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    Wednesday, September 9, 2009


    A child comes into the ER for a possible fracture. A skeletal survey is performed that reveals a healing right radial neck fracture. The medical record from the urgent care center is obtained. This includes a clinical note dated 4 months prior to patient's presentation to the ED, which described a visit for repeated emesis and irritability. A bruise on the chin was noted on that visit, and the explanation given was a fall inside the patient's crib that occurred 4 days prior to that visit. A report to the Department of Children and Families was found to have been made for missed well-child visits

    The level of suspicion for suspected abusive head trauma (AHT) and child abuse should be high. AHT in babies less than 1 year old represents a significant fraction of young children admitted for head injury. Approximately 30% of children aged 0-3 years admitted to pediatric hospitals for intracranial injury have been found to meet the criteria for abuse. Crying is thought to be a trigger for many cases of AHT and prevention efforts are directed toward caregiver response to colicky babies and crying infants.

    Approximately 30% of children with AHT may be missed on the initial presentation. Common misdiagnoses include viral gastroenteritis, sepsis, and accidental head injury. Common symptoms at presentation are often the result of acute brain injury (ie, lethargy, decreased level of consciousness, vomiting, apnea, hypotonia, and seizures).
    The physical examination findings may include evidence of soft tissue injury, particularly swelling or bruising; however, the absence of bruising or other evidence of trauma neither excludes injury nor abuse.

    Funduscopic examination should be performed in any child suspected to have abusive head injury, preferably by an ophthalmologist with sufficient pediatric experience to determine the significance of any identified injury.Retinal hemorrhages are a hallmark finding in abusive head injury, and they are present in a majority of children who carry the diagnosis. They may be unilateral or bilateral and involve 1 or more layers. The mechanism of retinal hemorrhages is unclear, but the leading theory is that they are caused by vitreous traction on the retina during acceleration/deceleration. Lasting visual impairment in those children who survive AHT is common.CT scanning is an essential part of the initial workup of suspected head trauma. CT scanning can also be helpful as a screening neuroimaging study in children with suspected abuse. Even without clinical examination findings of brain injury, a significant number of abused infants will have important findings on neuroimaging.

    Unilateral, bilateral, or parafalcine subdural hemorrhages are the most common radiologic finding in infants with AHT. Subdural hemorrhages of mixed attenuation have previously been considered as evidence for repeated head injury, with hyperdense components of the hemorrhage associated with injury occurring in the past 48-72 hours and hypodense components representing older injury occurring more than 3 weeks prior to the scan. Hyperacute bleeding or the mixing of blood and cerebrospinal fluid (CSF), however, can produce mixed-density lesions from a single injury. While the presence of subdural hemorrhage lends supporting evidence to the diagnosis of head trauma, inferences about the timing and mechanism of injury cannot be drawn with certainty from a single noncontrast CT scan.Magnetic resonance imaging (MRI) can be a useful study for demonstrating parenchymal contusion, axonal shearing, extra-axial hemorrhages, and posterior fossa injuries. Diffusion-weighted imaging and apparent diffusion coefficient mapping are particularly useful. Additional supportive evidence for child abuse is obtained through a skeletal survey. The presence of previously healed fractures in infants is strongly suggestive of chronic abuse.

    While the cause of subdural hematoma in association with retinal hemorrhage will most commonly be abusive head injury, a differential diagnosis for these findings must be considered. It is important for clinicians to be mindful of the diagnosis of AHT, but first rule out other rare causes that can mimic abuse.

    • Coagulopathies have been associated with retinal and intracranial hemorrhage in infants, including hemophilia, vitamin-K deficiency, and disseminated intravascular coagulopathy. Retinal hemorrhages in these disorders are typically confined to the posterior pole, and the nature of the bleeding problem can be detected by laboratory tests. It is recommended to perform a prothrombin time, activated partial-thromboplastin time, and a platelet count as minimum screening tests.

    • Glutaric aciduria type I, a rare metabolic disease, is associated with developmental delay and subdural hemorrhages. Performing an assay for organic acids in the urine can test for this disease.

    • Other causes of intracerebral hemorrhage include cerebral malaria, intracranial aneurysms, galactosemia, and meningitis.

    • Osteogenesis imperfecta is an uncommon connective tissue disorder that frequently results in fractures. Subdural hemorrhage has rarely been described as a complication of this disease.

    • Because these disorders can closely mimic abusive head trauma, it is important to maintain a nonaccusatory and open-minded posture during the initial evaluation, as parents are understandably sensitive to the possibility that they are being accused of harming their children. Some helpful statements include "I'm concerned that someone may have harmed your child" and "several diseases can explain this pattern of injury, including trauma. We need to check for other signs of these illnesses to make sure your child is safe."

    Notwithstanding the latest negative publicity about CT scans, clinicians should have a low threshold for performing CT scans of the head on infants coming in with nonspecific findings that could be explained by head injury, when appropriate.

    While reporting a reasonable suspicion for abuse is mandatory, it is not the job of the healthcare provider to determine the social or legal management of any case.

    A child protection team, if available, should be consulted with any concerns of abusive injury. AHT is likely underdiagnosed and underreported, which contributes to the dismal outcomes for children eventually diagnosed with abuse. In multiple series, the mortality is approximately 20%.
    The neurologic outcome is also poor, with many survivors having persistent neurologic and behavioral deficits.

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    *Tune in later for THE TREATMENT OF PINK EYE.

    Deepen your understanding of "medical malpractice"...

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