1. Abusive Head Trauma What, why, how and who… Kirsten Bechtel MD
Associate Professor of Pediatrics and of Emergency Medicine
Co-Chairperson, Connecticut Child Fatality Review Panel

2. Disclosures
I have no relevant disclosures.

3. Objectives What is Abusive Head Trauma (AHT) ?
Why do caregivers shake infants?
What are the injuries and what do these infants look like?
How do medical providers miss cases?
Who else should we worry about?
How can you make the diagnosis?

4. What is Abusive Head Trauma?
Abusive head trauma is a catastrophic form of child abuse.
Approximately 1.4/5000 infants less than 12 months old sustain AHT each year in the US.
10 cases each year in Connecticut
The majority of victims are infants between 3-8 months old.
These injuries can be seen less frequently in children up to 5 years old.
It  is a leading cause of traumatic brain injury and is responsible for up to 80% of all deaths from brain injuries in young children.
Survivors frequently have neurological and behavioral impairment.
It also has considerable economic costs. 
Average Lifetime Cost to society for non fatal case: $210, 000
Average Lifetime Cost to society for a death: $1.3 million

5. What causes Abusive Head Trauma?
Shaking is the most common mechanism when a caregiver admits to injuring an infant.
Starling et al 2006
In 81 cases of AHT, 68% (55) the caregiver admitted shaking the infant.
There was impact of the infant’s head in 46% (37) of cases.
None of the children were described as behaving normally after the event.
Adamsbaum et al 2010
112 cases of AHT, 26% (29) of caregivers admitted shaking the infant.
There was impact of the infant’s head in 24% (27) of cases.
Shaking was described as extremely violent in all admissions and was repeated an average of 10 times in 55% (62) of cases.

6. What is the relationship between shaking and crying?
Rates of Hospitalized Cases of AHT (Barr 2006)
The Crying Curve (Brazelton 1962)

7. Why do caregivers shake infants?
Shaking is an effective way to stop crying and to discipline children younger than 2 years old.
In Holland, 5% of caregivers agreed “that shaking is an effective means to stop crying” (Reijneveld et al 2004)
In the Carolinas, 2.6% of caregivers actually reported shaking their children as a form of discipline. (Theodore et al 2005)
This rate was 150-times higher than the number of recognized cases of AHT in this region during the time of the study.
Adamsbaum et al 2010: 62.5% of caregivers said shaking stopped the infant’s crying.
This could explain the gap in the overlap of the AHT and crying curves : a caregiver may have shaken an infant more than once before, but not enough to cause injury to bring the child to medical attention.

8. What are the injuries?
The hallmark of AHT is a triad of injures that include intracranial hemorrhage (subdural and subarachnoid), retinal hemorrhage and acute brain dysfunction.
Cervical spinal cord injury and subsequent hypoxic ischemic injury contributes to acute brain dysfunction in cases of AHT. .

9. What do these infants look like?
Abusive
Non-abusive
Subdural hemorrhage 🀐
Epidural hemorrhage
Cerebral ischemia
Skull fractures
+ ICH
- ICH
Fractures
Long bone
Rib
Metaphyseal
Seizures
Apnea
No adequate history to explain injuries
Piteau et al 2012 Systematic review of 14 “high quality studies” of clinical and radiographic characteristics of AHT.

10. How do medical providers miss cases of AHT?
Up to 31% of cases of AHT, there was at least one prior opportunity during a previous medical encounter when the provider did not recognize that the infant had AHT (Jenny et al 1999, Letson et al 2016).
Clinicians have been taught to strongly consider socioeconomic risk factors, evasive, hostile or abnormal affect by a caregiver and unreasonable delays in seeking care; when these are present should we consider that a child may have been abused.
This framework may result in poor, minority children to have more testing for abuse and more often being reported to child protective services while white children who are actually abused are missed. (Lindberg and Runyan 2016)
This faulty framework may also explain the gap in the overlap of the AHT and crying curves, as a subset of infants who are shaken are missed on initial medical evaluation because of racial and socioeconomic biases.

