Cindy W. Christian

Abusive Head Trauma in Infants and Children

Shaken baby syndrome is a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children. Although the term is well known and has been used for a number of decades, advances in the understanding of the mechanisms and clinical spectrum of injury associated with abusive head trauma compel us to modify our terminology to keep pace with our understanding of pathologic mechanisms. Although shaking an infant has the potential to cause neurologic injury, blunt impact or a combination of shaking and blunt impact cause injury as well. Spinal cord injury and secondary hypoxic ischemic injury can contribute to poor outcomes of victims. The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required. The American Academy of Pediatrics recommends that pediatricians develop skills in the recognition of signs and symptoms of abusive head injury, including those caused by both shaking and blunt impact, consult with pediatric subspecialists when necessary, and embrace a less mechanistic term, abusive head trauma, when describing an inflicted injury to the head and its contents.

Long-Term Outcome in Infants with the Shaking-Impact Syndrome

Nonaccidental injury accounts for nearly one quarter of all hospital admissions for head injury in infancy, and is associated with significant morbidity and mortality. Long-term outcome in survivors, however, has been incompletely studied. In this series, 84 infants 2 years of age and younger with the shaking-impact syndrome consecutively admitted to a single hospital between 1978 and 1988 were identified. A questionnaire detailing current medical, developmental, and behavioral status was developed, and attempts were made to locate the 62 children surviving the acute injury. Family instability and strict confidentiality restrictions precluded locating the majority of children, but 14 children with demographic and injury characteristics similar to those of the overall group were contacted at an average of 9 years after injury. Seven children were severely disabled or vegetative, 2 were moderately disabled, and 5 had a good outcome. Of the latter group, 3 had repeated grades and/or required tutoring. Acute factors associated with poor outcome included unresponsiveness on admission, need for intubation, age less than 6 months, and bilateral or unilateral diffuse hypodensity on CT scan. All children with bilateral diffuse hypodensity and loss of gray-white differentiation on CT scan remained blind, retarded, nonverbal, and nonambulatory in spite of aggressive medical and surgical management. This study suggests that the majority of children surviving the shaking-impact syndrome suffer major permanent morbidity, and that acute factors predicting long-term outcome may help guide aggressiveness of care.

Forensic Evidence Findings in Prepubertal Victims of Sexual Assault

Objective. The American Academy of Pediatrics recommends forensic evidence collection when sexual abuse has occurred within 72 hours, or when there is bleeding or acute injury. It is not known whether these recommendations are appropriate for prepubertal children, because few data exist regarding the utility of forensic evidence collection in cases of child sexual assault. This study describes the epidemiology of forensic evidence findings in prepubertal victims of sexual assault. Methods. The medical records of 273 children <10 years old who were evaluated in hospital emergency departments in Philadelphia, Pennsylvania, and had forensic evidence processed by the Philadelphia Police Criminalistics Laboratory were retrospectively reviewed for history, physical examination findings, forensic evidence collection, and forensic results. Results. Some form of forensic evidence was identified in 24.9% of children, all of whom were examined within 44 hours of their assault. Over 90% of children with positive forensic evidence findings were seen within 24 hours of their assault. The majority of forensic evidence (64%) was found on clothing and linens, yet only 35% of children had clothing collected for analysis. After 24 hours, all evidence, with the exception of 1 pubic hair, was recovered from clothing or linens. No swabs taken from the childs body were positive for blood after 13 hours or sperm/semen after 9 hours. A minority of children (23%) had genital injuries. Genital injury and a history of ejaculation provided by the child were associated with an increased likelihood of identifying forensic evidence, but several children had forensic evidence found that was unanticipated by the childs history. Conclusions. The general guidelines for forensic evidence collection in cases of acute sexual assault are not well-suited for prepubertal victims. The decision to collect evidence is best made by the timing of the examination. Swabbing the childs body for evidence is unnecessary after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis.

Evaluating children with fractures for child physical abuse

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center.

Background Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period. Methods This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institutions Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared. Results Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group. Conclusions Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse. Level of Evidence level III, prognostic study.

Patterns of health care use that may identify young children who are at risk for maltreatment

Objectives. Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children. Methods. We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non–emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child’s primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities. Results. We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40–4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96–24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints. Conclusions. Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment.

