Randell Alexander

Shaken baby syndrome and a baby's cry.

The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact.

Guidelines for Postmortem Protocol for Ocular Investigation of Sudden Unexplained Infant Death and Suspected Physical Child Abuse

Postmortem examination is a cornerstone in identifying the cause of unexplained sudden death in children. Even in cases of suspected or known abuse, an autopsy may help characterize the nature of the abuse, which is particularly important in the forensic autopsy of children in the first 3 to 4 years of life when inflicted neurotrauma is most common. Forensic examinations are vital in cases that might otherwise be diagnosed as sudden infant death syndrome. The ocular autopsy in particular may demonstrate findings that were not appreciated on antemortem clinical examination. This protocol for postmortem examination of the eyes and orbits was developed to promote more consistent documentation of findings, improved clinical and forensic decision making, and more replicable and coherent research outcomes.

Child Fatality Review Teams

The history of child fatality review (CFR) begins with the work of Ambrose Tardieu in 1860. More than a century later, in 1978, the first team was established in Los Angeles, California. This article reviews the history of CFR, the composition of teams, and its purpose based in preventive public health. The successes of three decades and challenges for the future of CFR are discussed.

Medical Evaluations Then and Now

The role of medicine for children suspected of having been sexually abused has advanced significantly since the 1980s. Newer tests such as DNA and nucleic acid amplification have added to the detection of perpetrators and disease, respectively. Non-acute examination physical findings are seen in only 5% to 10% of instances. Physical findings regarding the hymen and anus have been found to often be normal variants—findings that some used to regard as signs of sexual abuse. Newer considerations for clinicians include Internet child pornography, human trafficking, and use of video/photographic recording. New technologies such as high definition digital photography and telemedicine help to document abuse in a much improved way than existed several decades ago. Nevertheless, the basic approach of careful history-taking remains a bedrock for the diagnosis of child sexual abuse.

Introduction to the Special Section: Medical Advances in Child Sexual Abuse, Part 2

This volume is the second of a two-part special issue detailing state of the art practice in medical issues around child sexual abuse. The four articles in this special section discuss topics such as estimating the sexual maturity of a child from computer or photographic images; how several cases of supposed Neisseria gonorrhoeae meningitis actually were a different, but related, organism, thereby removing sexual abuse as a consideration as to etiology; what current laboratory methods are available today to detect specific sexually transmitted infections and what should be used; and how all the evidence in child sexual abuse cases is organized to make clear and accurate statements.

Neisseria-Avoiding the Jump to Conclusions.

Neisseria gonorrhoeae infection in a prepubertal child is virtually diagnostic of sexual abuse, provided perinatal infection has been excluded. Therefore, it is imperative that Neisseria gonorrhoeae be correctly identified. We present two cases of false positive Neisseria gonorrhoeae meningitis encountered at two different childrens hospitals. Both cases were evaluated by the child protection teams prior to establishing the correct diagnosis.

Prader-Willi Syndrome

Prader-Willi syndrome (PWS) is a genetic condition caused by a partial deletion of the 15th paternal chromosome. Persons with PWS have a broad range of signs and symptoms. The infant has problems feeding associated with hypotonia, but by 2–4 years of age there is the development of lifelong insatiable appetite often leading to morbid obesity if not strictly managed. Significant behavior problems with temper tantrums and stubbornness also begin around 2–4 year of age. Other features include short stature, characteristic facial features, under-developed genitalia, hypotonia, skin picking, difficulty with vomiting, and often mild intellectual disability. The intensity and range of signs and symptoms of PWS requires the help of a large variety of professionals, and is aided by a PWS interdisciplinary team where available. With careful management of weight and behaviors and with considerable effort, persons with PWS can live longer and healthier lives.

Commentary on Dialectics, Infant Shaking, and Perpetrator Statements in Child Maltreatment

Dialectical thinking is much like science. Hypotheses are generated, rationally discussed, contradictions identified, and an improved set of hypotheses are generated. The purpose is to be unemotional—distinguishing this from a debate, or as is seen with cases of shaken baby syndrome, a courtroom spectacle. If only it was only about science in these situations. With the shaking of babies comes not two but multiple viewpoints. Can you shake a child hard enough to cause injury? Some say no, most physicians and major medical societies say yes, and Dr. Geddes even said little shakes might do it— although, she has since retracted her hypothesis in court. Disagreement abounds in medicine and virtually any diagnosis will have differing points of view. While it might be expected that this would be especially true for child abuse, significant court challenges mostly center on abusive head trauma. In contrast to this commentary, it is not true that there has been any “step back” from the concept of shaking causing serious or fatal injury by the child abuse community. Children are correctly diagnosed every day. Also, as noted, perpetrators sometimes confess. There is an extensive data based literature from many countries that supports the concept and particulars of shaken baby syndrome, in contrast to essentially opinion pieces by those opposed (Adamsbaum et al. 2010; Bennett et al. 2011; Berger et al. 2011; De Leeuw et al. 2013; Denurku et al. 2013; Esernio-Jenssen et al. 2011; Finnie et al. 2012; Friedman et al. 2012; John et al. 2012; Mori et al. 2013; Niederkrotenthaler et al. 2013; Parks et al. 2012a; b; Sieswerda-Hoogendoorn et al. 2013; Stipanicic et al. 2008). There have been multiple efforts to reconcile differing points of view, exemplified best by the Pediatric Abusive Head Trauma research conference headed by Dr. Mark Dias. Yet there has been no apparent change in position. It is significant to note that this is a lopsided “debate” with no major medical organization denying shaking as a serious form of abuse. A civil dialogue would be nice, but with the legal entanglements it might be awhile before that occurs.