Abusive Head Trauma In Infants Research Articles

When soothing succeeds: Simulating a risk for repeated shaking in abusive head trauma in infants

PurposeTo investigate the observation that perpetrators of abusive head trauma engage in repeated shakings because shaking “works” to quiet the infant. MethodsSixty first-time parent couples individually cared for a programmable model infant in two consecutive 7-min trials. After six minutes of consolable followed by inconsolable crying, parents selected one of three soothing techniques. For trial one, parents were randomized to a “Successful” or “Failed” Soothing Condition. Whether the soothing technique was repeated after trial two was determined by the study investigators. Parents rated their frustration after each trial. ResultsAs hypothesized, parents were more likely to repeat a soothing technique that “worked” in trial one. Compared to fathers, mothers reported more frustration when soothing failed. ConclusionsThat caregivers were more likely to repeat a successful soothing technique converges with perpetrator confessions that crying cessation after shaking may be a reason why shaking is used repeatedly in response to crying.

A 15 year cohort review of in-hospital pediatric trauma center mortality: A catalyst for injury prevention programming

BackgroundThe objective of our study was to identify the most common mechanisms of injury leading to death in our pediatric population. MethodsA retrospective cohort of fatally injured children 0–17 years old treated at our trauma center during 2000–2015. ResultsThe mortality rate in our population was 8% (n = 103). Fifty-five percent were male. The majority (76%) of fatal injuries were blunt. Overall, motor vehicle collisions (MVCs) were the most common mechanism of injury (61%), followed by assault/abuse (9%). Of the deaths caused by MVCs, 37 (59%) were occupants, 11 (17%) were pedestrians, and 6 (10%) were cyclists. In the infant sub-population, assault/abuse was the most common mechanism of injury. ConclusionMVCs were the leading cause of death in this population. In the infant subpopulation (<1 year), abusive head trauma emerged as the leading mechanism. Injury prevention programming should target abusive head trauma in infants and teen road safety.

Retinal haemorrhage in infants with pertussis

AimsIt has been hypothesised that paroxysmal coughing in infantile pertussis (whooping cough) could produce retinal haemorrhages identical to those seen in abusive head trauma. We aimed to test this hypothesis.MethodsThis...

Barriers and Facilitators to Recognition and Reporting of Child Abuse by Prehospital Providers

Background: Prehospital care providers are in a unique position to provide initial unadulterated information about the scene where a child is abusively injured or neglected. However, they receive minimal training with respect to detection of Child Abuse and Neglect (CAN) and make few reports of suspected CAN to child protective services. Aims: To explore barriers and facilitators to the recognition and reporting of CAN by prehospital care providers. Design/Methods: Twenty-eight prehospital care providers participated in a simulated case of infant abusive head trauma prior to participating in one-on-one semi-structured qualitative debriefs. Researchers independently coded transcripts from the debriefing and then collectively refined codes and created themes. Data collection and analysis continued past the point of thematic saturation. Results: Providers described 3 key tasks when caring for a patient thought to be maltreated: (1) Medically managing the patient, which included assessment of the patient's airway, breathing, and circulation and management of the chief complaint, followed by evaluation for CAN; (2) Evaluating the scene and family interactions for signs suggestive of CAN, which included gathering information on the presence of elicit substances and observing how the child behaves in the presence of caregivers; and (3) Creating a safety plan, which included, calling police for support, avoiding confrontation with the caregivers and sharing suspicion of CAN with hospital providers and child protective services. Reported barriers to recognizing CAN included discomfort with pediatric patients; uncertainty related to CAN (accepting parental story about alternative diagnosis and difficulty distinguishing between accidental and intentional injuries); a focus on the chief complaint; and limited opportunity for evaluation. Barriers to reporting included fear of being wrong; fear of caregiver reactions; and working in a fast-paced setting. In contrast, facilitators to reporting included understanding of the mandated reporter role; sharing thought processes with peers; and supervisor support. Conclusions: Prehospital care providers have a unique vantage point in detecting CAN, but limited resources and knowledge related to this topic. Focused education on recognition of signs of physical abuse; increased training on scene safety; real-time decision support; and increased follow-up related to cases of CAN may improve their detection of CAN.