The Eye Examination in the Evaluation of Child Abuse

Retinal hemorrhage is an important indicator of possible abusive head trauma, but it is also found in a number of other conditions. Distinguishing the type, number, and pattern of retinal hemorrhages may be helpful in establishing a differential diagnosis. Identification of ocular abnormalities requires a full retinal examination by an ophthalmologist using indirect ophthalmoscopy through a pupil that has been pharmacologically dilated. At autopsy, removal of the eyes and orbital tissues may also reveal abnormalities not discovered before death. In previously well young children who experience unexpected apparent life-threatening events with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, victims of abusive head trauma, and children with unexplained death, premortem clinical eye examination and postmortem examination of the eyes and orbits may be helpful in detecting abnormalities that can help establish the underlying etiology.

Neck injuries in young pediatric homicide victims

OBJECT In this study, the authors estimate the prevalence of injuries to the soft tissue of the neck, cervical vertebrae, and cervical spinal cord among victims of abusive head trauma to better understand these injuries and their relationship to other pathophysiological findings commonly found in children with fatal abusive head trauma. METHODS The population included all homicide victims 2 years of age and younger from the city of Philadelphia, Pennyslvania, who underwent a comprehensive postmortem examination at the Office of the Medical Examiner between 1995 and 2003. A retrospective review of all available postmortem records was performed, and data regarding numerous pathological findings, as well as the patients clinical history and demographic information, were abstracted. Data were described using means and standard deviations for continuous variables, and frequency and ranges for categorical variables. Chi-square analyses were used to test for the association of neck injuries with different types of brain injury. RESULTS The sample included 52 children, 41 (79%) of whom died of abusive head trauma. Of these, 29 (71%) had primary cervical cord injuries: in 21 there were parenchymal injuries, in 24 meningeal hemorrhages, and in 16, nerve root avulsion/dorsal root ganglion hemorrhage were evident. Six children with abusive head trauma had no evidence of an impact to the head, and all 6 had primary cervical spinal cord injury (SCI). No child had a spinal fracture. Six of 29 children (21%) with primary cervical SCIs had soft-tissue (ligamentous or muscular) injuries to the neck, and 14 (48%) had brainstem injuries. There was a significant association of primary cervical SCI with cerebral edema (p = 0.036) but not with hypoxia-ischemia, infarction, or herniation. CONCLUSIONS Cervical SCI is a frequent but not universal finding in young children with fatal abusive head trauma. In the present study, parenchymal and/or root injury usually occurred without evidence of muscular or ligamentous damage, or of bone dislocation or fracture. Moreover, associated brainstem injuries were not always seen. Although there was a significant association of primary cervical cord injury with cerebral edema, there was no direct relationship to brainstem herniation, hypoxia-ischemia, or infarction. This suggests that cervical spinal trauma is only 1 factor in the pathogenesis of these lesions.

Evaluation for bleeding disorders in suspected child abuse

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding concerning for abuse requires an evaluation for bleeding disorders. In some instances, however, bleeding disorders can present in a manner similar to child abuse. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of the laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

Vitamin D Status in Abused and Nonabused Children Younger Than 2 Years Old With Fractures

OBJECTIVE: To examine vitamin D levels in children with (1) suspected abusive and accidental fractures, (2) single and multiple fractures, and (3) fracture types highly associated with inflicted trauma. DESIGN AND METHODS: A study of children younger than 2 years of age with fractures admitted to a large childrens hospital was performed. Bivariate analysis and test for trend were performed to test for the association of vitamin D status and biochemical markers of bone health with the primary outcomes of fracture etiology, number, and type. RESULTS: Of 118 subjects in the study, 8% had deficient vitamin D levels (<20 ng/mL; <50 nmol/L), 31% were insufficient (≥20 < 30 ng/mL; ≥50 < 78 nmol/L), and 61% were sufficient (≥30 ng/mL; ≥78 nmol/L). Lower vitamin D levels were associated with higher incidences of hypocalcemia (P = .002) and elevated alkaline phosphatase (P = .05) but not hypophosphatemia (P = .30). The majority of children sustained accidental fractures (60%); 31% were nonaccidental and 9% were indeterminate. There was no association between vitamin D levels and any of the following outcomes: child abuse diagnosis (P = .32), multiple fractures (P = .24), rib fractures (P = .16), or metaphyseal fractures (P = .49). CONCLUSIONS: Vitamin D insufficiency was common in young children with fractures but was not more common than in previously studied healthy children. Vitamin D insufficiency was not associated with multiple fractures or diagnosis of child abuse. Nonaccidental trauma remains the most common cause of multiple fractures in young children.