Pearls
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Infants and children with inflicted head or other traumatic injuries often appear in emergency departments with signs and symptoms of trauma or conditions suspicious of being of medical origin.
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While children who suffer abuse experience a wide range of injuries, the minority require critical care.
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Early consultation is recommended so that the appropriate forensic history and a complete physical examination, including photographs, are obtained early in the course of management.
The term sentinel injuries denotes injuries that, by themselves, appeared to be minor but have been associated with subsequent more severe trauma, including death.
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Trauma secondary to abuse typically is more severe than that from accidental injury.
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Abusive head trauma is the leading cause of fatal head injuries in children.
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The death of a child with suspected abusive injuries mandates notification of the coroner.
Evaluating and managing cases involving child maltreatment in the intensive care setting is challenging from many aspects. Beyond identifying and treating life-threatening conditions, the intensivist must be aware of the many components involved in nonaccidental trauma (NAT). Although the intensivist may be involved with cases of neglect (including medical neglect), psychological abuse, and sexual abuse, this chapter will focus on child physical abuse and the importance of its recognition as a potential etiology for the injuries. As a mandated reporter, the intensivist is expected to initiate a report of child abuse based on a reasonable suspicion that such abuse occurred.
This chapter provides a broad overview of the important components of a child abuse case. The intensivist should be knowledgeable about the difference between a medical and forensic evaluation, the significance of sentinel injuries, the scope of findings as related to accidental versus abusive trauma, and the importance of a multidisciplinary approach when developing a comprehensive assessment of critically ill and injured children. This chapter also reviews common abuse syndromes, provides guidance on recognizing signs or patterns of abuse, and reviews obligations for information sharing.
Case example
An 8-month-old male is transported by private car to the emergency department of a children’s hospital after allegedly falling 2 feet from a bed to the floor. The fall was not witnessed. In the emergency department, his Glasgow Coma Scale is 8, he is moaning and responding to noxious stimuli, and his eyes are deviated to the right. He has a bruise on the pinna of his right ear. He is intubated. A computed tomography (CT) scan reveals an occipital skull fracture extending into the parietal bone and a right subdural hematoma with a small midline shift. A subsequent CT scan of the abdomen and chest reveals a healing posterior fracture of the left seventh rib. An ophthalmologic examination reveals bilateral multilayered retinal hemorrhages.
Abuse vs. accident?
Infants and children with inflicted head or other traumatic injuries often appear in emergency departments with signs and symptoms of trauma or conditions suspicious of being of medical origin. The approach to these children involves the basic ABCs of management during which the patient is stabilized and then transferred to an inpatient setting to continue the evaluation and care. The history may not disclose the true nature of the traumatic event; the evaluating physician must be knowledgeable about child development and the biomechanics of injuries to make an informed assessment that the injuries are consistent with the story. The potential that injuries are secondary to inflicted trauma is always present. It is also important to be aware that some injuries, such as head and abdominal trauma, may present with nonspecific symptoms, such as vomiting, lethargy, apnea, and altered mental status. Physical findings—such as the presence of bruises, especially in certain areas of the body (sentinel injuries)—may provide the clue to the etiology of the symptoms.
There is currently a high degree of medical consensus that shaking alone can cause significant traumatic brain injury (TBI), retinal hemorrhages, and death. In 2009, the American Academy of Pediatrics Committee on Child Abuse and Neglect issued a statement supporting the medical use of the term abusive head trauma (AHT). Despite the significant amount of evidence supporting this as a diagnosis, there remains speculative theories unsupported by medical evidence designed to cast doubt on current consensus. Reports in the media and legal counsels promulgate these fringe theories. However, they exist only to effect the outcome of a legal case rather than contribute to the science. Lindberg et al. provide an excellent review examining these concepts and illustrate how they fail to provide evidence to refute the reality that shaking alone can cause significant brain damage.
Epidemiology
Statistics about child maltreatment have been gathered since 1988, when the Child Abuse Prevention and Treatment Act (CAPTA) was amended. This amendment created the National Child Abuse and Data System. On average, 700,000 cases of child abuse and neglect are reported annually. In 2016, the number of child deaths due to abuse or neglect was 1750. Physical abuse accounts for about 15% of all cases of reported abuse.
While children who suffer abuse experience a wide range of injuries, the minority require critical care. A 5-year review of 188 trauma cases of suspected NAT found that 24% required pediatric intensive care services and 48% had multiple injuries.
