Синдром сотрясения младенца: диагностика, противоречия и современные взгляды.

The condition is often caused as a result of a parent or caregiver becoming frustrated due to the child crying. Diagnosing the syndrome has proven to be both challenging and contentious for medical professionals because objective witnesses to the initial trauma are generally unavailable. This is said to be particularly problematic when the trauma is deemed 'non accidental'. Some medical professionals propose that SBS is the result of respiratory abnormalities leading to hypoxia and swelling of the brain. The courtroom has become a forum for conflicting theories with which generally accepted medical literature has not been reconciled. Complications include seizures, visual impairment, cerebral palsy, cognitive impairment, and death. Retinal hemorrhage (bleeding) occurs in around 85% of SBS cases and the severity of retinal hemorrhage correlates with severity of head injury. Fractures of the vertebrae, long bones, and ribs may also be associated with SBS. Dr. John Caffey reported in 1972 that metaphyseal avulsions (small fragments of bone torn off where the periosteum covering the bone and the cortical bone are tightly bound together) and "bones on both the proximal and distal sides of a single joint are affected, especially at the knee". which can raise pressure inside the skull and damage delicate brain tissue, although witnessed shaking events have not led to such injuries. Traumatic shaking occurs when a child is shaken in such a way that its head is flung backwards and forwards. In 1971, Guthkelch, a neurosurgeon, hypothesized that such shaking can result in a subdural hematoma, in the absence of any detectable external signs of injury to the skull. A biomechanical analysis by F. A. Bandak published in 2005 reported that "forceful shaking can severely injure or kill an infant, this is because the cervical spine would be severely injured and not because subdural hematomas would be caused by high head rotational accelerations an infant head subjected to the levels of rotational velocity and acceleration called for in the SBS literature, would experience forces on the infant neck far exceeding the limits for structural failure of the cervical spine. Furthermore, shaking cervical spine injury can occur at much lower levels of head velocity and acceleration than those reported for SBS." Other authors were critical of the mathematical analysis by Bandak, citing concerns about the calculations the author used concluding "In light of the numerical errors in Bandak's neck force estimations, we question the resolute tenor of Bandak's conclusions that neck injuries would occur in all shaking events." Other authors critical of the model proposed by Bandak concluding "the mechanical analogue proposed in the paper may not be entirely appropriate when used to model the motion of the head and neck of infants when a baby is shaken." Bandak responded to the criticism in a letter to the editor published in Forensic Science International in February 2006.

Diagnosis can be difficult as symptoms may be nonspecific.

While the findings of SBS are complex and many, they are often incorrectly referred to as a "triad" for legal proceedings; distilled down to retinal hemorrhages, subdural hematomas, and encephalopathy. SBS may be misdiagnosed, underdiagnosed, and overdiagnosed, and caregivers may lie or be unaware of the mechanism of injury. Commonly, there are no externally visible signs of the condition. Magnetic resonance imaging may also depict retinal hemorrhaging but is much less sensitive than an eye exam. Conditions that are often excluded by clinicians include hydrocephalus, sudden infant death syndrome (SIDS), seizure disorders, and infectious or congenital diseases like meningitis and metabolic disorders. CT scanning and magnetic resonance imaging are used to diagnose the condition.

The US Centers for Disease Control and Prevention identifies SBS as "an injury to the skull or intracranial contents of an infant or young child (< 5 years of age) due to inflicted blunt impact and/or violent shaking". In 2009, the American Academy of Pediatrics recommended the use of the term abusive head trauma (AHT) to replace SBS, in part to differentiate injuries arising solely from shaking and injuries arising from shaking as well as trauma to the head. The Crown Prosecution Service for England and Wales recommended in 2011 that the term shaken baby syndrome be avoided and the term non accidental head injury (NAHI) be used instead.

Some authors have suggested that certain cases of suspected shaken baby syndrome may result from vitamin C deficiency. This contested hypothesis is based upon a speculated marginal, near scorbutic condition or lack of essential nutrient(s) repletion and a potential elevated histamine level. However, symptoms consistent with increased histamine levels, such as low blood pressure and allergic symptoms, are not commonly associated with scurvy as clinically significant vitamin C deficiency. A literature review of this hypothesis in the journal Pediatrics International concluded the following: "From the available information in the literature, concluded that there was no convincing evidence to conclude that vitamin C deficiency can be considered to be a cause of shaken baby syndrome." The proponents of such hypotheses often question the adequacy of nutrient tissue levels, especially vitamin C, for those children currently or recently ill, bacterial infections, those with higher individual requirements, those with environmental challenges (e. g. allergies), and perhaps transient vaccination related stresses. At the time of this writing, infantile scurvy in the United States is practically nonexistent. No cases of scurvy mimicking SBS or sudden infant death syndrome have been reported, and scurvy typically occurs later in infancy, rarely causes death or intracranial bleeding, and is accompanied by other changes of the bones and skin and invariably an unusually deficient dietary history. In one study vaccination was shown not associated with retinal hemorrhages.

