1.3.1.1.1

Initial symptoms

The initial symptoms are as follows:

• •
  

  in the most serious cases, “the child is found dead”. In such an event, it is essential to follow the guidelines issued by the French National Authority for Health1 ⁵

  
  

  5 Management of the unexpected death of a baby (under the age of 2): good practice guidelines. HAS. February 2007.

  . In particular, an autopsy is essential. Unless otherwise decided by the State Prosecutor for forensic and legal reasons, performance of an autopsy requires the parents’ consent;
  
  
  
• •
  

  “Serious neurological damage” may be immediately apparent by: severe malaise, impaired vigilance (extending to coma), severe apnoea, convulsions, fixed upward gaze, signs suggesting acute intracranial hypertension and even tentorial herniation;

  
  
• •
  

  “Other signs suggestive of neurological damage”: poor contact and a decrease in the child’s capabilities;

  
  
• •
  

  “Some non-specific signs of neurological damage” can lead to misdiagnosis: behavioural changes (irritability, changes in sleep or feeding patterns), vomiting, interruption of breathing, paleness and apparent pain.

The clinical examination must be thorough and performed after undressing the child; in particular, it should include palpation of the fontanel, measurement of the head circumference (which should be checked against the growth chart to see whether there has been a change in the percentile class) and examination of the whole body (including the scalp) for bruises.

Given the lack of specificity of certain signs, “a combination of signs” may provide much more information: a combination of vomiting with a bulging fontanel, convulsions, axial hypotonia or vigilance disorders; a combination of convulsions with axial hypotonia or a bulging fontanel; a bulging fontanel with a sharp shift upwards of the head circumference curve.

1.3.1.1.2

Absence of a lucid interval

In most cases (or even in all cases), shaking produces immediate symptoms.

Of course, it must be borne in mind that the consultation may take place some time after shaking has occurred.

1.3.1.1.3

Other elements that can be suggestive of shaking

The other elements are:

• •
  

  data from the medical history and interview:

  
  
  
  
  • ∘
    

    a delay in seeking medical assistance,

    
    
  • ∘
    

    the lack of an explanation for the symptoms, an explanation that is not compatible with the child’s clinical status or developmental stage or an explanation that changes over time or differs from one person to another,

    
    
  • ∘
    

    a spontaneous report of a minor head injury that had occurred in the past,

    
    
  • ∘
    

    prior consultations for crying or any type of injury,

    
    
  • ∘
    

    a history of unexplained sibling death;

  
  
  
  
• •
  

  risk factors:

• ∘
  

  Boys, premature babies and children from multiple pregnancies are more likely to be shaken,

  
  
• ∘
  

  Although the shaker is usually a man living with the mother (who may be the child’s father or the mother’s partner), babysitters or carers are involved in about one case of shaking in five,

  
  
• ∘
  

  Although shaking occurs in all socioeconomic, cultural and intellectual settings, it has been noted that: a history of alcoholism, drug abuse or family violence is a risk factor and the shaker often has very poor knowledge of a child’s needs or normal behaviour,

  
  
• ∘
  

  The parents are often socially isolated.

1.3.1.1.4

Should the child be hospitalized?

If the physician suspects a diagnosis of SBS, he/she must tell the parents about his/her concern for the child’s status and inform them that emergency hospitalization is indicated.

1.3.1.2.1

Lesions observed in shaken baby syndrome

In SBS, the meninges, brain, eyes and spinal cord are likely to be damaged. Other lesions may also be present: injury to the neck and cervical spine, limb, rib and/or skull fractures and bruising and haematomas in the teguments and/or neck muscles:

• •
  

  intracranial lesions:

  
  
  
  
  • ∘
    

    SDH:

    
    
    
    
    • –
      

      SDH is generally multifocal ( Figs. 1–3 ). and may be accompanied by subarachnoid haemorrhages,

      
      
    • –
      

      However, it can also be localized,

      
      
    • –
      

      haemorrhage of the falx cerebri or posterior fossa is very suggestive of SBS,

      
      
    • –
      

      SDH is not always present in SBS;

    
    
    
    
  • ∘
    

    brain injury: this may be anoxic, oedematous or contusion-like.