Cyclic Head Rotations Produce Modest Brain Injury in Infant Piglets.

Repetitive back-and-forth head rotation from vigorous shaking is purported to be a central mechanism responsible for diffuse white matter injury, subdural hemorrhage, and retinal hemorrhage in some cases of abusive head trauma (AHT) in young children. Although animal studies have identified mechanisms of traumatic brain injury (TBI) associated with single rapid head acceleration-decelerations at levels experienced in a motor vehicle crash, few experimental studies have investigated TBI from repetitive head rotations. The objective of this study was to systematically investigate the post-injury pathological time-course after cyclic, low-velocity head rotations in the piglet and compare them with single head rotations. Injury metrics were the occurrence and extent of axonal injury (AI), extra-axial hemorrhage (EAH), red cell neuronal/axonal change (RCNAC), and ocular injury (OI). Hyperflexion/extension of the neck were purposefully avoided in the study, resulting in unscaled angular accelerations at the lower end of reported infant surrogate shaking kinematics. All findings were at the mild end of the injury spectrum, with no significant findings at 6 h post-injury. Cyclic head rotations, however, produced modest AI that significantly increased with time post-injury (p < 0.035) and had significantly greater amounts of RCNAC and EAH than noncyclic head rotations after 24 h post-injury (p < 0.05). No OI was observed. Future studies should investigate the contributions of additional physiological and mechanical features associated with AHT (e.g., hyperflexion/extension, increased intracranial pressure from crying or thoracic compression, and more than two cyclic episodes) to enhance our understanding of the causality between proposed mechanistic factors and AHT in infants.

A statewide nurse training program for a hospital based infant abusive head trauma prevention program

Successful implementation of universal patient education programs requires training large numbers of nursing staff in new content and procedures and maintaining fidelity to program standards. In preparation for statewide adoption of a hospital based universal education program, nursing staff at 85 hospitals and 1 birthing center in North Carolina received standardized training. This article describes the training program and reports findings from the process, outcome and impact evaluations of this training. Evaluation strategies were designed to query nurse satisfaction with training and course content; determine if training conveyed new information, and assess if nurses applied lessons from the training sessions to deliver the program as designed.Trainings were conducted during April 2008–February 2010. Evaluations were received from 4358 attendees. Information was obtained about training type, participants' perceptions of newness and usefulness of information and how the program compared to other education materials. Program fidelity data were collected using telephone surveys about compliance to delivery of teaching points and teaching behaviors. Results demonstrate high levels of satisfaction and perceptions of program utility as well as adherence to program model. These findings support the feasibility of implementing a universal patient education programs with strong uptake utilizing large scale systematic training programs.

Outcomes and factors associated with infant abusive head trauma in the US.

OBJECT Head trauma is the leading cause of death in abused children, particularly prior to the age of 2 years. An awareness of factors associated with this condition as well as with a higher risk of mortality is important to improve outcomes and prevent the occurrence of these events. The objective of this study was to evaluate outcomes and factors associated with poor outcomes in infants with diagnosed abusive head trauma (AHT). Patient characteristics, socioeconomic factors, and secondary conditions such as retinal bleeding, contusion, and fractures were considered. METHODS Data were obtained from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. From the Kids' Inpatient Database (KID) sample, the authors identified infants no older than 23 months who had been diagnosed with AHT in 2000, 2003, 2006, and 2009. All statistical analyses were conducted in SAS 9.2. Descriptive statistics were provided, and multivariate logistic regression models were applied to evaluate factors associated with mortality and nonroutine discharge. RESULTS A total of 5195 infants were analyzed in this study. Most infants (85.5%) had ages ranging between 0 and 11 months and were male (61.6%). Overall mortality was 10.8%, with a rate of 9.8% in the 0- to 11-month-old cohort and 16.5% in the 12- to 23-month-olds (p = 0.0003). The overall nonroutine discharge rate of 25.6% increased significantly from 23.3% to 39.0% with increasing age (0-11 vs 12-23 months of age, p < 0.0001). Assuming a multivariate model that adjusted for multiple confounders, the authors found that older infants (12-23 vs 0-11 months, OR 1.81, 95% CI 1.18-2.77) with a secondary diagnosis of retinal bleeding (OR 2.85, 95% CI 2.02-4.00) or shaken baby syndrome (OR 2.09, 95% CI 1.48-2.94) had an increased risk of mortality; these factors were similarly associated with an increased odds of a nonroutine discharge. A higher income ($30,001-$35,000 vs $1-$24,999) was associated with a reduction in the odds of mortality (OR 0.46, 95% CI 0.29-0.72). In the subset of cases (1695 [32.6%]) that specified the perpetrator involved in infant injury, the authors found that the father, stepfather, or boyfriend was most frequently reported (67.4%). A trend for a higher AHT incidence was documented in the early ages (peak at 2 months) compared with older ages. CONCLUSIONS Despite the higher incidence of AHT among infants during the earlier months of life, higher mortality was documented in the 12- to 23-month-olds. Retinal bleeding and shaken baby syndrome were secondary diagnoses associated with higher mortality and nonroutine discharge. Males (67.4%) were overwhelmingly documented as the perpetrators involved in the injury of these infants.

