Abusive Head Trauma Cases Research Articles

Illicit Drug Exposure in Patients Evaluated for Alleged Child Abuse and Neglect

Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs. The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect. The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study. Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034). The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.

Multicystic encephalomalacia as an end-stage finding in abusive head trauma

Abusive head trauma (AHT) is one of the most severe forms of physical child abuse. If a child initially survives severe AHT the neurological outcome can be poor. In recent years several children were seen who developed multicystic encephalomalacia (MCE) after documented severe AHT. A search of the Netherlands Forensic Institute database in The Hague was performed. Inclusion criteria were cases of AHT between 1999 and 2010 where the child was under the age of 1 year old at the time of trauma. Trauma mechanism and radiological information were collected. Five children, three boys and two girls (mean age 57 days, range 8–142 days) who developed cystic encephalomalacia after inflicted traumatic brain injury were included. Survival ranged from 27 to 993 days. In all cases judicial autopsy was performed. All cases came before court and in each case child abuse was considered to be proven. In two cases the perpetrator confessed, during police interrogation, to shaking of the child only. Although a known serious outcome, this is one of the few reports on MCE as a result of AHT. In all cases the diagnosis was confirmed at autopsy.

Abusive Head Trauma in Children: A Comparison of Male and Female Perpetrators

To evaluate the effect of perpetrator gender on victim presentation and outcomes, and perpetrator legal outcomes for abusive head trauma (AHT). We performed a retrospective chart review of AHT cases from 1998 to 2008. Patient clinical data and information regarding perpetrator legal outcome was obtained. Relationship of brain injury and retinal hemorrhages (RHs) and differences in categorical variables of perpetrator gender were compared by using Fisher's exact test. Differences in continuous variables between perpetrator gender were compared by using the Mann-Whitney Test. There were 34 cases of AHT with identified perpetrators, 17 of each gender. Mean age of the victims was 9.4 months (SD: 7.8). Thirty-two (94%) had intracranial hemorrhages, 14 (41%) had both primary and secondary brain injury, 28 (82%) had RHs, and 6 (18%) died. The severity of RH was related to the severity of brain injuries (P = .01). The median age for female perpetrators (34 years) was higher than that for males (27 years; P = .001). Six categorical variables were associated with male perpetrator gender: acute presenting symptoms of cardiopulmonary or respiratory arrest (P = .025), worse clinical outcome (P = .012), neurosurgical intervention (P = .037), death (P = .018), perpetrator confession (P = .0001), and conviction (P = .005). There were significant perpetrator gender differences of AHT in children. Male perpetrators were younger and more likely to confess and be convicted. Victims of male perpetrators had more serious acute presentations and neurosurgical intervention and suffered worse clinical outcomes.

Abnormal Neuroimaging is Associated with Early In-Hospital Seizures in Pediatric Abusive Head Trauma

Abusive head trauma (AHT) is a common condition in children. Little is known in this condition regarding the frequency of seizures, the factors associated with increased risk of seizures, or the association of seizures with outcome. We sought to determine frequency and risks for in-hospital seizures after AHT. This was a single-center, retrospective chart review study at a 270 bed tertiary care referral pediatric hospital. A total of 54 cases of AHT were identified during the study period. During the first week following hospital admission, 33% of patients were observed to have clinical seizures. The occurrence of clinical seizures after admission was associated with findings on initial CT including midline shift, cerebral edema, and loss of gray white differentiation. MRI findings associated with clinical seizures after admission included midline shift, cerebral edema, infarction, and restricted diffusion. The presenting complaint of seizures or acute mental status changes well as a variety of abnormal imaging findings including gray white blurring, infarction, and edema were associated with short-term outcomes. Specific neuroradiologic findings identify children at greater risk for seizures, both clinical and subclinical, following AHT. Clinical and subclinical seizures are common in the initial hospitalization for AHT.