  
  
  
  
• •
  

  RH:

  
  
  
  
  • ∘
    

    multiple RH are almost pathognomonic for SBS when profuse or flecked across the retina up to the periphery, with haemorrhagic retinoschisis or a perimacular retinal fold in some cases (type 3 RH, Table 1 ),

    
    
  • ∘
    

    however, other types of RH can be seen,

    
    
  • ∘
    

    RH are absent in about 20% of cases of SBS. They are therefore not essential for a diagnosis of SBS but, when present, are strongly suggestive of shaking;

  
  
  
  
• •
  

  skin lesions: in the absence of medical causes, bruising in a child that cannot walk unaided is very suggestive of abuse;

  
  
• •
  

  bone injury: bone injuries are suggestive of abuse (particularly rib fractures, signs of costal callus formation, metaphyseal fractures and periosteal spurs;

  
  
• •
  

  damage to neck muscles, the spine or the spinal cord.

Multifocal subdural haematoma of the tentorium cerebelli (indicated by an arrow) in a case of abusive HI caused by shaking.

Multifocal interhemisphere subdural haematoma (hyperdensity indicated by an arrowhead) and multifocal left pericerebral subdural haematoma (hyperdensity indicated by an arrow) in a case of abusive HI due to shaking.

Multifocal subdural haematoma of the vertex (indicated by arrows) in a case of abusive HI caused by shaking.

1.3.1.2.2

Clinical and paraclinical examinations in a living child

This part is as follows:

• •
  

  clinical examination: a thorough examination, particularly the head circumference curve, screening for traumatic injuries (which must be photographed, if found), the state of the fontanel and a neurological examination;

  
  
• •
  

  brain CT: the first-line examination. It reveals haemorrhagic lesions and cerebral oedema. In the event of doubt and if the initial result is normal, the CT scan can be repeated 12 or 24 hours later;

  
  
• •
  

  ophthalmological examination after dilatation: this must be performed by an experienced ophthalmologist within 48 to 72 hours, at the latest;

  
  
• •
  

  MRI: this examination should be performed as soon as the child’s state has stabilized. It is of significant diagnostic value in the acute phase and gives a complete overview of axial and extra-axial lesions (whether haemorrhagic or not). It also probes the brain stem, the spinal cord and the neck region. This forms part of the lesion screening that must be performed before the child is discharged from hospital;

  
  
• •
  

  other required examinations:

• ∘
  

  a complete blood count, PT, APTT, coagulation factors,

  
  
• ∘
  

  X-rays of the whole skeleton, performed according to the American Academy of Pediatrics guidelines ⁶

  
  

  6 A skeletal survey is mandatory in all cases of suspected physical abuse in children younger than 2 years (not a “whole body” X-ray): radiographies of the axial skeleton (anteroposterior and lateral views of the thorax, and possibly an oblique view to see the ribs, the upper dorsal and lumbar spine; anteroposterior and lateral views of the pelvis, in order to see the medial lumbar spine; a lateral view of the lumbosacral spine, anteroposterior and lateral views of the cervical spine, anteroposterior and lateral views of the skull [and other views, if necessary]) and all limb segments.

  ,
  
  
  
• ∘
  

  bone scintigraphy can show evidence of bone lesions that are not apparent on X-rays.

1.3.1.4.1

Action to be taken, depending on the clinical situation

Actions to be taken are:

• •
  

  a dead child: autopsy (requiring the parents’ consent) is recommended for all unexpected infant deaths – especially when non-accidental head injury is suspected. The physician must report the case to the State Prosecutor, who may order a forensic autopsy;

  
  
• •
  

  early, acute neurological distress: a brain CT scan in the emergency unit, in order to screen for intracranial haemorrhage and other signs;

  
  
• •
  

  signs that point towards neurological damage and certain non-specific signs (vomiting, respiratory disorders, paleness, apparent pain):

• ∘
  

  palpation of the fontanel and measurement of head circumference,

  
  
• ∘
  

  note whether several signs are present,

  
  
• ∘
  

  look for other signs of abuse,

  
  
• ∘
  

  any description of a shaking-like act.

It is essential to consider shaking and perform a comprehensive examination, including a brain CT scan and fundoscopy.

When confronted with the slightest suspicion of SBS, the physician must tell the parents about his/her concern for the child’s safety and inform them that emergency hospitalization is required.