Revisiting neuroimaging of abusive head trauma in infants and young children.

The purpose of this article is to use a mechanism-based approach to review the neuroimaging findings of abusive head trauma to infants. Advanced neuroimaging provides insights into not only the underlying mechanisms of craniocerebral injuries but also the long-term prognosis of brain injury for children on whom these injuries have been inflicted. Knowledge of the traumatic mechanisms, the key neuroimaging findings, and the implications of functional imaging findings should help radiologists characterize the underlying causes of the injuries inflicted, thereby facilitating effective treatment.

Imaging of skeletal injuries associated with abusive head trauma.

Skeletal injuries are commonly encountered in infants and young children with abusive head trauma. Although certain patterns of intracranial injury suggest abuse, none are diagnostic. Therefore demonstration of associated unsuspected skeletal injuries has important implications, particularly when highly specific fractures are present. Skull fractures are commonly associated with intracranial injury, but no fracture pattern is indicative of physical abuse. Other skeletal injuries including classic metaphyseal lesions and rib, spine and scapular fractures are strong predictors of abusive head trauma in infants with intracranial injury. It is mandatory to perform rigorous skeletal surveys in infants and young children with clinical and neuroimaging findings concerning for abusive head trauma.

The neonatal nurse's role in preventing abusive head trauma.

Abusive head trauma in infants occurs in 24.6 to 39.8 per 100,000 infants in developed countries. Abusive head trauma refers to any type of intentional head trauma an infant sustains, as a result of an injury to the skull or intracranial contents from a blunt force and/or violent shaking. The clinical question was: what evidence-based interventions have been implemented by neonatal nurses to prevent abusive head trauma in infants? PubMed was searched to obtain English language publications from 2005 to May 2014 for interventions focused on preventing abusive head trauma using the key term "shaken baby syndrome." A total of 10 studies were identified that met the inclusion criteria. All of the interventions targeted prevention of abusive head trauma with information about abusive head trauma/shaken baby syndrome and the "normal" infant crying behaviors. Interventions taught parents why infants cried, how to calm the infants, ways to cope with inconsolable infants, and how to develop a plan for what to do if they could not cope anymore. Parents who participated in the interventions were consistently able to explain the information and tell others about the dangers of shaking infants compared to the control parents. Only 2 studies calculated the preintervention abusive head trauma rate and the postintervention frequency of abusive head trauma. Each found significant differences in abusive head trauma.

Characterization of microstructural injury: a novel approach in infant abusive head trauma-initial experience.

