SBS: Biomechanics of Retinal Hemorrhages

February 23, 2012 

John  D. Lloyd, Ph.D., M.Erg.S., CPE, CBIS
Board Certified Ergonomist & Certified Brain Injury Specialist

The occurrence of retinal hemorrhages has been proclaimed as one of the three cardinal features of the triad in the clinical presentation of an infant injured by repetitive rotational acceleration/deceleration from abusive shaking, where the retinal findings were asserted to be the unique primary result of vitreous traction on the retina. However, such claims are unconfirmed and   biomechanically implausible. First, retinal hemorrhages are clearly not unique to infants abused by alleged shaking, since such hemorrhages have been reported to occur as a result of increased intracranial pressure of any etiology and are often found in cases of impact injury. Furthermore, efforts to confirm the vitreous traction hypothesis as a valid cause of extensive retinal hemorrhages, retinal schisis, or folds have failed.

Anatomy and Vasculature of the Eye

In the vitreous traction hypothesis, it is asserted that traction is generated between the vitreous humor and the retina inside the eye (Figure 1 ), causing hemorrhage from ruptured capillaries in the retina. However, the relative densities of the vitreous humor and the retinal both approximate that of water (1.0 kg/l). Moreover the point of rotation of the infant head during ascribed non-accidental trauma is the lower cervical spine, therefore the radius of curvature of the retina and the vitreous traction are, for all intents and purposes, equal. Given equal radius of curvature and equal densities, it is highly improbable that a mechanical differential would be generated, particularly at the levels of rotational acceleration/deceleration that might be generated during an abusive shaking. Hence, the concept of vitreous traction cannot be supported by principles of physics.

It is now generally understood and accepted by medical professionals that retinal hemorrhages are caused by any etiology, which increases intracranial pressure of the brain. The eye is the only externally visible element of the central nervous system, where the optic nerve and central retinal vasculature are sheathed within the dura (Figure 1). Since we know that arterial pressure exceeds venous pressure, the venous return from the central retinal vein will be impeded prior to obstruction of blood flow in the associated artery, thereby increasing pressures within capillaries in the retina, which consequently burst producing of retinal hemorrhage. Furthermore, since the underlying etiology is increased intracranial pressure, bilateral observations would be typical, where the extensiveness of hemorrhagic findings would be proportional to the intracranial pressure.
In summary, retinal hemorrhages are no longer generally accepted by medical doctors to be caused by vigorous shaking of an infant.
http://www.drergonomics.com/RetinalHemorrhages.html

SBS: Nebraska: Day care provider Kendra Fritsche charged with child abuse

April 14, 2011  BETSY FRIEDRICH
HOLDREGE — A Holdrege day-care provider has been charged with child abuse of an infant girl.

Kendra Fritsche, 38, was arraigned Tuesday on a Class II felony in Phelps County Court.

 Judge Robert Ide issued a warrant for Fritsche’s arrest Feb. 17 and set her bond at 10 percent of $50,000, or $5,000. The bond ordered that Fritsche have no contact with children other than her own, and she can have no children in her care.

Fritsche was arrested Feb. 18 and now is free on bond.
Court records outline the case against Fritsche:
On Oct. 16, the Nebraska State Patrol was asked by the Nebraska Department of Health and Human Services to investigate a possible child abuse case involving a 3-month-old girl who had been in her care from Sept. 7 to Oct. 15.
On Oct. 15, Fritsche contacted the girl’s mother saying she was “not acting right and need to go to the Phelps Memorial Health Center Emergency Room.”
The mother then took the girl to her doctor in Kearney, then to Good Samaritan Hospital, where the girl underwent additional tests and a CAT scan the following morning.
The CAT scan revealed the girl had suffered a skull fracture, which medical staff said was most likely not the result of a short fall but probably occurred from a significant blow to the head. A GSH ophthalmologist also examined the girl and said she had multiple retinal hemorrhaging in both eyes, which he concluded was consistent with shaken baby syndrome.
On Oct. 18, the girl was transported via medical helicopter to Omaha Children’s Hospital. That same day, a State Patrol investigator interviewed Fritsche, who said the girl’s injuries may have been caused when she put the girl down into a car seat too hard, and she may have knocked the wind out of the girl.
On Oct. 20, a Children’s Hospital doctor said the girl had suffered two separate trauma events, as determined by an MRI scan. One indicated a three-week-old bleed in the girl’s brain, and the other more current and acute bleed dated to the previous weekend when the girl suffered a left parietal skull fracture.
The doctor told police it was possible to cause the injuries by forcefully putting the child into a car seat. The doctor also said the girl’s injuries could result in learning difficulties later in life as well as temperamental mood changes over her lifetime.
Fritsche’s preliminary hearing was scheduled for 1 p.m. May 23. A Class II felony is punishable by one to 50 years in prison.
http://www.kearneyhub.com/news/local/article_539e79c8-66bf-11e0-a0ee-001cc4c03286.html

SBS: Viewpoint of an experienced neurosurgeon: Greg and Julianna Caplan

March 9, 2008

Ronald H. Uscinski (Neurosurgeon)The writer is on the faculties of Georgetown University Hospital and George Washington University Medical Center and is an adjunct fellow at the Potomac Institute for Policy Studies in Virginia.

In the 18th century, Sir William Blackstone articulated what is known today as the Blackstone ratio: "It is better that 10 guilty persons escape than that one innocent suffer." This phrase expresses a cornerstone of both English common law and American jurisprudence, the principle of "innocent until proven guilty."

But this principle sadly seems to have been unheeded or even deliberately overturned in matters of suspected child abuse. The D.C. code itself reads: "Where the petition alleges a child is a neglected child by reason of abuse, evidence of illness or injury to a child who was in the custody of his or her parent, guardian, or custodian for which the parent, guardian or custodian can give no satisfactory explanation shall be sufficient to justify an inference of neglect." So the stage is set.
I am the neurosurgeon who testified in defense of Greg and Julianna Caplan, whose 8-month-old twin girls were removed from their home by the D.C. government in a case recounted by Metro columnist Marc Fisher ["A Case of a Family Services Job Well Done, or Overdone?" Feb. 24]. The issue of retinal hemorrhages as a marker of so-called shaken-baby syndrome will not be settled on the editorial page of any newspaper; suffice it to say that the validity of such a marker has always been under serious question, as is the hypothesis (yes, it is still a hypothesis) that children must have been shaken manually to suffer such injuries. I believe that a true understanding based on objective science, and not subjective conjecture, will eventually prevail.
But the erosion of a fundamental tenet of our judicial system is another matter altogether, and it has gone unchecked and even accelerated over more than three decades, to the extent that such travesties as befell the Caplans now happen all over our country, and even beyond. Child protection agencies in virtually every state in the union have powers similar to those wielded in this case by the District, and they have used these powers in a similar fashion.