Medical vs. forensic assessment
While there is often overlap between a medical and forensic assessment, the purpose of a forensic assessment is to detect the presence of injuries that do not necessarily require medical intervention but whose presence helps establish inflicted trauma as the etiology. While the intensivist should be aware of the recommendations about the components of a forensic assessment, it is appropriate for the intensivist to consult with child abuse experts if such individuals are available at one’s institution. Early consultation is recommended so that the appropriate forensic history and a complete physical examination, including photographs, are obtained early in the course of management. The physical examination should be performed with the child completely unclothed, and the skin carefully examined for evidence of bruises, burns, or scars.
Depending on the age of the patient, a skeletal survey is recommended even if there are no apparent fractures. As noted in the opening case, rib fractures are not uncommon in physically abused infants. Rib fractures are commonly noted involving the posterior ribs and are often healing, indicative of prior trauma. Classic metaphyseal lesions (CML) are felt to be pathognomonic for inflicted trauma. Other fractures, especially earlier ones, would indicate physical abuse over a period of time. Long-bone fractures are particularly suspect in premobile children. Some skull fractures are also worrisome because of the nature of the skull bone in that area of the head and the biomechanics of children’s falls. For instance, parietal skull fractures can be seen with simple falls in young infants, but frontal and occipital skull fractures are uncommon. It is not unusual for adults to sustain an occipital skull fracture. The usual scenario involves an inebriated individual missing a curb and striking the head against the edge of the sidewalk. Children, particularly infants, have short necks; during a fall backwards, the occiput is protected by the upper back. Occipital fractures are more indicative of a forceful impact to the skull rather than a simple fall.
Liver enzyme studies should be performed to assess for occult injury. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) over 80 U/L are correlated with significant abdominal trauma that, in general, should be further evaluated with an abdominal CT scan with intravenous (IV) contrast. Ultrasound has not reached a level of sensitivity in which it can replace CT for evaluation of abdominal trauma. Coagulation studies are obtained to be certain that a child with bruises does not have an underlying coagulopathy. Children with significant trauma may have evidence of a consumptive coagulopathy from internal bleeding.
Sentinel injuries
Case example
A 3-week-old male infant was seen by his primary care physician for a routine check and was noted to have a torn frenulum (lip to maxilla). The mother had no explanation but said that the infant was a fussy feeder. She was advised by her pediatrician to return if feeding became difficult. The mother returned to the emergency department the next day reporting that the infant had vomited blood. The hemoglobin was 5 g/dL and the infant’s heart rate was 174 beats/min. The infant had a chest radiograph, which revealed six acute posterior rib fractures.
The term sentinel injuries was first introduced by Sheets et al. to indicate injuries that, by themselves, appeared to be minor but have been associated with subsequent more severe trauma, including death.
There are a number of mnemonics that are used to identify these injuries. TEN-4 refers to bruising or injuries to the torso, ear, or neck in infants 4 months old or younger that, if noted, should prompt concern for abuse. FACES (bruising to the frenulum, auricle, cheek, eyelid, subconjunctival hemorrhage) is another such mnemonic for areas classically involved in inflicted trauma cases. There is also an adage, “Those who don’t cruise rarely bruise” to denote the unlikelihood of bruises in very young infants, particularly those who are premobile. Facial bruising is always concerning, as are bruises to the pinna of the ear, subconjunctival hemorrhages, and intraoral lesions, such as torn frenula. There are three frenula: lip to maxilla, sublingual, and lip to mandible by the two central incisors. Intraoral tears may be secondary to forced feeding to quiet a fussy infant or to occlude the mouth in efforts to silence loud crying.
Infants with injuries to the head or torso, even if the infant appears to be well, warrant a further evaluation for occult injuries. Recognition requires a high level of suspicion, a detailed history, and thorough trauma workup. The intensivist must be knowledgeable about the important signs specific to NAT. Though they may not present an immediate risk of death, these signs may be precursors to life-threatening inflicted trauma ( Figs. 121.1 to 121.4 ).
Specific syndromes
Trauma secondary to abuse typically is more severe than that from accidental injury. Deans et al. performed a review of 2782 pediatric TBI patients; 315 (11%) were due to NAT. In comparison with patients with TBI secondary to accidental mechanisms, patients with NAT were younger (mean, 1 year vs. 8 years), had longer intensive care unit (ICU) stays (mean, 3 days vs. 1 day), and had higher rates of gastrostomy tube placement (4% vs. 1%; P < .0001). Similarly, in the subgroup of severe TBI, patients with AHT required gastrostomy tubes more often than those with TBI due to accidents (5% vs. 2%; P = .014). Factors independently associated with mortality were presence of nonaccidental mechanism, higher injury scores, and younger age.
