Melissa L. Currie, MD, FAAP Chief and Medical Director Kosair Charities Division of Forensic Medicine Associate Professor Department of Pediatrics Abusive.

Melissa L. Currie, MD, FAAPChief and Medical Director

Kosair Charities Division of Forensic MedicineAssociate Professor

Department of Pediatrics

Abusive Head Trauma and Child Physical Abuse:A Program for Physicians

Continuing Education Disclosures

• There is no conflict of interest or relevant financial interest by the faculty or planners of this activity.

• There is no commercial support of this activity.

• There is no endorsement of any product.

Objectives

• Understand the injuries involved and sequelae of pediatric abusive head trauma

• Understand the medical evaluation for suspected physical abuse, including abusive head trauma

• Recognize common presenting scenarios of pediatric abusive head trauma and other occult injuries

The Evolution of Terminology

• Nonaccidental Trauma• Inflicted Neurotrauma• Inflicted Head Injury• Shaken Baby Syndrome• Shaken-Impact Syndrome

• Abusive Head Trauma• Abusive Head Injury

Preferred terminologysince 2009

Why not “Shaken Baby Syndrome”?

• This type of inflicted injury is not limited to babies—it is seen regularly in children who are 2, 3, even 4 years of age. There have been reports of children as old as 8 years who have died from this form of abuse.

• We know from decades of research that often, the mechanism of injury for abusive head trauma is not limited to shaking alone. In some (but certainly not all) cases, impact and other mechanisms can also be involved.

Kentucky Statistics…

• In 2007, Kentucky was 1st in the nation for child abuse death rate.

• Kentucky averages 20-40 child deaths involving maltreatment per year, with another 30-60 “near fatalities” per year.

“We Can Do Better.” Oct, 2009 report from Every Child Matters Education Fund, a nonpartisan child advocacy organization.Kentucky Child Fatality Review System 2007-2013 Annual Reports and direct CHFS database query.

Incidence/Prevalence

• AHT is the most dangerous and deadly form of child physical abuse.

• It is very rare for a child to die from or be permanently disabled from maltreatment the first time they are abused/neglected.

• Physicians are in unique positions to recognize and intervene on behalf of these children.

Why are doctors so important to this issue?

• When physicians suspect abuse, we are immediately in a position to help ensure that the appropriate evaluation is performed right away.

• When physicians suspect abuse, we often have the last opportunity to obtain an unguarded history from caregivers (before they are aware that abuse is being suspected.)

• When physicians report abuse, our concerns are often weighted more heavily by investigators, due to the credibility that our training brings to the equation.

Abusive Head Trauma: What is it, exactly?

• Global brain injury caused by rotational/angular forces

• Involves shaking, impact or both• Subdural hematomas, +/- retinal hemorrhage,

scalp bruising, skull fracture…but it’s the injury to the brain tissue itself that causes death and disability

• Often triggered by crying• It is not typically a one-time event.

Abusive Head Trauma: What is it, exactly?

• The brain injury can be evident in a number of ways, but remember: the brain can be injured in the absence of obvious radiological abnormality (think concussion—usually no imaging findings).

• Brain injury can be evident from clinical symptoms, such as altered consciousness, history of loss of consciousness, apnea, irritability, loss of function, seizures, etc.

• It can be evident from increased intracranial pressure-related signs: rapid increase in head circumference, bulging fontanel, splayed sutures, hypertension/bradycardia, vomiting

How does shaking cause injury to a baby?

• Bridging veins stretch, rupture, and bleed, leading to subdural bleeding.

• Brain tissue is distorted/stretched during the event, causing damage to nerve cells and brain tissue (either temporary or permanent damage).

• The subdural can • Spontaneously resorb (most

cases)

• Not resorb, thereby causing a chronic subdural hemorrhage

• Be drained surgically

Subdural Hemorrhage: Usually (but not always) visible on head CT

*This is why the head CT is a cornerstone of our screening for abusive head trauma.

What DOESN’T cause Abusive Head Trauma injuries/findings?

