babyonknee

Unsafe playtime activity?

During my first clinical rotation in medical school, I found myself at the pediatric nurse station one afternoon waiting for a patient to arrive from the emergency department. An adorable older infant was there sitting in a bouncy chair, smiling and drooling as babies tend to do, and looking rather well for an inpatient. The nurse watching her explained that she had come a long way since first being transported to the facility by ambulance after being admittedly shaken (and almost certainly also beaten) by her mother’s new boyfriend one evening when she wouldn’t stop crying.

Now, cortically blind and facing a lifetime of disability, the child was awaiting placement by social services. I had experienced my first exposure to child abuse, a scourge of pediatric medicine that I hadn’t thought of at that point despite having decided on a career in pediatrics well before being accepted into medical school. I’ve since had many more opportunities to care for abused children, some of which involved considerably more visually disturbing findings and a couple that resulted in a child’s death. But I will never forget her and the feeling of utter revulsion I felt that day.

Child abuse is common and it comes in many forms that can involve physical abuse as well as neglect. Children under the age of 4 years are the most frequently affected, but children under a year tend to suffer the most severe manifestations. Head injuries make up the bulk of physical abuse in this age group, and they are often fatal. Roughly 40% of child abuse-related deaths occur in the first year of life and there is frequently both a history of abuse prior to the fatal event as well as missed opportunities for medical professionals to have intervened.

The head injuries that children suffer at the hands of abusive caregivers, if not fatal, are frequently still devastating. It is not uncommon for these children to suffer permanent neurologic injury which can include persistently altered mental status, cognitive impairment, cerebral palsy, blindness and recurring seizures. In addition to the child’s injuries, the psychosocial impact on the family can also be quite severe. I’ve seen families torn apart because of guilt and anger.

Now if you’ve read more than two of my posts on Science-Based Medicine, then you are probably well aware of my feelings on the shady marketing tactics of the overwhelming majority of practicing chiropractors. According to thousands of websites, commercials and print ads, the average chiropractor has the ability to prevent SIDS, resuscitate distressed newborns and treat a variety of common (and not so common) ailments usually managed by actual medical professionals. They make these claims despite a lack of appropriate education and training, and a blatant disregard for even our most successful medical interventions.

Until very recently, if asked what I thought was the most vile example of the chiropractic community taking advantage of parental fear in order to put more patients on the adjusting table I would have gone with their claims to prevent sudden infant death syndrome. I still would probably choose that but I may at least have discovered a close runner-up. It has come to my attention, thanks to yet another self-inflicted descent, with nose pinched and breath held of course, into the miasmic internet sewers of subluxation-based make-believe, that many chiropractors are using the terms and imagery of severe child abuse, specifically the infamous shaken baby syndrome, to encourage parents to have their infants and toddlers evaluated for injuries to the spine.

Child abuse, especially involving injury to the head and the precious contents within, deserves to be taken seriously by our society. And if the chiropractic community joined legitimate pediatric healthcare professionals in providing science-based education on ways to recognize and modify risk factors in order to potentially prevent abuse, or discussed ways of recognizing abuse after it has occurred and how to access appropriate resources, I would give them the credit they would deserve. Instead, and to be honest this didn’t surprise me in the slightest, they have decided seemingly en masse to provide blatant misinformation. But before I delve more into this inexcusable chiropractic practice-building technique, first a brief primer on shaken baby syndrome.

What is shaken baby syndrome, and what it isn’t?

First described by pediatric radiologist John Caffey in a 1972 paper, “On the theory and practice of shaking infants”, what is popularly called shaken baby syndrome is actually a somewhat outdated term that continues to be used publicly because of its utility in parental education and awareness campaigns. But it is too narrow in scope for clinical utility. The more accurate and preferred diagnosis is abusive head trauma (AHT). Children suffer injury to the skull, brain and spine via a variety of mechanisms, one of which might involve the extreme translational and rotational acceleration-deceleration forces seen during a shaking event.

The other major component of abusive head trauma in children is the force applied to the head via blunt impact. Historically, there has been controversy regarding the roles of shaking and impact forces, and the literature is a bit unclear. There are biomechanical models that have led some to question shaking alone as a cause of the physical manifestations of AHT. Or perhaps severe shaking causes injuries to the spinal cord that are difficult to discover on autopsy, without injuring the brain directly.

There are clear cases of blunt trauma causing severe injury, where the physical findings can be agreed upon by all and seen from across the room. But there are also many cases where there are minimal or no obvious findings consistent with an impact to the head and a caregiver who readily admits to shaking the child aggressively and with significant force. Of course it is entirely possible that they were lying or that they didn’t realize that one or more impacts occurred while the child was being shaken. The likely reality is that shaking plays some role, although perhaps a much smaller role than initially theorized, and only in some cases of AHT.

What are the effects of abusive head trauma?