What the Caplans have endured and still continue to struggle with is not limited by race, ethnicity or income level. No one is safe once suspicion is aroused within an entity that has too much authority and too little comprehension. I speak from first-hand experience, having testified in many such cases over the past decade as a subject-matter expert for the defense. (I have yet to be contacted by any prosecuting attorney to review such matters.)
This is not to say that child abuse does not exist. I have witnessed such cases, and have been deeply and painfully moved by the plight of innocents who have been injured or even killed. This is certainly not acceptable. And yet I am no less moved by the plight of the wrongfully accused (and even convicted), their families and their loved ones. This is particularly so when such accusations are based on impure science, a flawed legal foundation, and completely inadequate or inappropriate public policy.
This is the United States, a republic founded on legal, moral and ethical principles that have served us well. It is not wise to become complacent, or to be forgetful or ignorant of such principles. The words "chaos," perhaps even "tyranny," come to mind.

http://www.washingtonpost.com/wp-dyn/content/article/2008/03/07/AR2008030702529.html

SBS: Colorado; Tember Rector court of appeals decision reversed by Supreme Court

PEOPLE v. RECTOR

The People of the State of Colorado, Petitioner,

v.

Tember Terri Rector, Respondent.

John W. Suthers, Attorney General, Susan Eileen Friedman, Assistant Attorney General, Denver, Colorado, Attorneys for Petitioner.

Paul Grant, Parker, Colorado, Attorney for Respondent.

---

JUSTICE RICE delivered the Opinion of the Court.

A jury convicted respondent, Tember Rector, of felony child abuse. The court of appeals reversed the conviction, concluding that the trial court abused its discretion by failing to make sufficient findings regarding the reliability and potential prejudice of an expert's testimony and by failing to instruct the jury on the difference between medical and legal child abuse. We granted certiorari to review two of the evidentiary issues.¹ We now reverse the court of appeals.

I. Facts and Proceedings Below

Tember Rector and her husband were three-year-old T.D.'s foster parents in 2004. T.D. suffered a severe head injury on February 2, 2004, while in Rector's care. Conflicting testimony was presented at trial regarding Rector's whereabouts during the time the injury occurred. Rector testified that she did not witness T.D.'s injury because she was in the shower while T.D. was watching television on the bed in the master bedroom. Rector testified that she heard a crash and jumped out of the shower to find T.D. sitting on the floor with his arm twisted and the contents of the nightstand knocked to the floor. In contrast, the responding paramedic testified that Rector told him she was downstairs when she heard the crash upstairs.

Rector called 9-1-1 and the Castle Rock Fire Department was dispatched to Rector's home. The People presented evidence that Rector waited forty-five minutes before calling for medical assistance. When the paramedics arrived, they found T.D. unconscious, unresponsive, and exhibiting signs of severe head trauma. T.D. was taken to the closest hospital and from there airlifted to Children's Hospital. The treating physicians diagnosed T.D. with non-accidental head trauma. T.D. suffered life-threatening brain injuries that included retinal hemorrhaging in both eyes and a right-side acute subdural hematoma that caused significant bleeding and swelling in his brain. T.D. underwent emergency neurosurgery at Children's Hospital to alleviate the pressure in his brain and survived the injury. Rector was charged with felony child abuse under section 18-6-401(1)(a) and (7)(a)(III), C.R.S. (2010).²

Prior to trial, Rector's counsel submitted a motion entitled Defense Motion to Restrict People's Experts Including Ken Winston from Making Medical Speculation. In that motion, Rector sought to exclude any speculative testimony by the People's experts and asked to have an evidentiary hearing in accordance with People v. Shreck, 22 P.3d 68 (Colo. 2001). Rector's motion was general in nature and specifically challenged only one expert, Dr. Ken Winston, and only with respect to testimony about shaken-baby syndrome. At a hearing held as a result of this and other motions, Rector argued that she was entitled to a Shreck hearing "to determine whether or not . . . [the] diagnosis and opinions that [we]re going to be used at trial by medical experts who were inferring a cause from the evidence . . . [were] reliable." Rector did not, however, point to specific expert testimony that she sought to exclude — other than shaken-baby syndrome testimony — and she argued that she required additional expert discovery. The trial court denied a Shreck hearing on shaken-baby syndrome, ordered additional expert discovery, and deemed the request for a Shreck hearing premature in light of the requested additional expert discovery. Rector did not make another request for a Shreck hearing.

Later, at the trial, several of T.D.'s treating physicians testified as medical experts for the People, including Dr. Andrew Sirotnak, a pediatrician and Director of the Child Protection Team, who examined T.D. at Children's Hospital; Dr. Arlene Drack, a pediatric ophthalmologist, who examined T.D. at the emergency room; and Dr. Ken Winston, the neurosurgeon who performed T.D.'s emergency surgery. They each testified to the severity of T.D.'s injuries and opined that the injuries were non-accidental or inflicted and unlikely to have been caused by a fall from a bed.

Prior to Dr. Sirotnak's testimony regarding T.D., the prosecution established Dr. Sirotnak's qualifications and moved for his admission as an expert in the fields of pediatric medicine and child abuse under CRE 702. Rector's counsel requested an opportunity to examine Dr. Sirotnak about his qualifications, but did not inquire about Dr. Sirotnak's qualifications or introduce any evidence to suggest he was not qualified in pediatrics or child abuse. Instead, Rector's counsel asked Dr. Sirotnak about the different definitions of medical child abuse and legal child abuse. Dr. Sirotnak declined to provide a legal definition of child abuse, but acknowledged that the legal definition of child abuse differs from the medical definition. Rector's counsel then stated that he objected to Dr. Sirotnak's qualification as an expert in the field of child abuse, but that he did not object to Dr. Sirotnak "rendering opinions about his understanding of the medical use of the term child abuse." The trial court admitted Dr. Sirotnak as an expert in pediatrics and child abuse.³

Dr. Sirotnak then testified that T.D. suffered a right-sided acute subdural hemorrhage, a shift in the tissue of the brain, and retinal hemorrhages. Dr. Sirotnak testified that his responsibilities at Children's Hospital included evaluating and diagnosing patients when abuse or neglect was suspected. According to Dr. Sirotnak, the medical diagnosis of child physical abuse takes into consideration the presence of a severe traumatic injury with no history of trauma to explain that injury. Dr. Sirotnak stated that the explanation offered by Rector did not account for the severity of T.D.'s injuries. Dr. Sirotnak concluded that, in his expert opinion, within a reasonable degree of medical certainty, T.D.'s injuries were the result of abuse. Rector's counsel made no objection to Dr. Sirotnak's trial testimony.