11. How can you detect AHT without bias?
Hymel et al 2014
PICU
36 months old
ICH
(All 4)
Cowley et al Inpatient
(More than 3)
Acute respiratory compromise 🀐
Unexplained rib and/or long bone fractures
Retinal hemorrhage
SDH Interhemispheric or bilateral
Complex skull fracture
Seizures
Head and Neck bruising
Ear, neck, torso bruising
PPV 55% NPV93%
PPV 71.2% NPV 86.3%
Clinical Decision Rules may
be helpful to reduce clinician bias in recognizing AHT.

12. How can you detect AHT without bias?
The Pittsburgh Infant Brain Injury Score (PIBIS) is a clinical prediction rule to determine which “well appearing” infants should undergo cranial CT (Berger et al 2016).
The 5-point PIBIS included abnormality on skin examination (2 points), age > 3 months (1 point), head circumference > 85th percentile (1 point), and serum hemoglobin < 11.2 g/dL (1 point).
At a score of 2, the sensitivity for abnormalities found on cranial CT was 93.3% and the specificity was 53%.
The NPV for a score <2 was 96%.
Further study is needed before the PIBIS can be incorporated into routine clinical practice.

13. Who else should we be worried about?
Clinical characteristics associated with ALTE (BRUE) from AHT
(Guenther et al 2010)
Retrospective review of 627 patients with ALTE
Clinical Characteristic
Odds Ratio
911 call
4.93
Prior ALTE
2.39
Vomiting
5.30
Irritability
11.89
Seizure
9.40
This is a subset of ALTE (BRUE) that we should consider AHT as a cause.

14. How can you make the diagnosis?
Cranial CT is still the best modality for diagnosis in ED.
MRI is increasingly used alongside CT because it provides a better estimation of shear injuries, hypoxic-ischemic insult and the timing of lesions.
However, “Quick brain” or “Ultra-fast” MRI has low sensitivity for detecting acute intracranial traumatic hemorrhage, which may limit its usefulness as a substitute for CT (Kralik et al 2017)
A screening MRI protocol including axial T2, axial Gradient Echo and coronal T1-Weighted inversion recovery sequences has shown some promise for its improved sensitivity for intracranial hemorrhage in “well-appearing” infants at risk for AHT . (Flom et al 2016)
However the feasibility of this approach in clinical practice to replace cranial CT has not yet been determined.

15. What else can you do to make the diagnosis?
Retinal hemorrhages are a frequent feature of AHT, especially when seen in infants with brain injury aged < 6 months and with mental status changes (Bechtel et al 2004, Maguire et al 2013) .
Rates of RH %
Retinal hemorrhages seen in AHT are often present in all layers of the retina, extend into the periphery, and in both eyes.
Retinal hemorrhages are rare in accidental trauma, and, when present, are usually unilateral, confined to the posterior pole, and few in number.
Infants with skull fractures without intracranial hemorrhage most often do not have retinal hemorrhage.
RH may be missed by non-ophthalmologists so referral is necessary to document presence and extent of retinal hemorrhage.

