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Battered Baby Syndrome

Definition and Nomenclature

Battered baby syndrome (BBS) is a clinical condition in young children - usually under 3 years of age - who have received non-accidental, wholly inexcusable violence or injury on one or more occasions, at the hands of an adult in a position of trust (typically a parent, guardian, or foster parent). In addition to physical injury, there may be deprivation of nutrition, care, and affection in circumstances that indicate the deprivation is not accidental.

It is also known by the following names:

Caffey's syndrome (after John Caffey, the radiologist who first described the radiological features)
Child abuse syndrome
Maltreatment syndrome in children
Non-accidental injury (NAI) of childhood

The term "battered baby syndrome" was coined by C. Henry Kempe, who published the landmark 1962 paper in JAMA ("The Battered Child Syndrome").

Park's Textbook of Preventive and Social Medicine
The Essentials of Forensic Medicine and Toxicology, 36th ed.
Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology

Types of Child Abuse Recognized

Six patterns are recognized:

Physical abuse
Nutritional deprivation
Sexual abuse
Intentional drugging / chemical abuse (intentional poisoning)
Neglect of medical care or safety
Emotional abuse

Five Classical Features (Brandeis University Definition)

Obscure illness or unexplained injury in infants 6-8 weeks up to 4-5 years of age
Repeated abuse / physical hurt over weeks or months
By either or both parents, guardian, or babysitter
Who fail to report, or delay reporting, the incidents
Who mislead or deliberately deceive the nurse or doctor about the cause

The hallmark is an obvious discrepancy between the nature of injuries and the explanation offered by parents, combined with delay between injury and seeking medical attention.

Profile of the Victim

Feature	Details
Age	Usually <3 years; may occur at any age
Sex	Slightly more common in males (55-63%)
Position in family	Often the eldest or youngest; frequently unwanted
Child status	May be illegitimate, result of failed contraception, or a child whose paternity is doubted

Profile of the Perpetrator / Parent

Parents tend to be young (20-30 years), from lower socioeconomic class, with low education
Family is usually geographically isolated
History of family disharmony, long-standing emotional or financial problems
Many fathers have criminal records or are unemployed/socially unstable
Mother may be of lower IQ, often pregnant or premenstrual at the time
Unhappy childhood experiences are common in both parents - many battering parents were themselves battered children (intergenerational cycle)
Most parents suffer "guilt-amnesia"
Precipitating factors: the child's own actions - crying, refusal to be quiet, persistent soiling of nappies

Injuries

Surface Injuries

Bruises, abrasions, lacerations of different ages on the head, face, neck, trunk, and extremities - multiple and inconsistent with a simple fall
Laceration/tearing of the frenulum of the upper lip - the most characteristic lesion; results from blows to the mouth to stifle crying; may extend laterally to separate the lip from the base of the gums
Bruises on both sides of the chest and behind the axillae (grip marks from being shaken)
Slap marks showing clear petechial lines; knuckle punches producing rows of 3-4 round bruises
Bruising from belts, straps, canes, hairbrushes (common on buttocks/thighs)
Pinch marks appearing as butterfly-shaped bruises
Subgaleal hematoma from vigorous scalp pulling
Traumatic alopecia (bald patches from hair pulling) - very characteristic
Cigarette burns: small circular, pitted burns; pink/red when fresh, silvery centre with a narrow red rim when healing
Bite marks on cheeks, shoulders, chest, abdomen, arms, buttocks

Eye Injuries

Retinal hemorrhages and retinal detachment
Vitreous hemorrhages
Subhyaloid and subconjunctival hemorrhages
Lens displacement
"Black eye"

Visceral Injuries

Subdural hemorrhage in ~40% of fatal cases
Ruptured liver or spleen from abdominal compression
Perforations of hollow viscera (stomach, intestines, bladder)
Transection of the duodenum/jejunum
Mesenteric tears from whipping/deceleration forces
Extensive internal injuries may be present with minimal external signs

Burns

Cigarette stub burns (small, circular, pitted)
Burns from being made to sit on a hot stove/radiator
Immersion scalds from dipping in very hot fluids

Skeletal Injuries

Skull fractures: multiple, depressed, wide; commonly occipitoparietal
Large periosteal hematomas (periosteum strips easily in infants) - appear on X-ray as an extra line of opacity alongside the bone
Epiphyseal separations and periosteal shearing from pulling/twisting
Transverse and spiral fractures of long bones
Rib fractures: anteroposterior compression causes fractures in the midaxillary line; side-to-side squeezing causes costochondral junction fractures; multiple rib fractures along posterior angles
After 1-2 weeks, callus formation gives a "string of beads" appearance in the paravertebral gutter - these are called "nobbing fractures", caused by holding the child with both hands and shaking violently
Avulsion/chipping of the metaphyses and epiphyses (highly specific for NAI)

Shaken Baby / Infantile Whiplash Syndrome

Caffey (1974) described shaking as a major cause of subdural hematoma and intraocular bleeding. The mechanism: the child is gripped by the thorax and shaken, producing acceleration-deceleration forces. There may be no external head injuries or skull fractures, yet severe intracranial damage occurs. Permanent brain damage can result from habitual, prolonged shaking.

When to Suspect Battered Baby Syndrome

Suspect BBS in any child who:

Has injuries whose degree and type are at variance with the history given
Shows injuries of different ages in different stages of healing
Has had purposeful delay in seeking medical attention
Shows evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swelling, or skin bruising
Dies suddenly

Sequelae

Mental and neurological complications are the most worrying
Tentatively, 10-15% of cases of cerebral palsy and nearly double that proportion of new cases of mental retardation each year may result from BBS
Long-term psychological sequelae in survivors

Differential Diagnosis

Must be distinguished from:

Scurvy (subperiosteal hemorrhage)
Congenital syphilis (periostitis)
Osteomyelitis
Leukemia
Rickets
Juvenile osteoporosis with stress fractures
Osteogenesis imperfecta (fragile bones)
Infantile cortical hyperostosis (Caffey disease)
Paralytic disease with fractures

Medicolegal / Autopsy Considerations

The history may be completely misleading. A thorough postmortem includes:

Full-body photography (clothed + all injuries)
Whole-body X-ray before autopsy (to detect old fractures, metaphyseal/epiphyseal injuries in various stages of healing)
Microscopic sections of lesions
Toxicological analysis
Careful documentation of bruise colours (colour photographs reveal age differences in bruises)
Examination of external genitalia for sexual abuse
Careful internal examination of the head (coup vs. contre-coup lesions), neck, chest, and abdomen

Head injury is the most common cause of death, followed by rupture of an abdominal organ.

Sources: Parikh's Textbook of Medical Jurisprudence Forensic Medicine and Toxicology; The Essentials of Forensic Medicine and Toxicology, 36th ed.; PC Dikshit Textbook of Forensic Medicine and Toxicology; Park's Textbook of Preventive and Social Medicine; DiMaio's Forensic Pathology, 3rd ed.

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