Pediatric Abusive Head Trauma 2017 Annual Conference Kentucky Osteopathic Medical Association Selena G. M. Raines, DO

Learning Objectives Be able to recognize the signs of abusive head trauma in pediatric patients. Identify risk factors for pediatric abusive head trauma. Review techniques for prevention of pediatric abusive head trauma. Understand the process for reporting pediatric abuse.

House Bill 157, passed in 2014, requires all pediatricians, radiologists, family physicians, emergency and urgent care physicians to complete one hour of CME training prior to the end of 2017.

WHY?

Kentucky ranks near the top In 2015, Kentucky was ranked 11th in the number of abuse cases, and 27th in the number of abuse deaths, with 16. Our abuse rate of 18.7/1000 ranked us at number 2 in the nation. The national abuse rate is 9.2/1000. Kentucky is more than double the national average.

Numbers are increasing Child abuse numbers in Kentucky have been increasing each year. This is a trend that is being seen around the country.

Definition- What is Pediatric Abusive Head Trauma? The term pediatric abusive head trauma replaces shaken baby syndrome The CDC defines pediatric abusive head trauma as an injury to the skull or intracranial contents of an infant or child, younger than the age of 5, due to blunt impact or violent shaking. Injury can be caused by shaking, impact, crush, or a combination What is excluded from this definition are unintentional injuries that are the result of neglectful supervision. Also gunshot wounds, stab wounds, and penetrating trauma are excluded from this definition

Statistics Estimates show that 20-30 out of 100,000 children under age 1 are harmed from abusive head trauma 20% of these children die from their injuries; 66% suffer significant disability Over 40% of child abuse deaths occur in children less than 1 year of age

Importance of recognizing abuse About 20% of children who die as a result of child abuse have seen a healthcare provider within 1 month of their death Most of the children who die or suffer permanent disability from abusive head trauma have been previously abused Head trauma is the leading cause of death among child abuse victims

Identifying Pediatric Abusive Head Trauma History and physical are key to identification Complete medical history to include prior injuries, trauma, hospitalizations, illnesses and congenital conditions Family history, bleeding disorders, bone disorders, genetic conditions How the child is disciplined at home Family history of violence or abuse Developmental milestones Family history of substance abuse Recent social or financial stressors in the home Ask parents, caretakers, witnesses for details of the event/injury Ask in a non-accusatory manner Assess for consistencies in accounts

Identifying Pediatric Abusive Head Trauma Concerning elements of the history include No explanation for the injury Varying accounts of the event Explanations of the event that do not match the presenting injury Significant delay in care Explanation of the events does not match the developmental or physical capabilities of the child Accounts of the event change with further questioning

Identifying Pediatric Abusive Head Trauma In approximately 80-90% of cases of abusive head trauma, subdural hematoma is the main sign Other suspicious signs: Skull fractures Retinal hemorrhage Brain edema Head and neck bruising Rib and long bone fractures Apnea Seizures

Retinal Hemorrhages Frequently seen in abusive head trauma, but are less likely in accidental head injuries When caused by abuse they are frequently severe, numerous, involve multiple retinal layers,

But, will you always recognize abuse Remember that there may not always be outward signs of abuse Infants often present with nonspecific signs of injury As many as 30% can initially be misdiagnosed One retrospective study showed that in infant victims of abusive head trauma that was not initially recognized, 65% of them were described as being irritable on presentation and 56% were vomiting.

Other signs that may indicate trauma Lethargy Irritability Poor feeding or decreased appetite Disordered breathing Altered level of consciousness Lack of vocalization, smiling, or interaction Unequal pupils Rigidity or poor muscle tone

TEN-4 Rule Used to identify abuse in general Bruising on the Torso, Ear, or Neck in a child 4 years or under and bruising anywhere on a child under 4 months warrants further evaluation This was developed from a case-control study of children admitted to pediatric ICUs as a result of trauma. Initial study had a sensitivity of 97% and a specificity of 84%

Predicting Abusive Head Trauma (PredAHT) Tool Helps clinicians distinguish between accidental head trauma and abusive head trauma Abusive head trauma is highly likely if 3 or more of the following are present on exam: Long bone fractures Rib fractures Retinal hemorrhage Apnea Seizures Head or neck bruising

