M.D., a forensic pathologist from Wake Forest University Baptist Medical Center.

"Contrary to what many doctors have been taught, we found that number and location of hemorrhages of the eye's retina aren't always proof of child abuse," said Lantz, who reported the results today at the 58th annual meeting of the American Academy of Forensic Sciences in Seattle. "Retinal hemorrhages occur more often than most doctors think are associated with a wide variety of conditions."

Lantz found that about 16 percent of the 700 individuals he examined during autopsy had hemorrhages of the retina, which is light-sensitive nerve tissue at the back of the eye. The bleeding occurs when tiny blood vessels on the retina's surface rupture. Lantz found the hemorrhages in individuals who had died from ruptured aneurysms, falls, car wrecks, gunshot wounds, meningitis and even drug overdose.

"Our research shows that you see the hemorrhages in a lot of different situations," Lantz said. "Retinal hemorrhages occur in child abuse, but they don't always mean a child was abused. Unfortunately, many pathologists, pediatricians and ophthalmologists have been taught that retinal hemorrhages are diagnostic of child abuse unless the child was involved in a high-speed car crash or fell more than two stories."

Currently, when child abuse is suspected, doctors conduct an eye exam to look for retinal hemorrhages and other eye changes that are considered proof of child abuse. Lantz got the idea to question this common assumption after he found that another eye condition, a buckling of the retina, is not always diagnostic for shaken baby syndrome. He reported those results in the British Medical Journal.

To test his theory that retinal hemorrhages also may not always be indicative of child abuse, Lantz decided to look for the condition during autopsies to learn more about when they occur.

Previously, the only way to look for the hemorrhages during an autopsy was to remove the eyes. Lantz came up with an alternative -- performing eye exams during autopsies using a surgical headlight and a handheld lens. This simple technique is sometimes used by ophthalmologists when more sophisticated equipment is not available, but no one had ever reported using it during autopsies.

The 700 deaths were in people ranging in age from birth to 96. Causes of death or conditions associated with retinal hemorrhages included suffocation, sudden infant death syndrome, meningitis, blunt trauma to the head, ruptured cerebral aneurysms, hemorrhagic strokes, cancer that had spread to the brain, high blood pressure, bleeding disorders, diabetes and gunshot wounds to the head.

"Many doctors have been taught to look for the hemorrhages when they suspect child abuse and often will diagnose child abuse without considering other possibilities," Lantz said. "Our research shows that you see the hemorrhages in a variety of different situations in infants, children and adults."

According to medical literature, retinal hemorrhages in infants are rare except in cases of abuse. "We're finding just the opposite," said Lantz. "We've found more retinal hemorrhages in non-abuse cases than in abuse cases, but most doctors don't look in the eyes of children unless they suspect child abuse."

Retinal hemorrhages were found in 30 children under age 14, yet only 6 cases were associated with child abuse.

As one of the first pathologists to routinely look at the back of the eye during autopsies, Lantz has learned that the technique can help diagnose hypertension, glaucoma, Marfan syndrome and even diabetes. He has taught residents and medical students to conduct the examinations and published an article in the Journal of Forensic Science (Nov. 2005) on the technique.

Lantz's co-researcher was Constance A. Stanton, M.D., neuropathologist, from Wake Forest University Baptist Medical Center.



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Adapted from materials provided by Wake Forest University Baptist Medical Center, via EurekAlert!, a service of AAAS.
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Wake Forest University Baptist Medical Center (2006, February 26). Researchers Say Criterion For Diagnosing Child Abuse Not Always Accurate. ScienceDaily. Retrieved October 24, 2008, from http://www.sciencedaily.com­ /releases/2006/02/060226114611.htm

Perimacular retinal folds from childhood head trauma
BMJ  2004;328:754-756 (27 March), doi:10.1136/bmj.328.7442.754
P E Lantz, associate professor1, S H Sinal, professor2, C A Stanton, associate professor1, R G Weaver, Jr, associate professor3
 Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA, 2 Department of Paediatrics, Wake Forest University School of Medicine, 3 Department of Ophthalmology, Wake Forest University School of Medicine

No abstract available but in summary it is a case report of a 14month old child with retinal changes often described as pathognomonic for NAI, but where the cause was clearly documented to be accidental (A television fell on the child's head).  This publication comes at a time when the expert medical evidence for child abuse is coming under increasing scrutiny following the publicity around Roy Meadows cases in the UK. The Editorial (below) is worth reading if ever you might find yourself in the witness stand. MIKE


Editorial -  The evidence base for shaken baby syndrome
BMJ  2004;328:719-720 (27 March)

We need to question the diagnostic criteria

The phrase "shaken baby syndrome" evokes a powerful image of abuse, in which a carer shakes a child sufficiently hard to produce whiplash forces that result in subdural and retinal bleeding. The theory of shaken baby syndrome rests on core assumptions: shaking is always intentional and violent; the injury an infant receives from shaking is invariably severe; and subdural and retinal bleeding is the result of criminal abuse, unless proved otherwise.1 These beliefs are reinforced by an interpretation of the literature by medical experts, which may on occasion be instrumental in a carer being convicted or children being removed from their parents. But what is the evidence for the theory of shaken baby syndrome?