1.3.1.4.2

Diagnostic criteria as a function of the observed lesions

In a child under one, after differential diagnoses have been ruled out, a diagnosis of head injury inflicted by shaking is:

• •
  

  highly probable (or even certain) if all the following are present:

  
  
  
  
  • ∘
    

    Multifocal extra-axial haemorrhage: SDH ( Figs. 1–3 ), subarachnoid haemorrhage,

    
    
  • ∘
    

    AND RH profuse or flecked across the retina out to its periphery,

    
    
  • ∘
    

    AND a history that is absent, incoherent, changes over time or is incompatible with the observed lesions or the child’s age.

  
  
  
  

  The coexistence of the three above diagnostic elements should prompt a diagnosis of inflicted head injury (probably by shaking);

  
  
• •
  

  possibly accompanied by:

  
  
  
  
  • ∘
    

    hypoxic brain lesions,

    
    
  • ∘
    

    cervical lesions (spinal cord haematoma, medullary damage and lesions to the occipitovertebral or cervicodorsal junctions),

    
    
  • ∘
    

    description of violent shaking by an eyewitness.

  
  
  
  
• •
  

  a diagnosis of head injury inflicted by shaking is probable if:

  
  
  
  
  • ∘
    

    multifocal extra-axial haemorrhage ( Figs. 1–3 ), “with or without” any type of RH,

    
    
  • ∘
    

    OR localized, extra-axial haemorrhage with type 2 or 3 RH,

    
    
  • ∘
    

    AND a history that is absent, incoherent, changes over time or is incompatible with the observed lesions or the child’s age;

  
  
  
  
• •
  

  in the event of localized SDH and RH limited to the posterior pole (type 1), with a clinical history that is absent, incoherent, changes over time or is incompatible with the observed lesions or the child’s age, “there was no consensus within the Hearing Commission as to whether the diagnosis of shaking must be considered as «probable» or «possible»”;

  
  
• •
  

  a diagnosis of head injury inflicted by shaking is possible if both the following are present:

  
  
  
  
  • ∘
    

    localized SDH,

    
    
  • ∘
    

    AND a history that is absent, incoherent, changes over time or is incompatible with the observed lesions or the child’s age;

  
  
  
  
• •
  

  the diagnosis of shaking can be ruled out when there is:

• ∘
  

  localized SDH ( Fig. 4 ), with a potentially linear fracture and adjacent bruising,

  
  
• ∘
  

  AND an unvarying clinical description that is compatible with the lesions and the child’s age and describes a violent, accidental head injury.

Localized right frontoparietal SDH and adjacent bruising of the scalp (indicated by an arrow) in a case of accidental HI.

1.4.2.2.1

Retinal haemorrhages

It is difficult to date RH.

Intra-RH disappears within a few days. Only their association with scars, the sequelae of preretinal or sub-RH (circular white scars of retinal folds, macular retraction syndrome, zones of pigmentation and retinal atrophy, particularly in macular areas or at the extreme periphery of the retina, and fibroglial scarring) can be considered as demonstrating the coexistence of older and recent lesions.

1.4.2.2.2

Subdural haematoma and subarachnoid haemorrhage

The time range for dating acute SDH is wide (and always more than 10 days, whether on CT or MRI). It is thus difficult to obtain an accurate date by using imaging data.

Furthermore, it must be noted that:

• •
  

  heterogeneous SDH is not specific for a particular mechanism and does not imply repetition;

  
  
• •
  

  heterogeneous SDH can reflect new bleeding from the capillaries of a neoformed membrane in the absence of new shaking;

  
  
• •
  

  a child may have been the victim of several shaking episodes, with a possible superposition of lesions of differing ages. The presence of several SDH with different density then becomes highly informative.

1.4.3.1.1

First hypothesis: the observed widening of the pericerebral spaces is part of an expansion of the subarachnoid space (ESAS) – a clinical entity which may predispose the child to subdural haematoma

No data were found in the literature to support the hypothesis whereby ESAS predisposes to SDH in babies.

1.4.3.1.2

Second hypothesis: the observed expansion of the pericerebral space is the consequence of a previously undiagnosed head injury

Two prospective studies suggest that widening of the pericerebral space discovered during the initial phase of head injury corresponds to damage resulting from a previously undiagnosed head injury, rather than from ESAS.

A follow-up study of changes in brain images in a cohort of: young babies with ESAS and shaken babies would very useful in terms of understanding the natural history of these clinical entities.

