Can we deny that minor head injuries
can cause acute subdural hemorrhage in infants?
Hiroshi Nishimoto and Kazue Fujiwara
Recieved 16 February 2019
Outcomes of brain injuries in infants caused by short-distance falls arewell documented in the literature overseas. To date, however, few cases ofacute subdural hemorrhage caused by short falls witnessed by impartial thirdparties have been reported. As a result, the current tendency is to suspectchild abuse when brain injuries in infants are reported by family members as
having been caused by accidental falls at home, even though few such falls
are likely to be witnessed by people outside the family.
In Japan, by contrast, many cases of acute subdural hemorrhage in infants
attributed to accidents at home were reported in the 1960s and 1970s. Such
injuries were classified as “Nakamura type I”, after the researcher who firstreported minor injuries as a possible etiology of acute subdural hemorrhage
in infants. A paper published in Journal of Neurosurgery in 1984 discussed
such Nakamura type I cases, but it attracted criticism for not having drawn on
the expertise of professionals in multiple fields, and the consensus persisted
that most subdural hemorrhages in infants are attributable to child abuse.
Since then, the matter has received little international attention.
Since the 1980s, more and more attention has been paid to the importanceof detecting child abuse, and improvements have been made in the legal,social, and clinical environments surrounding the crime. Cross-disciplinarycase studies are now commonly carried out to diagnose child abuse, andchildren with head injuries suspected of being abused are carefully followed
up. Japan’s Ministry of Health, Labour and Welfare even states in its
guidelines that acute subdural hemorrhage cannot be caused by short falls,
and that child abuse should be strongly suspected if family members say thatinjuries were caused by accidents at home. As a result of these guidelines, it
is very common for clinicians today to report any case of head injury in an
infant to the Child Guidance Center.
Although it is true that these changes have played an important role inprotecting children from abuse, it is also important to recognize that headtrauma is not necessarily the result of abuse. While some people do nothesitate to conclude that an infant with acute subdural hemorrhage and retinal
hemorrhage must have suffered abuse, not a few Japanese experts have seen
infants with minor injuries in whom the mechanism of hemorrhage wasunlikely to have been abuse. The characteristic features of such injuries (i.e.,Nakamura type I) are as follows: (1) they generally occur in infants aged
6–10 months; (2) they are more frequent in boys; (3) they occur at home;(4) they normally result from occipital impact; (5) they cause disturbanceof consciousness, convulsions, and vomiting; (6) mild retinal hemorrhage isinvolved; (7) no obvious brain parenchymal damage is seen on radiologicalexaminations; and (8) they generally have good outcomes.
False accusations are a serious problem in modern Japanese society, andsome lead to lawsuits. This must be kept in mind when it comes to acutesubdural hemorrhage in infants. We recognize how important child protection
is and accept that there must always be a certain suspicion of abuse in casesof injury. However, we must also recognize that head trauma may easily be
the result of an accident and not of abuse.
The purpose of this statement is to point out that Nakamura type I injury
can cause acute subdural hemorrhage in infants. To produce the statement,
many pediatric neuro-surgeons, including us, have participated in thoroughfollow-ups of patients diagnosed with this type of injury. Needless to say,further study is needed to completely clarify the etiology of acute subdural
hemorrhage in infants.

H. Nishimoto and K. Fujiwara are pediatric neuro-surgeons in the Department ofPediatric Neurosurgery, Fujiwara QOL Research Institute, Tokyo.
e-mail: dr-taaco@nifty.com
http://www.fujiwaraqol.com/

Your baby being abused?

False accusation of abusive head trauma in Japan
Nobuhiko Aoki,MD, Bethlehem Garden Hospital, Tokyo, Japan

Kazue Fujiwara,MD, Fujiwara QOL Research Institute, Tokyo, Japan

Childhood physical abuse and associated trauma are a clinical andsocial agenda [1,2] and require accurate detection to protect children. We
acknowledge the guidelines issued by pediatrics experts [1–3] and, inparticular, the appraisal, “An investigation of possible abuse is a time ofcrisis for a family” [1]. Yet we have noticed little resource about this crisisand possible false accusation of child abuse in medical literature, while we
recognise it in a law review [4], a book [5], a movie (‘The Syndrome’), andother public media [6].
In Japan, there is a substantial issue and lack of standardisation of theprocedure of suspecting and diagnosing child abuse; informing child protection
service and caregivers, mostly parents, about abuse suspicion; and executing
associated legal processes. Alongside, false accusation of child abuse without
clear evidence has been recognised and reported as sporadically. The issue
has been partly attributed to little effort to minimise false accusation, while
we take the best effort to protect children, under the child protection law,separating a child from caregivers for protection from possible abuse or, atleast, a hazardous environment. Whereas this operation works well for true
abuse, the procedure rarely accounts for possible risks of false accusationand of psychological distress in a family. To highlight this, we report a recent
case of false accusation, causing a year-long family separation, and discuss
its implications. Informed consent for reporting was obtained from the casefamily.
A male child aged 10 months and 70.5 cm tall accidentally fell down while
he stood up grabbing a table leg in 2016. He got injured at the back of his head
hit on a floor with 15mm-thick carpet. This was witnessed by his mother andby the paternal grandparents who did not live together but visited the family
just at that time. After the child showed a whole-body tremor, his mothercalled a local emergency department, its service transferred the child to a
Received 20 December 2017; Accepted 20 February 2018

