Subdural haematomas and physical abuse in the first two years of life

Findings Associated With Nonaccidental Trauma in Children With Isolated Femoral Diaphyseal Fractures

BACKGROUND

Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT.

METHODS

All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated.

RESULTS

Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed.

CONCLUSIONS

In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Comparison of abusive head trauma versus non-inflicted subdural haematoma in infants: A retrospective cohort study

OBJECTIVES

To compare the characteristics of subdural haematoma (SDH) in children under the age of 2 years, between inflicted, otherwise known as abusive head trauma (AHT), and non-inflicted aetiologies.

METHODS

This was a retrospective cohort study of 37 cases of SDH in children under the age of 2 years presenting to the ED at an Australian tertiary children's hospital between January 2009 and December 2012 and been assessed by the Child Protection Unit. SDH aetiology was classified into AHT and non-inflicted groups, based on child protection interagency outcome. These groups were compared to determine clinical associations with AHT.

RESULTS

Of the 37 infants with SDH, 20 cases were deemed due to AHT, whereas 17 cases were determined to be non-inflicted SDH (15 cases due to accidental trauma and two cases due to congenital benign enlargement of the subarachnoid space). SDH due to AHT was associated with antenatal maternal drug use, previous Department of Child Safety involvement, delayed presentation, history of seizures, floppiness or altered level of consciousness; extracranial findings of fractures, bruising or retinal haemorrhages; radiological findings of >5 mm depth, bilateral, inter-hemispheric blood, posterior fossa blood and diffusion restriction; and outcomes of death or permanent disability. Non-inflicted SDH was associated with witnessed injury, falls and scalp haematoma on imaging.

CONCLUSIONS

Infant SDH due to AHT accounts for high mortality and morbidity. Early identification of these patients in the ED with referral to specialised units that investigate for potential child abuse is essential.

The Association Between Maternal Shaking Behavior and Inappropriate Infant Parenting: The Japan Environment and Children's Study

Background

Although many studies have identified risk factors for maternal shaking behavior, it is unknown whether mothers who have shaken their infants repeat shaking behavior or show other inappropriate parenting behaviors. Using data from the Japan Environment and Children's Study (JECS) birth cohort study, we investigated the associations between continuous shaking behavior and the associations between shaking behavior and other inappropriate parenting behaviors.

Methods

JECS data starting from 2011 were used. Logistic regression was used to perform a cross-sectional analysis. The explanatory variable was shaking behavior and the dependent variables were leaving the infant home alone and hitting the infant (both at 1 month postpartum), and non-vaccination and infant burns (both at 6 months postpartum). A longitudinal analysis using logistic regression was also performed; here the explanatory variable was shaking behavior at 1 month postpartum and the dependent variables were shaking behavior, non-vaccination of the infant, and infant burns (all at 6 months postpartum).

Results

In this study, 16.8% and 1.2% of mothers reported shaking behavior at 1 month and 6 months postpartum, respectively. Mothers who shook their infants at 1 month postpartum were approximately five times more likely to shake them at 6 months postpartum compared with mothers who had not shown previous shaking behavior (OR = 4.92, 95% CI [4.22, 5.73], p &lt; 0.001). In Cross-sectional study, there were associations between shaking behavior and inappropriate parenting behavior such as hitting the infant and infant burns.

Conclusion

The findings suggest that mothers who report early shaking behavior tend to subsequently repeat this behavior, and that shaking behavior may be associated with other inappropriate parenting behaviors.

Ophthalmology referral as part of a multidisciplinary approach to suspected abusive head trauma

OBJECTIVE

To determine the use of ophthalmology consultation as part of investigation of children with suspected abusive head trauma (AHT).

METHODS

Retrospective chart review of children under age 3 years evaluated at McMaster Children's Hospital for suspected AHT from January 2011 to December 2017.

RESULTS

Fifty-seven children were investigated, and 29 (50.9%) of these were determined to have likely AHT. Eleven (19.3%) had other nonaccidental injuries. A mean of 3.6 consulting services were involved. Neuroimaging was performed for 52 patients (91.2%), including all patients in the AHT group. Intracranial hemorrhage (ICH) was present in 21 of the 29 AHT children (72.4%). All 57 patients had a dilated fundus examination, and retinal hemorrhages (RH) were seen in 23 patients (40.4%), including 16 (55.2%) in the AHT group. All patients with RH in AHT also had ICH. In the AHT group, there were more cases of hemorrhages too numerous to count (68.8% vs 28.6%), multilayered hemorrhages (75.0% vs 57.1%), and hemorrhages in the posterior pole and periphery (87.5% vs 42.9%) when compared with patients with RH from other etiologies. Retinoschisis was seen in the AHT group only in 3 patients (18.8%).