A jury convicted Rector of felony child abuse. She was sentenced to fifteen years in prison plus five years of mandatory parole. Rector appealed her conviction, arguing, among other issues, that the trial court erred in denying her a Shreck hearing related to Dr. Sirotnak's testimony regarding medical child abuse. The court of appeals reversed Rector's conviction and remanded for a new trial, concluding that the trial court abused its discretion in failing to make adequate inquiry or specific findings regarding the reliability and potential prejudice of Dr. Sirotnak's testimony under Shreck. The court of appeals further determined that Dr. Sirotnak's testimony that T.D.'s injuries resulted from child abuse was not proper because such testimony concerned the ultimate legal determination of Rector's guilt.⁴

^{PART EXCISED}

III. Conclusion

The trial court did not abuse its discretion when it declined to hold a Shreck hearing. Rector's pretrial Shreck motion challenged testimony by Dr. Winston about shaken-baby syndrome — a diagnosis none of the experts intended to offer. The pretrial motion did not challenge testimony by Dr. Sirotnak or the medical diagnosis of child abuse and no subsequent Shreck challenge was raised. Likewise, no contemporaneous objection was made during Dr. Sirotnak's trial testimony to alert the trial court that Rector challenged the expert testimony as to reliability or prejudice. Whether Dr. Sirotnak's testimony about medical child abuse usurped the role of the jury was not properly before the court of appeals, nor did the admission of the testimony amount to plain error. Accordingly, we reverse the court of appeals.

March 14, 2011.

Supreme Court of Colorado, EN BANC.

Case No. 09SC708.

SBS: Vitreoretinal traction may be important in development of retinoschisis due to shaken baby syndrome

Alex V. Levin

PHILADELPHIA — The low incidence of skull fracture in infants with macular retinoschisis due to abusive head injury suggests that vitreous traction at the macula is key to the disease's pathogenesis, a presenter said here.
Of infants with shaken baby syndrome, 85% have retinal hemorrhages and one-third of these have retinoschisis, Alex V. Levin, MD, MHSc, said at the Wills Eye Institute Alumni Conference.
"Shaken baby syndrome, which is a form of abusive head trauma ... is a syndrome in which a perpetuator violently submits a child to repeated acceleration-deceleration forces with or without blunt head impact," he said.
Retinoschisis has only been reported in shaken baby syndrome, fatal head crush injuries and fatal motor vehicle accidents, according to Dr. Levin.
He and colleagues reviewed the medical records of 147 abused children, mean age 9.33 months, at Alberta Children's Hospital and the Hospital for Sick Children, Toronto.
Twenty-five percent had retinoschisis; of these, 60% were unilateral cases. Severe retinal hemorrhages occurred in 83% of patients, while 23% had skull fractures.
The study suggests that retinoschisis is associated with severe shaken baby syndrome and high rates of cerebral edema, papilledema and adverse neurologic and visual outcomes, the study authors said.
"I think all of this does support the ongoing theory ... that it is the vitreoretinal traction that actually causes the ocular pathology in [macular retinoschisis]," Dr. Levin said.
http://www.osnsupersite.com/view.aspx?rid=81533

SBS: Pennsylvania: Dusty Neal McCauley charged

 February 25, 2011  Josh Krysak

A Waynesburg man accused of injuring a baby in his care in Greene County in December will have his day in court.
Greene County Assistant District Attorney Linda Chambers said Dusty Neal McCauley, 23, was charged in January before Magisterial District Judge Glenn Bates with two counts each of aggravated assault, simple assault, endangering the welfare of children and recklessly endangering another person.

Bates held one count of each charge filed against McCauley for Greene County Court following a preliminary hearing Thursday. The second count of each charge was dismissed.
Chambers said the charges were filed after McCauley allegedly assaulted 11-month-old Miranda Turk at 123 Mountain View Gardens in Franklin Township, Greene County.
According to police, the incident occurred at 6 p.m. Dec. 26 when McCauley requested emergency personnel for a baby that was having trouble breathing.
Police said the girl was taken from the residence to Southwest Regional Medical Center in Waynesburg, where doctors recognized she suffered bilateral subdural hemorrhages. Police said she was then flown by medical helicopter to Children's Hospital in Pittsburgh for medical treatment.
According to Chambers, further evaluation of the baby by doctors in Pittsburgh revealed the child suffered multiple subdural hemorrhages in several regions of the head and extensive retinal hemorrhaging.
Chambers said doctors concluded that the injuries suffered by the child were consistent with abusive head trauma or shaken-baby syndrome.
McCauley remains in the Greene County Prison on $50,000 straight cash bond.
http://www.heraldstandard.com/news/local_news/article_fe5669df-b9c1-5836-8954-edfa1a39a705.html