AB

Fig.1 10 month-old boy with acute subdural hemorrhage
by short fallFig.2 Brain images of injured boy(A) On admission, non-contrast CT scan showsan acute subdural hemorrhage in right parietotemporal region, with minimal mass effect.
(B) MRI three days later, failed to show
abnormal findings in the brain parenchyma
apart from residual subdural hemorrhage.

nearby hospital (Fig.1). There, a pediatrician identified subdural hematoma(SDH) and retinal haemorrhage (RH). On the same day (Day 1), the childshowed recovery and no relapse of any symptoms onward(Fig.2). Without any
evidence of bruising or other typical abusive symptoms [2], however, SDHand RH resulted in suspicion of abusive trauma (Day 4), diagnosis of abusive
trauma, and the reference to child protection service in the local area (Day5). On Day 6, the mother and the paternal grandfather were independently
interviewed once by a pediatrician and asked only about the event. Despite noadmission, evidence, or any question about any abuse or potentially abuserelated history, the family members were considered cooperatively fabricating
the event as an accident and concealing the mother’s abuse. Until Month6, the child was kept away from the family members including his father.
Supported by a private lawyer hired, the parents were permitted to care thechild with the third person until Month 9. The family identified the author(Aoki) through the Internet and received his second opinion. The author
reported the possible false diagnosis of abusive head trauma, accounting for
multiple factors including the witness by the third person (the grandparent),no evidence of other abusive symptoms or history, immediate emergency
call after the event, and regular use of social service (e.g. vaccination) forthe child. In Month 12, the family obtained permission to live together whilea social worker visited the home for monitoring purpose. In Month 13, themonitoring was terminated.

There were multiple implications in this crisis. First, this case involved
the false assumption that SDH plus RH would be sufficient evidence fordiagnosis of abusive head trauma. The assumption or ‘myth’ has been wellrecognised as invalid [4,6]; and, in Japan, known as invalid since 1970s[7] when accidental SDH without a cranial fracture in children was wellcharacterised as Nakamura’s Type 1 SDH and where abusive trauma is rarer
than other countries [7,8]. Although a short-distance fall causing SDH plus
RH is rare, the rarity does not justify the diagnosis of abusive head trauma[4]. Its positive predictive value is no more than 97% even when identifying
SDH, RH, and other four typical abusive symptoms [2,9,10]. Our caseindicates a lack of hospital’s preparedness for the rare event in the process tothe diagnosis of child abuse. Preparedness for an accidental head trauma anda diagnostic procedure, even if it is rare, should be promulgated, standardised
and adherently operated in each society.
Second, standardisation is needed in the process of executing an action
based on abuse suspicion. Because the decision must be carefully made[1,3], beside detailed clinical examination [2], for example, the process issuggested to receive an independent second opinion, make strategic nonjudgemental communication, involve interviews to neighbours or any othersof a case family about possible abuse, and assess interviews objectively via
recording: these options were reported to be absent in our case. A survey,characterisation, and standardisation of the multidisciplinary procedure andrelated training [11] remain missing in Japan and crucial to operate widely
to minimise possible regional inequity in medical judgement and minimise
distress among caregivers, physicians, and social workers for child protection[1,3].
Third, our case raises serious concerns of psychological burdens amongfamily members over the period. In our case, while the suspicion itself
may have been unnecessary, the year-long period of separation could havebeen shortened. Physicians in a hospital, social workers, or both could haveinformed availability and importance of the second opinion, ensured thephysical safety in the family’s house, and helped arrange the condition where
the child could live with the first- and second-degree relatives as early aspossible. Such effort must be made because deprivation of a mother-childrelationship induces acute adverse psychosocial effects on a family. Its long-term adverse effect is also possible, increasing the risk of child’s psychosocial
problems [12].
Pediatrics and social service play key roles to protect children from abuseor injury as the primary and secondary prevention. At the same time, false
accusation and its associated distress must be recognised and prevented.
The preventive actions against false accusation are insufficient, without
education, investigation, or intervention, and need to be directed by experts’community. In our local community, cases of false accusation have beenshared with pediatricians. A wider community and academic society shall use
those experiences and lessons strategically and effectively to conduct proper
research, train experts, and minimise false accusation of child abuse as wellas to protect children from any types of injuries.
Acknowledgements:
The authors acknowledge hosital staff and the family in this article forproviding the detailed information. The authors acknowledge Dr Fumiaki
Imamura, University of Cambridge Medicial Research Council Epidemiology
Unit, for his insightful contribution to this article.
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