Gestational problems affecting both mother and fetus, the birthing process, prematurity and nutritional deficits can accelerate skeletal and hemorrhagic pathologies that can also mimic SBS, even before birth.

Interventions by neonatal nurses include giving parents information about abusive head trauma, normal infant crying and reasons for crying, teaching how to calm an infant, and how to cope if the infant was inconsolable may reduce rates of SBS.

Treatment involves monitoring intracranial pressure (the pressure within the skull). Treatment occasionally requires surgery, such as to place a cerebral shunt to drain fluid from the cerebral ventricles, and, if an intracranial hematoma is present, to drain the blood collection. The most frequent neurological impairments are learning disabilities, seizure disorders, speech disabilities, hydrocephalus, cerebral palsy, and visual disorders.

In 1971, Norman Guthkelch proposed that whiplash injury caused subdural bleeding in infants by tearing the veins in the subdural space. The term "whiplash shaken infant syndrome" was introduced by Dr. John Caffey, a pediatric radiologist, in 1973, describing a set of symptoms found with little or no external evidence of head trauma, including retinal bleeds and intracranial bleeds with subdural or subarachnoid bleeding or both. Development of computed tomography and magnetic resonance imaging techniques in the 1970s and 1980s advanced the ability to diagnose the syndrome. Similarly, the Maguire model, suggested in 2011 as a potential statistical model for determining the probability that a child's trauma was caused by abuse, has been questioned. A proposed clinical prediction rule with high sensitivity and low specificity, to rule out Abusive Head Trauma, has been published. In July 2005, the Court of Appeal of England and Wales heard four appeals of SBS convictions: one case was dropped, the sentence was reduced for one, and two convictions were upheld. The court found that the classic triad of retinal bleeding, subdural hematoma, and acute encephalopathy are not 100% diagnostic of SBS and that clinical history is also important. In the Court's ruling, they upheld the clinical concept of SBS but dismissed one case and reduced another from murder to manslaughter. The court did not believe the "unified hypothesis", proposed by British physician J. F. Geddes and colleagues, as an alternative mechanism for the subdural and retinal bleeding found in suspected cases of SBS. In 2012, Norman Guthkelch, the neurosurgeon often credited with "discovering" the diagnosis of SBS, published an article "after 40 years of consideration," which is harshly critical of shaken baby prosecutions based solely on the triad of injuries. Again, in 2012, Guthkelch stated in an interview, "I think we need to go back to the drawing board and make a more thorough assessment of these fatal cases, and I am going to bet that we are going to find in every – or at least the large majority of cases, the child had another severe illness of some sort which was missed until too late." Furthermore, in 2015, Guthkelch went so far as to say, "I was against defining this thing as a syndrome in the first instance. To go on and say every time you see it, it's a crime It became an easy way to go into jail." Teri Covington, who runs the National Center for Child Death Review Policy and Practice, worries that such caution has led to a growing number of cases of child abuse in which the abuser is not punished. Shortly after her conviction, Squier was given the "champion of justice" award by the International Innocence Network for her efforts to free those wrongfully convicted of shaken baby syndrome. Squier denied the allegations and appealed the decision to strike her off the medical register. As her case was heard by the High Court of England and Wales in October 2016, an open letter to the British Medical Journal questioning the decision to strike off Squier, was signed by 350 doctors, scientists, and attorneys. On 3 November 2016, the court published a judgment which concluded that "the determination of the MPT is in many significant respects flawed". The judge found that she had committed serious professional misconduct but was not dishonest. She was reinstated to the medical register but prohibited from giving expert evidence in court for the next three years. In 2022, Channel 4 in the UK broadcast a documentary called The Killer Nanny: Did She Do It? concerning the Louise Woodward case. In it, civil rights lawyer Clive Stafford Smith stated, "shaken baby syndrome is bullshit".