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Shaken and stirred

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    Whiplash shaken infant syndrome (WSIS) has two main causes, motor accidents and child abuse. The acute syndrome is well described and short term follow up studies have suggested that up to half of the children have fully recovered after a year. A recent report from Brussels, however, has shown that there is often a latent period after initial recovery and before the long term sequelae become evident (Christine Bonnier and colleagues, Developmental Medicine and Child Neurology 1995;37:943-56).  Thirteen children with severe WSIS due to child abuse were admitted over eight years to a hospital with a multidisciplinary child abuse service and followed up for up to 14 years. There was one early death and at necopsy that infant had widespread intracerebral and pericerebral blood vessel damage, section of the cerebral peduncles, and tears due to shearing between cerebral hemisphere grey and white matter.  Of the 12 survivors, six were severely affected from the start and did badly but the other six initially recovered and were considered normal two months after the incident. Only one of these remained normal on follow up to aged 5. Five showed further neurological disability after latent intervals of between six months and five years. All five had global learning disorders with measured IQ of between 53 and 80. Two developed a hemiparesis, three had behavioural problems, and all needed special education. The deficits appeared in chronological sequence: slowing of brain growth (four months after injury), long tract signs (six to 12 months), epilepsy (up to two years), and behavioural and psychological problems (three to six years).  Severely shaken children need prolonged follow up and early return to normality should not be taken as an indication that all is well.

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