16. What else can you do to make the diagnosis?
Documenting the presence of spinal cord injury (SCI) may be helpful.
36% of children referred for AHT evaluations may have cervical SCI (primarily ligamentous injury) (Kadom et al 2014)
Most often seen in infants with hypoxic ischemic brain injury.
This suggests that cervical spine injury is one factor in the pathogenesis of HIE.
Cervical SCI is a frequent finding in young children with fatal abusive head trauma (Matschke et al 2015).
MRI of the cervical spine should routinely be considered in the setting of spinal injuries on a trauma survey or abnormal findings on a neurologic examination (flaccid paralysis).
Although detection of cervical spine injuries by MRI alone does not discriminate between accidental and abusive mechanisms, it can be helpful to establish the diagnosis of AHT, as these injuries are most often seen in high-energy mechanisms (MVCs) and not from household falls.
Object. In this study, the authors estimate the prevalence of injuries to the soft tissue of the neck, cervical vertebrae, and cervical spinal cord among victims of abusive head trauma to better understand these injuries and their relationship to other pathophysiological findings commonly found in children with fatal abusive head trauma.
Methods. The population included all homicide victims 2 years of age and younger from the city of Philadelphia, Pennyslvania, who underwent a comprehensive postmortem examination at the Office of the Medical Examiner between 1995 and A retrospective review of all available postmortem records was performed, and data regarding numerous pathological findings, as well as the patient’s clinical history and demographic information, were abstracted. Data were described using means and standard deviations for continuous variables, and frequency and ranges for categorical variables. Chi-square analyses were used to test for the association of neck injuries with
different types of brain injury.
in 21 there were parenchymal injuries, in 24 meningeal hemorrhages, and in 16, nerve root avulsion/dorsal root ganglion hemorrhage were evident.

17. Summary Who to worry about? Infants younger than 12 months with
Seizures
Macrocephaly (older than 3 months)
Apnea
BRUE with EMS transport, irritability, vomiting, seizures, prior BRUE
Bruising (TEN-4 FACES)
Sentinel injury (scleral hemorrhage, frenulum injury)
What to do? Obtain cranial CT
What else can you do? Ophthalmology for RH, MRI for SCI
Who to call when you have questions? DART (888-YNHH-BED)
It doesn’t matter what the infant’s race or SES or how the caregivers act; if you think of AHT due to infant’s clinical presentation, then obtain brain imaging.

18. Thank you. ↖︎

19. Questions
What is concerning about this specific history – is there any thing in the first visit that would prompt a further work up by you and your team? What work up would you take on (can discuss a little more about sentinel injury and abuse, BRUE and abuse)
How do your teams make decisions regarding the eval of siblings/other children in home (do you have them come to the ED at that time for eval?) (PROVIDE DATA ON contacts and abuse- lindberg et al)
How does DCF make safety decisions when no perpetrators are definitively found? Legally, what happens if no perpetrator found (In this case, father vs girl friend as suspects)
Additional Questions:
Data regarding LFTS and occult injury  when to seek abd imaging and what kind of imaging
Any ED based rules about when to get head CT (Related to Brue, Rachel Berger work)
What features of RH are concerning for AHT

20. Another form of AHT (rare)
The clinical triad of isolated ear bruising, hemorrhagic retinopathy, and a small ipsilateral subdural hematoma with severe cerebral swelling defines the tin ear syndrome.
TEN 4 FACES

21. How can you make the diagnosis? (Eye injury)
May be missed by non-ophthalmologist
AHT Prevalence 60-95%
Causes include:
CPR
Seizures
Vaginal delivery
Increased ICP
Accidental head trauma
Up to 10% may have RH, but different from AHT

22. Occult head injury in asymptomatic abused children
Occult head injury in high-risk abused children.
Rubin DM1, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR
Pediatrics. 2003 Jun;111(6 Pt 1):
Asymptomatic abused children < 1 year of age
37% had occult AHT
Majority did not have RH
Universal head imaging in this group

23. LFTs and abuse
Laboratory testing may be useful to exclude abusive intra-abdominal injury in otherwise asymptomatic children.
Several studies have found that liver transaminases may be useful in identifying occult abusive intra-abdominal injury in asymptomatic children evaluated for suspected abuse.
For children with a serum alanine aminotransferase or aspartate aminotransferase > 80 IU/L, or with significant signs and symptoms of abdominal trauma, CT is the best initial diagnostic modality to evaluate for abusive intra-abdominal injury.
Lindberg D, Makoroff K, Harper N, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009;124(2):
Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013;131(2):
American Academy of Pediatrics Section on Radiology. Di- agnostic imaging of child abuse. Pediatrics. 2009;123(5):