SBS: Montana: Christopher R. Lewis

PERRY BACKUS
 January 19, 2011

HAMILTON - A Corvallis man pleaded no contest Wednesday to assaulting his 9-week-old son last January.
Christopher R. Lewis, 22, agreed to enter the plea in return for the state dropping a felony charge of assault on a minor at a hearing before Ravalli County District Judge Jeffrey Langton.
Under terms of the plea bargain agreement, Lewis could face up to 20 years in prison, with 10 suspended. The agreement allows both sides to argue their position at a March 9 sentencing hearing.
Lewis was arrested last February after the mother of the baby took her son to the Corvallis Family Medical Center when the infant was unable to keep from vomiting food, court records said.
The baby was taken to a Missoula hospital, where a CAT scan found bleeding in the boy's brain. Physicians there believed the injuries were non-accidental.
When Lewis was confronted about the nature of the child's injury, he immediately left for a nearby casino, where he became intoxicated. When he returned to the hospital, he argued with the physician until he was forcibly removed by the Missoula police.
Lewis provides the majority of the child care for the infant, court records said. He initially maintained that nothing happened to the boy while he was under his care.
A physician found extensive retinal hemorrhage in the 9-week-old.
Dr. Todd Murdoch - an expert on shaken baby syndrome - told investigators that there was no question the child had incurred injuries consistent with that syndrome.
Two days after being admitted to the hospital, the baby had a shunt surgically placed in his head to relieve the pressure from bleeding injuries. At the time, physicians said the shunt may become a permanent fixture and that it was likely the child would be developmentally delayed due to his injuries.
A surgeon also operated on both of the child's eyes, which could also be permanently damaged.
Family members told officers they had seen Lewis spanking his older son when he was only a month old and that he sometimes smothered the boy in his armpit, court records said. Another person told officers she saw Lewis dangle the older boy upside down by his ankle and walk across the room in order to change a diaper.
***
The boy's mother initially maintained Lewis wasn't capable of those types of behaviors.
She later told investigators that Lewis had fallen on top of the 9-week-old after his ankle gave way and had made her promise not to tell anyone.
Officers found a book entitled "Taking Care of Your Child," with a piece of paper marking the "Emergencies" section.
The boy's mother told investigators that Lewis insisted that they could use information garnered from the book to nurse their youngest child back to health after she complained the baby was dehydrated.
"Noteworthy," court records said, "cost was not a factor as (the couple's) medical bills were paid for them by public welfare."
Investigators found marijuana pipes, bongs and other paraphernalia in the couple's apartment. Neither of the couple was registered on the medical marijuana registry.
Lewis was on probation at the time of his arrest for the assault on the child for a drug related conviction. In the drug case, he was arrested after cocaine was delivered to a Hamilton residence. At the time, he had his son with him.
Lewis is being held at the Ravalli County Detention Center without bond until the sentencing hearing.

Ravalli Republic reporter Perry Backus can be reached at pbackus@ravallirepublic.com.
http://missoulian.com/news/state-and-regional/article_b23c4a82-2448-11e0-a86c-001cc4c03286.html

SBS: Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma

Anuradha Ganesh, MD et al. [from well respected institutions]:

To report 3 patients with type I osteogenesis imperfecta (OI) who developed retinal hemorrhages and subdural hematomas after minor trauma.

Design

Observational case series.

Method

Children with OI who developed retinal hemorrhages after minor trauma were identified through an international e-mail–based mailing list for professionals with an interest in child abuse.

Results

Three patients with type I OI who presented to the emergency department after a short fall were identified. Clinical evaluation included pediatric and ophthalmic examination. Investigations included complete blood count, coagulation profile, computed tomography of the brain, and a skeletal survey. Ophthalmologic examination revealed retinal hemorrhages in all the children. In the first patient, these were flame shaped and located in the posterior pole of the left eye. The second patient had vitreous and retinal hemorrhages in both eyes. The third patient had scattered intraretinal hemorrhages in both eyes. Computed tomography demonstrated a subdural hematoma in all of the patients and, in patient 2, a simple parietal skull fracture. The child protection teams that investigated the cases believed the explanations offered for the injuries to be plausible, and a diagnosis of accidental injury was made in all 3 patients.

Conclusion

This is the first report of retinal hemorrhages and subdural hematoma after trivial trauma in patients with type I OI. The collagen defects underlying this disorder of bone and connective tissue may predispose patients with type I OI to retinal hemorrhages and subdural hematomas after minor trauma.
http://www.ophthalmologyjournaloftheaao.com/article/S0161-6420(04)00153-8/abstract

SBS: Ohio: Erica Colopy

A doctor from Nationwide Children’s Hospital who has extensive experience in observing cases of retinal hemorrhaging, testified Tuesday that the death of 4-year-old Donavon Poole was the result of shaken baby syndrome.
Erica Colopy, the then live-in girlfriend of Ricky Poole, Donavon’s father, is on trial for involuntary manslaughter in Knox County Court of Common Pleas.
Dr. Phillip Scribano, director for the Center for Child and Family Advocacy at Nationwide Children’s Hospital, told Knox County Prosecutor John Thatcher that Donavon’s eyes pointed to evidence of trauma.
“These facts are consistent with a different mechanism than just impact,” said Scribano, pointing out the visual differences between injuries from a fall and those of a “shaking mechanism.”
“This is what laymen may refer to in the term of shaken baby syndrome ... regardless of age,” said Scribano. In referring to Colopy’s report of Donavon falling on the stairway, “This is a history that is just incompatible with the injuries on Donavon,” said Scribano. “I do not believe his injuries are only the result of him falling down a stairway.”
Scribano said he believes it is the result of the “shaking mechanism,” which can cause alteration in consciousness and an impairment of breathing. Other reasons for his conclusion, he pointed out, are documented ear injuries and genital injuries that are not expected from a fall down a flight of stairs and the retinal photos suggest insight involving a “shaking mechanism.”
Thatcher then asked Scribano if Donavon died from injuries sustained in circumstances he had just described.
“Yes,” Scribano said.
Scribano said he observed Donavon after he was admitted to Nationwide Children’s Hospital in October 2009. Thatcher shared numerous photos with Scribano showing the injuries to Donavon, which Scribano stated showed bruises to the left side of his cheek, scars above one eyelid and bruising over his nose. Also reported were extensive bruising on his right flank, and bruising on parts of his back, as well as his pelvis and pubic area.
A skeletal survey was also conducted, but Scribano stated it did not show any evidence of skeletal fractures.
Colopy’s attorney, James Giles, questioned Scribano about his knowledge of literature focusing on retinal hemorrhaging which suggests young children are more susceptible to head injuries since they have a larger head-to-body ratio than adults. Giles suggested factors of distance and surface are paramount when looking at instances where children fall.
http://www.mountvernonnews.com/local/10/12/16/doctor-abuse-was-cause-of-boys-death

SBS: Nicholas McKee charged: Pediatrician says baby suffered abusive head trauma; Neurosurgeon says she might have suffered cardiac arrest

DON AINES
October 7, 2010
dona@herald-mail.com

Expert witnesses presented opposing views Thursday of how a 5-week-old girl incurred the injuries that led to her death, during the second-degree murder trial of the girl’s father in Washington County Circuit Court.

Nicholas Ray McKee, 23, of Warfordsburg, Pa., also is charged with first-degree child abuse resulting in death, first-degree assault, manslaughter, second-degree child abuse, second-degree assault and reckless endangerment in the Jan. 9, 2010, death of Bella Appel-McKee, who suffered brain damage Jan. 3 while in his care at the Hancock home he shared with the baby’s mother, Jordan Appel.

McKee waived his right to a jury trial. The case is being heard by Circuit Judge Daniel P. Dwyer.

