Pediatric Abusive Head Trauma – Kentucky

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Introduction and Objectives 

Pediatric Abusive Head Trauma (AHT), also known as Shaken Baby Syndrome, includes an array of symptoms and complications resulting from injury to a child or infant’s head and brain after violent or intentional shaking or impact. There are approximately 1,300 reported cases of AHT each year and it is the leading cause of child abuse deaths nationally. For those children who survive, most suffer lifelong complications and disabilities (7).   

This serious and tragic injury may be a challenge to diagnose because obvious signs of injury may not be easily detectable right away, and those responsible for the injuries may avoid taking the child for treatment (4). Therefore, it is incredibly important for healthcare professionals who work in pediatrics or emergency medicine to be able to identify at-risk individuals and recognize signs and symptoms of potential victims of AHT. It is also 100% preventable, and proper training on how to mitigate the risks and situations that lead to AHT can help healthcare professionals reduce the incidence of this horrific injury. Upon completion of this course, the learner will be able to:  

1. Identify risk factors and common mechanisms of injury for pediatric abusive head trauma. 
2. Describe signs and symptoms and diagnostic tools used to identify pediatric abusive head trauma. 
3. List potential outcomes of pediatric abusive head trauma and their prevalence. 
4. Understand the legal considerations of mandated reporters, process of reporting, and penalties for pediatric abusive head trauma perpetrators in the state of Kentucky  
5. Identify ways that societal and healthcare interventions can help reduce the prevalence of pediatric abusive head trauma 

Epidemiology/Risk Factors  

Though pediatric abusive head trauma most often occurs in children under age 5, the majority of these injuries are in children under the age of 1 year. There is a slight difference in incidence between genders, with 57.9% of victims being male and 41.9% being female. There is a peak occurrence of AHT between 3 and 8 months (4). Babies of this age are particularly vulnerable for a multitude of reasons, including large head size, weak neck muscles, fragile and developing brains, and the discrepancy in strength between infant and abuser. Sleep deprivation paired with longer and louder crying spells of very young infants sets the stage for high levels of caregiver frustration, which often precedes AHT injuries. The perpetrator is almost always a parent or caregiver (7).  

Besides infant age, there are many social factors that increase the risk of AHT, including a lack of childcare experience, young or poorly supported parents, single-parent homes, low socioeconomic status, low education level, and a history of violence. These factors paired with a lack of prenatal care or parenting classes often leads to poorly prepared parents who have not been taught to anticipate crying spells or how to deal with the frustration in a safe manner (7).  

Unfortunately, Kentucky has one of the highest rates of child abuse in the country. In 2019, there were more than 130,000 reports of suspected abuse or neglect, and 15,000 of those had substantial evidence to support abuse had occurred. Of those, nearly 76 were nearly fatal or fatal, and 32 of those were due to pediatric abusive head trauma(1).  

Case Study 

A Nursery nurse on a Labor, Delivery, and Postpartum unit is providing discharge information to the parents of a 2 day old baby girl, Violet, who is going home today. This is the first child for both parents. They are 19 years old, living in an apartment together while the mother works part time as a waitress and the father works full time for a lawn mowing company. The child’s maternal grandmother lives nearby and will be helping the mother care for the baby the first few weeks and then watching the baby a few days per week when the mother returns to work.   

Pathophysiology of Pediatric Abusive Head Trauma

While anyone can sustain a head injury, the relatively large size of young children’s heads paired with their weak and underdeveloped neck muscles is what makes them particularly susceptible to AHT. When a child’s head moves around forcefully, the brain moves around within the skull, which can tear blood vessels and nerves, causing permanent damage. Bruising and bleeding may occur when the brain collides with the inside of the skull or fractured pieces of skull. Finally, swelling of the brain may occur, which builds up pressure inside the skull and makes it difficult for the body to properly circulate oxygen to the brain (6).   

It should be noted that bouncing or tossing a child in play, sudden stops or bumps in the car, and falls from furniture (or less than 4 feet) do not involve the force required to mimic the injuries of AHT (7).  

Also important to understand is that AHT is a broad term used to describe the injury, but there are a collection of various mechanisms of injury within AHT. Among these different causes are Shaken Baby Syndrome (SBS), blunt impact, suffocation, intentional dropping or throwing, and strangulation. It is recommended to classify all of these injuries as AHT so as to avoid any confusion or challenges in court if multiple mechanisms of injury were involved (4).   

Diagnosis of Pediatric Abusive Head Trauma  

Parents or caregivers who have inflicted injury onto a child may delay seeking treatment for fear of consequences. It is important to gather a thorough history and be on the lookout for inconsistent stories, changing details, or mechanism of injury that does not match the severity of symptoms (7).   

Symptoms that typically lead caregivers to seek treatment for their child include:  

• Decrease in responsiveness or change in level of consciousness 
• Poor feeding 
• Vomiting 
• Seizures 
• Apnea 
• Irritability 

Upon exam, these children may exhibit:   

• Bradycardia 
• Bulging fontanel 
• Irritability or lethargy  
• Apnea 
• Bruising 

A lack of any external injuries or obvious illnesses when presenting with these symptoms should alert the healthcare professional to the possibility of AHT, particularly in young children or infants. Additionally, unexplained fractures, particularly of the skull or long bones, bruising around the head or neck, or any bruising in a child less than 4 months are red flags (4).   