High-profile court cases, news media, perpetrators and professional defense witnesses have all alleged the following as potential explanations for the injuries found with abusive head trauma:

• Short falls*• Bouncing a child on your knee or vigorous play• Immunizations• Vitamin C or D deficiency• Birth trauma (special case)• Toddlers, pets, siblings

* Chadwick et al. Pediatrics. 2008; 121:1213-1224

American Academy of Pediatrics

“The act of shaking leading to shaken baby syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child.”**

**Shaken Baby Syndrome: Rotational Cranial Injuries—Technical Report. AAP Committee on Child Abuse and Neglect. Pediatrics. July 2001.

The Question of Impact

• If impact is involved, we might see skull fracture, scalp bruise, or scalp swelling---but not necessarily.

• Impact into soft surfaces can leave no evidence of impact.

• Likewise, be aware that absence of soft tissue swelling over a skull fracture is NOT sufficient evidence to suggest the fracture is “old.”

In other words, absence of evidence of impact does not mean impact didn’t occur.

Possible Associated Injuries In Other Areas of Body…

• Metaphyseal, rib, and other fractures

• Bruising of the skin (can include torso, arms, legs)

• Internal abdominal injury (won’t necessarily see bruising!)

• OR NOTHING. When considering occult injury, never be falsely reassured by the absence of bruising. It is astounding the severity of injury in children that can remain clinically occult.

Metaphyseal fractures…

Also known as “corner fractures” or “bucket-handle fractures”. This kind of injury is EXTREMELY rare from typical accidental injury.

Rib Fractures

• Posterior rib fractures are caused by violent squeezing of the chest

• Back is unsupported, so that ribs bend back over the sides of the backbone

• Posterior fractures are not a result of direct impact

• Highly specific for physical abuse

Spine

Chest

TEN-4 BRUISING RULEANY bruising of the • TORSO• EARS

or• NECK

in a child 4 years of age or younger

OR

ANY bruising, ANYWHERE, on a child 4 months of age or younger

Pierce et al. Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma. Pediatrics. December 2009.

ANY Bruising, ANYWHERE, ona child 4 months of age or younger*

* Those Who Don’t Cruise Rarely Bruise!

Sugar, Taylor, Feldman et al. Bruises in Infants and Toddlers: Those Who Don’t Cruise Rarely Bruise. ARCH PEDIATR ADOLESC MED/VOL 153, APR 1999.

Blamed on car seat buckle

Common Explanations for Bruises

• Slept on pacifier (cheek bruises) Head dropped on a toy during tummy time (chin/neck bruises)

• Holding face for nasal suction or med administrations (chin/neck bruises)

• Pinched while strapping into car seat

• Hit head on handle of car seat or car door/frame (this one is true at times—but we’ve also heard it in abuse cases)

What is Normal?

• Normal accidental bruises in toddlers and older children are typically

– On the front of the body

– Over bony prominences (forehead, elbows, knees, shins)

AHT: Common presenting scenarios

• Infants with bruises

• Vomiting without diarrhea

• Apparent life-threatening event (ALTE)

• Seizure without fever

AHT: Common presenting scenarios

• Sudden increase in head

circumference

• Inconsolable crying

• Occult (hidden) fracture/incidental

finding

• Developmental delay

Other presenting scenarios for abuse

• Bright red blood from the mouth of infants (distinguish from hematemesis)

• Torn maxillary, mandibular, or sublingual frenulum

• Soft palate, tonsillar or pharyngeal lacerations (inflicted esophageal perforations are well-described and can be fatal if left unrecognized)

Severity of symptoms can vary by severity of brain injury

• Vomiting• Poor feeding• Poor focus/tracking• Irritability• Lethargy/difficult to arouse • Unusual sleepiness or seeming “spaced out”• Seizures• Breathing difficulty/gasping respirations/apnea• Bradycardia/cardiac arrest/death

The Medical Evaluation

• Head CT (looking for subdural bleeding, brain swelling) if acute injury is a concern

• Skeletal survey and follow-up skeletal survey in 10-14 days (NOT a babygram!) for those 2 years and under