It appears that infants are more likely than older children and adults to develop “shaken baby syndrome”, whether from actual shaking or from blunt impacts, because of their unique anatomy and physiology. The infant brain not only has a bit more room to move around within the skull, thus increasing the opportunity for injury as it sloshes around during acceleration and deceleration, it is encased in a thin and less-rigid skull that does not provide the same degree of protection as in older kids and adults. The large head of a baby is also poorly stabilized by their weak neck muscles, leaving them less able to counteract forces occurring during vigorous shaking. Their brains are also generally less dense and their nerves largely lacking a protective myelin sheath.

The pathophysiology of AHT involves both primary and secondary sources of neurologic injury. Primary injury occurs when the child’s head is rotated or moves in a straight line (translational) quickly and forcibly followed by sudden deceleration. This can occur either during shaking back and forth and side to side or when the head is impacted by a blunt object like a table or caregiver’s hand. Although again there is some controversy over the exact mechanism of primary injury, the most widely accepted belief is that these forces injure nerve fibers and lead to bleeding within the retina and between the brain and the thick membrane that covers it.

As if this wasn’t enough, the related secondary injury can play an even larger role in the development of acute and chronic neurologic manifestations of AHT. This occurs when the brain is starved of oxygen for a long enough period of time for cell injury and ultimately death to occur. Acute primary injury can result in periods of breathing cessation and prolonged seizure activity, to name just two of the possible mechanisms of secondary injury.

There are more injuries seen in the setting of AHT than simply the classic triad of subdural hemorrhages, retinal hemorrhages and diffuse injury to the brain. Bleeding is often seen in other areas such as between the skull and dura, and within the brain itself. Fractures of the skull, although common, aren’t always present, even in the setting of severe intracranial injury. Fractures involving other bones also frequently accompany AHT, with posterior rib, femur, humerus and metaphyseal fractures associated with abuse more so than accidental injury.

How is abusive head trauma in children diagnosed?

AHT can be challenging to diagnose with certainty in some cases. Severe brain injury frequently occurs absent a history of trauma, although it should not come as a shock to hear that an alleged child abuse perpetrator might not be too keen on ‘fessing up to healthcare professionals or the authorities. More importantly there are also frequently no or only minimal external findings on physical examination. Adding to the complexity of AHT in children is the fact that accidental head injury, as well as a few medical conditions, can potentially result in overlapping presentations.

So if the mechanism of AHT is somewhat murky, and we can’t always count on the presence of overt findings of blunt trauma to the child’s head, how is it diagnosed? Very carefully considering the possible repercussions to the family and involved medical professionals if the wrong call is made. Children are often removed from their home and people go to jail. It keeps some of us up at night with worry, and unfortunately I have no doubt that the system doesn’t always get it right. But if the appropriate steps are taken, the likelihood that a medical condition or incidental injury would truly present in the same fashion as AHT is very low.

Diagnosis typically involves an expert combination of forensic interviewing, physical examination, radiologic imaging and laboratory analysis in order to rule out potentially confounding medical conditions that can result in a similar pattern of findings. The assistance of pediatricians specially trained in child abuse, when available, as well as experts in pediatric radiology, ophthalmology and neurosurgery, are often called for. And when there is suspicion of abuse, child protective services and/or law enforcement are notified. The role of the pediatrician in these situations isn’t to assist in a criminal investigation or to assign blame but to care for an injured child, although we are often asked to interpret medical information.

AAP recommendations for pediatricians regarding abusive head trauma

The American Academy of Pediatrics has released guidelines regarding the diagnosis and discussion of AHT:

  1. Pediatricians should be alert to the signs, symptoms and head injury patterns associated with AHT.
  2. Pediatricians should know how to begin a thorough and objective medical evaluation of infants and children who present for medical care with signs and symptoms of potential AHT. Consultants in radiology, ophthalmology, neurosurgery and other areas are important partners in medical evaluation and can assist in interpreting data and reaching a diagnosis.
  3. Pediatricians should consider consulting a subspecialist in the field of child abuse pediatrics to ensure that the medical evaluation of the patient has been complete and that the diagnosis is accurate.
  4. Pediatricians should use the term “abusive head trauma” rather than a term that implies a single injury mechanism, such as shaken baby syndrome, in their diagnosis and medical communications.
  5. Pediatricians should continue to educate parents and caregivers about safe approaches to calming and coping with crying infants and the dangers of shaking, striking, or impacting an infant’s head.

What is the chiropractic approach to abusive head trauma?

Now that I’ve provided a decent, although far from complete, review of abusive head trauma from the standpoint of science-based medicine, let’s look into how the chiropractic community tackles this complicated subject. Keep in mind their push in many states to gain primary care practitioner status. A search of the American Chiropractic Association yielded no discussion of child abuse in general, let alone AHT. The International Chiropractic Pediatric Association mentions the concept of shaken baby syndrome in an issue of their Pathways to Family Wellness magazine:

Shaken Baby Syndrome was originally referred to as a “whiplash” injury. Shaken Baby Syndrome occurs when a child is shaken violently in a to-andfro [sic] fashion. Such violence can cause hematomas (bruising) in the area between the skull and the brain, retinal hemorrhaging (bleeding in the eyes), and, less commonly, fractures to the skull.