“I concluded Bella had suffered abusive head trauma,” Dr. Tanya Hinds, a pediatrician at Children’s National Medical Center in Washington, D.C., testified during the second day of McKee’s trial. Hinds testified that the girl sustained brain hemorrhaging and swelling, and injuries to the muscles and spinal cord in her neck.

Dr. Ronald H. Uscinski, a neurosurgeon, testified for the defense that the girl might have suffered cardiac arrest that deprived her brain of oxygen and that the bleeding on her brain could have been caused by spikes in intracranial pressure brought on by attempts to resuscitate her. The cardiac arrest could have been triggered by the baby vomiting and cutting off her airway, he testified.

Appel left her daughter in the care of McKee on the night of Jan. 3 to have dinner nearby at her grandmother’s home, she testified Wednesday. She left the girl behind because the child appeared to have a cold and it was cold outside, she testified.

About 30 minutes later, a relative called to tell her that there were firetrucks near her house, Appel testified. The girl was taken to War Memorial Hospital in Berkeley Springs, W.Va., then to Children’s National Medical Center, where she died six days later, according to trial testimony.

Hinds and Uscinski had opposing interpretations of MRIs, CT scans, photos and other medical records, from prenatal exams and pediatric exams before the injuries to examinations of the injuries and the autopsy report.

Hinds testified that the bleeding in the girl’s brain could have occurred within two days to two weeks of an MRI taken Jan. 5 and that the injuries were indicative of “acute, recent, high-energy events” similar to the trauma that might be sustained in a vehicle crash.

“They are also caused by vigorous repetitive shaking,” Hinds testified. “It would not be a birth injury.”

The injuries also could have been caused by grasping and twisting an infant’s head, or by holding the baby by the head, she testified. The girl had no outside bruising that would indicate an impact injury, but Hinds testified she could not rule that out.

The retinal hemorrhages in the girl’s eyes were “too numerous to count” and injuries of that extent could not be caused by efforts to revive her, Hinds testified.

“I don’t believe in the Shaken Baby Syndrome,” testified Uscinski, who said he had treated suspected cases and found there usually was another explanation for the injuries other than shaking.

Uscinski testified that the girl’s brain images showed evidence of both fresh and old blood, and that a high percentage of infants have some bleeding on the brain resulting from the trauma of birth. The subdural bleeding the girl suffered could have been “rebleeding” from that birth trauma, he testified.

Uscinski testified he could detect no evidence of neck injuries in the images that might be caused by shaking. The retinal hemorrhaging could be attributed CPR and other efforts to resuscitate the girl, Uscinski testified.

As for several fractures to the occipital bone of the girl’s skull, Uscinski testified those could have occurred at birth or after the girl’s death. The head of an infant deforms as it passes through the birth canal, which can result in injury, he testified.

http://www.herald-mail.com/?cmd=displaystory&story_id=254358&edition_id=1625&format=html

SBS: Texas: New Results Of Autopsy Spur Plea

LISE OLSENSept. 14, 2009,

The Harris County Medical Examiner’s office has quietly rewritten the results of a 1998 autopsy, prompting renewed innocence claims on behalf of a baby sitter sent to prison nearly a decade ago for allegedly shaking a 4-month-old infant hard enough to cause fatal injuries.

The original autopsy classified the baby’s death as a homicide and was used by prosecutors as a key piece of evidence against Cynthia Cash, now 53, a former nurse convicted of fatal injury to a child after 4-month-old Abbey Clements died after being rushed to the hospital from Cash’s home.

But the modified autopsy report made public in a new appeal calls the cause of death “undetermined” and found no evidence of “trauma” in the postmortem exam. Those changes came five years after local officials announced a review of problematic autopsies conducted by a former Harris County associate medical examiner, Dr. Patricia Moore. Moore, who declined requests for comment, left Harris County in 2002 but still works for Southeast Texas Forensic Center, a Conroe-based company that provides forensic work for six counties.

It is at least the fourth time Harris County officials have reclassified a child’s autopsy that Moore originally labeled as a homicide. Two women have been cleared in other cases — including Brandy Briggs, who was jailed at 19 after rushing her baby to the hospital and who spent several years in a prison isolation cell before being freed in 2005. Dr. Luis Sanchez, head of the medical examiner’s office, did not respond to Chronicle questions about Cash’s case or whether he has finished an audit he promised to conduct after finding problems in the Briggs case.

After learning about the new autopsy results, Cash’s husband contacted Briggs’ attorney, Charles Portz, to file an innocence claim on her behalf. The pending appeal asks for her release or a new hearing — though Cash now has only six months left to serve on her seven-year sentence for felony injury to a child. The case is being considered by Harris County District Court Judge Mark Ellis, who oversaw the original trial a decade ago.

Assistant District Attorney Lynn Hardaway said prosecutors remain confident about their case based on other “evidence presented at trial from doctors who thought she was a victim of shaken baby syndrome.”

Conflicting opinions

Abbey Clements received three vaccinations at a checkup a few hours before Cash, her baby sitter, claimed to have found the baby blue in her crib after a nap. Cash had kept Abbey and her brother along with her own son and five other children.

Abbey died at Texas Children’s Hospital. Doctors there later testified that though she did not have any external injuries, she suffered swelling of the brain and retinal hemorrhages — injuries they described as consistent with so-called shaken baby syndrome.

A neurologist expert for the defense testified at trial that he found none of the broken bones, external bruises or other injuries considered to be classic signs of shaken baby syndrome and the girl likely suffered an extremely rare fatal reaction to vaccines. Dr. Richard M. Hirshberg also reviewed the new autopsy and repeated his argument for Cash’s appeal: “It’s my firm belief now as it was during the Feb., 5, 1999, trial that this defendant is innocent.”

The modified autopsy issued in February 2008 says “a diagnosis of trauma cannot be substantiated,” though no other cause of death was determined. The report also says that doctors who testified in Cash’s trial made some “erroneous” conclusions, wrongly describing bleeding patterns found in the examination of the child’s brain as evidence of trauma.

The revised autopsy, however, also says it could not substantiate claims made by defense experts that the baby likely died from anaphylactic shock — a severe allergic reaction to vaccines. Such rare reactions are well documented in medical literature but generally occur soon after a vaccination is administered.

Paul Clements, Abbey’s father, said he had been briefed on the new results but said “one ME changing an autopsy still doesn’t change what we think happened because of all the other evidence presented at the trial.”

Clements said he also bases his conviction that Cash was guilty on his experience of seeing his daughter “right after it happened and discussing it with the doctors in the hospital. They had never seen a baby shaken as badly as Abbey.”

