Greater than or equal to 90% of participants will know pediatric abusive head trauma risk factors, prevention strategies, clinical presentation and prognosis in order to identify and report pediatric Abusive Head Trauma (AHT).
After completing this continuing education course, the learner will be able to:
Pediatric abusive head trauma (AHT) may also be referred to as shaken baby syndrome (SBS). AHT is defined as the various injuries or conditions that may result following vigorous shaking, slamming, or impacting the head of an infant or young children. The effects of this type of head impact and/or violent shaking action results in serious health issues. Children may have severe brain or cervical spine injuries, bleeding in the brain or back inside layer of the eyes, skeletal fractures, or death.1
It has been identified as a leading cause of death and long-term disability in children, increasingly so in children less than 12 months of age. Timely diagnosis is often delayed at initial presentation and evaluation due to nonspecific clinical features and caregiver reports of absent physical trauma. Consequently, victims of AHT may not receive prompt treatment and, therefore, have increased risk of long-term disability or fatal injuries. Identifying risk factors and consequences, providing family and caregiver education and support, and addressing the safety of other children in high-risk homes can decrease and prevent the incidence of AHT.
Pediatric abusive head trauma is a severe form of child abuse that is the most common cause of death and long-term disability as a result of physical child abuse. AHT commonly occurs when a caregiver is frustrated or upset with the child’s incessant crying. In response, the caregiver shakes the infant or child uncontrollably or hits the infant/child’s head into an object in an effort to cease the crying.1 The use of physical force, including shaking, throwing, hitting or hurting, is never the correct way to stop infant or child crying.
Greater than 49 percent of deaths from child abuse occurs in children less than one year of age and AHT is the leading cause of physical child abuse deaths in children under age 5 in the United States.1, 2 Between 1999-2014, the National Vital Statics System data was utilized to examine trends in fatal AHT; mortality numbers were estimated as high as 2,250 in children less than five years of age, residing in the United States.3
However, accuracy and inconsistency of identifying and reporting child fatality due to physical abuse present a challenge in determining the actual incidence rate.1 It is suspected that AHT rates are underreported related to:
Although the exact number of children affected by AHT annually is unknown, the prevalence of identified physical child abuse remains a serious problem in the United States.
Infant and children presenting with AHT may have a severe brain injury, often in the absence of significant trauma and with minimal or no signs of external injury.7 Distinguishing features of AHT include subdural hemorrhage, diffuse multi-layered retinal hemorrhages, and diffuse brain injury or edema.8 Additional injuries may include those of the spinal cord, ligamentous, vertebral and paraspinal soft tissues.9, 10 The physical mechanisms associated with shaking include rapid and repetitive flexion, extension, and rotation of the head and neck which have been proposed to explain this pattern of injury. Visible signs of injury may not always be apparent. Whereas with impact, a more notable physical injury may be present, such as bruising, broken bones, lacerations or bleeding. Additional findings may include lethargy and irritability.
Due to the physical nature of infant and children’s anatomy, they are more vulnerable to injury as a result of angular (rotational) deceleration than that of adults.8 It has been identified that the following features are contributors to pediatrics AHT injury susceptibility11,12,13:
Identification of AHT in children is through an objective, thorough history, physical examination, laboratory tests, and imaging studies, including retinal exam. Commonly, the pediatric patient will present for medical care related to symptoms of their injury, without a history of preceding trauma. In cases of child abuse, the history provided by the caregiver is often inconsistent, incomplete, or incorrect. Some children may present with mild or nonspecific symptoms and may be misdiagnosed, only to return with more several or fatal injuries.4 Therefore, awareness and understanding around the clinical presentation and associated findings in pediatric AHT can aid in early identification and treatment.
Physical exam of the patient may raise suspicion for abuse when noting multiple injuries at different stages of healing or injury that does not correlate with the developmental level of the child. For example, bruising is uncommon in an infant that is not ambulating. Other varied symptoms may include mild flu-like symptoms, altered consciousness, and coma. By providing a complete nursing assessment, with a focus on neurological exam, it can provide pertinent clues leading towards necessary testing to confirm the diagnosis. As reviewed, symptoms may be nonspecific and may include:
Additional diagnostic studies for these patients include blood work such as CBC, CMP, platelets and coagulation studies. Urinalysis and toxicology screening may also be considered in the evaluation of child abuse. Necessary imaging studies include computed tomography (CT or CAT) scan for diagnosis of intracranial injury and a skeletal survey for additional bone examination. Possible follow up imaging, such as an MRI, for further diagnosis and clarification of findings. Finally, an ophthalmologic exam, to asses for retinal hemorrhage is to be expected.