• Eye exam (to look for retinal hemorrhages)• Trauma and bleeding labs to screen for signs of

internal injury or bleeding disorder and abdominal CT if OAT labs abnormal (OAT=occult abdominal trauma)

• MRI of the brain and spinal cord if CT is abnormal (MRI can demonstrate subtle brain injury that CT can miss)

• Photograph all visible injuries • Report to DCBS whenever maltreatment is a

reasonable concern (DCBS=Department of Community Based Services, aka Child Protective Services in Kentucky. In Indiana, it is called DCS=Department of Child Services)

The Medical Evaluation

• Head CT—perform when there are signs/symptoms of increased ICP, bruising in an infant, fracture in a child < 1 year, ALTE, or whenever a full evaluation is indicated acutely

• Skeletal survey – 21 different images, perform in children < 2 years of age. Older children only in special circumstances.

• Abd CT (not ultrasound) for abnormal OAT labs or abdominal bruising/symptoms

• Eye exam – if retinal heme is present, ask ophtho to take photos if possible

• Labs: CBC, PT, PTT, AST, ALT, amylase, lipase, bag urinalysis (NOT catheterized if possible)

• Photograph all visible injuries as soon as possible

Forensic vs. Clinical Significance

• Most of us have been taught to identify clinically significant injuries—those for which we can affect the medical outcome by providing some sort of treatment or monitoring

• In child maltreatment, it is equally as important to identify injuries with forensic significance (ALT>80*)—even if not clinically significant

*Utility of Hepatic Transaminases in Children With Concern for Abuse. Lindberg, Shapiro, et al. Pediatrics; originally published online January 14, 2013; DOI: 10.1542/peds.2012-1952

Common Missteps

• Abnormal head CT is not followed by an MRI

• No follow-up skeletal survey in 10-14 days

• Inadequate description/documentation of retinal hemorrhages

• OAT labs not done, or abd CT not done for AST>80

• Babygram instead of complete skeletal survey

Side-by-side comparison of babygram to single image of complete skeletal survey

Common Missteps

• Poor-quality photographs: we need to see the borders of the injuries

• Inexperienced commentary re: plausibility of injuries from the history provided—insertion of conjecture into the history

• Attempts to “date” bruises

A word about radiation exposure and cancer risk…

• All of the proposed increased risk is primarily theoretical.

• On the other hand, the risk of fatality when child abuse is missed is 10%. That’s not theoretical.

• The risk of abuse greatly outweighs the theoretical risk of x-ray—and the consequences of missing the diagnosis can be catastrophic.

A few words about reporting…

• We are all mandated reporters in Kentucky, which means we MUST report any reasonable suspicion.

• There are different levels of certainty, however. • For example, if an infant presents with bruising, and the

CBC indicates a platelet count of 25, then neither additional workup for abuse nor report to DCBS is necessary…the bruising is explained by thrombocytopenia

• If in doubt, however, call in a report.• You should NOT reserve reports for only those cases in

which you are certain there is abuse.

Outcomes

• Mortality rate approximately 20-30%*

• Long-term morbidity (disability) high amongst survivors—up to 90% affected*

• Disabilities include learning disabilities, emotional/behavioral issues, speech and language delays, vision/hearing, hormone/growth problems (due to pituitary injury)

* Visual Diagnosis of Child Abuse on CD-ROM 3rd Edition

Supporting the Survivor

• Establish a medical home.

• Monitor closely for developmental issues (First Steps), emotional/ behavioral issues (esp. attachment problems), hormone problems (panhypopituitarism), learning disabilities

• Older siblings that might have witnessed violence may need ongoing therapy/counseling

Triggering situations

• Crying baby

• Feeding issues/frustration

• Toilet training

• Child’s misbehavior

• Discipline gone awry

• Argument/family conflict

• Caregiver stressors outside the home, including financial concerns, job loss, legal trouble, relationship problems

Caregiver Characteristics

• Unrealistic expectations of child’s behavior

• Immature parent/poor coping skills

• CPS history/prior removals

• Caregiver abused as child

Fatality Risk Factors

Top three risk factors for fatal abusive injury include:

•Substance Abuse•Domestic Violence•Criminal History•Untreated/undiagnosed mental illness

among adult caregivers in the home.

