Pediatric Abusive Head Trauma Rebecca Girardet Associate Professor of Pediatrics Director, Division of Child Protection Pediatrics McGovern Medical School at The University of Texas Health Science Center at Houston
Objectives Review the epidemiology of child maltreatment in Texas Define anatomy terms associated with head trauma Describe the forces associated with different forms of head trauma Review injuries that are often associated with inflicted head trauma in infants Understand why infant head trauma can be occult Know whom to contact for medical expertise regarding child maltreatment
Numbers of Texas CPS child maltreatment cases proportional to state child population (total CPS investigated cases=130,764; Texas child population=14,213,806)
FY 2013 30.00% Reason to Believe 25.00% 20.00% 15.00% 10.00% MedNeg % of total MedNeg PhAb % of total PhAb PhNeg % of total PhNeg 5.00% 0.00%
Incidence estimates for infant inflicted head trauma (Ellingson, Leventhal, Weiss, Am J Prev Med 2008) Cases identified using billing codes in a large national database (Kids Inpatient Database) Cases per 100,000 infants per year: 1997: 27.5 2000: 27.5 2003: 32.2 Applied to Texas infant population (<1 yr) => ~137 in 2015 Data from statewide CAP network (6/9 CAP centers) for 9/1/2012 8/31/2014: 303 cases of intracranial injury with concerning or substantial evidence of PhAb
Layers of the head
Infants are at greater risk of head trauma than adults Infant s head is 15 20% of his body weight, vs. 2 3% for an adult Infant brain consistency is very soft due to high water content, immaturity of brain cells, and less myelin, so more subject to sheering forces Subarachnoid space is thinner than adults, therefore provides less cushioning Young child s neck is less strong
Types of head trauma Static / crush relatively rare Dynamic head moves (fall or shake) Repeated movement (dynamic loading) results in differential motion between brain and skull. Since the dura moves with the skull, bridging veins are torn.
Types of head trauma Focal - impact to the head: Visible with the naked eye (though maybe only on autopsy) Scalp contusion (bruise), laceration Skull fracture Brain contusion Epidural hemorrhage Focal subdural hemorrhage Diffuse Microscopy required to fully assess Bilateral / Interhemispheric subdural hemorrhage Traumatic diffuse axonal injury
Skull Fractures Results from linear/contact forces Can occur from limited vertical falls Simple linear fractures Most commonly seen in accidental injuries Short falls Complex, diastatic or depressed skull fractures imply greater force
Epidural Hematoma Bleeding between the dura and the bone May be venous or arterial Occurs from linear contact forces Usually associated with a skull fracture May have delayed presentation ( lucid interval ) Mass effect - Pressure on the brain causes vomiting, headache, fussiness, loss of consciousness, and death if severe Often are accidental
(picture) skull brain ear
Causes of bilateral or interhemispheric subdural hemorrhages (diffuse head trauma) A significant degree of force applied to the head Tearing of bridging vein(s) Rotational forces NOT bouncing baby on one s knee, fall off the couch, etc.
