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Chapter: Forensic Medicine: Paediatric forensic pathology

The battered-baby syndrome (Caffey's syndrome or non-accidental injury syndrome)

1. Description 2. Injuries 3. Obligation to report: medical practitioners and other professionals

The battered-baby syndrome (Caffey's syndrome or non-accidental injury syndrome)



Violence against infants and children is as old as recorded history. Infanticide was an accepted practice for dealing with unwanted children in prehistoric and ancient cultures in the face of scarce resources. Darwin actually said that one could correlate the beginning of human civilisation with infanticide. ``Our early semi-human progenitors would not have practised infanticide ... .

For the instincts of the lower animals are never so perverted as to lead them regularly to destroy their own offspring''.

We now know that the first medical article on child abuse was written in Paris in 1860 by Ambroise Tardieu, a professor of legal medicine. He reported on autopsies of 32 children who had died violently, mainly at the hands of their parents. Tardieu's article described the same medical lesions (multiple injuries and traumatic lesions of skin, bone, and brain) and the same demographic and social factors (the perpetrators were generally the parents who had contradictory explanations for the injuries) as Kempe et al described more than a hundred years later.

In 1946 the father of paediatric radiology, John Caffey, described six cases of multiple fractures in the long bones of infants who had chronic subdural haematomas  -   classic signs of physical abuse. At one time he stated that a clotting defect as yet unrecognised was responsible for this phenomenon. Caffey noted that there was no X-ray evidence of any underlying pathological bone condition in these children, that subdural haematomas were best explained by trauma, and that the bone lesions were traumatic in nature, adding: ``[T]he injuries which caused the fractures in the long bones of these patients were either not observed or were denied when observed. The motive for denial has not been established.'' Dr Caffey believed that these children were victims of inflicted injury but was concerned about legal repercussions.

In 1956 Caffey further made a statement which was in line with our thinkingabout child abuse in a speech before the congress of the British Institute of Radiology by urging early diagnosis to save abused children from further injury: ``The correct early diagnosis of injury may be the only means by which the abused youngsters can be removed from their traumatic environment and their wrongdoers punished.''

Dr Kempe wrote as follows:

``My involvement in child abuse was at first far from humane; it was, candidly, intellectual, at least in part. Day after day, while making rounds at the University of Colorado Medical School, I was shown children with diagnoses by residents and by consultants and attending physicians which simply were examples of either ignorance or denial. I thought very much the latter. I was shown children who had thrived for seven months and then developed `spontaneous subdural haematoma' ...

`multiple bruises of unknown aetiology' in whom all tests were normal, who had no bleeding disorders and who did not bruise in the ward even when they fell; `osteogenesisimperfectatarda' ... in kids who had normal bones by X-ray, except that they showed on whole-body X-ray many healing fractures which could be dated; `impetigo' in kids with skin lesions which were clearly cigarette burns; `accidental burns of buttocks' in symmetrical form which could only occur from dunking a child who had soiled into a bucket of hot water to punish soiling. In these cases and many others, we did often learn from one or both parents, in time and with patient and kindly approaches, that these were all inflicted accidents or injury.''

Thanks to Drs Kempe and Caffey, the public as well as the medical profession became aware that child abuse is a common problem and can occur in families of any socio-economic status. Health professionals are generally cognisant of the forms abuse takes, the causative factors, and the potentially lethal nature of this ``disease'' of parenting.

We now understand that physical abuse requires four basic factors:

1.           There is a parent with the potential for abuse. Such parents were usually not parented well themselves, often were themselves victims of abuse, are isolated, do not trust others, and have unrealistic expectations of children.

2.           There is a child who usually exhibits ``some behaviour ... which the parent, correctly or incorrectly, justifiably or unjustifiably, perceives as aversive and as requiring some intervention to change''.

3.           There is a stressful situation or incident that serves as a trigger.

4.           The family lives in a culture in which corporal punishment is sanctioned or encouraged.

In one sense all parents have the potential to abuse, but most of us keep our murderous inclinations in check because we have impulse control, inner resources, and support systems.

The so-called ``battered baby'' or Caffey syndrome is associated with young children who cannot give verbal evidence of the events.

The story of each case is so similar as to be almost a carbon copy of the other.

A child is taken to the doctor or hospital, and found to be injured or dead. In the event of death, there may be a subdural haematoma with or without a fracture of the skull, or there may be a fracture of a long bone or of the ribs, and often multiple bruises on the trunk and head. A common explanation is that the child sustained the injuries as a result of some accident, such as falling from a table, or that ``it bruises easily''. What is usually significant is the length of time which elapsed between the ``accident'' and the seeking of medical assistance. This is often a clue to the situation, because the behaviour of a normal parent is to seek help at once in case of any serious injury. In many of the ``battered-baby'' cases some hours may have elapsed, possibly spent in ``hoping for the best'' or thinking up an excuse.

