The following was adapted from the Canadian Paediatric Society's statement on "Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma." Please see the full statement for the full recommendations from the Canadian Paediatric Society. For more information, please see our PedsCases podcast on "Physical Abuse in Children."
Background
Abusive Head Trauma (AHT) is a specific form of traumatic brain injury, defined with a constellation of signs, symptoms, laborratory investigations, imaging and pathologic findings that are consequence of violent shaking, impact or a combination of the two. AHT usually is seen in infants and young children but can occur in older children. The name AHT has been adopted in favour of past terms including Shaken Baby Syndrome as a more precise descriptor of the range of possible injuries.
Presenting features of AHT are often non-specific. There may be no external signs of injury so it is important to consider AHT in the differential in any child with altered level of responsiveness without a clear etiology. Presenting features may include:
- Altered level of responsiveness
- Lethargy
- Decreased feeding
- Irritability
- Vomiting
- Respiratory distress or apnea
- Seizures
Characteristic injuries which may be seen on examination or imaging include:
- Intracranial haemorrhage
- Retinal haemorrhage
- Brain injury
- Fractures of the skull, ribs and the metaphyses of long bones
The identification, investigation and management of AHT is complex and requires a multidisciplinary approach. These guidelines outline the role of each discipline, and include overall guiding principles for managing this complex subject. This summary, targeted for learners in medicine, will focus on the role of the health sector. For more details on the complexity of this issue please see the completestatement.
General Principles
The following general principles apply to all professionals involved in a suspected case of AHT:
- Protection of the child and other children in the family is of paramount importance, and the child should be provided the best quality of medical care available.
- When AHT is suspected it is mandatory to provide early notification to child protection so they can begin their investigation. Child protection will notify the police if warranted.
- One member of the health care team should be designated to share information and convene a case conference as soon as appropriate.
- Professionals should avoid contamination of the evidence. Statements and actions (such as probing questions) from a professional can affect the process or outcome of an investigation.
- When talking to familes, be cautious about providing information about possible mechanisms of injury. It is best to simply say that the child's injuries are the result of trauma.
- Professionals should document all encounters with the patient and involved parties. All documentation must be specific, easy to understand and available to the treatment team as soon as possible. Documentation should be accompanied by diagrams, and/or photographs to provide clarity where appropriate. Caution should be taken in making definitive statements about the cause of injury before assessment is complete.
- Consider if other children in the family or in the home may be at risk. Make plans to evaluate and protect other children as necessary.
- All professionals may be required to testify regarding their assessments in court proceedings.
Health Sector
The health sector team involved may include medical, surgical and nursing staff. Primary responsibilities of this team include diagnosis and management of medical concerns.
A complete history and physical exam should be completed. It is important to note that the accompanying caregiver may have no knowledge of the injury and/or may not give a complete or accurate history. The physical exam should look for any associated injuries with special attention to examination of the nervous system and eyes.
Every child should be assessed by an experienced opthalmologist with an indirect opthalmoscope and dilated pupils. A child with diffuse multilayered retinal hemorrhages suggests AHT. The documentation of retinal findings is essential, with photographs if possible.
Imaging of the head is necessary in all suspected cases of AHT. A CT scan is indicated acutely, and an MRI may be used later to provide additional information. Findings of a subdural hematoma or cerebral edema support a diagnosis of AHT.
A skeletal survey is required to detect bony injury. A bone scan may be used to identify some subtle and acute bony injuries.
Investigations should include a CBC and coagulation studies. Additional tests may be indicated to confirm or rule out other diagnoses.
Consultations with the following physicians may be required (preferably with pediatric expertise):
- Physician with experience in child maltreatment
- Opthamologist
- Neurosurgeon
- Neurologist
- Radiology
These guidelines do not discuss detailed medical management of a child with AHT, however the level of care may vary widely depending on the severity of the injury.
In the event of a child's death, the post-mortem examination should be conducted according with local legislations for deaths of children under suspicious circumstances.
Other Professionals
The roles of other professionals include, but are not limited to:
- Psychosocial Professionals (Social Workers, Psychologists, Spiritual Care Providers) - Assessment of capacity and risk to the child. Provision of emotional, physical, financial and spiritual support. Discharge planning and referral to communities agencies
- Child Protection Agencies - Immediately contacting the police to conduct a joint investigation. Hold primary responsibility for the safety of the child during the investigation. Decisions related to status, access, supervision and placement.
- Police - Conduct a joint investigation with child protection. Hold primary responsibility for the criminal investigation. Act as a liaison between Crown prosecutors and other professionals involved.
- Medical Examiners and Coroners - Report all unexplained or unexpected child deaths to the the child and family service agency. Perform an autopsy. Publish and annual report on child deaths.
- Crown Prosecutors - Lead the prosecution whenever possible. Determine if there is sufficient evidence to proceed to trial. Obtain and prepare appropriate expert witnesses in the field of AHT.
For more details on the roles of other professionals, please see the complete statement.
Last updated by PedsCases: May 8, 2015