Symptoms with subdural bleeds The forces that cause SDH often result in sheering (tearing) of brain tissue Torn brain tissue results in swelling and cell death Symptoms include vomiting, headache, fussiness, loss of consciousness, and death if severe
Diffuse head trauma Parenchymal (Brain Tissue) Injury Diffuse Axonal Injury (injury to brain nerve cells) Cerebral edema (brain swelling) Shear injury (visible tears in brain tissue)
Diffuse Axonal Injury Immediate LOC The caretaker who witnessed onset of unconsciousness was very likely present at the moment of injury May result in coma, severe disability
What DOESN T Cause Diffuse Head Trauma Tipped out of car seat Rolled off the couch/bed Bouncing on the knee The sibling did it. Burping, patting the back Inexperienced CPR Bumped the head Spontaneous bleeding
Kleinman, 1998
Missed Abusive Head Trauma Frequent Erroneous Diagnoses Made in Cases of Missed Abusive Head Trauma Diagnosis No. of Times Diagnosis Made Viral gastroenteritis or influenza 14 Accidental head injury 10 Rule out sepsis 9 Increasing head size 6 Non-accidental trauma (not head injury) 4 Otitis media 5 Seizure disorder 5 Reflux 3 Apnea 3 Upper respiratory tract infection 2 Urinary tract infection or pyelonephritis 2 Bruising of unknown origin 2 Hydrocephalus 2 Meningitis 2
Patient Age, months Time Between Visits 18 First visit 7 Days after first visit 11 Days after first visit Documented Clinical Signs Evaluation Results Diagnosis Vomiting, alert and responsive, normal respiration, new bruising Vomiting, alert and responsive, normal respiration, new bruising Vomiting, coma, unresponsive to pain, respiratory arrest None None Retinal hemorrhage, subdural hemorrhage, focal brain injury, diffuse brain injury, noncranial trauma Influenza Otitis media AHT 2 7 First visit 141 Days after first visit Failure to thrive, vomiting, alert and responsive, normal respiration, bruising to face and chest Seizures, coma, unresponsive to pain, respiratory arrest Normal computed tomography result with missed subdural hemorrhage and brain shearing tears Retinal hemorrhages, skull fracture, subdural hemorrhage, diffuse brain injury, noncranial trauma, old cranial trauma Apnea AHT 5 First visit 6 Days after first visit 9 Days after first visit Vomiting, irritability, sleepiness, normal respiration, went limp Vomiting, diarrhea, irritability, alert and responsive, normal respiration Vomiting, irritability, coma, seizures, unresponsive to pain, cardiorespiratory arrest None None Retinal hemorrhages, subdural hemorrhages, diffuse brain injury Anxiety secondary to new day care Acute gastroenteritis AHT 3 First visit 8 Days after first visit Vomiting, irritability, alert and responsive, normal respiration, dehydration Coma, unresponsive to pain None Retinal hemorrhage, subdural hemorrhage, diffuse brain injury, old brain injury, old cranial trauma Acute gastroenteritis AHT
Physician training in child maltreatment Medical school: The Liaison Committee on Medical Education (LCME) standards state that the curriculum of a medical education program must prepare medical students for their role in addressing the medical consequences of common societal problems (e.g., provide instruction in the diagnosis, prevention, appropriate reporting, and treatment of violence and abuse). The responsibility for curriculum development rests with medical school faculty.
General practitioner: Texas requires a minimum of 1 year of postgraduate training for US and Canadian medical school graduates, 2 years for IMG s, to qualify for an unrestricted license Family practitioner: 3 year post graduate training program No requirement regarding child maltreatment Must have minimum 200 hours and 250 patient encounters dedicated to the care of ill children in the hospital and/or ER, and minimum 200 hours or 250 patients encounters dedicated to the care of children in an ambulatory setting Emergency Medicine: 3 year post graduate training program No requirement regarding child maltreatment Residents must demonstrate proficiency in pediatric trauma resuscitation
Pediatrician: 3 year post graduate training program The overall structure of the program must include a minimum of 4 subspecialty education units (months) from the following: child abuse, medical genetics, pediatric allergy and immunology, pediatric cardiology, (9 more). Residents must demonstrate the ability to interview patients and families about the particulars of the medical condition for which they seek care, with specific attention to behavioral, psychosocial, environmental, and family unit correlates of disease Ambulatory experiences must include elements of child advocacy ~2% or board questions concern child abuse and neglect (Duty to report; guidance of families during an investigation; basic findings; treatment and outcomes)
Starling et al. A 2006 survey of pediatric residency programs indicated that one-quarter of accredited pediatric residency programs offered no rotation in child abuse and neglect and only 41% required mandatory clinical experience. A majority of residency programs felt that more training was needed.
Child abuse pediatrician 6 years post graduate training (3 in general pediatrics + 3 fellowship years) 6-page document outlines fellowship training requirements 99 pages of board questions devoted to child maltreatment
https://facntx.org https://www.dshs.state.tx.us/mch/medcares.shtm/
Make it a group effort