1.5.1.1.3.1

The civil procedure

The State Prosecutor may deliver an OPP; this means that the child will be immediately placed under care and prevents the parents from recovering him/her when discharge to home would endanger the child. This decision has no right of appeal and is valid for one week, during which the case can be referred to a juvenile court. The latter will give a ruling within two weeks of taking up the matter and after having summoned the legal guardians. The judge may extend the OPP, issue a permanent care order (which can be appealed by the parents) or implement other educational assistance measures.

1.5.1.1.3.2

The criminal procedure

Referring the matter to the State Prosecutor will trigger an immediate criminal inquiry, in order to identify and potentially prosecute the perpetrator(s). In the event of death and if there is medical opposition to burial, a forensic autopsy can be ordered by the State Prosecutor.

1.5.1.1.9.1

Risks incurred by the physician

Article 44 of the French Code of Medical Ethics obliges the physician, except under particular circumstances that he/she shall consider in all conscience, to alert the judicial, medical or administrative authorities in the event of abuse or privation in a child aged 15 or under.

For cases of severe abuse, a report to the State Prosecutor is recommended by the French Medical Council.

The fact that this obligation is accompanied by a conscience clause does not make it any less imperative. Hence, if the physician does not alert the authorities, he or she must explain the circumstances that prompted this decision. If a physician does invoke the conscience clause, he/she must nevertheless ensure that effective protective measures are implemented in order to avoid recurrence of the shaking or other abuse.

In the event of death and if shaking seems highly probable, the physician who delivers the death certificate must mention the fact that the death raises legal issues; if he/she does not, he/she may face criminal charges for falsification as well as disciplinary sanctions.

1.5.1.1.9.2

Risks incurred by other professionals

People subject to a professional duty of confidentiality may or may not choose to report crimes and abuse but always have a legal obligation to assist a person in danger.

1.5.1.1.14.1

The criminal inquiry

In France, criminal inquiries are led by the police force or the gendarmerie (usually a specialist child protection unit under the supervision of the State Prosecutor’s Office).

The members of the hospital team and professionals in contact with the family may be interviewed. They must state their knowledge of the situation and pass on any information or documents required for the purposes of the inquiry . Hospital and social services staff workers cannot claim an overriding professional duty of confidentiality when information is requested by a crime squad officer duly mandated and overseen by a legal authority.

If the physician receives a summons as part of a preliminary inquiry, he/she may communicate the facts known to him/her but is not obliged to do so – he/she can plead a professional duty of confidentiality.

Medical records may be requisitioned during the inquiry or investigation. This procedure must comply with and maintain physician-patient confidentiality.

Importantly, experts who become involved in the matter after the start of the judicial inquiry should be competent in the field concerned: paediatrics, ophthalmology, neurology, physical and rehabilitation medicine, radiology and even biomechanics.

1.5.1.1.14.2

The outcome of the criminal inquiry

The case may: be closed forthwith if the offense cannot be proven due to lack of evidence or lack of an identifiable perpetrator or give rise to a prosecution that may lead to dismissal of charges or a trial before a Magistrates Court (if the incident is considered to be a minor offence) or a Court of Assizes (for serious offences).

1.5.1.1.14.3

Initiation of a child protection procedure

If the matter is referred to a juvenile court judge, the latter usually orders an investigation and a 6-month care review procedure ( investigation et orientation éducative , IOE ⁷

7 Due to be renamed as a mesure judiciare d’investigation educative (MJIE).

If the presumption of innocence leads to the dismissal of legal proceedings (in the event of doubt as to the intention to cause harm or the identity of the perpetrator), this of course should be no obstacle to the protection of the child.

1.5.1.1.14.4

What are the potential criminal charges and sentences for perpetrators of shaking?

There is no specific criminal charge of “shaking” per se but the latter act always constitutes a violation of the law. The usual criminal charges relate to involuntary or voluntary assault with aggravating circumstances. It is important to differentiate between the intent to shake and consideration of the consequences of this act: shaking cannot be qualified as an involuntary act.

The severity of the sentences handed down by the courts very clearly illustrates the importance of the disapprobation associated with all violent acts inflicted on a child under the age of 15 by an ascendant (the legal, natural, or adoptive parents or the grand-parents, if the child has been entrusted to them) or a person with responsibility for the child (a child-minder, the latter’s spouse or partner, a partner of one of the parents or any other person charged with looking after the child). The possible sentences are presented in detail in the Advisory Report.

In addition to the main perpetrator, other people in the child’s environment may be prosecuted for not having prevented a crime or offence against the child, failure to assist a person in danger or (for ascendants or persons with authority over the child) lack of care and endangerment of the child’s health.

