Neonatal Injuries in Child Abuse Clinical Presentation

• More than half of the patients who present to the emergency department (ED) or a physician's office with suspected above have no history of previous abuse.

  • One fourth have a history of minor trauma.
  • A small percentage present with a seizure, with varying levels of consciousness (eg, coma, apnea, respiratory arrest).
  • Other symptoms failure to thrive, poor feeding, and other vague symptoms.
• The typical patient is a frequent visitor to the ED because of various symptoms.

  • Common historical accounts that suggest abuse include injury inflicted by sibling, a fall down the steps, suddenly turning blue and stopping breathing, being left alone for a few minutes, and falling from a low height.
  • Patients occasionally present with minor symptoms, such as earache, ear pulling, cough, or colds.
• The true nature of the problem is often discovered only after CT is preformed and evidence of intracranial pathology is found.
• The most common intracranial lesion is subdural hemorrhage.

  • The symptoms are related to signs of increased intracranial pressure, but some patients have no evidence of increased intracranial pressure.
  • Other findings are cerebral edema, subarachnoid hemorrhage, and even intraparenchymal hemorrhage.
  • Interhemispheric bleeding is an early and specific finding in intracranial bleeds caused by shaking.
• Skull fractures are seen in as many as 95% of patients with serious intracranial injury.

  • The fracture is usually in the occipital or parietal bones.
  • Abuse should be considered if the patient has bilateral depressed fractures or multiple fractures, especially if they cross the suture lines.
• Retinal hemorrhage is a characteristic and diagnostic feature of shaken baby syndrome. It can be detected even before intracranial hemorrhages are seen. Several types of retinal hemorrhages have been described.
• Whether cardiopulmonary resuscitation (CPR) can cause retinal hemorrhage is controversial. Kanter evaluated 54 patients for retinal hemorrhage after CPR. Among the patients, 45 had no trauma, and only 1 patient (2%) had evidence of retinal hemorrhage. Of the 9 patients who had evidence of trauma, 5 had retinal hemorrhage, and 4 of had evidence of child abuse.^[10] CPR-associated retinal hemorrhages rarely, if ever, occur. However, if they do occur from CPR, they are few in number and confined to the posterior pole.^[11]
• Characteristics of retinal hemorrhages in abusive head trauma are bilateral, although asymmetric and unilateral are well recognized. In most cases of abusive head trauma, they are too numerous to count and extend to the ora serrata. Two thirds of retinal hemorrhages associated with abusive head trauma occur in multiple layers.^[11]
• In 1998, Jayawant identified 9 characteristics of supposed and proven nonaccidental injury in children with subdural hematoma. These characteristics suggest a set of criteria that may be used to increase the precision of diagnosis.

  • Boys account for two thirds of the children studied.
  • Four fifths of the perpetrators are men.
  • In about one eighth of all cases, the child and/or his or her siblings were previously abused by the same perpetrator.
  • More than half of the caregivers change their stories several times.
  • About half of all perpetrators eventually admit to shaking the child.
  • About half of all patients have a hemoglobin level of less than 10 g/L at presentation.
  • The skeletal survey is positive in 60% of cases involving nonaccidental injury.
  • About 60% of patients have evidence of present or past trauma.
  • Retinal hemorrhages are present in 80% of patients.

• Ludwig and Warman in 1984 characterized the presenting physical findings of shaken baby syndrome.^[11]

  • An enlarged head circumference was seen in slightly more than half of all patients, as was a bulging fontanelle.
  • Nonspecific bruising was noted in one third of the patients.
  • Neurologic involvement was seen in fewer than 50% of patients.
• The key to diagnosis is the presence of retinal hemorrhages, which are seen in 80% of patients.

  • Retinal hemorrhage is considered the hallmark of shaken baby syndrome.
  • Retinal hemorrhages can be seen as early as 48 hours before any intracranial lesions can be detected on brain CT or MRI.
  • After vaginal delivery, retinal hemorrhages are occasionally seen without intracranial lesions.
  • The incidence of perinatal retinal hemorrhages ranges from 20-30% among infants examined in the first 24 hours of life and 10-15 % in infants examined the first 72 hours of life. These hemorrhages appear to be related to obstetrical and perinatal changes, as well as peripartum prostaglandin release. They can occur with any type of delivery but are more common in deliveries that are spontaneous vaginal deliveries or with vacuum assisted. Perinatal retinal hemorrhages may be numerous and extend to the periphery.^[12]

Certain risk factors increase the probability of child abuse.

• Characteristics of the child abuser include increased stress, social difficulties, and low educational achievement. Cases of abusive head trauma have doubled during the recent recession.^[13]
• Crying of the infant or child may also play a role.
• Infants who are premature and have congenital defects, developmental delays, or difficult temperament are at greater risk for child abuse, possibly due to poor parental bonding.