Abusive Head Trauma

By Anne Abel, MDChild Abuse Pediatrics, MUSC

9/12/2013

• WHO IS HERE TODAY?

• QUESTIONS WELCOME

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

Early Definition – Shaken Baby Syndrome (SBS)

• Classic triad – Subdural Hematoma(s)– Brain Injury– Retinal Hemorrhages in one or both eyes in 80%

SBS troubling fact

• Close to ½ of infants with AHT have no visible injury to the rest of the body

Portraits of Promise – 1995SBS based video

• Participant Comments on Portraits of Promise

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.

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)

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

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

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

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

Importance of AHT

• IT IS PREVENTABLE!

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

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

ADULT Risk Factor for AHT

• Fathers, boyfriends, female babysitters and mothers

• Psychiatric or substance abuse history• Inappropriate expectations of child

development

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

Details of the Head Injury Findings

• Subdural Hematoma – most likely• Subarachnoid Hematoma – sometimes• Retinal hemorrhages – 80%• Brain tissue injury – 100% in varying degrees

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

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

How often do parents shake babies?

• Zolotar study – anonymous phone surveys in NC – 1% of mothers reported shaking their baby

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

Review of Importance of AHT

• It is illegal• It is very dangerous to infant or young child• It is preventable

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)

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

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

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

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

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

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?

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

• Discussion

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.

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

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

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)

Typical AHT Case

• Clinician checks results of consultations of other specialists such as:– Ophthalmology– Hematology– Neurosurgery– Neurology– General Surgery

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

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

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

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.

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

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.

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.