CONCLUSIONS

A multidisciplinary approach is important when investigating suspected AHT. Not every child with RH had suffered AHT; however, children with AHT showed more widespread and more multilayered RH. The only finding specific to AHT was retinoschisis.

SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations

Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.

Enlarged subarachnoid spaces and intracranial hemorrhage in children with accidental head trauma

OBJECTIVE Benign external hydrocephalus (BEH) is an enlargement of the subarachnoid spaces (SASs) that can be seen in young children. It is controversial whether children with BEH are predisposed to developing subdural hemorrhage (SDH) with or without trauma. This issue is clinically relevant as a finding of unexplained SDH raises concerns about child abuse and often prompts child protection and law enforcement investigations. METHODS This retrospective study included children (1-24 months of age) who underwent head CT scanning after an accidental fall of less than 6 feet. Head CT scans were reviewed, cranial findings were documented, and the SAS was measured and qualitatively evaluated. Enlarged SAS was defined as an extraaxial space (EAS) greater than 4 mm on CT scans. Clinical measurements of head circumference (HC) were noted, and the head circumference percentile was calculated. The relationship between enlarged SAS and HC percentile, and enlarged SAS and intracranial hemorrhage (ICH), were investigated using bivariate analysis. RESULTS Of the 110 children included in this sample, 23 had EASs greater than 4 mm. The mean patient age was 6.8 months (median 6.0 months). Thirty-four patients (30.9%) had ICHs, including subarachnoid/subpial (6.2%), subdural (6.2%), epidural (5.0%), and unspecified extraaxial hemorrhage (16.5%). Enlarged SAS was positively associated with subarachnoid/subpial hemorrhage; there was no association between enlarged SASs and either SDH or epidural hemorrhage. A larger SAS was positively associated with larger HC percentile; however, HC percentile was not independently associated with ICH. CONCLUSIONS Enlarged SAS was not associated with SDH, but was associated with other ICHs. The authors' findings do not support the theory that BEH predisposes children to SDH with minor accidental trauma.

Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review

AIM

To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT).

METHODS

A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT.

RESULTS

Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined.

CONCLUSIONS

Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.

[Hospital admissions due to child maltreatment over a fifteen year period]

AIM

To measure the incidence of admissions for maltreatment between 1995 and 2009 and to determine their main clinical and epidemiological characteristics.

METHODS

Retrospective review of children diagnosed with maltreatment over 15 years in a third level hospital.

RESULTS

A total of 97 cases (median incidence 0.5 cases per 1000 children admitted per year) were found. There was an increasing rate of physical maltreatment, while those of sexual abuse declined. 51 (53.6%) female; median age 3.3 years (p25-75: 7.6 months-10.0 years). Just under half (43.3%) or 42 patients, had a primary complaint unrelated to abuse. The most common injuries were haematomas (43; 44.3%). In 91 (93.8%) cases the perpetrator was found to be a member of the child's own family (77; 74.9%, one of the parents or both).

CONCLUSIONS

The increase in admissions for physical maltreatment stresses the need to insist in a prevention policy. The decrease in admissions for sexual abuse was probably attributable to changes in the care circuit rather than a real decrease. In almost half of the cases the suspicion of maltreatment arose upon physical examination or after complementary tests, making it advisable that maltreatment is included in the differential diagnosis in multiple consultations. The majority of maltreatment occurred in the context of the victim's family.

Multicystic encephalomalacia as an end-stage finding in abusive head trauma

Abusive head trauma (AHT) is one of the most severe forms of physical child abuse. If a child initially survives severe AHT the neurological outcome can be poor. In recent years several children were seen who developed multicystic encephalomalacia (MCE) after documented severe AHT. A search of the Netherlands Forensic Institute database in The Hague was performed. Inclusion criteria were cases of AHT between 1999 and 2010 where the child was under the age of 1 year old at the time of trauma. Trauma mechanism and radiological information were collected. Five children, three boys and two girls (mean age 57 days, range 8–142 days) who developed cystic encephalomalacia after inflicted traumatic brain injury were included. Survival ranged from 27 to 993 days. In all cases judicial autopsy was performed. All cases came before court and in each case child abuse was considered to be proven. In two cases the perpetrator confessed, during police interrogation, to shaking of the child only. Although a known serious outcome, this is one of the few reports on MCE as a result of AHT. In all cases the diagnosis was confirmed at autopsy.

Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine

Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.

Neuroimaging of abusive head trauma

The diagnostic process for evaluating suspected abusive head trauma in infants and children has evolved with technological advances in neuroimaging. Since Caffey first described a series of children with chronic subdural hematomas and multiple long bone fractures, radiologists have played an important role, along with pediatricians and pathologists, in evaluating abused children. Neuroimaging modalities include ultrasound, CT scans, and MRI technology. Each has distinct clinical applications, as well as practical uses in the clinical diagnostic process of AHT. Importantly, neuroimaging assists in the process of differential diagnosis of other conditions which may mimic AHT. Collaboration between neuroradiologists, clinicians, and pathologists remains critical to making the appropriate diagnosis. Careful history, physical examination, and investigation by legal authorities form the components that result in accurate assessment of any case. This paper reviews pertinent neuroimaging modalities currently utilized in the diagnosis of AHT, describing clinical indications and a collaborative approach to this process.

[Severe child abuse admitted to paediatric ICU]

OBJECTIVE

To describe cases of severe child abuse admitted to PICU.

METHODS AND PATIENTS

It is a retrospective study (2000-2008) in which patients diagnosed with physical child abuse admitted to PICU were included. Other abuse patterns were excluded (severe negligence, sexual abuse or scalding).

RESULTS

There were 8 patients included (3 boys and 5 girls). The median age was 5.2 months, with 6 patients were less than 7 months old. The most frequent sign was neurological symptoms: seizures (4 patients), subdural haematoma (2 patients), traumatic brain injury (1 patient). Other: haemothorax (1 patient) and cardiac arrest of no known aetiology (1 patient). The CT showed a subdural haematoma in 5 patients, 3 of which needed surgical drainage. Child abuse was confirmed using the social history and the presence of inflicted injuries. There were long bones fractures (tibia, ulna and radius, bilateral rib fractures) in 3 patients and 4 patients had retinal haemorrhages. There was one death and 3 had severe neurological after effects.

CONCLUSION

Severely abused children can be falsely diagnosed with a casual neurological disease. The most frequent injury is subdural haematoma with or without another injury associated to child abuse. It very important to diagnose child abuse in order to prevent recurrent injuries.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

BACKGROUND

Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality.

METHODS

Selective literature review including an overview over national and international recommendations.

RESULTS

Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations.

CONCLUSIONS

The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

Abusive head trauma in infants and young children: a unique contributor to developmental disabilities

Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.

Shaken baby syndrome

Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.

Inflicted traumatic brain injury: advances in evaluation and collaborative diagnosis

The determination that a traumatic brain injury is not accidental requires data collection from multiple domains: historical, clinical, laboratory, radiographic, environmental and psychosocial. These essential, yet disparate, types of information must be synthesized in a collaborative and interdisciplinary process to formulate a medical opinion with regard to the cause of an injury, and the final opinion has tremendous consequences for children and families. Medically directed child protection teams have emerged as the standard of care in many children's hospitals and child abuse pediatrics is now a recognized medical subspecialty with board certification available in the next several years. Not only do the child and family benefit from this coordinated effort, but there are also great benefits for the members of the child protection team: more clearly defined responsibilities, redirected focus on treatment for the surgeon, and increased confidence that the opinion is based upon consensus and current scientific knowledge. By this process and its division of labor, the child abuse pediatrician assumes responsibility for ensuring that a final medical opinion is arrived at, and then advocates for appropriate disposition for the child. The child abuse pediatrician is responsible for establishing institutional standards for family evaluation, collecting all necessary medical data and directing a consensus-based decision making process that is based upon current medical knowledge, medical literature and experience. The child abuse pediatrician also assumes the role of primary communication conduit for investigational agencies and the courts. The neurosurgeon is a key member of the child protection team and relies on the team to obtain necessary historical information to address consistency of the mechanism with the sustained injuries and has an integral role in determining the team's final opinion. An interdisciplinary response to inflicted traumatic brain injury is the cornerstone for establishing a rigorous standard of care; it also fosters education across medical subspecialties where controversy has been a significant part of the landscape. Valid and useful clinical research that describes head injury as accidental or inflicted can only be performed in the context of an interdisciplinary, medically directed child protection team that strives for objectivity and precision in the determination of the manner of an injury.