Cash’s husband, Ken Cash, and her attorney, Portz, both claim that Cash never would have been indicted if the autopsy had been conducted correctly in the first place.

“All I want for her is justice,” said Cash, who sold his house to help pay legal fees and raised their young son on his own after his wife was imprisoned. “They railroaded her in that autopsy report. She is innocent.”

The Harris County District Attorney’s office, however, opposes the appeal.

“The Court of Criminal Appeals held that a claim of actual innocence based upon newly discovered evidence should not be overturned lightly and the burden on the defendant who has had error-free proceedings is exceedingly heavy,” the prosecutor’s answer in the case says, later continuing: “There is considerable evidence in the record to support the … conviction.”

lise.olsen@chron.com

MOORE AUTOPSY PROBLEMS:

Dr. Patricia Moore, a former associate medical examiner in Harris County, was repeatedly disciplined for failing to follow procedures and for favoring the prosecution in 1998 and 1999, Harris County personnel records show. She left Harris County in 2002 for personal reasons, but her work on children’s autopsies here continues to be challenged:

• New innocence claim: After a baby’s 1998 death was reclassified from homicide to undermined causes last year, family and an attorney for 53-year-old former baby-sitter Cynthia Cash recently filed an appeal claiming innocence and seeking her release.

• Mother freed in 2005: Moore’s original autopsy called 2-month-old Brandon Lemons’ 1999 death a homicide, but it was reclassified years later as “undetermined.” The new report suggested that the baby may have died from lack of oxygen because of a medical error. Lemons’ mother, Brandy Briggs, was subsequently freed.

• Mother cleared in 2004: Prosecutors dropped charges against another woman originally accused of reckless injury to her newborn after Moore’s autopsy was challenged and the baby’s cause of death was changed to undetermined.

• Other cases questioned: Trenda Kemmerer, a woman convicted in 1997 in another child’s death remains in prison, though the child’s autopsy was changed and Moore reprimanded for failing to show objectivity in the case. And Moore herself changed the results of a Montgomery County child’s autopsy in 2007.

Source:

http://www.chron.com/disp/story.mpl/metropolitan/6617198.html

 

http://medicalmisdiagnosisresearch.wordpress.com/2010/09/18/new-results-of-autopsy-spur-plea/

SBS: Trial in Newfoundland, Canada

A doctor testifying during a Newfoundland second-degree murder trial said yesterday that the baby boy who died may have been shaken.
Dr. Dorothy Bautista, a pediatric ophthalmologist, was testifying in the trial of Jeffery Isaac Tippett in provincial court in Corner Brook. Tippett was charged in the 2007 death of 11-month-old Tameron Rose of Corner Brook.
Bautista, who examined Rose's eyes at the Janeway Children's Hospital, said that she found retinal hemorrhages in both of the child's eyes.
Bautista also testified that her recommendation was to investigate the possibility the child had been shaken.
She said the severity of the injuries were consistent with a being shaken, especially in the absence of no obvious trauma to the outside of the child's body.
Court has also heard testimony that revealed the child's autopsy showed he had a skull fracture.
She said she had seen similar injuries in a child who had fallen from a third-storey balcony in her past clinical experience.
Under cross-examination, Bautista told defence lawyer Keir O'Flaherty that she later learned Tameron Rose had, in fact, suffered a skull fracture, which was not discovered until his autopsy.
O'Flaherty asked Bautista if she had been aware, at the time of her examination, that Tippett's partner - Tanya Tulk, who was caring for Rose with Tippett on Jan. 30, 2007 - had told police the child had banged his head on a crib earlier in the day. Bautista said she wasn't.
http://timestranscript.canadaeast.com/news/article/1231222

Child abuse: Indiana

 LIZ SHEPARD September 22, 2010

Port Huron Police Detective Brian Kerrigan held a binder on his forearm, demonstrating the way Scott Syzak showed him he had put oil on his 4-month-old daughter during a bath in 1995.

The detective then violently flipped his arm over, throwing the notebook to the ground, the same way he said Syzak demonstrated he put his daughter down.

The smack of the notebook hitting the ground in District Judge John Monaghan's courtroom seemed to send a tremor through the room, with those watching Syzak's preliminary examination gasping, covering their faces and dabbing away tears.

Kerrigan said that, while Syzak demonstrated how he put his daughter down, he spoke of his frustration with life and difficulties adjusting to life outside of prison at the time of the incident.

Syzak had been charged with abusing a 6-month-old child he was baby-sitting in 1989 in Tuscola County. He was sentenced to 32 to 48 months in prison.

Kerrigan said Syzak also told him during an interview that he did not like to be alone with the 6-month-old.

Syzak, 43, of Hobart, Ind., was bound over to circuit court on a charge of open murder, habitual offender fourth, after about two hours of testimony Tuesday.

In 1995, Syzak and his wife, Candace Syzak, told authorities the baby had fallen while getting a bath from her mother.

Kerrigan said he traveled to Indiana on Aug. 26 to interview Syzak after law-enforcement officials informed Port Huron authorities Syzak had made comments about the death of his daughter.

Kerrigan said Syzak's story of what happened the day his daughter was injured changed. In the first scenario, she had slipped out of his arms. In the later scenario, he had put her down with too much force.

Officials have said Jessica Syzak died of her injuries about a month afterward. The family was living in Port Huron at the time of the child's death.

Richard Anderson, the acting medical examiner in 1995, said he performed an autopsy on the infant.

He said the girl had a large skull fracture and the brain tissue underneath it had disintegrated.

"That is a massive injury," Anderson said, adding his findings were not consistent with a fall of about two feet.

As the doctor detailed the injuries he found on the girl, Syzak looked toward the courtroom windows, his legs constantly moving, making his shackles and the attached chains jingle.

Anderson said that in 1995 he ruled the death might have been caused by a seizure, but that was a direct result of the head injury.

He also found hemorrhaging behind the girl's eyes, a sign of shaken baby syndrome, he said.

Jessica also had nine broken ribs in the process of healing, Anderson said.

"That indicates child abuse," he said.

Anderson said he also believed the scene at the Syzak's home had been staged.

He said Jessica was wearing a blue sleeper, which was very clean.

"That's very unusual for a death scene," Anderson testified.

He said the child also showed signs of rigor mortis, which can take hours to set in after a death.

