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

1. Abusive Head Trauma
By Anne Abel, MD
Child Abuse Pediatrics, MUSC
9/12/2013

2. • WHO IS HERE TODAY?
• QUESTIONS WELCOME

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.