Neonatal Injuries in Child Abuse

Neonatal Injuries in Child Abuse

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Child abuse is often misdiagnosed and under recognized by physicians and caregivers. Child abuse occurs in many forms and is best defined as purposeful infliction of physical or emotional harm, sexual exploitation, and/or neglect of basic needs (eg, nutrition, education, medical care). Child abuse is an important cause of death in children. Among child abuse fatalities, head injury is the leading cause of death in infancy.

Shaken baby syndrome (SBS) is of particular interest to the neurologist, as it affects the nervous system. Shaken baby syndrome may cause long-term sequelae in the developing nervous system, and the effects may even be lethal. See the image below.

In 1946, Caffey reported a series of patients with multiple fractures and chronic subdural hematoma, which fit the profile of what is now defined as shaken baby syndrome. [1] Kempe et al coined the term battered child syndrome. [2] In 1967, Gilkes and Mann first reported the funduscopic findings of battered babies. [3] In 1972, Caffey wrote about the syndrome of shaken infants. His report brought attention to this form of child abuse. [4]

The term “shaken baby syndrome” has been commonly used to describe symptoms consistent with shaking an infant, which produces bilateral retinal hemorrahge and diffuse brain injury. However, the term shaken impact syndrome is used for injuries that exceed those just from shaking and have evidence of blunt head trauma. “Abusive head trauma” is now the recommended term by the American Academy of Pediatrics. This term describes the type of injury rather than the mechanism of injury.

The American Academy of Pediatrics in 2009 recommended the use of the term “abusive head trauma,” rather than shaken baby syndrome or non-accidental injury. [5]

Abusive head trauma (AHT) is a well-recognized brain injury associated with the direct application of force to an infant that results in physical injury to the brain and/or its contents. [6]

Anatomic features make infants especially prone to neurologic injury from excessive shaking or trauma. Infants have a large head compared with their body size, and the cervical paraspinal muscles are weak. (This accounts for head lag observed during the first month of life.) The infant brain has a higher water content than that of the adult brain, and it is incompletely myelinated. The subarachnoid spaces are also larger in infants than in adults, given the small size of their brains.

When the infant is shaken, movement of the immature brain in relation to the skull and the poor muscle tone in the neck cause the bridging vessels to tear, resulting in the classic finding of a subdural hematoma. Retinal hemorrhages are produced when venous congestion causes rupture of the retinal vasculature. Therefore, shaken baby syndrome is defined by subdural hemorrhage and retinal hemorrhage. One additional feature is occult fractures, particularly of ribs and long bone metaphyses.

The mechanism by which brain damage occurs is controversial. Traditionally, shearing forces from direct trauma were believed to cause axonal damage. Geddes et al suggested hypoxia-ischemia as the mechanism rather than axonal injury that is seen in older children and adults with lethal head trauma. [7, 8] They also thought that acceleration and deceleration forces may damage the neuraxis to cause apnea, with consequent ischemia and cerebral edema.

Biomechanical studies of infant trauma injuries have shown that the magnitude of angular deceleration is 50 times greater when the infant’s head strikes a surface than when he or she is only shaken. This force is distinct from those of other accidental traumas that occur in infants. This evidence suggests that the term shaking-impact syndrome is more accurate than shaken baby syndrome.

Nationally in 2015, an estimated 1670 children died from abuse and neglect in the United States. Nearly 700,000 children are abused in the United States annually. An estimated 683,000 children (unique incidents) were victims of abuse and neglect in 2015, the most recent year for which there is national data. The youngest children were most vulnerable to maltreatment. Children in the first year of their life had the highest rate of victimization—24.2 per 1000 children in the national population of the same age. [9]

Abuse and neglect account for 5–14% of all deaths of children. The youngest children were most vulnerable to maltreatment. Children in the first year of their life had the highest rate of victimization—24.2 per 1000 children nationwide. [9]

In Missouri in 2015, 35 deaths as a result of abuse or neglect were reported. [10] In Illinois in 2015, 77 child deaths as a result of abuse or neglect were reported. [11]

In children younger than 1 year, homicide is the leading cause of death. This is the only cause of death in children that is increasing in frequency. [12]

Boys are affected more often than girls.

The perpetrator is usually alone with the victim. Men are the abusers in 90% of cases. The abuser is usually the biologic father or, in some cases, the mother’s boyfriend. The most common female attacker is a babysitter.

According to a Philadelphia-based study, 1 in 7 mothers who were abused as children admitted to using corporal punishment on their children. [13]

In 2009, 3.3 million cases of child abuse and neglect were reported. Of these, 331,500 cases were substantiated. About 20.282% of the affected children were younger than 3 years, and 20.6% were younger than 1 year. [14] The typical abused child is younger than 6 months.

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Caffey J. On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child. 1972 Aug. 124(2):161-9. [Medline].

American Academy of Pediatrics. Abusive Head Trauma in Infants and Children. Pediatrics 2009. 2009 May. 123:1409-1411. [Full Text].

American Academy of Pediatrics. Understanding Abusive Head Trauma in Infants and Children: Answers from America’s Pediatricians. American Academy of Pediatrics. Available at https://www.aap.org/en-us/Documents/cocan_understanding_aht_in_infants_children.pdf. 2015 Jun 01; Accessed: 2018 Jan 12.