A circuit court arraignment date has not been scheduled for Syzak.

http://www.thetimesherald.com/article/20100922/NEWS01/9220306/Witness-Syzak-s-stories-changed

SBS: Kansas

ERIN MATHEWS
Prosecutor Christina Trocheck pushed a button Monday afternoon and a large photograph of an infant lying on a pink blanket appeared on a screen in Saline County District Court.
"There are some facts that are not disputed in this case," said Trocheck, an assistant county attorney, in her closing argument. "One is that N.B. was an infant -- unable to care for herself, protect herself or tell anyone about the events of March 5, 2009."
There is a reason the jury wasn't shown a current photo of the child, who is now more than (?) 10 years old, said attorney Roger Struble, who represents Patrick Armer, the baby's father.
"I would suggest her injuries are resolved and she would appear to be normal," Struble told the four-man, eight-woman jury.
After hours of deliberation, those jurors found Armer guilty of child abuse and intentional aggravated battery causing great bodily harm in connection with injuries the child suffered. His sentencing was set for 9:30 a.m. Nov. 22.
Armer testified in his own defense Monday. He said he didn't tell investigators for several hours that he'd fallen on top of the baby because they were asking how he had shaken the baby.
"They insisted that I shook her and the injuries came from shaking her, and I did not shake her," Armer said.
Armer agreed that he had become angry and frustrated when the baby cried, "indirectly yelling" obscenities at her, kicking her crib on a couple of occasions and once stating that he would "give her something to cry about."
Initially, Armer told authorities he had no idea how the child could have sustained retinal hemorrhages in both eyes, bleeding around the front and back of her brain, and new and partially healing rib fractures.
He said Monday he initially denied knowledge because doctors had said the child's injuries were caused by shaking and he had never shaken the baby.
Police officers testified previously that after Armer was handcuffed to a table and told he was being arrested, he tearfully said he wanted to tell the truth and described the fall.
"They convinced me through eight hours of interrogation that I hurt her," Armer testified Monday. "So, if I did it, it was through a fall and an accidental fall, at that."
Armer said he thought he'd heard the baby cry downstairs and went down to pick her up from her crib. He said he headed quickly back upstairs with the child to continue watching a movie.
On the third or fourth step, he stumbled and fell forward, landing on top of the little girl, he said. He said the child's head struck a metal strip on the lip of a step.
"I'm 210 pounds, and she's 6 pounds and some ounces," he said. "I could have swore I heard a crush."
He said the baby didn't cry and appeared to be "knocked out." He said she was overly warm, so he removed her clothing and laid her on the bed. He described her as pale, having difficulty breathing, and her right eye was rolling to the side and toward the back of her head.
Trocheck asked the jury to thoroughly consider testimony from several medical professionals that a fall of the type Armer described could not account for the child's injuries. She said that despite what he told the jury, the baby's injuries and the fact that she became unresponsive and started having seizures while in his care were evidence that he physically shook her to get her to stop crying.
"Simply because Ms. Trocheck suggests to you that the baby was shaken doesn't mean it happened," Struble argued in his closing. "Just because she says Mr. Armer did it doesn't mean he did."
Trocheck said the evidence from medical professionals who treated the child and research on infants who have been violently shaken by an adult would suggest otherwise.
"Infants don't just develop those conditions unless someone inflicts them," she said.


http://www.saljournal.com/news/story/armer-9-20-10

SBS: Alberta Canada trial

TONY BLAIS, Court Bureau

 September 20, 2010

A three-week-long baby shaking trial began Monday for a former Edmonton day home operator accused of injuring a 20-month-old girl who was in her care.

Bethany Joy Perry, 29, has pleaded not guilty to a charge of aggravated assault and court heard her repeatedly deny harming the toddler during a videotaped police interview played in court.
“I didn’t ever shake her,” said Perry to Det. Francine McVeigh of the Edmonton police child abuse unit.
Perry told the detective she had put the child down for a nap in a playpen in a basement bedroom of her home near 61 Street and 102 A Avenue about noon on Dec. 2, 2008, and had gone downstairs after hearing a noise.
She said she found the toddler lying on her side on the floor between the playpen and a wooden hope chest and picked her up under the armpits to get her to stand up.
But, when the child wouldn’t stay up, Perry said she got “upset” with the girl and put her back down on the floor.
“I was mad and frustrated and I don’t know why,” said Perry, who later explained her frustration came from the fact the child had got out of the playpen and hurt herself.
At one point during the interview, Perry said she “got mad” when the child wouldn’t stand up, but still couldn’t explain why she had become frustrated.
Perry told the detective she then picked the toddler up again and carried her upstairs and called 911.
“I was scared,” she said. “I didn’t know what she had done and I was scared for her.”
McVeigh told the day home operator the child had suffered a skull fracture and also had retinal hemorrhaging, which she explained is typically from being shaken as opposed to falling backwards onto the head.
However, Perry continued to deny shaking the child.
http://www.edmontonsun.com/news/edmonton/2010/09/20/15418546.html

SBS: Newfoundland, Canada trial

The injuries an 11-month-old boy in Corner Brook sustained before dying in 2007 are consistent with shaken-baby syndrome, according to an eye doctor who testified Wednesday at a murder trial in western Newfoundland.
Jeffery Tippett, 35, is charged with second-degree murder in the death of Tameron Rose.
Pediatric ophthalmologist Dorothy Bautista was called as an expert witness at Tippett's trial in Corner Brook. She examined the baby's eyes the day after he was sent to the Janeway Hospital in St. John's in 2007.
Tameron died on Jan. 31, 2007. He had been admitted the previous day to Western Memorial Hospital in Corner Brook. Bautista said the baby had injuries that were most likely caused by shaking.
She ruled out infection, diabetes or leukemia as the cause of the injuries, and said the degree of bleeding she saw is consistent with a fall on the head from a three-storey building.
Jeffrey Tippett, 35, is on trial in Corner Brook on a charge of second-degree murder. (CBC)She said her investigation showed that Tameron had some bleeding in his left eye and moderate to severe bleeding in his right eye.
The defence is scheduled to cross-examine Bautista on Wednesday afternoon on her conclusion that the baby's injuries were caused by shaking.
Tippett's trial began Sept. 16 with evidence from the boy's mother, Maria Rose. She told the court that her son was pleasant and did not cry unless he was being bothered by his teething.
Tippett was babysitting the boy before he was taken to hospital with brain injuries.
About 30 witnesses are expected to be called in his trial, which has been delayed several times.
In September 2009, an entire jury was dismissed.
Last Wednesday, the trial was briefly postponed while authorities sought out a 12th juror. A publication ban is in effect on the events that led to the jury being short of a full complement.
http://www.cbc.ca/canada/newfoundland-labrador/story/2010/09/22/nl-bautista-tipett-922.html

