BATTERED BABY SYNDROME OR NON-ACCIDENTAL INJURY OF CHILDHOOD

Is is also Known as child abuse syndrome, Caffey's syndrome, and

maltreatment syndrome in children. The typical form of this condition
is very rare in India.
A battered child is one who has received repetitive physical injuries
as a result of non-accidental violence, produced by a parent or guardian.
In addition to physical injury, there may be non-accidental deprivation of nutri
tion,
care and affection.
The classical features of syndrome are obvious discrepancy between the nature of
the
injuries and explanation offered by the parents, and delay between the injury,
and medical attention which cannot be explained. The constant feature is repetet
ion of
injuries at different dates, often progressing from minor to more sevre.
Features
1 AGE - Usually less than three years old, though it may occur at any age.
2 SEX - Slightly more in males (55 to 63%)
3 POSITION IN FAMILY - On child of a family, commonly the eldest or the youngest
and
often unwanted, such as the result of pregnancy before marriage, failure of
contraception or an illegitimate child.
4 Socio-economic factors - Parents tend to be young between 20 to 30 years,
and belong to lower social class and lower education. The family is usually iso
lated.
There if often a history of family disharmony, long-standing emotional problems
or financial problems. Many of the fathers has criminal records, unemployed or
socially unstable.
Many mothers have multiple social and psychiatric problems with a chaotic and v
iolent
home background. The mother is of lower I.Q., often pregnant or in the premenst
rual
period at the time of battering. Unhappy childhood experiences are common in bo
th parents were
"Battered Children" themselves. Most of the parents suffer guilt-amnesia.
5 HISTORY - There is obvious difference between the nature of the injuries and
the explanation given by the parents, which may change on several times of repe
tition,
each time child is taken to different doctor.
6 TREATMENT - There is always delay between the injury and medical attention.
7 PRECIPITATING FACTORS - Violence is precipitated by actions of the child itse
lf,
e.g., crying, refusal to be quiet, persistent soiling of napkins, etc.

INJURIES
Direct manual violence is the commonest method of injury.
SURFACE INJURIES:

Soft tissue injuries are very common and may be seen almost anywhere on childs
body.
The head, face and next show bruises, abrasions and lacerations of different age
s.
Multiple bruises are seen on brows, cheeks, mouth and neck.
Laceration of mucosa inside the upper lip often tear of the fraenulum is the mos
t characteristic
lesion.
This may extend laterally and separate the inner surface of the lip from the bas
e of the gums.
This injury results from a blow on the mouth or due to other efforts to silence
a scraming or
crying child.
Multiple bruises of various ages all over the body from rough handling, beating,
kicking, or
throwing the
infant are common. Bruises may be seen on either side of the chest behind axilla
e and down
the anterior chest wall, where the child has been gripped roughly, between two a
dult hands and shaken.
Caffey (1974) described the effects of shaking a child as a major cause of subdu
ral haematoma
and intraocular bleeding in battered babies, the so-called
"infantile whiplash syndrome". Recent research has thrown doubt on the common ac
ceptance of this
mechanism. Some pathologists believe the impact to the head is necessary. In suc
h cases, bruises are produced in areas where the child is
held by the hands, but there are no external injuries to the head or fractures
of the skull, but there may be
traction lesions of the periosteum of the long bones without fracture.
Permanent brain damage may be caused due to habitual, prolonged shaking.
BITE MARK : may be found on
cheeks, shoulders, chest, abdomen, arms, legs and buttocs.
Bruises are usually present around the elbows and knees due to gripping of the c
hild, so as to shake
or pull him, or hurl him into cot or against furniture, etc. Slap Marks may show
clear lines of
petechial haemorrhages. Knuckle punches show as rows of three or four roughly ro
und bruises.
Bruising caused by belts, straps, canes may be seen frequently on the buttocks a
nd thighs. Pinch
mark may appear as butterfly-shaped bruiseswith one wing caused by thumb larger
than the other.
Subgaleal haematoma resulting from vigorous pulling on the scalp is characterist
ics.Bald patches
on the scalp due to pulling out the hair(traumatic alopecia) is very characteris
tics.
EYE: Retinal seperation, lens displacement, retinal haemorrhages, vitreous haemo
rrhages, subconjunctival
haemorrhages, and subhayaloid haemorrhages and black eye have been found.
VISCERAL INJURIES: Subdural haemorrhages is found in about 40% of fatal cases. c
rushing
or compressing force applied to the abdomen produce either "bursting" injuries
of the liver or spleen, or perforations of distended hollow viscera including th
e
stomach, intestine or urinary bladder. The second part of the duodenum and jejun
um may be completely
transected. Deceleration or whipping forces produced by punches or blows tear th

e mesentery
and can lead to disruption of the small intestine. Extensive internal injuries
may be present with minimal external signs.
BURNS: Stubbing of cigarette end upon the skin produce small circular, pitted bu
rns
which are pink or red when fresh. When healing they tend to be silvery in centre
with narrow red rim. The child may be made to sit upon a hot stove or
electric radiater or he may be dipped in very hot fluids.
SKELETAL INJURIES : Skull fractures are common in occipito-paretal area.
The fractures are multiple, depressed and wide. Large periosteal haematomas are
common
because periosteum is readily striped in infants. Bleeding under the periosteum
causes
calcification, which is seen on X- ray as an extra line of opacity running along
side.
The violent forces applied to the limbs involve pulling and twisting,
both capable of producing epiphyseal separation and
periosteal shearing. Transverse and spiral fractures of long bones result
from compression , bending and direct forcible blows.
Anteroposterior compression of the chest causes fractures of ribs in
midaxillary line. Violent squeezing of the chest from side to side causes fract
ures
at the costochondral junctions. Multiple rib fractures also occur along the pos
terior angles
of the ribs. After one to two weeks, callus is formed, and on X-Ray "a string o
f beads"
appearence is seen in the paravertebral gutter (NOBBING FRACTURES).
Avulsion of the metaphysis or chipping of the edges of the metaphyses seen isola
ted on X-Ray.
Before autopsy, a whole body x-ray should be taken to detect old fractures and e
specially metaphyseal
and epiphyseal injuries in various stages of healing. Head injury is the most co
mmon
cause of deth followed by rupture of an abdominal organ.
DIAGNOSIS :
The diagnosis depends upon
(1) nature of injuries
2 time taken to seek medical advice , and
3 recurrent injuries.
Differential diagnosis has to be made from scurvy, congenital syphilis,
osteomyelitis, leukaemia, rickets, juvenile osteoporosis with stress fractures,
paralytic
disease with fractures, infantile cortical hyperostoses and osteogenesis imperf
ecta. Radiological manifestations of
trauma and especially the metaphyseal lesions are specific to the battered baby
syndrome.