Abusive Head Trauma and Child Physical Abuse:
A Program for Physicians
Melissa L. Currie, MD, FAAP
Chief and Medical Director
Kosair Charities Division of Forensic Medicine
Associate Professor
Department of Pediatrics
Continuing Education
Disclosures
•
There is no conflict of interest or relevant
financial interest by the faculty or planners of
this activity.
• There is no commercial support of this
activity.
• There is no endorsement of any product.
Objectives
• Understand the injuries involved and sequelae of
pediatric abusive head trauma
• Understand the medical evaluation for suspected
physical abuse, including abusive head trauma
• Recognize common presenting scenarios of
pediatric abusive head trauma and other occult
injuries
The Evolution of Terminology
•
•
•
•
•
Nonaccidental Trauma
Inflicted Neurotrauma
Inflicted Head Injury
Shaken Baby Syndrome
Shaken-Impact Syndrome
Preferred • Abusive Head Trauma
terminology • Abusive Head Injury
since 2009
Why not “Shaken Baby Syndrome”?
• This type of inflicted injury is not limited to
babies—it is seen regularly in children who
are 2, 3, even 4 years of age. There have
been reports of children as old as 8 years who
have died from this form of abuse.
• We know from decades of research that often,
the mechanism of injury for abusive head
trauma is not limited to shaking alone. In
some (but certainly not all) cases, impact and
other mechanisms can also be involved.
Kentucky Statistics…
• In 2007, Kentucky was 1st in the
nation for child abuse death rate.
• Kentucky averages 20-40 child
deaths involving maltreatment per
year, with another 30-60 “near
fatalities” per year.
“We Can Do Better.” Oct, 2009 report from Every Child Matters Education Fund, a nonpartisan child advocacy organization.
Kentucky Child Fatality Review System 2007-2013 Annual Reports and direct CHFS database query.
Incidence/Prevalence
• AHT is the most dangerous and deadly
form of child physical abuse.
• It is very rare for a child to die from or be
permanently disabled from maltreatment
the first time they are abused/neglected.
• Physicians are in unique positions to
recognize and intervene on behalf of
these children.
Why are doctors so
important to this issue?
• When physicians suspect abuse, we are
immediately in a position to help ensure that the
appropriate evaluation is performed right away.
• When physicians suspect abuse, we often have
the last opportunity to obtain an unguarded history
from caregivers (before they are aware that abuse
is being suspected.)
• When physicians report abuse, our concerns are
often weighted more heavily by investigators, due
to the credibility that our training brings to the
equation.
Abusive Head Trauma: What is it, exactly?
• Global brain injury caused by rotational/angular
forces
• Involves shaking, impact or both
• Subdural hematomas, +/- retinal hemorrhage,
scalp bruising, skull fracture…but it’s the injury to
the brain tissue itself that causes death and
disability
• Often triggered by crying
• It is not typically a one-time event.
Abusive Head Trauma: What is it, exactly?
• The brain injury can be evident in a number of
ways, but remember: the brain can be injured in
the absence of obvious radiological abnormality
(think concussion—usually no imaging findings).
• Brain injury can be evident from clinical symptoms,
such as altered consciousness, history of loss of
consciousness, apnea, irritability, loss of function,
seizures, etc.
• It can be evident from increased intracranial
pressure-related signs: rapid increase in head
circumference, bulging fontanel, splayed sutures,
hypertension/bradycardia, vomiting
How does shaking cause injury to a baby?
• Bridging veins stretch, rupture,
and bleed, leading to subdural
bleeding.
• Brain tissue is
distorted/stretched during the
event, causing damage to nerve
cells and brain tissue (either
temporary or permanent
damage).
• The subdural can
• Spontaneously resorb (most
cases)
• Not resorb, thereby causing a
chronic subdural hemorrhage
• Be drained surgically
Subdural Hemorrhage:
Usually (but not always)
visible on head CT
*This is why the head CT is
a cornerstone of our
screening for abusive head
trauma.
What DOESN’T cause Abusive
Head Trauma injuries/findings?