Additional sentences may be handed down: a temporary or permanent professional ban for the person charged with looking after the child, for example.

1.5.1.1.14.5

Under which conditions can the victim receive compensation?

Compensation is possible once the act of shaking is established – It is therefore important that it be established, even if the perpetrator is never identified. Reporting the shaking to the legal authorities is essential for enabling the possible award of long-term compensation to the shaking victim.

The appointment of an ad hoc legal guardian compensates for the fact that the child has no legal competence.

Referral to the Crime Victim Compensation Committee (CIVI) is essential, regardless of whether the perpetrator is economically disadvantaged or has not been identified. The matter can be referred to the CIVI immediately, within three years of the date of the offence or in the year following the final verdict issued in a public or civil prosecution before the criminal courts. The fact that the victim is a child suspends the time restriction; The victim can pursue the matter before the CIVI up until his/her 21st birthday.

1.5.1.3.1.1

Team coordination

For a diagnosis of “probable” SBS, the medical team (at least two healthcare professionals) must meet and review the symptoms and the reported facts, pool and compare the gathered information, make a diagnosis, consider (as appropriate) any other associated mistreatments, clarify each person’s positions and discuss whether a report should be filed. This meeting must take place without delay and must be summarized in writing. A report may be filed immediately.

In addition, a multidisciplinary medical, psychological and social evaluation of the situation is essential, in order to analyse the child’s situation, identify risk factors and consider the child’s future and potential protection measures. Consulting with colleagues is never a waste of time. The healthcare professional should not confuse speed and haste.

1.5.1.3.1.2

Reporting

Each hospital service should define the reporting procedures to be followed by its staff in cases of shaking, as follows:

• •
  

  in urgent cases, establish an initial report that includes the essential information (see the text box above Section 1.8.5.1.6) and then add further information after a multidisciplinary evaluation;

  
  
• •
  

  the report should be signed by the attending hospital physician and social services staff. In some cases, it may be completed by the psychologist or psychiatrist who has interviewed the family. It is essential to provide information on context and congruency as well as recording the medical facts;

  
  
• •
  

  the report should be sent by both fax and registered post with signed-for delivery, while keeping a copy for the hospital records;

  
  
• •
  

  if the report is sent directly to the State Prosecutor’s Office, a copy must be sent to the Chairperson of the County Council.

An OPP temporary placement order ordered by the State Prosecutor will not influence subsequent legal proceedings and is recommended – if only to provide the child with immediate protection.

Reporting should be performed as quickly as possible, in order to provide the child with immediate protection and not jeopardize the inquiry: the sooner after the event the report is filed, the sooner an effective criminal inquiry can start.

In this respect, the County’s procedure (established in compliance with the French Child Protection Act 2007-293 dated March 5, 2007) and involving the council itself, the State Prosecutor’s Office, hospitals and other parties likely to be aware of children in danger in general and shaking victims in particular) should contain advice that is clear and is applicable to the county as a whole.

As soon as a diagnosis of SBS is stated as the cause of (or one of the possible causes of) a baby’s death, the physician who delivers the death certificate must mention the fact that this death raises legal issues.

1.5.1.3.1.3

Dialogue with the parents and the family

In the diagnostic phase, dialogue with the parents is essential – notably in order to obtain their explanations concerning the child’s injuries. It is not a question here of forming an opinion on the circumstances of and justifications for shaking, identifying the perpetrator and deciding whether the latter should be prosecuted – these issues are the sole responsibility of the State Prosecutor.

The physician should inform the parents that in light of the severity of their child’s condition, the State Prosecutor’s Office will be contacted. He/she should also specify that the State Prosecutor will decide on any further actions to be taken. This approach, which means taking time and making an effort to listen, is best led by a senior physician in the presence of another staff member. It is essential to try to make the parents understand that the goal is not to denounce them but to draw attention to a dangerous situation and protect their child.

The parents must be informed of the report (except when contrary to the child’s interests), the possibility that an OPP may be issued by the State Prosecutor and the possibility of filing a complaint against person or persons unknown if they themselves agree there was shaking but attribute it to someone else.

However, this necessary dialogue and the obligation to provide the parents with information must not hinder or jeopardize the criminal inquiry.

1.5.1.3.1.4

Exchanging information with the State Prosecutor’s Office

It is recommended that a form be used for the exchange of information between the State Prosecutor’s Office and the reporting person. In order to establish this practice, the form should be part of the reporting protocol.