The injuries usually follow a pattern: one or more localised bruises on the head, quite inconsistent with a simple fall, apart from their severity; bruises on the chest and face and sometimes on the trunk and limbs, consistent with grip marks. If the doctor is alert he will arrange for a full X-ray examination of the child. This may show other injuries such as fractured ribs or long bones, or epiphyseal separations of different ages, of which some have closed again. Further questioning will usually reveal that medical assistance was sought on previous occasions quite commonly at some other hospital. Inevitably the parents deny that they hit the child, although they may admit to one slap. Often only one of the parents was present when the incident occurred. One or both parents are usually of low intelligence, and the child is most commonly the first or, if not, the youngest. If not illegitimate, the child will usually be found to be not really ``wanted'' because the pregnancy was accidental, the child interfered with freedom of movement or earning capacity, or there are already too many children in the family. The child often appears well cared for; the acts of violence are intermittent. The violence could be the result of sudden loss of temper due to provocation by the crying or disobedience when the parent was tired or worried.

In 1967 Simpson (Currie 1970: 635) defined the battered-child syndrome according to six characteristics:

·              Infants, usually of two to three years of age, are subjected to

·              persistent or repeated violence at the hands of

·              either or both parents or guardians who

·              either fail to report  -   or delay reporting  -   the injuries they are aware of, and who

·              affect ignorance or lie; offering a simple explanation for the injuries, and who are usually

·              inadequate, subnormal or simple, but seldom under medical care.

We have to distinguish between the battered child and the neglected child, the exploited child, the deprived child and the murdered child, although there is a considerable overlap.

Out of a total of 208 battered children reported, 83% were three-year-olds or younger and 36% were younger than six months. This is because children older than 3 years can run away or tell others what happened to them.



Head injuries

When an infant falls from a table, hospital trolley, or bed (even onto a hard floor) he is unlikely to sustain a fracture of the skull, and is almost certainly assured of escaping major intracranial injury. Falls from greater heights (between 1 and 2 meters), for example from a standing adult's shoulder, may result in a single linear parietal hairline fracture of the skull. Serious intracranial injury is extremely unlikely.

The force used in physical abuse, for example when swinging a child's head against a wall, is so much greater that the pattern of injury is different. Fractures are more likely to be extensive, multiple, depressed, involving several individual skull bones. The occipital bone and base of the skull, which are hardly ever fractured in simple falls, are common sites of injury. Children who were shaken but who did not suffer blunt trauma to the head will have no fracture but may share a similar pattern of intracranial injury to that associated with acceleration/deceleration forces. The neck muscles of small children are inadequately developed to support the relative heavy head when they are shaken. There is often an associated brain injury in a child with a head injury caused by physical abuse. Unexplained neurological deficit, seizures, apnoeic attacks (inability to breathe), hydrocephalus and raised intracranial pressure may be manifestions of child abuse.

a Subdural haematoma

Subdural haematoma in an infant that cannot be explained satisfactorily, strongly suggests physical abuse, such as violent shaking. A simple fall is not sufficient to explain such an injury. There is often no accompanying fracture, and the haematoma arises from disrupted bridging veins spanning the surface of the brain to the dura. The presentation may be immediate or delayed, with fits, poor feeding, lethargy, drowsiness, or rapidly developing unconsciousness.

Cerebral contusion, haemorrhage, and oedema (Hobbs 1985:1169-1170)

Cerebral contusion, haemorrhage, and oedema are responsible for most of the deaths and long-term illnesses resulting from physical abuse. Neurological deficit after widespread neuronal damage from repeated shaking, parallels the punch-drunk syndrome of professional boxers. Intraventricular haemorrhage can present as late secondary hydrocephalus (an accumulation of fluid in the skull). Focal or generalised convulsions may be a further sign of cerebral injury.

c Retinal haemorrhages

Like subdural haematoma, the presence of retinal haemorrhage without adequate explanation should create a strong suspicion of physical abuse. However, this is not the case in the newborn. A short-term rise in intracranial pressure  -   for example, after shaking  -   is responsible for the increased pressure in the central retinal vein, causing retinal haemorrhages.

Bone fractures

These fractures are often of different ages and involve the ribs and long bones.

Skin wounds

Most of the injuries will be caused by the hands of the adult, and contusions due to the child having been slapped or marks due to grasping may be present. The latter typically has a round or oval-shaped appearance and appear on the upper arms and torso. Injuries caused by burning cigarettes may also be present.


Obligation to report: medical practitioners and other professionals (Child Care Act 74 of 1983, s 42)

Every dentist, medical practitioner, nurse or social worker who examines or deals with any child in circumstances giving rise to the suspicion that that child has been ill-treated, or suffers from any injury, single or multiple, the cause of which probably might have been deliberate, or suffers from a nutritional deficiency disease, shall immediately notify the Director-General of Health or any officer designated by him for the purposes of this section of those circumstances.

On receipt of a notification in terms of subsection (1) the Director-General or the said officer may issue a warrant in the prescribed form and manner for the removal of the child concerned to a place of safety or a hospital.

The Director-General or the said officer shall thereupon arrange that the child and his parents receive such treatment as the Director-General or the said officer may determine.

This section shall not exclude any other action against or treatment of the parent and his child in terms of this Act.

Any dentist, medical practitioner or nurse who contravenes any provision of this section shall be guilty of an offence.

No legal proceedings shall lie against any dentist, medical practitioner, nurse or social worker in respect of any notification given in good faith in accordance with this section.


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