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Abusive Head Trauma


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Abusive head trauma with babies and children. …

Abusive head trauma with babies and children.
Anne Abel, MD
Child Abuse Pediatrics
Medical University of South Carolina

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  • 1. Abusive Head Trauma By Anne Abel, MD Child Abuse Pediatrics, MUSC 9/12/2013
  • 3. CURRENT DEFINITION of ABUSIVE HEAD TRAUMA (AHT) • Brain injury from abusive trauma to the head and neck – usually in baby, sometimes in toddler • Violent shaking plus or minus impact to head from a slam to a surface or a direct blow
  • 4. Early Definition – Shaken Baby Syndrome (SBS) • Classic triad – Subdural Hematoma(s) – Brain Injury – Retinal Hemorrhages in one or both eyes in 80%
  • 5. SBS troubling fact • Close to ½ of infants with AHT have no visible injury to the rest of the body
  • 6. Portraits of Promise – 1995 SBS based video
  • 7. • Participant Comments on Portraits of Promise
  • 8. History of AHT • 19th century - Auguste Tardieu, French Forensic Pathologist • 1946 – John Caffe, Pediatric Radiologist, NY SDH’s with fractures – trauma link • 1962 – C. Henry Kempe, Pediatrician, Denver, Battered Child Syndrome • 1972 – Norman Guthkelch, British Neurosurgeon – SDH and whiplash due to violent shaking • 1972 – John Caffe, Whiplash Shaken Infant Syndrome from Trauma.
  • 9. Various Names for AHT • SBS – no longer preferred due to newer research and because it is a narrow term that describes a mechanism rather than the type of injuries – problematic term now in court • Inflicted Traumatic brain Injury • Inflicted Pediatric Neurotrauma • Shaking-Slam Injury • Shaking-Impact Injury • Abusive Head Trauma (AHT)
  • 10. Importance of AHT • 30 deaths yearly per 100,000 infants under age 1 year documented • 3.8 deaths yearly per 100,000 children over age 1 year documented – less frequent as baby gets bigger/older • Uncounted undocumented cases missed or not resulting in death – disabilities common
  • 11. Importance of AHT • The leading cause of mortality and morbidity in child physical abuse • Only the most severe cases are recognized • In recognized cases greater than 30% had medical evidence of past AHT episode
  • 12. Importance of AHT • It is illegal – SC law, Offenses Against the Person • Section 16-3-96 - Infliction or allowing great bodily injury upon a child • Section 16-3-85 – Homicide by child abuse – causes or aids and abets
  • 13. Importance of AHT • SC Law, Chapter 7 – Care of the Newly Born – Section 44-37-50 – Shaking infant video and infant CPR information to be made available to parents or caregivers of newborn infant • Hospitals • All Child Care Facilities and Providers • Doctor’s Offices • All adoptive parents
  • 14. Importance of AHT • IT IS PREVENTABLE!
  • 15. Risk Factors • Risk is a term that applies to groups of people • Risk does not mean that all people in that group will abuse the infant • Risk does not mean the same as cause in a specific case
  • 16. FAMILY Risk Factors for AHT • Young parents • Lower SES • Urban • Unstable family situation • Single parent • Parent in military • Unrelated or extended family living in the home
  • 17. ADULT Risk Factor for AHT • Fathers, boyfriends, female babysitters and mothers • Psychiatric or substance abuse history • Inappropriate expectations of child development
  • 18. CHILD Risk Factors for AHT • Child Characteristic which increase risk of AHT – Prematurity – Disability – Crying baby – good example of why risk does not mean cause. All babies cry
  • 19. Details of the Head Injury Findings • Subdural Hematoma – most likely • Subarachnoid Hematoma – sometimes • Retinal hemorrhages – 80% • Brain tissue injury – 100% in varying degrees
  • 20. Acute and Delayed Clinical Signs in recognized cases: seconds, hours, days or weeks • Craniofacial soft tissue injury • Inconsolable • Decreased appetite or vomiting • Altered sleep pattern • Seizure • Cardiopulmonary compromise or arrest
  • 21. Late Clinical Findings of AHT in recognized cases: weeks, months or years later • Feeding difficulties • Sensory deficits (hearing, vision, etc.) • Motor impairments • Dev. Delay • Intellectual deficits, ADHD, educational dysfunction
  • 22. How often do parents shake babies? • Zolotar study – anonymous phone surveys in NC – 1% of mothers reported shaking their baby
  • 23. Importance of AHT • Prevention Efforts with home visits by health care professionals – especially RN’s with special training, greatly reduced incidence of AHT in past studies
  • 24. Review of Importance of AHT • It is illegal • It is very dangerous to infant or young child • It is preventable
  • 25. What the Doctor Must Exclude before making AHT Diagnosis • Nonabusive Trauma (forceps del., vacuum extraction del., breech del., MVA, complex accidental fall or long fall • Congenital or metabolic condition such as Glutaric Aciduria, aneurysm, AV malformation in brain, benign extra axial hematoma (subarachnoid, not subdural)
  • 26. More things to exclude • Neoplasm such as leukemia or brain tumor • Bleeding problem such as hemophilia A, hemorrhagic disease of the newborn, ITP or VWD