High-profile court cases, news media, perpetrators and professional
defense witnesses have all alleged the following as potential
explanations for the injuries found with abusive head trauma:
•
•
•
•
•
•
Short falls*
Bouncing a child on your knee or vigorous play
Immunizations
Vitamin C or D deficiency
Birth trauma (special case)
Toddlers, pets, siblings
* Chadwick et al. Pediatrics. 2008; 121:1213-1224
American Academy of Pediatrics
“The act of shaking leading to shaken
baby syndrome is so violent that
individuals observing it would
recognize it as dangerous and likely
to kill the child.”**
**Shaken Baby Syndrome: Rotational Cranial Injuries—Technical
Report. AAP Committee on Child Abuse and Neglect. Pediatrics. July
2001.
The Question of Impact
• If impact is involved, we might see skull
fracture, scalp bruise, or scalp swelling---but
not necessarily.
• Impact into soft surfaces can leave no
evidence of impact.
• Likewise, be aware that absence of soft
tissue swelling over a skull fracture is NOT
sufficient evidence to suggest the fracture is
“old.”
In other words, absence of evidence
of impact does not mean impact
didn’t occur.
Possible Associated Injuries In
Other Areas of Body…
• Metaphyseal, rib, and other fractures
• Bruising of the skin (can include torso, arms, legs)
• Internal abdominal injury (won’t necessarily see
bruising!)
• OR NOTHING. When considering occult injury,
never be falsely reassured by the absence of
bruising. It is astounding the severity of injury
in children that can remain clinically occult.
Metaphyseal fractures…
Also known as “corner fractures” or “bucket-handle
fractures”. This kind of injury is EXTREMELY rare from
typical accidental injury.
Rib Fractures
• Posterior rib
fractures are caused
by violent squeezing
of the chest
• Back is unsupported,
so that ribs bend
back over the sides
of the backbone
• Posterior fractures
are not a result of
direct impact
• Highly specific for
physical abuse
Chest
Spine
TEN-4 BRUISING RULE
ANY bruising of the
• TORSO
• EARS
or
• NECK
in a child 4 years of age or
younger
OR
ANY bruising, ANYWHERE, on a
child 4 months of age or
younger
Pierce et al. Bruising Characteristics Discriminating Physical Child
Abuse From Accidental Trauma. Pediatrics. December 2009.
ANY Bruising, ANYWHERE, on
a child 4 months of age or younger*
*
Those Who Don’t Cruise Rarely Bruise!
Sugar, Taylor, Feldman et al. Bruises in Infants and Toddlers: Those Who Don’t Cruise
Rarely Bruise. ARCH PEDIATR ADOLESC MED/VOL 153, APR 1999.
Common Explanations for Bruises
• Slept on pacifier (cheek bruises) Head
dropped on a toy during tummy time
(chin/neck bruises)
• Holding face for nasal suction or med
administrations (chin/neck bruises)
• Pinched while strapping into car seat
• Hit head on handle of car seat or car
door/frame (this one is true at times—but
we’ve also heard it in abuse cases)
What is Normal?
• Normal accidental bruises in toddlers and older
children are typically
– On the front of the body
– Over bony prominences (forehead, elbows,
knees, shins)
AHT: Common presenting scenarios
• Infants with bruises
• Vomiting without diarrhea
• Apparent life-threatening event (ALTE)
• Seizure without fever
AHT: Common presenting scenarios
• Sudden increase in head
circumference
• Inconsolable crying
• Occult (hidden) fracture/incidental
finding
• Developmental delay
Other presenting scenarios for abuse
• Bright red blood from the mouth of
infants (distinguish from hematemesis)
• Torn maxillary, mandibular, or
sublingual frenulum
• Soft palate, tonsillar or pharyngeal
lacerations (inflicted esophageal
perforations are well-described and can
be fatal if left unrecognized)
Severity of symptoms can vary
by severity of brain injury
•
•
•
•
•
•
•
•
•
Vomiting
Poor feeding
Poor focus/tracking
Irritability
Lethargy/difficult to arouse
Unusual sleepiness or seeming “spaced out”
Seizures
Breathing difficulty/gasping respirations/apnea
Bradycardia/cardiac arrest/death
The Medical Evaluation
• Head CT (looking for subdural bleeding, brain swelling)
if acute injury is a concern
• Skeletal survey and follow-up skeletal survey in 10-14
days (NOT a babygram!) for those 2 years and under
• Eye exam (to look for retinal hemorrhages)
• Trauma and bleeding labs to screen for signs of
internal injury or bleeding disorder and abdominal CT if
OAT labs abnormal (OAT=occult abdominal trauma)
• MRI of the brain and spinal cord if CT is abnormal (MRI
can demonstrate subtle brain injury that CT can miss)
• Photograph all visible injuries
• Report to DCBS whenever maltreatment is a
reasonable concern (DCBS=Department of Community Based Services, aka
Child Protective Services in Kentucky. In Indiana, it is called DCS=Department of Child Services)
The Medical Evaluation
• Head CT—perform when there are signs/symptoms
of increased ICP, bruising in an infant, fracture in a
child < 1 year, ALTE, or whenever a full evaluation is
indicated acutely
• Skeletal survey – 21 different images, perform in
children < 2 years of age. Older children only in
special circumstances.