Abusive head trauma (AHT) is the leading cause of morbidity and mortality among abused children, yet the neuroanatomical underpinnings of AHT outcome is incompletely understood. The aim of this study was to characterize white matter (WM) abnormalities in infants with AHT using diffusion tensor imaging (DTI) and determine which microstructural abnormalities are associated with poor outcome. Retrospective DTI data from 17 infants (>3 months) with a diagnosis of AHT and a comparison cohort of 34 term infants of similar post-conceptual age (PCA) were compared using a voxel-based DTI analysis of cerebral WM. AHT cases were dichotomously classified into mild/moderate versus severe outcome. Clinical variables and conventional imaging findings were also analyzed in relation to outcome. Outcomes were classified in accordance with the Pediatric Cerebral Performance Category Score (PCPCS). Reduced axial diffusivity (AD) was shown in widespread WM regions in the AHT infants compared with controls as well as in the AHT severe outcome group compared with the AHT mild/moderate outcome group. Reduced mean diffusivity (MD) was also associated with severe outcome. Radial diffusivity (RD), conventional magnetic resonance findings, brain metric measurements, and clinical/laboratory variables (with the exception of Glascow Coma Scale) did not differ among AHT outcome groups. Findings support the unique role of DTI techniques, beyond conventional imaging, in the evaluation of microstructural WM injury of AHT. Reduced AD (likely reflecting axonal damage) and MD were associated with poor clinical outcome. DTI abnormalities may uniquely reflect AHT patterns of axonal injury that are not characterized by conventional imaging, which may have both therapeutic and prognostic implications.

Imaging of spinal injury in abusive head trauma: a retrospective study

Spinal imaging has been a neglected part of abusive head trauma (AHT) imaging. As most of the radiographs and CT spine are negative in AHT in infants, the cervical spine is assumed to be normal. There is increasing evidence in the role of injury to brainstem and cervical cord in the pathogenesis of AHT. In addition, in courts of law, there is fierce debate about AHT, its mimics and other disparate nontraumatic diagnoses explaining the neuroradiological and skeletal findings. However, this discussion ignores the evidence and significance of spinal injury. We sought to study the cervical spine in an AHT cohort to understand the true prevalence of spinal injuries in AHT and contrast it with cohorts of accidental and nontraumatic groups to give the clinicians a robust diagnostic tool in evaluating AHT. The purpose of this study is to compare the relative incidence of spinal ligamentous and soft-tissue abnormalities on spinal MRI among three groups of children ages <48months: 1) those with AHT, 2) those with accidental trauma, and 3) those with nontraumatic conditions. This comparative study included 183 children who underwent spine MRI: 67 with AHT, 46 with accidental trauma and a clinical suspicion of spinal injury, and 70 with nontraumatic conditions. Clinical and radiographic findings were collected in all cases and were analyzed retrospectively to identify MRI evidence of traumatic spinal injuries. The incidence of spinal injuries among the three groups was compared. The incidence of spinal ligamentous injuries was calculated for those with and without radiographic evidence of hypoxic-ischemic encephalopathy. All comparisons were performed using Fisher exact test with P < 0.05 considered statistically significant. Cervical spine ligamentous injuries (predominantly the nuchal, atlanto-occipital and atlanto-axial ligaments) were present in 78% of the AHT group, 46% of the accidental trauma group and 1% of the nontraumatic group; all of these differences were statistically significant. Among the AHT group, ligamentous injuries were statistically correlated with evidence of brain ischemia. Injury to the cervical spinal posterior ligamentous complex is common in AHT and even more prevalent than in clinically symptomatic traumatic cases. The high correlation between the radiographic findings of occipitocervical ligamentous injuries and hypoxic-ischemic brain injury is consistent with an interpretation that transient upper occipitocervical spinal cord injury in AHT leads to disordered breathing and results in hypoxic-ischemic encephalopathy. We recommend imaging the entire spine in AHT to properly identify and classify these injuries.

Infant abusive head trauma prevention: acceptability of the Period of PURPLE Crying® program in far north Queensland, Australia

A study examined the appropriateness and likelihood of usage of the north American Period of PURPLE Crying® intervention program in far north Queensland, to educate families about the risk of infant abusive head trauma (AHT)/shaken baby syndrome. A mixed-method cross-sectional study with a questionnaire and semi-structured interview was conducted with 33 health professionals in far north Queensland (FNQ) to gauge their opinions of the Period of PURPLE Crying program's educational materials. Seventy per cent of participants were aware of infant AHT; 87.8% agreed the program would be appropriate for far north Queensland populations; 90% agreed that new parents/carers could learn new strategies to deal with inconsolable crying, and that men would be particularly advantaged. In their present form, the educational materials of the Period of PURPLE Crying are appropriate for use. As such, the researchers intend to undertake a pilot implementation in FNQ.