Physical Exam General assessment Mouth and teeth exam Scalp exam Alertness Responsiveness Eye opening Mouth and teeth exam Scalp exam Funduscopic exam Skin exam Palpation for tenderness Deep tendon reflexes, muscle tone

What imaging is needed? A skeletal survey is recommended in all cases of suspected abuse is children under the age of 2 Appendicular skeleton : Humeri (AP) , Forearms (AP) , Hands (PA) , Femurs (AP) , Lower legs (AP) , Feet (AP) Axial skeleton : Thorax (AP, lateral, right and left obliques), to include ribs, thoracic and upper lumbar spine ; Pelvis (AP), to include the mid lumbar spine; Lumbosacral spine (lateral); Cervical spine (lateral); Skull (frontal and lateral) Single image, or “babygram” is not sufficient and are not recommended Symptomatic children- Non-contract head CT Asymptomatic children- MRI brain

Radiographic Evidence of Abuse Highly Specific: classic metaphyseal lesions, rib fractures (posteromedial), sternum, scapula, spinous process fractures Moderately Specific: multiple fractures, fractures in different states of healing, epiphyseal separations, vertebral body fractures and subluxations, digital fractures, complex skull fractures Less Specific: clavicular fractures

Classic Metaphyseal Lesions Photo courtesy of Medscape http://reference.medscape.com/features/slideshow/child-abuse#page=11

Lab studies These may be considered

Long term effects of abusive head trauma Physical and learning disabilities Vision and hearing impairment Behavior disorders Seizures Cerebral palsy Cognitive deficits

Risk Factors Poor social and economic situation Substance abuse Young age of parents Family history of violence Mental, physical, and social development of the child

What triggers abusive head trauma? Inconsolable crying is the most common trigger for abusive head trauma

How can we educate parents? Educate parents that babies cry a lot during the first few months of life, but crying will lessen as the child gets older. Teach parents about soothing methods, such as rocking, pacifier use, walking with the baby, singing or talking to the baby Educate parents on how trying to assess the needs of a crying baby; hunger, diaper change, illness, discomfort Educate parents that if they feel themselves getting angry or frustrated, they should place the child in a safe place and walk away. Call a friend, family member, or neighbor for help. Don’t leave your baby with a person who is known to be easily irritated or has a temper; history of violence

Prevention There is no evidence for specific screening protocols Education CDC website National Center on Shaken Baby Syndrome Prevent Child Abuse Kentucky Public awareness Commercially available education programs PURPLE Period Crying Letters P= peak of crying is 2 months, U= unexpected, crying can come and go, R= resists soothing, P=pain-like face, L= long-lasting, up to 5 hours per day, E=evening, baby cries more in the evening

When to report abuse According to Kentucky law (KRS 620.030) anyone who believes a that a child is being abused, neglected, or is dependent, is required by law to report their suspicions Knowingly failing to report abuse is subject to the following criminal charges: Class B Misdemeanor for the first offense Class A Misdemeanor for the second offense Class D Felony for each subsequent offense Physicians are not exempt from reporting abuse

How to report abuse 24- Hour Hotline 1-877-597-2331 (877-KYSAFE1) Childhelp National Child Abuse Hotline 1-800-422-4453 (800-4- ACHILD) The Department for Community Based Services in your county If you believe a child is in imminent danger call your local police department or 911 If there is a reasonable cause to believe that a child is being abused or neglected, you must file a report

References Cowle, L.E., Morris, C.B., Maguire, S.A., Farawell, D.M., and Kemp, A.M. Validation of a Prediction Tool for Abusive Head Trauma. Pediatrics. 2015; 136(2):290-298. Kodner, C.; Wetherton, A. Diagnosis and Management of Physical Abuse is Children. Am Family Physician. 2013;88(10):669-675. Centers for Disease Control and Prevention. Preventing Abusive Head Trauma in Children. https://www.cdc.gov/violenceprevention/childmaltreatment/abusive-head- trauma.html National Center on Shaken Baby Syndrome website. https://www.dontshake.org U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2017). Child Maltreatment 2015. Available from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics- research/child-maltreatment.

Questions??