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

2. 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.

3. 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.

4. WHY?

5. 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.

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

7. 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

8. Statistics
Estimates show that 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

9. 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

10. 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

11. 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

12. 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

13. 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,

14. 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.

15. 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

16. 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%

17. 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

18. 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

19. 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

20. 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

21. Classic Metaphyseal Lesions
Photo courtesy of Medscape

22. Lab studies
These may be considered

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

24. 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

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

26. 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

27. 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

28. When to report abuse
According to Kentucky law (KRS ) 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

29. How to report abuse 24- Hour Hotline 1-877-597-2331 (877-KYSAFE1)
Childhelp National Child Abuse Hotline ( 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

30. 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):
Kodner, C.; Wetherton, A. Diagnosis and Management of Physical Abuse is Children. Am Family Physician. 2013;88(10):
Centers for Disease Control and Prevention. Preventing Abusive Head Trauma in Children. trauma.html
National Center on Shaken Baby Syndrome website.
U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2017). Child Maltreatment Available from research/child-maltreatment.

31. Questions??