Infant Abusive Head Trauma in a Military Cohort

Evaluate the rate of, and risk factors for, abusive head trauma (AHT) among infants born to military families and compare with civilian population rates. Electronic International Classification of Diseases data from the US Department of Defense (DoD) Birth and Infant Health Registry were used to identify infants born to military families from 1998 through 2005 (N = 676 827) who met the study definition for AHT. DoD Family Advocacy Program data were used to identify infants with substantiated reports of abuse. Rates within the military were compared with civilian population rates by applying an alternate AHT case definition used in a civilian study. Applying the study definition, the estimated rate of substantiated military AHT was 34.0 cases in the first year of life per 100 000 live births. Using the alternate case definition, the estimated AHT rate was 25.6 cases per 100 000 live births. Infant risk factors for AHT included male sex, premature birth, and a diagnosed major birth defect. Parental risk factors included young maternal age (<21 years), lower sponsor rank or pay grade, and current maternal military service. This is the first large database study of AHT with the ability to link investigative results to cases. Overall rates of AHT were consistent with civilian populations when using the same case definition codes. Infants most at risk, warranting special attention from military family support programs, include infants with parents in lower military pay grades, infants with military mothers, and infants born premature or with birth defects.

Infant Abusive Head Trauma in a Military Cohort

Infant Abusive Head Trauma in a Military Cohort

Abusive head trauma: Report of 3 cases

Abusive head trauma (AHT) is perpetrated when an infant or young child is shaken violently by an abuser, resulting in injuries to various intracranial structures, historically called "shaken baby syndrome" (SBS). Three cases of AHT with different constellations of clinical symptoms are presented here. Case 1- Three-month-old female infant was admitted with recurrent seizures, drowsiness, and low grade fever. Ophthalmologic examination revealed retinal hemorrhages (RH) in the left eye. Computed tomography of cranium showed left frontal intra-parenchymal subdural hematoma (SDH). Case 2- Twelve-month-old male infant was admitted with a history of favoring left leg. Ophthalmologic examination revealed RH in the right eye. Cranial magnetic resonance imaging (MRI) revealed subacute SDH in the right frontoparietal region. Case 3- Three-month-old male infant was admitted with irritability and seizures. Ophthalmologic examination revealed bilateral disseminated RH. Cranial MRI scan showed bilateral frontoparietal subacute SDH. All cases were reported to Child Protective Services, who decided not to remove children from homes, but evaluated psychosocial risks and developed a safety plan, including home visits and family education. Physicians must be aware of possibility of AHT in infants presenting both subtle and overt neurologic symptoms. It is important to provide training on AHT to staff involved in the management of these cases.

Abusive head trauma in infants and why we CAN afford to prevent it

Abusive head trauma in infants and why we CAN afford to prevent it

Clues to Abusive Head Trauma in Infants with ALTE

Clues to Abusive Head Trauma in Infants with ALTE

Reply to Pr Charles Hyman: the scientific controversy over abusive head trauma in infants

Reply to Pr Charles Hyman: the scientific controversy over abusive head trauma in infants

Reply to Dr John Melville: the scientific controversy over abusive head trauma in infants

markedly between the two studies, abuse being much more common when only intradural lesions are considered. Regarding the diagnosis of child abuse, our protocol is similar to many centers', with the originality of systematic fundoscopy for all head-injured infants and a very regular and systematic approach to the eventuality of abusive trauma. We assume that our approach has been fairly uniform all along the recruitment of this database, now in its tenth year. We agree with Dr. Melville that systematic X-rays and social inquiry might have disclosed more cases of abuse; however, such measures are perceived as invasive and intrusive, and we know of no team in which this practice is standard in clear-cut cases of mild trauma, with a consistent history compatible with the lesions and the child's developmental level, no clinical evidence of extracranial lesion, and with the additional security of fundoscopy showing no evocative retinal hemorrhage.