An ophthalmology consult to assess for retinal hemorrhage should be obtained. The force used with AHT can cause a shearing effect with the retina and is visible with a simple fundal exam of the eye. This type of injury does not typically occur with accidental or blunt head trauma and is typically considered highly indicative of abuse. That same shearing force often causes bleeding within the brain, and subdural hematomas are often revealed on CT or MRI (4).   

Any of the above criteria, or other suspicious story or injuries, should be reported for further investigation. Mild injuries are harder to detect but only occur around 15% of the time. Severe injury from AHT accounts for 70% of cases (4).

Case Study Cont.

Baby Violet is now 5 weeks old and is brought to the ED by her parents. Her mother reports that she has been eating poorly and acting strange since this morning. Her father reports he thinks she has been sleeping excessively for 2 days now. On exam, the baby is found to have a bulging fontanel, slow heart rate, and a bruise on the side of her head. Her mother states she sustained that bruise when she rolled off of her changing table yesterday.  

Outcomes and Sequelae  

For children diagnosed with even mild to moderate AHT, the prognosis is fairly grim. Up to 25% of children with AHT end up dying from their injuries, and for those who survive, 80% will have lifelong disabilities of varying severity (7).    

The most common complications and disabilities include: blindness, hearing loss, developmental delays, seizures, muscle weakness or spasticity, hydrocephalus, learning disabilities, and speech problems. Lifelong skilled care and therapies are often needed for these children, accruing over $70 million in healthcare costs in the United States annually (4).  

Legal Considerations in the State of Kentucky  

In the state of Kentucky, anyone with a reasonable suspicion that abuse or neglect is occurring is mandated by law to report the incident, and there are legal consequences (from misdemeanor all the way to felony) for willfully failing to make a report. For healthcare professionals, this is particularly important to note, as you will come in contact with many different types of families, injuries, and stories, and must remain vigilant in assessing for abuse (5).  

A report of suspected abuse should be made at the first available opportunity and can be made by contacting the child abuse hotline (1-877-KYSAFE1), local law enforcement, Kentucky State Police, or the Cabinet for Health and Family Services. The child’s name, approximate age and address, as well as the nature and description of injuries, and the name and relationship of the alleged abuser should all be included in the report (9).   

Once a report has been made, the Department for Community Based Services will determine if an investigation is warranted. If the home is deemed to be unsafe or there is a threat of immediate danger to a child, the child will be removed from the home, but in all other cases, every effort will be made to maintain the family (5).

Case Study 

It is later determined that Baby Violet was violently shaken by her mother during a crying spell one evening. During legal proceedings for the incident, it is revealed that the grandmother witnessed this abuse.

Prevention  

While accurate detection of AHT is incredibly important, another key consideration for this injury and its poor outcomes, is that these incidents are 100% preventable. Much of the time, AHT is preceded by extreme frustration by a parent or caregiver when an infant is crying for long periods or is inconsolable. Proper education and preparedness about when and why this occurs, and what to do when it does, can help prevent AHT from occurring. For healthcare professionals who regularly care for infants, children, and expecting or new parents, there is a huge potential for positive impact (2).  

Identifying those most at risk is a great starting place and new parenting courses, educational discussion and pamphlets, as well as regular check-ins are extremely beneficial for at-risk families. Young or inexperienced families, families without a lot of external support, or those with low socioeconomic status or poor education should be looked at first.   

Once the most at risk families have been identified, provide them with information and services that may help reduce risks. These interventions are useful for anyone with an infant or small child, but special attention and close follow up should be given to those with more risk factors (8).   

1. Educate about infant crying: The PURPLE Crying program is particularly useful for this and includes facts and common symptoms of excessive or colicky infant crying. PURPLE stands for:   

• Peak of Crying, with crying increasing weekly after birth and peaking around 8 weeks  
• Unexpected, where crying may come and go with no apparent cause 
• Resists soothing, where your baby won’t settle no matter what you try 
• Pain like face, where your baby looks like they are in pain even if nothing is wrong 
• Long-lasting, with crying lasting as long as 5 hours 
• Evening, with excessive crying being more common in the evening or at night (8)

2. Enhance parenting skills: Let parents know it is okay to feel frustrated. Take a deep breath, count to 10, place your infant in a safe place and walk away for a few minutes to collect yourself. Many parents don’t know that this is okay to do (3).   

3. Strengthen socioeconomic support: Make sure families are aware of and utilizing access to supportive services like WIC to help ease financial strain.

4. Emphasize social support and positive parenting: Ask about nearby help in the form of relatives or friends. Encourage them to reach out for emotional support, or even a break from caring for the infant. Connect families with community resources like motherhood support groups or playdates. Schedule for early childhood home visits (2).  

Conclusion  

Though the goal is for there to be no scenarios where children suffer head trauma at the hands of an abuser, there is a long way to go before that objective can be reached. In the meantime, healthcare professionals must be vigilant in maintaining a high level of suspicion for pediatric abusive head trauma whenever they are caring for children. Understanding contributing risk factors, as well as signs and symptoms, and how to properly assess for and diagnose pediatric abusive head trauma will lead to more accurate detection, appropriate treatment, and hopefully better outcomes. On the other end of things, those in a position to influence parenting education and community health standards should consider the ways in which caregiver frustration might be better handled to prevent the abuse from even occurring. There is much work to be done when it comes to AHT, but well informed medical professionals is an essential step in the right direction.  

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