1.5.1.3.1.5

Requisition of medical records

It is advisable to photocopy requested documents prior to their transmission, in order to: comply with the healthcare establishment’s obligation to store its medical data and counter the risk of not having the requisitioned items returned.

It is advisable to request the return of requisitioned items. This request must be sent to the investigating judge if it is made during the legal proceedings (article 99, paragraph 1 of the Criminal Procedure Code) or to the ruling jurisdiction if the case is closed (Article 373 and article 484, paragraph 2 of the Criminal Procedure Code).

1.5.1.3.1.6

Disclosure of cause for concern

To disclose concern to the CRIP, the physician should follow the county’s procedure, in compliance with article L. 226-3 of the Social Action and Family Code ⁸

8 “…procedures to this end must be established by the Chairperson of the County Council, the State’s representative in the county and the legal authorities with a view to centralizing disclosures of concern within a specialist unit for gathering, processing and evaluating this information”.

1.5.1.3.4.1

For professionals in contact with young children

Since many shaking incidents occur in child care facilities), initial training, continuing professional education and staff support must be implemented in order to maintain high levels of awareness.

In general, any professional likely to become aware of shaking incidents in some way must receive at least basic training on this issue: social services staff, child aid supervisors, magistrates, police officers, etc.

When justified by the context, it is advisable to identify all the resources that can potentially be leveraged in the family environment to help parents better fulfil their parental role. In general, personal and life problems experienced by people looking after children should act as a warning sign for any professionals who know about them.

1.5.1.3.4.2

For parents and families

It is advisable to organise frequent, appropriate awareness-raising and information campaigns (targeted at people in contact with babies, above all) on the dangers of shaking and the precautions that should be taken.

In maternity wards and in the days following discharge to home, parents should always be made aware of the danger of shaking.

“Parent and child drop-in centres” at which the relationship between the parents and the child can be built or strengthened are recommended solutions.

It is important to offer appropriate support to parents and implement support measures when requested. Referral to maternal and child health professionals (notably with home visits) must be envisaged. The same is true for various forms of home help (provided by social and family services).

1.5.1.3.4.3

In the child’s interest

We recommend that France borrows elements of Canadian law in which an ad hoc legal guardian can be appointed whenever necessary in the child’s interest and in defence of the child’s rights.

2.3.1.1.1

Symptômes initiaux

Les symptômes initiaux sont comme suit :

• •
  

  dans les cas les plus graves, « l’enfant a été trouvé mort ». Il est essentiel de suivre dans ce cas les recommandations de la Haute Autorité de santé ⁹

  
  

  9 Prise en charge en cas de mort inattendue du nourrisson (moins de deux ans). Recommandations de bonne pratique. HAS. Février 2007.

  . En particulier l’autopsie est essentielle ; sauf indication médicolégale et décision du procureur de la République, elle requiert l’autorisation des parents ;
  
  
  
• •
  

  « une atteinte neurologique grave » peut être évoquée d’emblée : malaise grave, troubles de la vigilance allant jusqu’au coma, apnées sévères, convulsions, plafonnement du regard, signes orientant vers une hypertension intracrânienne aiguë, voire vers un engagement ;

  
  
• •
  

  « d’autres signes orientent aussi vers une atteinte neurologique » : moins bon contact, diminution des compétences de l’enfant ;

  
  
• •
  

  « certains signes non spécifiques d’atteinte neurologique » peuvent égarer le diagnostic : modifications du comportement (irritabilité, modifications du sommeil ou des prises alimentaires), vomissements, pauses respiratoires, pâleur, bébé douloureux.

L’examen clinique doit être complet, sur un nourrisson dénudé ; il comprend en particulier la palpation de la fontanelle, la mesure du périmètre crânien qu’il faut reporter sur la courbe en cherchant un changement de couloir, la recherche d’ecchymoses sur tout le corps, y compris sur le cuir chevelu.

Étant donné l’absence de spécificité de certains signes, « leur association » présente un intérêt majeur : association de vomissements avec une tension de la fontanelle, des convulsions, une hypotonie axiale, un trouble de la vigilance ; association de convulsions avec une hypotonie axiale, une tension de la fontanelle ; tension de la fontanelle avec cassure vers le haut de la courbe de périmètre crânien.