Regarding mortality, inflicted abuse typically portends worse outcomes than accidental trauma (AT). A study performed at Children’s Medical Center in Dallas examined the differences in incidence, severity, and outcome between AT and NAT in children. NAT victims had a greater severity of injury and a sixfold higher mortality rate. Delay in recognition occurred in nearly 20% of the cases, contributing to the worse outcome.
Patients requiring critical care admission typically have head injury. The second most common type of critical injury in NAT is abdominal trauma. While this chapter focuses on these injuries, it is important to keep in mind that abusive injuries can be wide ranging.
Abusive head trauma
Appreciation of the injuries that occur in AHT requires knowledge of the anatomy and development of the head and neck after birth. The skull of a neonate is relatively soft and malleable to enable passage through the birth canal. The relative softness of the skull and the presence of sutures allows forces applied to the skull to propagate directly into maturing brain tissue. The lack of myelination and the brain’s higher water content creates a fragile environment more susceptible to damage from shearing forces, which can occur when being shaken. The young child’s head is approximately 15% to 20% of total body weight, as opposed to 2% to 3% in adults. A relatively heavier head with a lack of nuchal muscular strength predisposes to significant injury in infants and toddlers as opposed to older children. Furthermore, young children may not have the ability to control and coordinate head and body motion, which increases vulnerability, as they are not able to protect themselves.
AHT is the leading cause of fatal head injuries in children and responsible for 53% of severe or fatal TBI cases. , TBI from accidental causes are typically either blunt or penetrating. In cases of inflicted injury, the mechanisms have a broader range. AHT can be secondary to blunt impact, shaking with blunt impact, or shaking alone. Whiplash shaking and jerking subjects the brain to significant rotational acceleration and deceleration forces, which explains brain injury and retinal hemorrhage in the absence of external signs.
While the acute medical and surgical management of injury from AHT is not unique, other considerations related to the mechanism and time course of AHT (e.g., delay in seeking care and diagnosis) often differs from TBI due to accidental mechanism.
Presentation
The clinical presentation of AHT can vary widely. While AHT can present as severe acute TBI or death, victims may present with more subtle clinical signs: irritability with poor feeding, apnea, seizures, suspicious marks or bruises in unusual locations, or respiratory compromise. Other features may include unsuspected finding on imaging, failure to thrive, developmental delay, or other neurologic concerns.
An important point to keep in mind is the lack of specificity: one review found that 35% of AHT cases presented without neurologic signs or symptoms and only with nonspecific complaints such as irritability or vomiting. In another review by Jenny et al. of 173 AHT cases in children younger than 3 years of age, practitioners initially missed 54 of those cases (31%). This highlights the need for the practitioner to maintain a high index of suspicion and to keep in mind the broad spectrum of presentations. This is only magnified by the fact that the circumstances and mechanisms involved in AHT generally cause greater neurologic disability and death when compared with accidental trauma.
Diagnosis
As with any other medical or surgical diagnosis, AHT can be determined only after examining all of the historical, physical, laboratory, and radiologic data.
One of the hallmarks of NAT is a history that is inconsistent with the clinical findings. The two most common stories proffered are a short fall or no history of trauma. Hettler and Greenes examined the diagnostic utility of certain historical features for identifying cases of AHT. Forty-nine cases of abuse were identified by radiologic, ophthalmologic, and physical examination findings; the investigators then examined the histories associated with the injuries. Having no history of trauma had a positive predictive value (PPV) of 0.92 and a specificity of 97% for abuse. In the patients discharged with persistent neurologic abnormality, having a history of no or low-impact trauma had a specificity of 100% and a PPV of 1.0 for abuse. Therefore, in a child presenting with moderate to severe TBI with no history of trauma, NAT must be high on the differential diagnosis.
Short falls, from less than 5 feet, are unlikely to cause moderate to large subdural hematoma (SDH) in children and are rarely fatal. In a classic study, Chadwick et al. reported that the incidence of a fatality after a fall from less than 5 feet was 0.48 in 1 million. The most common injury from a short fall is focal scalp contusion or laceration. Skull fractures are known to occur; however, these are typically linear, parietal, and usually without intracranial hemorrhage. In the event that intracranial bleeding occurs, it is more often epidural or a focal SDH. In either case, the hemorrhage is located at the fracture site ( Figs. 121.5 and 121.6 ).