Although no single physical finding definitively identifies pediatric AHT, there are hallmarks of child abuse and AHT. Combinations of clinical conditions or injuries can help accurately identify patients who have a high likelihood of pediatric AHT. These conditions include, but are not limited to:
Unfortunately, many cases of pediatric AHT do not survive or do with extensive damage resulting in long-term disabilities. Major disability has been observed in two-thirds of pediatric AHT cases. Observed disabilities can manifest as developmental delays; sensory deficits (hearing impairment or blindness); motor impairments; attention deficits; feeding difficulty; seizures; intellectual and educational difficulties; and behavioral issues.1
The long-term medical burden has a significant economic impact. Care of the surviving child with pediatric AHT may be lifelong, including physical, occupational, speech-language, and educational therapies, and in severe cases, long-term nursing care. According to the Centers for Disease Control and Prevention year 2008 data, the total lifetime cost associated with just one year of confirmed cases of child maltreatment is approximately $124 billion.16
Risk factors associated with AHT have been identified through observational studies and can be categorized into infant/child, situational, and caregiver, see table 1 below.1,5,6 Through healthcare providers taking the time to assess and identify areas of risk, the provider more accurately is equipped to identify patients at risk for pediatric AHT and/or provide resources in education or support to reduce the risk of pediatric AHT.
|Perinatal illness (prematurity)||Low socioeconomic status||Low education level|
|Major birth defect||Family dysfunction||Substance abuse|
|Hospitalization||Community violence||Young maternal age|
|Incessant crying (“colicky”)||Multiple caretakers||Behavioral health history|
|Male sex||Family disruption/separation||History of domestic violence|
|Prior history of abuse||Frustration|
|Isolation||Lack of caregiver experience|
The American Academy of Pediatrics states that AHT is largely preventable.4 Evidence from the Centers for Disease Control and Prevention formalized efforts for consistent tracking of AHT, evaluation of interventions focused on prevention has demonstrated a decline in AHT rates after 2009. AHT rates in 2013 and 2014 were 0.41 per 100,000 children less than five years of age and 0.43 per 1000,000, respectively, the lowest rates during the 16-year data collection.3 Through identifying risk factors, clinicians can provide focused formalized interventions in supporting families and caregivers to prevent AHT.
With the most common incident leading up to AHT being infant crying, educating caregivers on safe interventions and where to find support is an important intervention in preventing AHT.1 In over 40 years of research, the American Academy of Pediatrics supports that early infant crying follows a period of increased and then decreased crying starting at about two weeks and lasting until the third or fourth month of life. Educating parents and caregivers that this crying is a normal stage of development and unrelated to infants having a disease or physical problem or parents having different caregiving styles.17
Healthcare providers have an important role in recognizing and preventing abuse. Clinicians can educate caregivers regarding:
Each state has mandatory reporting requirements for professionals that are required to report suspected child abuse. For information on reporting in your state, use the national hotline for child abuse, Child Help USA at 1-800-4-A-Child (1-800-422-4453).
In Kentucky, the law states that it is the duty of everyone who has reasonable cause to believe that a child dependent, abused or neglected to report this information. Additionally, the following persons, but not limited to, are required to submit a more detailed/written report: physician, nurse, teacher, school personnel, social worker, coroner/medical examiner, child care personnel, resident, intern, optometrist, dentist, EMT/paramedic, or healthcare professional.
Six months old, Emelia, presents to the emergency department via EMS. She presents status post seizure, limp and unresponsive. After acute stabilization, the physical assessment reveals scattered bruising at different stages of healing. A CT scan reveals a serious head injury, a subdural hematoma and skeletal survey suggests two fractured ribs. It was later diagnosed as abusive head trauma as a result of shaking without head impact. Social work is notified.
Once the father arrives, he provides a more detailed history of events. Emelia’s mother, who has a history of substance abuse, has recently been incarcerated. In order to work, he has been sending Emelia to a neighbor’s house for childcare. He received a call from the child-caregiver explaining Emelia had been very irritable and seemed sick and that he needed to pick her up. The father reports that the caregivers told him she had been lethargic, with flu-like symptoms, including vomiting and decreased intake. Upon arriving at the in-home childcare, he noticed Emelia having a seizure and called 911.
The in-home child care provider was reported to the state of Kentucky's child abuse hotline by calling 1-877-597-2331. Emelia is transferred to the ICU for further medical care. Social work coordinates efforts with the father in determining what further support he will need moving forward.