  • 27. More things to exclude • Acquired causes such as meningitis, superior sagittal sinus thrombosis, obstructive hydrocephalus • Connective Tissue diseases such as Osteogenesis Imperfecta or Ehler-Danlos Syndrome
  • 28. Mechanism of Injury in AHT • Shaking alone – with rapid BRAIN acceleration/deceleration in a rotational manner, causing BRAIN deformation and tearing of bridging veins leading to SDH’s. Includes whiplash involving head and neck • Shaking plus impact to head
  • 29. Other injuries which may or may not be present in AHT cases • Skull fracture or scalp swelling or bruise • Bruises or scars on the rest of the body • Torn frenulum • Subtle fractures called CML’s: which are highly specific for child abuse in infants • Abdominal trauma
  • 30. Research – Hundreds of Studies • Initial controversy with 1987 article by Duhaime concluded that impact required, not just shaking. Flawed modeling however. • Many subsequent studies that shaking alone can cause AHT, including subsequent biomedical modeling and a series of confessions. • Majority consensus by MD’s that adults abusive actions can cause devastating or fatal AHT in infants and young children
  • 31. Defense Strategies • “Not my client – “Who done it?” – timing of injuries • Shaking alone could not cause this – allegation of “pseudo science” • If other injuries are present, how can one attribute them all to one defendant or one time?
  • 32. Defense Strategies • “My client would never do this” – character witnesses • Retinal hemorrhages can be caused by other things – yes of course, but the other causes can be excluded by thorough medical evaluation • Short fall caused this – see Chadwick, 2012, Annual Risk of Death from Short Falls Among Young Children is Less than 1 per million
  • 33. • Discussion
  • 34. Typical Case of AHT • 911 call – my baby is not breathing – CPR given and baby transported to Emer. Dept. • Emer. Dept. stabilizes, further resuscitation if needed, Head CT, ET tube and baby transported to a Children’s Hospital with Pediatric Intensive Care and Neurosurgeon.
  • 35. Typical AHT Case • DSS and LE called if MD suspects abuse – they begin investigation • Parents/caregivers interviewed by MD, by investigators – usually separately. Usually there is a denial of trauma or a history of a short fall. STORY DOES NOT MATCH DEGREE OF INJURY
  • 36. Typical Case of AHT • Clinician gets time line from caregiver, starting when baby was last acting well (eating, sleeping, interacting normally with others) • Clinician obtains past medical history, social history, family medical history and does physical exam on baby, usually in presence of parent/caregiver
  • 37. Typical Case of AHT • Clinician checks lab results such as CBC, clotting Studies, comprehensive metabolic panel, lipase, U/A, urine organic acid and serum amino acid or serum ammonia. • Clinician checks imaging, such at CT of brain and neck, MRI’s of same, Osseous Survey (20 separate images)
  • 38. Typical AHT Case • Clinician checks results of consultations of other specialists such as: – Ophthalmology – Hematology – Neurosurgery – Neurology – General Surgery
  • 39. Typical AHT Case • Clinician makes diagnosis and recommendations • Clinician communicates verbally with investigators, family, PICU physicians, writes report and later communicates with attorneys, judge and jury, per subpoena
  • 40. Typical AHT Case • Communication and team work between the clinician, the hospital social worker and the investigating agencies critical to successful safety plan for the baby and for prosecution as needed – interdisciplinary meetings at hospital near time of diagnosis very helpful
  • 41. Long Term Outcomes of AHT • 20-30% die immediately or within a year of the injury • 70-80% live, many with disabilities such: – Ranges from apparently unimpaired (minority) to mild learning disabilities, attention problems, explosive disorders, cerebral palsy and visual impairment, feeding tubes and incontinence, and vegetative state
  • 42. Some Examples of Survivors of AHT • Dev. Disabled boy with feeding tube in medically fragile program in a special needs foster home. No contact with parents now. • Blind boy, abused by military father, father confessed, convicted and served time. Family now reunited. • Deceased girl, brain dead by father – wall incident in DV – father pled guilty and incarcerated.
  • 43. References • Annual Risk of Death Resulting From Short Falls Among Young Children: Less than 1 in 1 Million. D. Chadwick, G Bertocci, E. Castillo, L. Frasier, E. Guenther, K. Hansen, B. Herman and H. Krous, Pediatrics 2008:121:1213. • Identifying Abusive Head Trauma, Knowing What to Look for Can Save Babies From Future Harm, A. Fingarson and M. Clyde Pierce, Contemporary Pediatrics Feb. 2012:16-24
  • 44. References • Jenny C, Hymel K, Ritzen A, Reinert SE, Hay TC, Analysis of Missed Cases of Abusive Head Trauma. JAMA 1999; 28(7):621-626. • Starling SP, Patel S, Burke BL, Sirotnak AP, Stronks S, Rosqust P. Analysis of Perpetrator Admissions to Inflicted traumatic Brain Injury in Children. Arch Pediatr Adolesc Med. 2004, 158(5): 454-458.
  • 45. References • Levin AV. Retinal Hemorrhage in Abusive Head Trauma. Pediatrics 2010; 126(5): 961-970 • Child Abuse and Neglect, Diagnosis, Treatment, and Evidence, Jenny C Editor, 2011 by Saunders, an imprint of Elsevier, Inc., Chapters 6, 39, 41, 42, 43, 44, 45, 47, 48.