Prevalence of Retinal Hemorrhages in Perpetrator-Confessed Cases of Abusive Head Trauma

Prevalence of Retinal Hemorrhages in Perpetrator-Confessed Cases of Abusive Head Trauma

Fatal Abusive Head Trauma Cases

Missed diagnosis of child abuse may lead to chronic abuse with potential for death. This paper reports 3 such cases. This is a retrospective chart review of 38 cases diagnosed as abusive head trauma between January 1, 2004 and December 31, 2006 at a university hospital. We sought to identify fatal cases with a past medical history of physical abuse that was missed by the medical staff. Three cases (7.9%) had a past medical history of physical abuse that was missed by the medical staff. Infants were 2 males and 1 female. Their ages were 2.5, 3.5, and 6 months, respectively. Missed abuse episodes involved rib fractures, a metaphyseal tibial fracture, and a shaking episode, respectively. The intervals that had elapsed between the missed and the fatal abuse episodes were 24 hours, 12 days, and 6 weeks, respectively. Perpetrators of fatal head trauma were all biological fathers. One plead guilty, and 2 were convicted of involuntary manslaughter. The infants were in the care of the perpetrators of the fatal abuse episodes at the time the missed abuse episodes occurred. Physicians assessing children, especially infants, should be alert to indicators of abusive trauma to recognize abuse early on. Including abusive trauma in the differential diagnostic list and taking appropriate steps to rule out or confirm the diagnosis are of paramount importance in establishing child protective services and preventing further abuse and neglect that may at times be fatal.

Characteristics That Distinguish Abusive From Nonabusive Head Trauma Among Young Children Who Underwent Head Computed Tomography in Japan

Distinguishing abusive head trauma in young children from other diseases by symptoms is difficult in practice. Comparisons between abusive and nonabusive head trauma in young children in Japan, where computed tomography is widely and easily available, might contribute to identifying markers of abusive head trauma that differ from that in Western countries. The objective of this study was to compare the characteristics of abusive and nonabusive head trauma in young children in Japan. A comparative case series study involving a retrospective medical chart and social work record review of children who were aged 0 to 2 years, visited the National Center for Child Health and Development (Tokyo, Japan) from March 1, 2002, to December 31, 2005, and underwent computed tomography scanning because of suspected intracranial injury was performed. Patients (N = 260) were identified and classified as having either abusive or nonabusive head trauma on the basis of the published definition. Demographic and perinatal characteristics, injury history, clinical presentation, and outcomes were compared by using chi2 and Fisher's exact tests. Patients with abusive head trauma were significantly younger than patients with nonabusive head trauma and had a peak at approximately 2 to 4 and 7 to 9 months. Patients with abusive head trauma more likely presented no injury history by the caregiver, neurologic symptoms (unconsciousness, seizure, paralysis), subdural hemorrhage, and retinal hemorrhages. Although patients with abusive head trauma had severe clinical outcomes, only 32% of them were separated from the caregiver by social welfare services. This study highlights the several clinical markers to detect abusive head trauma at a medical visit, including an absence of injury history, neurologic symptoms, subdural hemorrhage, and retinal hemorrhage. These markers can be used to detect abusive head trauma cases by physicians and social welfare workers to protect children from additional abuse.

Functional time limit and onset of symptoms in infant abusive head trauma

To analyse medical and witness evidence collected during investigations of infant abusive head trauma with a view to (i) isolating cases where a functional time limit could be established and (ii) examining those cases for evidence of the onset of neurological symptoms. A retrospective study was undertaken of severe infant abusive head trauma cases investigated by the Queensland Police Service over a 10-year period. In cases where sufficient reliable (non-perpetrator) evidence was available, a functional time limit was documented. Those files were then examined for further medical, witness or perpetrator evidence of the infant victim's response to the assault. A functional time limit was established in 16 of 52 cases (31%). In 11 of the 16 cases there was evidence of an immediate neurological response on the part of the victim. The study suggests that the period between assault and onset of symptoms in infant abusive head trauma is brief, particularly in cases of an acute deterioration where proximate medical intervention is required. In those cases with sufficient evidence of the victim's condition post-injury, the symptoms presented without delay.

Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experienced abusive head trauma.

