1. Head Injury: Inflicted or Accidental? Robert Allan Shapiro, M.D. Children’s Hospital Medical Center Cincinnati, Ohio 513-636-7966

2. Robert A Shapiro, MD, Patricia A. Myers, MSW What is the minimal trauma that can result in serious head injury/death? Clinical experience - type of injury/fall Published studies of head injuries –short distance falls –falls out of bed –falls down stairs –falls out of walkers –falls out of shopping carts –witnessed and un-witnessed falls

3. Robert A Shapiro, MD, Patricia A. Myers, MSW Mechanism of Injury distance fallen propelled free or “broken” fall landing surface characteristics spread of energy (% body involved, fractures) Primary vs. Secondary brain injury

4. Robert A Shapiro, MD, Patricia A. Myers, MSW Deaths from Falls in Children: How Far is Fatal? Chadwick, et al: Journal of Trauma, 1991 (San Diego) 10' - 45'1181 death (CHI) 4' - 10'650 deaths < 4'1007 deaths (CHI) 5/7 had signs of abuse (e.g. RH, fracture)

5. Robert A Shapiro, MD, Patricia A. Myers, MSW Injuries from witnessed & corroborated free falls Williams. J Trauma, 1991 With independent witness –106 falls < 2-70 feet –3 small depressed skull fractures –1 death after a 70’ fall Without independent witness –53 falls < 5 feet –2 deaths

6. Robert A Shapiro, MD, Patricia A. Myers, MSW Additional indications of nonaccidental head injury Other injuries –Bruises; rib, long bone & other fractures Retinal hemorrhages –present in 70-80% of SBS –extent of hemorrhage correlates w/ injury severity intra-retinal hemorrhage subretinal / vitreous hemorrhage Social/family risk factors

7. Robert A Shapiro, MD, Patricia A. Myers, MSW Whiplash Shaken Baby Syndrome (Caffey 1972) Infants < 2 y/o with intracranial injury Chief Complaint / History: –lethargy, irritability, poor feeding –trauma, apnea, seizure, DOA Exam: retinal hemorrhages –other trauma often minimal or absent C-T: subdural/subarachnoid hemorrhages

8. Robert A Shapiro, MD, Patricia A. Myers, MSW Serious Head Injury in Infants: Accident or Abuse? Billmire, Myers. Pediatrics, 1985 Infants < 1 y/o over a 2 year period 19 infants w/SDH or other intracranial injury –18 Abuse –1 Accident (MVA)

9. Robert A Shapiro, MD, Patricia A. Myers, MSW Diagnosis of Shaken Baby Syndrome Consider SBS in infants with: –intracranial injury after minor trauma scan infants with symptoms indicative of head injury –retinal hemorrhages Does the history explain the injuries? If not –look for other indications of abuse –diagnose other illnesses that can be mistaken for SBS

10. Robert A Shapiro, MD, Patricia A. Myers, MSW Injuries resulting when small children fall out of bed Helfer et al: Pediatrics, 1977 161 children < 5 y/o fell at home –6 fractures (3.7%) 85 children < 5 y/o fell in hospital –1 fracture (1.2%) 0 intracranial injuries

11. Robert A Shapiro, MD, Patricia A. Myers, MSW Falling out of bed: A relatively benign occurrence Lyons, Oates. Pediatrics, 1993 207 children < 6 y/o –fell 25” - 54” from hospital beds –1 skull fracture –1 clavicle fracture –0 intracranial injuries

12. Robert A Shapiro, MD, Patricia A. Myers, MSW Bunk Bed Injuries Selbst, Baker, Shames. AJDC, 1990 (Philadelphia) 68 falls from bunk beds (6 feet) 37% < 2 y/o 8 concussions (12%) 1 skull fracture w/SDH (1.5%)

13. Robert A Shapiro, MD, Patricia A. Myers, MSW Infant Walker Related Injuries Smith, et al: Pediatrics, 1997 (Columbus) 271 babies (96% fell down stairs) contusions / abrasions / lacerations: 192 (72%) skull fracture: 26 (10%) – > 10 stairs increased incidence of skull fracture concussion: 35 (13%) intracranial hemorrhage: 3 (1%)

14. Robert A Shapiro, MD, Patricia A. Myers, MSW Infant Walker Related Injuries Chiaviello, et al: Pediatrics, 1994 (Charlottesville) 65 children < 5 y/o (95% < 1 y/o) skull fracture: 10 (15%) concussion: 8 (12%) intracranial hemorrhage: 5 (8%) C-2 fracture: 1

15. Robert A Shapiro, MD, Patricia A. Myers, MSW Stairway Related Injuries in Children Chiaviello, et al: Pediatrics, 1994 (Charlottesville) 69 children < 5 y/o (mean 2 y/o) Concussion: 11 (16%) skull fracture: 5 (7%) Intracranial injury (2/3 were carried by adult) –cerebral contusion: 2 (3%) –SDH: 1 C-2 fracture: 1

16. Robert A Shapiro, MD, Patricia A. Myers, MSW Stairway Injuries in Children (including falls in walkers) Joffe, Ludwig: Pediatrics, 1988 (Philadelphia) 363 children head and neck injuries predominated (73%) –only 2.7% had injury to more than one body area any fracture: 25 (7%) (skull fracture 2%) – 40% skull fracture if carried by adult during fall concussion: (1%) intracranial hemorrhage: 0

17. Robert A Shapiro, MD, Patricia A. Myers, MSW Injuries to children related to shopping carts Smith: Pediatrics, 1996 (Columbus) 62 children head injuries (79%) skull fracture: 5 (8%) LOC: (4 - 10%) intracranial injury: 0 (14% had C-T)

