Pediatric Abusive Head Injury: Lessons Learned

Antonia Chiesa, MD
Attending physician, the Kempe Child Protection Team at Children's Hospital Colorado.

Baby M. died on November 2 at three months old. She was brought to the hospital after an episode of apnea while at home and in the care of her father. He told medical providers that he had awakened in the night with Baby M., and he was trying to console her crying when she stopped breathing.

When Baby M. arrived at Children's Hospital Colorado, she had bruises over her face and arms. She was resuscitated and stabilized in the Emergency Department before being transferred to the Pediatric Intensive Care Unit. She had no cough, gag or other signs of brainstem function. Her head CT showed massive cerebral edema and an acute subdural hematoma. She eventually progressed to brain death and she was removed from life support three days after her admission. At autopsy, severe retinal hemorrhages and two healing rib fractures were observed. The cause of death was determined to be head trauma and the manner of death was ruled a homicide.

An investigation into the case revealed significant psychosocial risk factors, including domestic violence, poverty and parental mental health problems. In addition, Baby M. had been seen in urgent care and by her primary care practice on several other occasions for unexplained facial bruising. Concerns of abuse were not documented at those times and opportunities to protect her from further harm were therefore lost. In retrospect, had the appropriate referrals been made, her death may have been prevented.

Abusive head injury is the leading cause of traumatic death for children under one year of age. “Shaken Baby Syndrome” has been used to refer to the unique constellation of injuries that includes subdural hemorrhage and retinal hemorrhages. Different types of injury to the brain and head can result from inflicted trauma. Categorizing every feature into one specific term has been problematic. The more general term, abusive head injury, is used to describe the clinical findings without assuming the exact mechanism of injury. Associated injuries can include fractures, bruises and abdominal trauma.

A diagnosis of abuse should be considered in any young child with a traumatic brain injury without a correlating history of an accident to explain the injury. The symptoms of head injury in a young child can vary. Subtle neurologic signs such as isolated vomiting or apnea can make the diagnosis difficult, and cases can be missed if the provider does not consider the diagnosis.

When clinically suspected, a detailed history of present illness and past medical history, including other traumas, are important to obtain. Efforts should be made to elicit a thorough social history for the identification of other risk factors. In the case of Baby M., the significance of prior medical visits for bruising would have been critical to explore. Any unexplained bruising in a young, non-ambulatory infant should raise suspicion of child physical abuse.

A referral to a pediatric trauma center for further studies and input from trauma specialists is prudent. A head CT is the standard imaging technique to confirm head injury. A dilated retinal exam should be performed by an ophthalmologist, preferably one with pediatric experience. Other studies available include skeletal survey, MRI, abdominal CT and coagulation studies. When underlying medical conditions that may effect the patient’s presentation are suspected, consultation from subspecialty services, such as hematology, genetics or orthopedics should be obtained. Child abuse specialists (a subspecialty board certification for pediatricians will be available later this year) are increasingly available to provide assessments and make recommendations about work-up.

As mandated reporters, physicians who have a suspicion of abuse of a child are required to report those concerns to social services or the police. Communicating these issues to parents can be a difficult task. Starting from a place of empathy and concern for the health and safety of the child can be helpful. Stating “I’m worried someone may have hurt your child” is an objective and non-judgmental way to express your thinking. It is useful to explain to caregivers that you are legally required to report suspicions so that those with the appropriate authority can then look into the safety and welfare of the patient.

Primary care providers also are in a unique position to effect change through universal and secondary prevention strategies. Counseling parents about the difficulties of caring for a young infant, especially with regard to normal crying patterns, can help foster positive, non-violent coping strategies. Secondary prevention efforts should focus on identifying high risk issues such as substance abuse, family violence or mental health problems. Early intervention and referral for services can be valuable before abuse occurs.

Pre-existing risk factors are commonly discovered in cases of child abuse. With regard to Baby M., the presence of prior bruising in a young infant should have prompted more intervention from the medical community. The recognition and reporting of high risk injuries in children are important and can prevent more severe injuries later. Take the time to address issues of abuse and neglect with your patient population. If you suspect child abuse or neglect, a report should be made to the county department of human services in which the patient resides. While it may not be a simple process, a life may be saved by your actions.

The American Academy of Family Physicians has clear policy statements regarding the care and reporting of abused or neglected children. The American Academy of Pediatrics (www.aap.org) is also an excellent resource for Continuing Medical Education opportunities and further training in the area of child abuse.

For more information on a Colorado-wide Shaken Baby Prevention program, visit
www.CalmACryingBaby.org or www.PreventChildAbuse.com/shaken.htm.

Parenting resources

Families First : This website includes information about the services offered by Families First, a Colorado non-profit organization. Their services, which nurture children and strengthen families, include parent support groups, parent education classes, a children’s group, a family support line and residential treatments.