An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma

Abusive head trauma and crying infant-Public awareness of newborn and infant trauma

AIM

Crying seems to be a common trigger for abusive head trauma (AHT), which is the leading cause of fatalities from physical abuse in infants. Our objective was to evaluate knowledge of AHT, crying infants and correct behavioural measures in a general population.

METHODS

An online questionnaire (LimeSurvey) was created to assess the risk of shaking. The online survey contained a total of 41 questions, including a demonstration of a previously recorded video in which an infant doll is shaken.

RESULTS

A total of 319 people, 245 of them (76.8%) with own children, participated in the study. Almost all respondents (98.4%) were aware of serious injuries due to shaking, even to the point of death (98.1%). Most participants (97.5%) had heard the term 'shaking trauma' prior but did not receive any professional information, neither before nor after birth (85.2% or 86%), or during follow-up examinations (88.5%). The majority of the participants (95%) considered that useful coping strategies in infant crying were inappropriate.

CONCLUSION

The consequences of shaking an infant were common knowledge in a normal population, whereas there was a knowledge gap regarding the management of excessive crying infants. Prevention programmes should mainly focus on male caregivers during postnatal care.

An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse

Abusive head trauma (AHT) is an extreme form of physical child abuse, a subset of which is shaken baby syndrome (SBS). While traumatic injury in children is most readily observed as marks of contusion on the body, AHT/SBS may result in internal injuries that can put the life of the child in danger. One pivotal sign associated with AHT/SBS that cannot be spotted with the naked eye is retinal injury (RI), an early sign of which is retinal hemorrhage (RH) in cases with rupture of the retinal vasculature. If not addressed, RI can lead to irreversible outcomes, such as visual loss. It is widely assumed that the major cause of RI is acceleration-deceleration forces that are repeatedly imposed on the patient during abusive shaking. Still, due to the controversial nature of this type of injury, few investigations have ever sought to delve into its biomechanical and/or biochemical features using realistic models. As such, our knowledge regarding AHT-/SBS-induced RI is significantly lacking. In this mini-review, we aim to provide an up-to-date account of the traumatology of AHT-/SBS-induced RI, as well as its biomechanical and biochemical features, while focusing on some of the experimental models that have been developed in recent years for studying retinal hemorrhage in the context of AHT/SBS.

Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence

The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine.

Retinodural haemorrhage of infancy: Support for continuing current terminology and approaches

This commentary is on the invited review by Squier on pages 290–297 of this issue.

Evidence for significant misdiagnosis of abusive head trauma in pediBIRN data

Independently witnessed events are used as a reference standard to robustly categorize accidental or non-abusive head trauma (non-AHT) cases in the pediBIRN data set of acutely symptomatic infants with closed head injuries. Findings in such independently witnessed non-AHT cases are compared to findings in cases that were diagnosed as AHT but were not independently witnessed. The data shows that 14% of independently witnessed non-AHT cases are misdiagnosed as AHT, and that risk factors for misdiagnosis include acute encephalopathy, bilateral or interhemispheric SDH, and/or severe retinal hemorrhages, findings that are commonly associated with AHT. The data also shows that "dense retinal hemorrhages extending to the periphery" are not highly suggestive of AHT, as they also occur in independently witnessed non-AHT cases.

Why admitted cases of AHT make a low quality reference standard: A survey of people accused of AHT in France

Several influential articles that attempt to establish diagnostic methods for Abusive Head Trauma (AHT) use admitted cases as a reference standard. This study analyses a survey of people accused of AHT in France, to understand the environment and situations in which such admissions are made. Multiple reasons to question the reliability of admissions to AHT are demonstrated in the responses, including reduced sentences, the return of children to the family home, a desire to stop accusations being leveled at a partner and for legal proceedings to end. These factors must be considered in the context of proceedings that are long, expensive and stressful, leading to depression and financial hardship, and that seem to be inevitably heading towards conviction. The ineluctable conclusion is that admitted cases do not make a suitably reliable reference standard for undertaking scientific investigation, or for validating the diagnostic methods used for AHT.

The association of subcortical brain injury and abusive head trauma

BACKGROUND

Abusive head trauma (AHT) remains a major pediatric problem with diagnostic challenges. A small pilot study previously associated subcortical brain injury with AHT.

OBJECTIVES

To investigate the association of subcortical injury on neuroimaging with the diagnosis of AHT.

PARTICIPANTS AND SETTING

Children <3 years with acute TBI admitted to 18 PICUs between 2011 and 2021.

METHODS

Secondary analysis of existing, combined, de-identified, cross-sectional dataset.

RESULTS

Deepest location of visible injury was characterized as scalp/skull/epidural (n = 170), subarachnoid/subdural (n = 386), cortical brain (n = 170), or subcortical brain (n = 247) (total n = 973). Subcortical injury was significantly associated with AHT using both physicians' diagnostic impression (OR: 8.41 [95 % CI: 5.82-12.44]) and a priori definitional criteria (OR: 5.99 [95 % CI: 4.31-8.43]). Caregiver reports consistent with the child's gross motor skills and historically consistent with repetition decreased as deepest location of injury increased, p < 0.001. Patients with subcortical injuries were significantly more likely to have traumatic extracranial injuries such as rib fractures (OR 3.36, 95 % CI 2.30-4.92) or retinal hemorrhages (OR 5.97, 95 % CI 4.35-8.24), respiratory compromise (OR 12.12, 95 % CI 8.49-17.62), circulatory compromise (OR 6.71, 95 % CI 4.87-9.29), seizures (OR 3.18, 95 % CI 2.35-4.29), and acute encephalopathy (OR 12.44, 95 % CI 8.16-19.68).

CONCLUSIONS

Subcortical injury is associated with a diagnosis of AHT, historical inaccuracies concerning for abuse, traumatic extracranial injuries, and increased severity of illness including respiratory and circulatory compromise, seizures, and prolonged loss of consciousness. Presence of subcortical injury should be considered as one component of the complex AHT diagnostic process.

Mild abusive head injury: diagnosis and pitfalls

Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury. An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries. Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.