Though most people feel that Shaken Baby Syndrome occurs only as an act of violence, it can also occur during play activities that were never meant to harm. These activities include:

  • Repeated and vigorous tossing of a child into the air. This allows a “whipping” motion of the head and neck.
  • Jogging with infant on back or shoulders. Just because the infant is in a carrying restraint does not mean that head is supported in a neutral position.
  • Bouncing the child on knee or swaying the leg back and forth, creating a to-and-fro motion and a “whipping” motion of the head and neck.
  • Swinging child around by ankles. The child will attempt to move head against force of motion. This can cause “whipping” of the head and neck.
  • Spinning child around in circles. The child’s head will feel very heavy and will often fall backwards, causing the “whipping” motion.

Signs and/or symptoms of brain stem swelling (e.g. Shaken Baby Syndrome) include: constant crying, stiffness, inability to wake up or sleeping more than usual, and vomiting. If you see any of these symptoms in your infant or child after any play or injury, take them to their doctor immediately. Please use caution at all times in order to best protect your infant or child from such injuries.

Many individual chiropractic practice websites express even more blatant misinformation:

This damage has been known to occur after playfully throwing the child up in the air and catching him/her. The damage caused is called Shaken Baby Syndrome. Not only being shaken or thrown but being spanked can also cause spinal or neurological damage to a child. Any child who has been subjected to this rough behavior desperately needs a chiropractic checkup to prevent possible nerve damage.

Another:

An infant’s spine is very susceptible to injury. “Shaken Baby Syndrome”, which occurs when a baby is severely shaken, can cause eye and brain damage, blindness, paralysis, convulsions, and even death. It is a cause of post-natal brain damage that most medical doctors don’t even recognize. Chiropractors have been dealing with the effects of SBS for over a century.

Childhood is a very “physical” time for all of us. Although they are all part of normal childhood, running, jumping, falls, and accidents can all cause VSC [verterbral subluxation complex] and nerve damage, with serious consequences.

It only makes sense for parents to have their children’s spines checked regularly throughout the growing years.

When Playtime Can Be Unsafe“:

As parents and caregivers it is important to be aware of how fragile our children and their delicate bodies can be. As chiropractors, when adjusting newborns and children, our mission is to remove all nerve interference that prevents a child from reaching their optimum potential. This happens through our adjustments of course, but educating our patients about preventing activities that cause injury and nerve interference in the first place is also a big part of our mission.

Mention of shaken baby syndrome most frequently comes up on chiropractic websites when touting their ability to cure colic. They rightfully state that babies perceived as having colic are at increased risk of being abused. Tired and stressed caregivers are more likely to both interpret their infant as being fussy and to have poor coping skills, sometimes resulting in “losing it.” But chiropractors are begging the question that they can do anything about infant crying. I’ve covered chiropractors and colic in a prior post.

It is abundantly clear, and hardly a shock, that chiropractors have an extremely limited understanding of abusive head trauma in children. And their use of “shaken baby syndrome” is a marketing ploy that preys on parental fear rather than informs caregivers how to reduce the incidence of abuse. Their claim that a child might suffer brain damage during normal activity and play is absurd and abhorrent. There may be controversy over the exact mechanism of injury in AHT, but it is well accepted that the force applied must be violent in nature. Even incidental falls involving impact to the head rarely result in the patterns and severity of injuries seen with AHT.

Finally, some chiropractors even attribute shaken baby syndrome to injury from vaccinations. This topic has been well covered by others, so I’ll leave it at that.

Conclusion

Abusive head trauma is a tragic event associated with high rates of mortality and severe morbidity in the most vulnerable among the pediatric population. Although imperfect, over the past several decades our understanding of the risk factors and underlying mechanism of injury has steadily improved, and pediatric medical professionals at every level of care strive to prevent abuse or at least recognize it as soon as possible. We are aware of our limitations and even our failures in this endeavor via the process of scientific endeavor, but remain steadfast in our goal of saving lives and preserving families.

The chiropractic community, a substantial percentage of which would like to serve as primary care practitioners for young children, appears to take a different approach. Taking advantage of the mental imagery attached to severe child abuse, primarily the entity known as shaken baby syndrome, they seek to increase their income by telling parents of healthy children that routine activity and play might lead to a similar outcome. And naturally they claim the ability to detect and correct injury before it results in serious problems.

To be fair, I don’t really know what is in the hearts of the chiropractors that do this. It’s entirely possible if not likely that the majority of them truly believe it. Yet no evidence exists to support the claim that neurologic injury remotely as severe as that associated with shaken baby syndrome or abusive head trauma can occur with routine activity and play. Similarly the evidence that chiropractic training, even their own version of advanced training in pediatrics, provides insight into childhood illness or injury management is also lacking. But ignorant or evil, the end result is the same.

 

 

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.