• Abd CT (not ultrasound) for abnormal OAT labs or
abdominal bruising/symptoms
• Eye exam – if retinal heme is present, ask ophtho to
take photos if possible
• Labs: CBC, PT, PTT, AST, ALT, amylase, lipase, bag
urinalysis (NOT catheterized if possible)
• Photograph all visible injuries as soon as possible
Forensic vs. Clinical Significance
• Most of us have been
taught to identify clinically
significant injuries—those
for which we can affect
the medical outcome by
providing some sort of
treatment or monitoring
• In child maltreatment, it is
equally as important to
identify injuries with
forensic significance
(ALT>80*)—even if not
clinically significant
*Utility of Hepatic Transaminases in Children With Concern for Abuse. Lindberg, Shapiro, et al. Pediatrics; originally published online
January 14, 2013; DOI: 10.1542/peds.2012-1952
Common Missteps
• Abnormal head CT is not followed by
an MRI
• No follow-up skeletal survey in 10-14
days
• Inadequate description/documentation
of retinal hemorrhages
• OAT labs not done, or abd CT not done
for AST>80
• Babygram instead of complete
skeletal survey
Side-by-side
comparison
of babygram
to single
image of
complete
skeletal
survey
Common Missteps
• Poor-quality photographs: we need to
see the borders of the injuries
• Inexperienced commentary re:
plausibility of injuries from the history
provided—insertion of conjecture into
the history
• Attempts to
“date” bruises
A word about radiation exposure and
cancer risk…
• All of the proposed
increased risk is primarily
theoretical.
• On the other hand, the
risk of fatality when child
abuse is missed is 10%.
That’s not theoretical.
• The risk of abuse greatly
outweighs the theoretical
risk of x-ray—and the
consequences of missing
the diagnosis can be
catastrophic.
A few words about reporting…
• We are all mandated reporters in Kentucky, which means
we MUST report any reasonable suspicion.
• There are different levels of certainty, however.
• For example, if an infant presents with bruising, and the
CBC indicates a platelet count of 25, then neither additional
workup for abuse nor report to DCBS is necessary…the
bruising is explained by thrombocytopenia
• If in doubt, however, call in a report.
• You should NOT reserve reports for only those cases in
which you are certain there is abuse.
Outcomes
• Mortality rate approximately 20-30%*
• Long-term morbidity (disability) high amongst
survivors—up to 90% affected*
• Disabilities include learning disabilities,
emotional/behavioral issues, speech and language
delays, vision/hearing, hormone/growth problems
(due to pituitary injury)
* Visual Diagnosis of Child Abuse on CD-ROM 3rd Edition
Supporting the Survivor
• Establish a medical home.
• Monitor closely for developmental issues (First
Steps), emotional/ behavioral issues (esp.
attachment problems), hormone problems
(panhypopituitarism), learning disabilities
• Older siblings that might have witnessed violence
may need ongoing therapy/counseling
Triggering situations
• Crying baby
• Feeding issues/frustration
• Toilet training
• Child’s misbehavior
• Discipline gone awry
• Argument/family conflict
• Caregiver stressors outside the home, including
financial concerns, job loss, legal trouble, relationship
problems
Caregiver Characteristics
• Unrealistic expectations of child’s behavior
• Immature parent/poor coping skills
• CPS history/prior removals
• Caregiver abused as child
Fatality Risk Factors
Top three risk factors for fatal abusive
injury include:
•
•
•
•
Substance Abuse
Domestic Violence
Criminal History
Untreated/undiagnosed mental
illness
among adult caregivers in the home.