Child Characteristics

• 0-3 years of age

• Drug affected/Neonatal abstinence

• Premature birth/NICU stays/multiples

• Colic

• Physical/developmental disabilities

Perpetrator Statistics

Physical abuse:

• Father• Mother’s BF (paramour) • Mother

“Children living in households with one or more male adults that are not related to them are at increased risk for maltreatment injury death.” **

(Specifically, they are 8 times more likely to die of maltreatment than children in households with two biological parents. Risk of maltreatment death was not increased for children living with only one biological parent.)

Stiffman et al. Pediatrics. April 2002. Household Composition and Risk of Fatal Child Maltreatment. **Note: This statistic does NOT apply to same-sex couples.

Why do perpetrator statistics matter?

Physical abuse: • Father• Mother’s BF (paramour) • Mother

Take-Home Message: As a primary care provider or a physician who is trying to determine if a finding/situation is related to maltreatment, it is critical to know who is living in the child’s home.

Case Review

• 4-month-old baby boy presents for well child exam and is noted to have two fingertip-sized bruises on each thigh.

• Parents explain that they came from a diaper change when the child was squirming. Social history offers no red flags.

• The doctor has seen the older sibling for the past

two years.

What should this doctor do?

..........continued

• Unfortunately, this pediatrician didn’t understand the significance of bruising in an infant.

• One week later, the patient was brought to the emergency department unresponsive and having seizures.

• He was found to have bilateral subdurals and 13 broken bones (most healing, meaning that they WOULD have been identified had a skeletal survey been performed the week before).

• Pediatrician described family as “very nice, no concerns.” Under social hx: “Family appropriate.”

The Lessons Learned

Bruising in babies is NOT normal.

Maltreatment can and does occur in “nice families”.

The absence of risk factorsis not the same as the absence of risk.

Prevention: What Can I Do?

• Help parents understand it’s okay for a baby to cry—it’s how they communicate! It doesn’t mean the baby dislikes them.

• Help parents understand it is normal to feel frustrated by a crying baby—and it is okay to take a break and ask for help. Have an action plan for when frustration becomes overwhelming.

• Depending on your practice, consider screening mothers for postpartum depression at all visits during the first 4-6 months of age.

• Screen for and address substance abuse, domestic violence, undiagnosed or untreated mental illness in parents/caregivers

Prevention: What Can I Do?

•Thorough skin exams whenever possible.

•Know household members and caregivers whenever possible—and update that information often. “Are there any changes in your child’s environment? New caregivers? New individuals in or around the home?”

•Learn about the HANDS program in your area and refer all eligible families.

•Teach parents about SAFE SLEEP…particularly regarding the dangers of co-sleeping while under the influence of drugs (legally prescribed or otherwise) or alcohol. ABC: Alone, on their Back, in a Crib

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AHT: Take-Home Messages

• Abusive Head Trauma is the most dangerous and deadly form of child physical abuse.

• Experience tells us that we often fail to recognize early warning signs—and we therefore miss opportunities to intervene and prevent further harm to abused children.

• The absence of risk factors is NOT the same as the absence of risk.

AHT: Take-Home Messages

• Remember the TEN-4 Bruising Rule

• A thorough medical evaluation is crucial—know which facilities in your area are equipped to do it.

• Long term effects from AHT vary from subtle learning and behavioral issues to complete dependence for all care.

• Education of caregivers regarding techniques for soothing a crying infant and the dangers of shaking can be an effective prevention tool.

For Assistance

• The Kosair Charities Division of Pediatric Forensic Medicine at UofL is available 24 hours a day, 7 days a week for telephone support.

• Call the Kosair Children’s Hospital operator to reach the forensic nurse specialist on call: 502-629-6000.

Reporting Abuse

24 hour statewide hotline for pediatric and adult reporting:

1-877-KY-SAFE-1

For non-emergent reports, web reporting is available at https://prd.chfs.ky.gov/ReportAbuse/home.aspx

(or just search for Kentucky DCBS web portal on your browser)

Thank you for your attention.