24. Siblings of abused contacts
Skeletal surveys should be obtained in the siblings of injured abused children who are aged ≤ 2 years, regardless of physical examination findings.
Twins are at high risk for abusive fractures when compared to nontwin household contacts.
Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130(2):

25. Sentinel injuries Sheets et al 2013
Relatively minor abusive injuries can precede severe physical abuse in infants.
Of the 200 definitely abused infants, 27.5% had a previous sentinel injury compared with 8% of the 100 infants with intermediate concern for abuse (odds ratio: 4.4, 95% confidence interval: 2.0–9.6; P < .001).
None of the 101 non-abused infants (controls) had a previous sentinel injury (P < .001).
The type of sentinel injury in the definitely abused cohort was bruising (80%), intraoral injury (11%), and other injury (7%).
Sentinel injuries occurred in early infancy: 66% at <3 months of age and 95% at or before the age of 7 months.
Medical providers were reportedly aware of the sentinel injury in 41.9% of cases.
Case-control, retrospective study of 401, <12-month-old infants evaluated for abuse in a hospital-based setting
A sentinel injury was defined as a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible.
CONCLUSIONS: Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.

26. What do these infants look like ?

27. Other causes of retinal hemorrhage
Retinal hemorrhages may be present in about 30% of infants after vaginal delivery and tend to be localized around the optic discs and in the posterior pole; most resolve within 4 weeks.
Retinal hemorrhages after cardiopulmonary resuscitation (CPR) are rare and usually occur in the presence of other risk fac- tors for hemorrhage.
Levin AV. Retinal hemorrhages: advances in understanding. PediatrClin North Am. 2009;56(2):
Pham H, Enzenauer RW, Elder JE, et al. Retinal hemorrhage after cardiopulmonary resuscitation with chest compressions. Am J Forensic Med Pathol. 2013;34(2):

28. Why do so many CTs? Campbell et al 2007
Cost-effectiveness of a policy of CT in selected infants with either (1) unexplained scalp bruising or (2) a history of an apparent life-threatening event.
Do you think the risk of radiation is less than the risk of missing AHT?
Campbell KA, Berger RP, Ettaro L, et al. Cost-effectiveness of head computed tomography in infants with possible in- flicted traumatic brain injury. Pediatrics. 2007;120(2):
Now AHT is the one you don’t want to miss .Even though girls under the age of 1 have the highest risk of malignacy from CT
Conclusions
Models demonstrate that CT for inflicted traumatic brain injury can be cost-effective and improve outcomes.
The finding of higher societal cost reflects the substantial short-term costs of child protection.
Study supports a low medical threshold for CT screening and highlights the need for improved understanding of long-term costs and outcomes of child abuse.
Sensitivity analysis demonstrated costs less than $50,000 per severe or fatal inflicted traumatic brain injury averted in scenarios in which initial inflicted traumatic brain injury prevalence was >3%.
From a medical payer perspective, head CT for inflicted traumatic brain injury in infants with unexplained scalp bruising saved money. From a societal perspective, costs of child protection made head CT for inflicted traumatic brain injury more expensive.
Infants with undiagnosed inflicted traumatic brain injury were at increased risk of repeat inflicted traumatic brain injury. We used available literature to estimate probabilities, costs, and outcomes. The models terminated at death or at 52 weeks of age. Outcomes considered were severe and fatal inflicted traumatic brain injury cases averted through early detection of mild inflicted traumatic brain injury. DATA SOURCES: We conducted a literature review for estimates of inflicted traumatic brain injury incidence, outcome probabilities, and medical and societal costs. Wide ranges were set for sensitivity and
Health states modeled were no inflicted traumatic brain injury, misdiagnosed inflicted traumatic brain injury, mild inflicted traumatic brain injury (diagnosed or undiagnosed), and severe and fatal inflicted traumatic brain injury.

29. How does shaking cause injuries ?

31. Who else should we be worried about?
Parker and Pittetti 2011

32. Matrix