1. NON ACCIDENTAL HEAD INJURY in CHILDREN
Various terms are used – “abusive head trauma, inflicted brain injury, non accidental injury and shaken baby syndrome”
Leading cause of infant death from injury
Impact and non-impact (shaken)

2. Non Accidental Head injury
“The Battered Child Syndrome” Kempe et al 1962
“The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash induced intracranial and intraocular bleeding, linked with residual permanent brain damage and mental retardation” John Caffey 1974

3. EPIDEMIOLOGY Scottish study 25 cases/100,000 children<1
United Kingdom SDH 21/100,000<1 year
United Kingdom SDH 13/100,000<2 year
North Carolina incidence 17/100,000<2 year with a fatality rate of 22% (3-4/100,000)

4. NON ACCIDENTAL HEAD INJURY IN CHILDREN; SYDNEY EXPERIENCE
J Neurosurgery (Paediatrics ) 103: , 2005
Examined the demographics, clinical & radiological features and clinical outcomes of presumed NAI of 65 consecutive cases

5. Triad of “shaken baby syndrome” John Caffey
Subdural haematomas
Little signs of external trauma
Retinal haemorrhages
Other “red flags” might be changing history and incompatible history – when there is no history of trauma or only minor trauma with subdural haematomas & retinal haemorrhages the PPV for abuse is 0.92

6. Diagnosis There is no diagnostic test for non accidental injury
The diagnosis is made on a balance of probability
Careful exclusion of other possible causes eg accidental injury and medical conditions ( rare metabolic disorders, coagulation disorders, infective encephalopathies etc)

7. Diagnosis
Established by a multidisciplinary team of CPU, neurosurgical, neurology, paediatric, ophthalmology and radiology staff
Detailed family interviews
Exclusion of underlying diseases and accidental injuries

8. Total = 65
Range months
Age 8.2 months (mean)
M:F 39:26

9. Perpetrators Known in 41/65 cases and usually the male partner (70%)
Maternal age 22.6
Male partner 24.5
Risk factors family disruption, separation in 50% cases
History of abuse of the child or another family member in 24%

10. Family Dynamics
There was a high incidence of family disruption, substance abuse and prematurity

11. Seizures
35 patients out of the 65 had seizures on admission or a preceding history before admission and 17 had epilepsy on follow up

12. Skull Fractures
Were seen in 36.9% of cases

13. Retinal Haemorrhages
Seen in 60% of cases and most were bilateral

14. Retinal Haemorrhages
The subject of controversy. When associated with trauma almost always inflicted injury. But can be associated with increased ICP, coagulopathies, spontaneous SAH, retinal dysplasia, retinopathy of prematurity, galactosaemia, glutaric aciduria and hypertension as well as severe accidental head injury

15. A History of Trauma
Was given in 31 cases (50%) but the mechanism of trauma was inconsistent with the child’s development in the majority of cases (70%)
Scalp haematomas 30%
Facial bruising 40%
Truncal bruising & limb bruising 20%

16. Presenting symptoms prior to admission for the 65 cases
Seizures, irritability, “breathing problems” lethargy, apnoea, sleepy, arrest, poor feeding and failure to thrive, vomiting, a “big head” and coma.
# Apnoea (rib fractures) and retinal haemorrhages have a high odds ratio for association with inflicted head injury – a systematic review 2009 (literature review )

17. Level of consciousness on admission

18. Other Injuries Rib fractures & collapsed lung
Abdominal trauma (hepatic & renal)
Burns to forearm, limbs & trunk
Skeletal injuries > 50%
( often occult)

19. Skeletal Injuries (60)
> 50% investigated found to have positive bone scans or skeletal survey, although clinical evidence for these injuries existed in only 20%
Multiple areas of skeletal injury in 30%
Limb fractures in 40%
Rib fractures 30%
Facial fractures
Spinal fractures

20. Admission to Non-accidental Injury
Was made at some stage during the hospitalization in only 14 cases

21. Hospital Stay The mean duration of stay was 18 days Range 1-127 days
Ventilation required in 30 cases (46%)

22. Neuro Imaging CT Scan - all patients had at least one CT head scan
MRI Scan - 37 patients (57%) also had MRI scans
MRI scanning picked up hypoxic changes, infarction, shearing injury, cerebral contusion & haemorrhage, small subdural haematomas and subarachnoid haemorrhage not seen on CT

23. MRI Scanning
In summary MRI scans revealed additional pathological findings not visible on CT scanning in 18(49%) of 37 children
Investigation of choice

24. CT and MRI Subdural haematoma 53 Cerebral oedema or ischaemia 22
Cerebral contusion
Skull fracture
Subarachnoid haemorrhage
Extradural haematoma

31. Characteristics of subdural haematoma
Cerebral convexity
Inter-hemispheric
Posterior fossa
Multiple locations
Acute
Chronic
Differing ages

36. Surgical Procedures
A total of 35 operations were performed in 17 children mainly for subdural and further subdural recollection

40. Surgical Procedures Burr-hole drainage of subdural 21
Insertion of subdural shunt
Insertion of ventricular shunt
External ventricular drain
Removal of shunt
Craniotomy

41. Glasgow Outcome Score 1 Dead 4 2 Vegetative 7 3 Severe Disability 17
4 Moderate Disability
5 Good

42. Care Arrangements
After discharge were known for 59 cases and 29 were placed into foster care, 16 to care of relatives and 14 to care of parent

43. Statistical Analysis
Patients were categorized as having a poor outcome if their GOS was 3 or less and a good outcome if 4 or 5 (for statistical analysis)
The only statistically significant correlation was seen between CT or MRI findings of ischemia or oedema and outcome

44. If there were radiological findings of cerebral ischemia or oedema
Poor Outcome
If there were radiological findings of cerebral ischemia or oedema

45. Discussion
Risk factors included young parents, unstable family situations, low socioeconomic status and prematurity
The epidemiological characteristics consistent with published data
The most frequent perpetrators were the fathers and the maternal male partners

46. Discussion
In 24% of cases the families were already known to have a history of abuse
The presentation of NAI or inflicted head injury can be subtle and non specific
An association was seen between the radiological findings of ischemia or oedema and outcome

47. Discussion Mortality 6% and severe disability or vegetative 31%
The outcome in this study compares favourably with published data
Recurrence of subdural collections occurs in nearly half of the cases treated with burr-hole drainage

48. Conclusions Non specific clinical presentation
Routine use of MRI to detect ischemia
Routine screening of NAI with bone scans
High rate of subclinical (occult) skeletal injuries
Recurrence of subdural haematomas after surgery
Families with history of abuse