Retinal haemorrhage is one of the criteria used, and many doctors consider retinal haemorrhage with specific characteristics pathognomonic of shaking. However, in this issue Patrick Lantz et al examine that premise (p 754) and conclude that it "cannot be supported by objective scientific evidence."2 Their study comes hard on the heels of a recently published review of the literature on shaken baby syndrome from 1966 to 1998, in which Mark Donohoe found the scientific evidence to support a diagnosis of shaken baby syndrome to be much less reliable than generally thought.3

Shaken baby syndrome is usually diagnosed on the basis of subdural and retinal haemorrhages in an infant or young child,1 although the diagnostic criteria are not uniform, and it is not unusual for the diagnosis to be based on subdural or retinal haemorrhages alone.w1 The website of the American Academy of Ophthalmology states that if the retinal haemorrhages have specific characteristics "shaking injury can be diagnosed with confidence regardless of other circumstances."4 Having reviewed the evidence base for the belief that perimacular folds with retinal haemorrhages are diagnostic of shaking, Lantz et al were able to find only two flawed case-control studies, much of the published work displaying "an absence of... precise and reproducible case definition, and interpretations or conclusions that overstep the data."2 Their conclusions are remarkably similar to those of Donohoe, who found that "the evidence for shaken baby syndrome appears analogous to an inverted pyramid, with a very small database (most of it poor quality original research, retrospective in nature, and without appropriate control groups) spreading to a broad body of somewhat divergent opinions."3 His work entailed searching the literature, using the term "shaken baby syndrome" and then assessing the methods of the articles retrieved, using the tools of evidence based inquiry. Reviewing the studies achieving the highest quality of evidence rating scores, Donohoe found that "there was inadequate scientific evidence to come to a firm conclusion on most aspects of causation, diagnosis, treatment, or any other matters," and identified "serious data gaps, flaws of logic, inconsistency of case definition."3

The conclusions of Lantz et al and of Donohoe make disturbing reading, because they reveal major shortcomings in the literature relating to a field in which the opportunity for scientific experimentation and controlled trials does not exist, but in which much may rest on interpretation of the medical evidence.5

If the concept of shaken baby syndrome is scientifically uncertain, we have a duty to re-examine the validity of other beliefs in the field of infant injury. The recent literature contains a number of publications that disprove traditional expert opinion in the field. A study of independently witnessed low level falls showed that such falls may prove fatal, causing both subdural and retinal bleeding.6 w2 A biomechanical analysis validates that serious injury or death from a low level fall is possible and casts doubt on the idea that shaking can directly cause retinal or subdural haemorrhages.7 w3 An important lucid interval may be present in an ultimately fatal head injury in an infant.8 Neuropathological studies have shown that abused infants do not generally have severe traumatic brain injury and that the structural damage associated with death may be morphologically mild.9 10 What is the relevance of the craniocervical injuries to corticospinal tracts, dorsal nerve roots, and so on that have been described?10 11 We do not know. What is the force necessary to injure an infant's brain? Again, we do not know.

While most abused children indisputably show the signs of violence, not all do. No one would be surprised to learn that a fall from a two storey building or involvement in a high speed road traffic crash can cause retinal and subdural bleeding, but what is the minimum force required? "It is one thing clearly to state that a certain quantum of force is necessary to produce a subdural hematoma; it is quite another to use examples of obviously extreme force... and then suggest that they constitute the minimum force necessary."12

Research in the area of injury to infants is difficult. Quality evidence may need to be based on finite element modelling from data on infants' skulls, brains, and neck structures, rather than living animals. Any studies on immature animal models, if performed, will need to be validated against the known mechanical properties of the human infant. Pending completion of such studies, the reviews by Lantz and Donohoe are a valuable contribution and provide a salutary check for anyone wishing to cite the literature in support of an opinion. Their criticisms of lack of case definition or proper controls can be levelled at the whole literature on child abuse. If the issues are much less certain than we have been taught to believe, then to admit uncertainty sometimes would be appropriate for experts. Doing so may make prosecution more difficult, but a natural desire to protect children should not lead anyone to proffer opinions unsupported by good quality science. We need to reconsider the diagnostic criteria, if not the existence, of shaken baby syndrome.

J F Geddes, retired (formerly reader in clinical neuropathology, Queen Mary, University of London)

London (j.f.geddes@doctors.org.uk)

J Plunkett, forensic pathologist