18. Robert A Shapiro, MD, Patricia A. Myers, MSW Summary: Intracranial injury from known trauma

19. Robert A Shapiro, MD, Patricia A. Myers, MSW Injuries that result in intracranial trauma falls 3’ & 6’ couch, bedkitchen counterporch standing, chairchanging table top of slide coffee tablebunk bed, stairsbaby walker Highly UnexpectedReasonable unlikelybut possible

20. Robert A Shapiro, MD, Patricia A. Myers, MSW Exceptions Epidural hemorrhage Hemorrhage with pre-existing intracranial defect –increased extra-axial spaces –prior intracranial bleed –cerebral atrophy Bleeding disorder Ruptured AVM or other vascular malformation

21. Robert A Shapiro, MD, Patricia A. Myers, MSW Mechanism of retinal hemorrhages Raised intraocular venous pressure –from sudden rise in ICP –raised CVP Rapid deceleration (whiplash) Cycles of rapid accelerations & decelerations

22. Robert A Shapiro, MD, Patricia A. Myers, MSW Retinal findings after head trauma in infants & young children Buys, et al: Ophth 1992 79 children < 3 y/o Retinal hemorrhages present in only 3 –all abused None of the children with accidental trauma had retinal hemorrhages

23. Robert A Shapiro, MD, Patricia A. Myers, MSW Accidental head trauma and retinal hemorrhage Johnson, et al: Neurosurgery, 1993 161 children –21 excluded because of suspected abuse –MVA, falls, assault, other –skull fractures or intracranial injury 2 children with accidental trauma had RH –high speed MVA –back seat of car with side impact

24. Robert A Shapiro, MD, Patricia A. Myers, MSW Anecdotal reports of accidental trauma causing retinal hemorrhages Child died from CHI after being kicked by horse Child's head and chest crushed by car Children in MVA with intracranial injury Child fell down stairs in walker with SDH

25. Robert A Shapiro, MD, Patricia A. Myers, MSW Other causes of retinal hemorrhages Ruptured AVM, CNS infection & tumor Birth trauma –flame hemorrhages resolve in 1 week; dot/blot 6 weeks Coagulopathies, liver disease Endocarditis, vasculitis Hypertension Carbon monoxide poisoning CPR

26. Robert A Shapiro, MD, Patricia A. Myers, MSW Case reports of RH following CPR Pre-resuscitation exam revealed no RH –Kramer, Clinical Peds; 17 mo old with 15% dehydration & fever No pre-resuscitation exam available –Bacon, BMJ; near miss SIDS –Kirschner, AJDC; 3 mo old after vigorous CPR –Weedn; Am J Forensic Path; 4 mo old burn victim

27. Robert A Shapiro, MD, Patricia A. Myers, MSW Retinal hemorrhage after CPR or child abuse. Kanter, J Pediatrics 1986 6/54 children had RH after CPR –55% < 2 y/o 4 children with head injury from abuse 1 child with head injury following MVA 1 child with severe hypertension

28. Robert A Shapiro, MD, Patricia A. Myers, MSW Retinal hemorrhage after CPR: An etiologic reevaluation. Goetting, Pediatrics 1990 20 children admitted to PICU after CPR –2wk - 17 y/o 2 children had retinal hemorrhages –2 y/o near drowning in tub (abuse w/u negative) multiple, large, bilateral RH –6 w/o infant r/o sepsis, died 38hr after admission single, small unilateral RH, otherwise - postmortem

29. Robert A Shapiro, MD, Patricia A. Myers, MSW Prevalence of retinal hemorrhage after in-hospital CPR Odom, Pediatrics 1997 (Memphis) 43 children had CPR –mean age 23 months –mean duration of chest compressions: 16 minutes –all patients survived CPR until ophthalmologic exam –93% had elevated PT &/or PTT; 50% low platelets only one patient had small punctate hemorrhages

30. Robert A Shapiro, MD, Patricia A. Myers, MSW Significance of retinal hemorrhages in head injured children Very unusual after accidental head injury –high velocity injuries –injuries with high rotational component –stairway fall in walker? CPR may rarely cause small punctate hemorrhages Other conditions may cause RH but abuse is most likely if head injury is also present

31. Robert A Shapiro, MD, Patricia A. Myers, MSW Family Risk Factors Substance abuse Lack of support Economic stress and poverty Lack of knowledge of child development Domestic violence Male perpetrators

32. Robert A Shapiro, MD, Patricia A. Myers, MSW Morbidity of Shaken Baby Syndrome 10 - 20 cases / year in Cincinnati death rate: 30-40% developmentally handicapped: 80-90%

33. Robert A Shapiro, MD, Patricia A. Myers, MSW National Prevention Organizations Children’s Trust and Prevention Funds Don’t Shake the Baby Parents Anonymous National Committee to Prevent Child Abuse

34. Robert A Shapiro, MD, Patricia A. Myers, MSW Individual Prevention Efforts Recognition of high risk families Support of new parents Recognition of frustration & exhaustion Parenting materials and group supports Development of an escape plan Referral to community resources Lobby for more prevention programs Speak at local community groups

35. Robert A Shapiro, MD, Patricia A. Myers, MSW Conclusion Differentiating inflicted from accidental head injury is challenging. Infants rarely sustain intracranial injury after falls at home. Intracranial injury with retinal hemorrhages is usually child abuse. Infants will sustain contusions / fractures / epidural hemorrhages from minor falls.