2.3.1.1.2

Absence d’intervalle libre

Dans la majorité des cas, sinon dans tous les cas, le secouement entraîne immédiatement des symptômes. Cela est bien sûr distinct du fait qu’il peut y avoir un délai entre le secouement et la consultation.

2.3.1.1.3

Autres éléments pouvant faire évoquer un secouement

Les autres éléments sont :

• •
  

  données de l’anamnèse :

  
  
  
  
  • ∘
    

    retard de recours aux soins,

    
    
  • ∘
    

    absence d’explications des signes, ou explications incompatibles avec le tableau clinique ou le stade de développement de l’enfant, ou explications changeantes selon le moment ou la personne interrogée,

    
    
  • ∘
    

    histoire spontanément rapportée d’un traumatisme crânien minime,

    
    
  • ∘
    

    consultations antérieures pour pleurs ou traumatisme quel qu’il soit,

    
    
  • ∘
    

    histoire de mort(s) non expliquée(s) dans la fratrie ;

  
  
  
  
• •
  

  facteurs de risque :

• ∘
  

  les bébés secoués sont plus souvent des garçons, des prématurés ou des enfants issus de grossesses multiples,

  
  
• ∘
  

  l’auteur du secouement est la plupart du temps un homme vivant avec la mère (qui peut être le père de l’enfant ou le compagnon de la mère), mais les gardiens de l’enfant sont en cause dans environ 1 cas sur 5,

  
  
• ∘
  

  tous les milieux socioéconomiques, culturels, intellectuels peuvent être concernés, mais il a été noté, d’une part, qu’une histoire de consommation d’alcool, de substance illicite ou de violence familiale est un facteur de risque, d’autre part, que les auteurs du secouement ont souvent une méconnaissance importante des besoins ou comportements normaux de leur enfant,

  
  
• ∘
  

  il existe fréquemment un isolement social et familial des parents.

2.3.1.1.4

Faut-il hospitaliser ?

Penser au diagnostic de secouement doit conduire le médecin à faire part aux parents de son inquiétude sur l’état de l’enfant et à poser l’indication d’une hospitalisation en urgence.

2.3.1.2.1

Lésions observées en cas de secouement

Sont susceptibles d’être lésés dans le SBS les méninges, l’encéphale, l’œil et la moelle épinière. D’autres lésions peuvent être associées : lésions du cou et du rachis cervical, fractures des membres, des côtes, du crâne, ecchymoses et hématomes des téguments, des muscles du cou:

• •
  

  lésions intracrâniennes :

  
  
  
  
  • ∘
    

    hématomes sous-duraux (HSD) :

    
    
    
    
    • –
      

      habituellement plurifocaux ( Fig. 1–3 ) qui peuvent être associés à des hémorragies sous-arachnoïdiennes,

      
      
    • –
      

      mais l’HSD peut être unifocal,

      
      
    • –
      

      une hémorragie au niveau de la faux du cerveau ou de la fosse postérieure est très évocatrice du diagnostic,

      
      
    • –
      

      les hématomes sous-duraux ne sont pas constants dans le SBS ;

    
    
    
    
  • ∘
    

    lésions cérébrales : elles peuvent être anoxiques, œdémateuses ou à type de contusion ;

  
  
  
  
• •
  

  hémorragies rétiniennes :

  
  
  
  
  • ∘
    

    les hémorragies rétiniennes (HR) sont quasi-pathognomoniques de SBS quand elles sont multiples, profuses ou éclaboussant la rétine jusqu’à sa périphérie, avec parfois rétinoschisis hémorragique, pli rétinien périmaculaire (HR de type 3, Tableau 1 ),

    
    
  • ∘
    

    mais d’autres types d’HR peuvent se voir,

    
    
  • ∘
    

    elles sont absentes dans environ 20 % des cas. Elles ne sont donc pas indispensables au diagnostic, mais leur présence est un argument fort en faveur du diagnostic de secouement ;

  
  
  
  
• •
  

  lésions cutanées : les ecchymoses sont, en l’absence de cause médicale, très évocatrices de mauvais traitements chez un enfant qui ne marche pas seul ;

  
  
• •
  

  lésions osseuses : les lésions osseuses sont évocatrices de mauvais traitements, particulièrement les fractures de côtes ou les images de cals costaux, les arrachements métaphysaires, les appositions périostées ;

  
  
• •
  

  lésions des muscles du cou, du rachis ou de la moelle cervicale.

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