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Geddes JF, Vowles GH, Hackshaw AK, et al. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain. 2001 Jul. 124(Pt 7):1299-306. [Medline].

U.S. Department of Health and Human Services. National Statistics on Child Abuse. Child Maltreatment 2015. 2015. Available at https://www.acf.hhs.gov/sites/default/files/cb/cm2015.pdf.

Child Welfare League of America. Missouri’s Children at a Glance. Missouri’s Children 2017. April 2017. Available at http://www.cwla.org/wp-content/uploads/2017/03/MISSOURI.pdf.

Child Welfare League of America. Illinois’s Children at a Glance. Illinois’s Children 2017. April 2017. Available at http://www.cwla.org/wp-content/uploads/2017/04/ILLINOIS-revised-1-1.pdf.

Missouri Department of Social Services Children’s Division. Missouri Child Fatality Review Program Annual Report from 2011. Available at http://www.dss.mo.gov/re/pdf/can/cancy11.pdf. Accessed: June 24, 2013.

Busko M. Depressed, Abused Mothers More Likely to Spank Their Children. Medscape Medical News. Available at https://www.medscape.com/viewarticle/581070. September 25, 2008;

HHS. U.S. Department of Health and Human Services: Administration for Children and Families. Child Maltreatment 2011. [Full Text].

Kanter RK. Retinal hemorrhage after cardiopulmonary resuscitation or child abuse. J Pediatr. 1986 Mar. 108(3):430-2. [Medline].

Brian Forbes, MD, MPH. Abusive head trauma in infants and young children: Ophthalmologic aspects. UpToDate. Available at http://uptodate.com/contents/abusive-head-trauma-in-infants-and-young-children-ophthalmologic-aspects. Accessed: July 27, 2011.

Cindy Christian, MD Erin E Endom, MD. Evaluation and diagnosis of abusive head traum in infants and children. UpToDate. Available at http://www.uptodate.com/contents/evaluation-and-diagnosis-of-abusive-head-trauma-in-infants-and-children. Accessed: July 27, 2011.

Madonna Behen. Abusive Head Trauma in Infants Doubled During Recession: Study. US News And World Report. Available at http://health.usnews.con/health-news/family-health/brain-and-behavior/articles/2011/04/13. Accessed: July 22, 2011.

Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015 May. 135(5):e1337-54. [Medline].

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Christian CW, Block R. Abusive head trauma in infants and children. Pediatrics. 2009 May. 123(5):1409-11. [Medline].

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Andreadou E. Yapijakis C, Paraskevas GP, et al. Hereditary neruopathy with liability to pressure palsies: the same molecular defect can result in diverse clinical presentation. J Neurol. 1996 Mar. 243 (3):225-30.

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Donohoe M. Shaken baby syndome (SBS) and non-accidential injuries (NAI). Vaccine Website. Available at http://www.whale.to/v/sbs.html. Accessed: March 18, 2009.

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US Department of Health and Human Services. Administration for Children and Families. Factsheets/Publications. Child Maltreatment Reports. Child Maltreatment 2006: Reports from the States to the National Child Abuse and Neglect Data Systems. Available at http://hyyp://www.acf/hhs.gov/programs/cb/publications/cmreports.htm..

Wilkinson WS, Han DP, Rappley MD, Owings CL. Retinal hemorrhage predicts neurologic injuryi n the shaken baby syndrome. Arch Ophthalmol. 1989 Oct. 107 (10):1472-4.

Nitin C Patel, MD, MPH, FAAN Professor of Clinical Pediatrics and Neurology, Southern Illinois University School of Medicine; Private Practice, Columbia Center for Child Neurology

Nitin C Patel, MD, MPH, FAAN is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, Child Neurology Society

Disclosure: Nothing to disclose.

Robin D Riggins, RN, MSN, CPNP Pediatric Nurse Practitioner, Department of Pediatric Neurology, University of Missouri Health Care Hospitals and Clinics

Robin D Riggins, RN, MSN, CPNP is a member of the following medical societies: National Association of Pediatric Nurse Practitioners, American Association of Neuroscience Nurses

Disclosure: Nothing to disclose.

Bhagwan I Moorjani, MD, FAAP, FAAN Consulting Staff, Department of Neuroscience, Director, Department of Neuroscience, Division of Evoked Response Laboratory, Children’s National Medical Center

Bhagwan I Moorjani, MD, FAAP, FAAN is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Kenneth J Mack, MD, PhD Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic

Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, Society for Neuroscience

Disclosure: Nothing to disclose.

Amy Kao, MD Attending Neurologist, Children’s National Medical Center

Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Child Neurology Society

Disclosure: Have stock (managed by a financial services company) in healthcare companies including AbbVie, Allergan, Celgene, Cellectar Biosciences, Danaher Corp, Mckesson.

Robert Stanley Rust, Jr, MD, MA Thomas E Worrell Jr Professor of Epileptology and Neurology, Co-Director of FE Dreifuss Child Neurology and Epilepsy Clinics, Director, Child Neurology, University of Virginia School of Medicine; Chair-Elect, Child Neurology Section, American Academy of Neurology

Robert Stanley Rust, Jr, MD, MA is a member of the following medical societies: Child Neurology Society, Society for Pediatric Research, American Headache Society, International Child Neurology Association, American Academy of Neurology, American Epilepsy Society, American Neurological Association

Disclosure: Nothing to disclose.

Neonatal Injuries in Child Abuse

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