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Neonatal shaken baby syndrome: an aetiological view from Down Under

The potential dangers of vigorous chest physiotherapy in premature infants have not been widely communicated

However hard we may strive to be up to date in our medical specialty, we are limited by the material we have to hand. There are the twin difficulties of ever increasing medical publication and disseminating crucial information to a wider critical readership. Sometimes though, in an unrelated area of medicine, new information occurs that illuminates other fields. This not only informs but may guide future practice. The controversy about vigorous chest physiotherapy for extreme preterm infants may have wider implications for professionals concerned with child protection.

In the 1990s there was a debate about strategies to prevent chronic lung disease in the extreme premature infant. The use of vigorous chest physiotherapy became the subject of an official enquiry by the New Zealand Ministry of Health,1 which appears largely unknown to paediatricians and neonatologists in the Northern Hemisphere. The New Zealand Group report difficulty in publishing their findings until 1998.2 A Cochrane review in this area was last updated in 1997.3

Between 1988 and 1990, postnatal encephaloclastic porencephaly (ECPE), a new and previously unrecognised distinctive pattern of brain injury, was seen in an English neonatal unit. This was strikingly different from previously seen neonatal brain injury as it presented late in the neonatal period with extensive bilateral, full thickness cortical necrosis (deaths occurred at between 13 and 42 days of age). No cause was identified: 14 of the 15 cases described were fatal, and the sole survivor had a severe neurological deficit at 12 months of age. The English neonatologists, in a review of their practice, recognised the similarities between ECPE and shaking injuries in older children. They changed physiotherapy management so that the infant's head was held steady during the procedure, …