To describe the clinical use of a wide-field digital ophthalmic camera (RetCam 120; Massie Research Laboratories, Inc, Dublin, Calif) for the documentation of retinal hemorrhages in patients who experienced abusive head trauma. Case series. Pediatric intensive care unit at a tertiary care center. Children with suspected abusive head trauma. Eight children were studied during a 9-month period. The median age of the children was 2.25 months (range, 0.8-18.0 months). There were 4 male and 4 female patients. All patients had intracranial bleeding, documented by computed axial tomographic scans of the head. Of the 8 patients, 6 had bilateral retinal hemorrhages. All patients underwent a formal examination by a pediatric ophthalmologist (R.S. and others) using a wide-field digital ophthalmic camera. Three children died. The wide-field digital ophthalmic camera allowed good visualization and produced high-quality photographic images, resulting in instant bedside documentation of retinal pathological features. The wide-field digital ophthalmic camera provides a new tool for the evaluation and precise documentation of retinal hemorrhages in suspected and confirmed cases of abusive head trauma.

Chapter Eighteen: Controversies in Shaken Baby/Shaken Impact Syndrome

Summary Controversies invariably exist when hypotheses about biological phenomena cannot be studied directly (in clinical settings where information is readily available) or indirectly (with the creation of biological models approximating the organism in question). This creates missing links in the chain of logic and results in incomplete faith in some conclusions about these phenomena. Such is the case in shaken baby /shaken impact syndrome. Because abusive head trauma occurs without witnesses other than the perpetrator in most cases, we need to infer certain information to fill the gaps of validated facts. This leaves room for scientific and legal challenge. But there is increasing clinical and research data elucidating this condition. Although SBS cannot be studied in the bench laboratory tradition or even in the tradition of the hospital-based research scientist, there is a generation of new knowledge that is providing answers. These answers are being found in studies done by a wide range of scientists who have contact with abusive head trauma cases at some point in the process of care. Emergency department clinicians, intensive care specialists, hospital attending clinicians, forensic pediatricians, pediatric ophthalmologists, neurosurgeons, radiologists, forensic and neuro-pathologists all have contributed to this literature.

Nearly One-Third of Abusive Head Trauma Missed

Nearly One-Third of Abusive Head Trauma Missed

Analysis of missed cases of abusive head trauma.

Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children. To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis. Retrospective chart review of cases of head trauma presenting between January 1, 1990, and December 31, 1995. Academic children's hospital. One hundred seventy-three children younger than 3 years with head injuries caused by abuse. Characteristics of head-injured children in whom diagnosis of AHT was unrecognized and the consequences of the missed diagnoses. Fifty-four (31.2%) of 173 abused children with head injuries had been seen by physicians after AHT and the diagnosis was not recognized. The mean time to correct diagnosis among these children was 7 days (range, 0-189 days). Abusive head trauma was more likely to be unrecognized in very young white children from intact families and in children without respiratory compromise or seizures. In 7 of the children with unrecognized AHT, misinterpretation of radiological studies contributed to the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%) experienced medical complications related to the missed diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been prevented by earlier recognition of abuse. Although diagnosing head trauma can be difficult in the absence of a history, it is important to consider inflicted head trauma in infants and young children presenting with nonspecific clinical signs.

Establishing a register of children with special needs.

<h3>Objective</h3> In March of 2008, an expert panel was convened at the Centers for Disease Control and Prevention to develop code-based case definitions for abusive head trauma (AHT) in children under 5 years of age based on the <i>International Classification of Diseases, 10th Revision</i> (<i>ICD-10</i>) nature and cause of injury codes. This study presents the operational case definition and applies it to US death data. <h3>Methods</h3> National Center for Health Statistics National Vital Statistics System data on multiple cause-of-death from 2003 to 2007 were examined. <h3>Results</h3> Inspection of records with at least one <i>ICD-10</i> injury/disease code and at least one <i>ICD-10</i> cause code from the AHT case definition resulted in the identification of 780 fatal AHT cases, with 699 classified as definite/presumptive AHT and 81 classified as probable AHT. The fatal AHT rate was highest among children age &lt;1 year with a peak in incidence that occurred at 1–2 months of age. Fatal AHT incidence rates were higher for men than women and were higher for non-Hispanic African–Americans compared to other racial/ethnic groups. Fatal AHT incidence was relatively constant across seasons. <h3>Conclusions</h3> This report demonstrates that the definition can help to identify population subgroups at higher risk for AHT defined by year and month of death, age, sex and race/ethnicity. This type of definition may be useful for various epidemiological applications including research and surveillance. These activities can in turn inform further development of prevention activities, including educating parents about the dangers of shaking and strategies for managing infant crying.