SBS: more om BC case

VICTORIA — A baby that suffered devastating brain injuries — possibly after being violently shaken — was absolutely lovely, didn't cry a lot and didn't cry loudly, her former foster mother testified Monday in Victoria provincial court.
"We thought we might adopt her," said Micheline Slader, testifying at the trial of her former boyfriend Avtar Basi for the aggravated assault of 11-week old Baby E.
But on the morning of Nov. 26, 2008, Baby E stopped breathing and was rushed to Victoria General Hospital where she was found to have major brain injuries.
Crown counsel Nils Jensen argues the injuries were caused because Basi violently shook Baby E that morning. However, defence lawyer John Green said Basi will testify that Baby E went limp and, in a panicked reaction, he shook her three times to try to revive her.
Slader testified on Monday that Basi phoned her. "I believe his words were, 'I think there's something wrong with Baby E. I think she's not breathing,'" Slader recalled. "I said, 'call 9-1-1.'"
She rushed home and found Basi giving rescue breaths to the infant, assisted by an emergency dispatcher on the phone.
"I pushed him out of the way and took over. I had no idea what happened to her," said Slader.
Paramedics arrived within minutes — though, she said, "it felt like forever."
Slader will continue her testimony later this week.
Also on Monday, Dr. Victor Pegado, an expert in pediatric ophthalmology, testified that he examined Baby E at the hospital and found multiple retinal hemorrhages, 50 to 100, scattered in both of her eyes.
"The one thing I want the intensive-care doctor and other doctors to know is that this was consistent with non-accidental head injury" said Pegado.
"Which includes shaken-baby syndrome?" asked Jensen.
"Yes," Pegado replied.Read more: http://www.vancouversun.com/news/Vancouver+Island+infant+centre+shaken+baby+trial+rarely+cried+court+hears/3524432/story.html#ixzz10MIPU3rC

SBS: When Should Retinal Hemorrhages be Considered Suspicious for Non-Accidental Head Injury?

August 30th, 2010
Patient Presentation
A 6-month-old male came to the emergency room with a history of falling out of his mother’s arms onto a bed. The infant cried and mother placed him into the crib as it was time for his nap. About 1 hour later, the infant was crying, had vomitted and the mother felt he was lethargic. The radiologic evaluation showed frontal and interhemispheric acute subdural hematomas and the infant was transferred to a regional children’s hospital for neurosurgical care. The past medical history revealed a full-term, normal spontaneous vaginal delivery without complications. The patient had received routine care and immunizatons. The family history was negative for neurological or congenital abnormalities. There were no reported early or unexplained deaths or miscarriages in the families.
The pertinent physical exam showed normal vital signs. Weight was 10%, head circumference was 95% and length was 25%. The infant had an irritated cry. The anterior fontanelle was bulging. There was bruising from intravenous catheter placement attempts but no other bruising. The rest of the examination was normal. The work-up was negative including screening trauma labs, urine drug screen and hair studies, bleeding studies, urine organic acids, and skeletal survey. The ophthalmological consultant found superficial and deep bilateral retinal hemorrhages that were too numerous to count and covered most of the retinas. During the patient’s clinical course he was placed on anti-epileptic medication and did not have any seizures. Along with the child protection services team, the inpatient hospital physicians reported the child to the Department of Family Services as highly suspicious for a diagnosis of non-accidental trauma. The investigators agreed and the child was discharged to kinship foster care after two weeks of monitoring in the hospital for stabilization of the subdural hemorrhages. The child was to follow-up with neurosurgery in 2 weeks.

Axial image from an unenhanced computed tomography scan of the brain demonstrates high density right frontal and interhemispheric acute subdural hematomas. There is some associated mild swelling of the right cerebral hemisphere.

Discussion
Shaken baby syndrome (SBS) is a form of non-accidental head injury (NAHI) that occurs when someone violently shakes a child. It may result in brain, eye and/or skeletal injury. The long-term survival is poor with cognitive/behavioral problems, cognitive impairment, cerebral palsy, and/or epilepsy as common problems. In one report 19% of the children died as a direct result of SBS and only 22% had no sequelae at discharge. SBS can be misdiagnosed particularly if it is less severe, has no external bruising (21% of cases) and no history of previous abuse (40%).
SBS often occurs in infancy but can occur in children up to 8 years of age in the literature. Incomplete ophthalmological examination may under-estimate the presence and/or extent of retinal hemorrhages (RH). Complete examination of the entire retina is needed for proper evaluation, which usually means by an ophthalmologist.
Learning Point
Togioka states “[a]lthough the presence of RH [retinal hemorrhage] does not confirm the diagnosis of SBS. RHs are common in abused children and exceedingly rare in cases of accidental head injury.”
Injury typeRH presence is much more common in NAHI (53-80%) than in AHI (accidental head injury, 0-10%). The AHI that has RH associated with it is usually of significant force (e.g. motor vehicle accident). Short falls (< 4 feet) are extremely unlikely to cause RHs. In one study of 287 children, no children who had an accidental fall < 4 feet had RH, while 25% of those with a fall in the abused group had RHs.
Anatomy
Flame shaped RHs are the most common form of RH seen in SBS. RHs appear to generally start more centrally and superficially within the retina and then spread more peripherally and deeper with an increasing amount of force/trauma. Studies have shown peripheral RHs are seen in 27% of NAHI and 0% in AHI. Unilateral retinal hemorrhages can be seen in NAHI (14-21%). Bilateral RH are found in 58-100% with NAHI and in only 1.5% of accidental head injury. Other ophthalmological pathology has been linked to NAHI including hemorrhages in other parts of the eye, retinal folds, macular folds and Roth spots.
Other diseases that can cause RH include:
Glutaric aciduria type 1
Hemorrhage disease of the newborn
Hermansky-Pudlak Syndrome
Osteogenesis imperfecta
Protein C deficiency (homozygous) and other coagulopathies
Terson syndrome
Data shows that forceful emesis, forceful coughing, seizures and prolonged chest compressions basically do not cause the RHs seen in SBS. RH can be seen after birth in up to 30-40% of deliveries but most are resolved in 3-9 days after birth.While alternative explanations for NAHI can be hypothesized, Moran noted that “[t]here is no disease or condition that fully mimics the complete diagnostic picture of SBS.”
/span>http://www.pediatriceducation.org/2010/08/30/