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Category D: unknown whether ill treatment is cause
  1. E A S Nelson
  1. Department of Paediatrics, The Chinese University of Hong Kong Prince of Wales Hospital, Shatin, Hong Kong; tony-nelson{at}

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I would like to congratulate Southall and colleagues for their very important paper, which represents extremely well the clinical and practical reality of the spectrum of child abuse.1

However, I have one fundamental concern relating to unexplained subdural haematomas. The authors state that “sometimes the parent is ignorant about the extent of damage that the impulsive act may cause. For example, in some societies it is not generally known that shaking of a young infant can tear veins around the brain.” It is suggested that because of widespread publicity in the UK about shaken baby syndrome such injuries might be best classified under category A. Although perhaps unfashionable, there is an increasing acknowledgement that we understand very little about the mechanism of this often catastrophic event.2–7 If the purported mechanism of injury (violent shaking of the inconsolable infant) is correct, then it would be logical to predict that the peak incidence would be in infants aged under three months. Yet the actual peak of unexplained subdurals is around eight months.8 Until we have a much better understanding of this condition, I suggest that the proposed classification should also have a Category D (unknown whether ill treatment is cause of the injury). This category would enable appropriate classification of those previously well cared for infants who have no other signs of injury but present with subdural haematoma, retinal haemorrhages and “no adequate history of injury”. Even in those infants that have rib fractures we need to consider whether there may be a less sinister explanation in some cases.9–11


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