Child Characteristics
• 0-3 years of age
• Drug affected/Neonatal abstinence
• Premature birth/NICU stays/multiples
• Colic
• Physical/developmental disabilities
Perpetrator Statistics
Physical abuse:
• Father
• Mother’s BF (paramour)
• Mother
“Children living in households with one or more male
adults that are not related to them are at increased risk for
maltreatment injury death.” **
(Specifically, they are 8 times more likely to die of maltreatment than children in
households with two biological parents. Risk of maltreatment death was not
increased for children living with only one biological parent.)
Stiffman et al. Pediatrics. April 2002. Household Composition and Risk of Fatal Child Maltreatment.
**Note: This statistic does NOT apply to same-sex couples.
Why do perpetrator
statistics matter?
Physical abuse:
• Father
• Mother’s BF (paramour)
• Mother
Take-Home Message: As a primary care
provider or a physician who is trying to determine
if a finding/situation is related to maltreatment, it
is critical to know who is living in the child’s
home.
Case Review
• 4-month-old baby boy presents for well child exam
and is noted to have two fingertip-sized bruises on
each thigh.
• Parents explain that they came from a diaper
change when the child was squirming. Social
history offers no red flags.
• The doctor has seen the older sibling for the past
two years.
What should this doctor do?
..........continued
• Unfortunately, this pediatrician
didn’t understand the
significance of bruising in an
infant.
• One week later, the patient was
brought to the emergency
department unresponsive and
having seizures.
• He was found to have bilateral
subdurals and 13 broken bones
(most healing, meaning that they
WOULD have been identified
had a skeletal survey been
performed the week before).
• Pediatrician described family as
“very nice, no concerns.” Under
social hx: “Family appropriate.”
The Lessons Learned
Bruising in babies is NOT normal.
Maltreatment can and does occur
in “nice families”.
The absence of risk factors
is not the same as the
absence of risk.
Prevention: What Can I Do?
• Help parents understand it’s okay for a baby to cry—it’s how
they communicate! It doesn’t mean the baby dislikes them.
• Help parents understand it is normal to feel frustrated by a
crying baby—and it is okay to take a break and ask for help.
Have an action plan for when frustration becomes
overwhelming.
• Depending on your practice, consider screening mothers for
postpartum depression at all visits during the first 4-6 months
of age.
•
Screen for and address substance abuse, domestic violence,
undiagnosed or untreated mental illness in
parents/caregivers
Prevention: What Can I Do?
• Thorough skin exams whenever possible.
• Know household members and caregivers whenever
possible—and update that information often. “Are
there any changes in your child’s environment? New
caregivers? New individuals in or around the home?”
• Learn about the HANDS program in your area and
refer all eligible families.
• Teach parents about SAFE SLEEP…particularly
regarding the dangers of co-sleeping while under the
influence of drugs (legally prescribed or otherwise) or
alcohol. ABC: Alone, on their Back, in a Crib
AHT: Take-Home Messages
• Abusive Head Trauma is the most dangerous and
deadly form of child physical abuse.
• Experience tells us that we often fail to recognize
early warning signs—and we therefore miss
opportunities to intervene and prevent further harm
to abused children.
• The absence of risk factors is NOT the same as
the absence of risk.
AHT: Take-Home Messages
• Remember the TEN-4 Bruising Rule
• A thorough medical evaluation is crucial—know which
facilities in your area are equipped to do it.
• Long term effects from AHT vary from subtle learning
and behavioral issues to complete dependence for all
care.
• Education of caregivers regarding techniques for
soothing a crying infant and the dangers of shaking can
be an effective prevention tool.
For Assistance
• The Kosair Charities Division of Pediatric
Forensic Medicine at UofL is available 24
hours a day, 7 days a week for telephone
support.
• Call the Kosair Children’s Hospital
operator to reach the forensic nurse
specialist on call: 502-629-6000.
Reporting Abuse
24 hour statewide hotline for pediatric
and adult reporting:
1-877-KY-SAFE-1
For non-emergent reports, web
reporting is available at
https://prd.chfs.ky.gov/ReportAbuse/home.aspx
(or just search for Kentucky DCBS web portal on your
browser)
Thank you for your attention.