eMedicine Specialties > Neurology > Pediatric Neurology

Neonatal Injuries in Child Abuse: Follow-up

Author: Nitin C Patel, MD, MPH, Associate Professor of Clinical Neurology and Child Health, Department of Child Health, Interim Division Chief for Developmental Pediatrics and Child Neurology, Specialist in Pediatrics/Neurology, University of Missouri Hospital and Clinics at Columbia
Coauthor(s): Robin D Davenport, BS, MSN, Pediatric Nurse Practitioner, Department of Pediatric Neurology, University of Missouri Health Care Hospitals and Clinics; 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
Contributor Information and Disclosures

Updated: Mar 18, 2009

Follow-up

Further Inpatient Care

  • Further inpatient rehabilitation therapy may be indicated to manage the acute intracranial pathology, depending on the severity of injury.
  • If long-term inpatient care is required, the patient should be transferred to a pediatric rehabilitation unit for maximal multidisciplinary care.

Further Outpatient Care

  • The patient may require continued physical and occupational therapy after discharge.
  • Continued follow-up with a neurologist is recommended.
  • Closely watch the patient for spasticity, and control this with medication as needed.

Inpatient & Outpatient Medications

  • Antiepileptic medication may be indicated if evidence of seizures is noted.
  • Neurosurgeons tend to prescribe prophylactic therapy for all patients. However, this practice is not a universal recommendation.

Complications

  • The main complications after shaken baby syndrome affect the neurologic and visual systems.
  • After retinal hemorrhages resolved, the following visual complications may occur: macular thinning, retinal pigment epithelial atrophy, and visual loss.
    • Wilkinson et al showed that the degree of retinal hemorrhage reflects the degree of neurologic injury.12
    • Patients with bilateral retinal hemorrhages tend to have acute, severe neurologic injury.
    • Large subhyaloid hemorrhage, vitreous hemorrhage, or diffuse involvement of the fundus is likely to be associated with severe neurologic injury.
  • Neurologic complications include varying degrees of learning disabilities, spasticity and weakness, hydrocephalus, developmental delay, acquired microcephalus, seizures, hearing loss, and cortical blindness.

Prognosis

The prognosis depends on the severity of the neurologic injury and the involvement of other organ systems.

Patient Education

For excellent patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education article Child Abuse.

Miscellaneous

Medicolegal Pitfalls

  • In most states, reporting suspected child abuse to the authorities is mandatory.
  • Advocates recommend medical tests that support nonaccidental injury, especially in cases of shaken baby syndrome. The tests considered include those discussed in Imaging Studies and Other Tests, specifically head CT/brain MRI, ophthalmologic consultation for dilated funduscopic examination, and radiological skeletal survey.
  • Five controversies have been identified in the field of nonaccidental trauma to children. They pertain to the 5 major assumptions reflected in the sworn testimony of state medical experts.
    • The first assumption is that shaking alone of a healthy child causes retinal hemorrhages and subdural hematomas. Biomechanical research and human case data suggest that shaking alone cannot cause these symptoms, but experts can state that short falls cannot.
    • The second assumption is that falls over a short distance do not kill infants or children. However, findings from medical research and case studies do suggest that infants and children can and do die from such falls.
    • The third controversy states that chronic subdural hematomas do not spontaneously rebleed. The literature about adult patients suggests that rebleeding can also occur in children with a subdural hematoma, with or without abuse.
    • The fourth controversy is that a lucid interval is not a feature of pediatric head injury. However, the medical literature suggests the occurrence of a lucid interval in head injuries affecting children, as well as adults.
    • The fifth controversy is that retinal hemorrhage occurs only in shaken baby syndrome. However, this hemorrhage is found in different situations, such as injuries related to childbirth, coagulation disorders, and CPR.
 


More on Neonatal Injuries in Child Abuse

Overview: Neonatal Injuries in Child Abuse
Differential Diagnoses & Workup: Neonatal Injuries in Child Abuse
Treatment & Medication: Neonatal Injuries in Child Abuse
Follow-up: Neonatal Injuries in Child Abuse
Multimedia: Neonatal Injuries in Child Abuse
References
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References

  1. Caffey J. Multiple fractures in long bones of infants suffering from chronic subdural hematoma. AJR Am J Roentgenol. 1946;36:163-73.

  2. Kempe CH, Silverman FN, Steele BF, et al. The battered-child syndrome. JAMA. Jul 7 1962;181:17-24. [Medline].

  3. Gilkes MJ, Mann TP. Fundi of battered babies. Lancet. 1967;2:468-9.

  4. 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. Aug 1972;124(2):161-9. [Medline].

  5. Geddes JF, Hackshaw AK, Vowles GH. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain. Jul 2001;124(Pt 7):1290-8. [Medline].

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

  7. HHS. Child Maltreatment 2006. Administration for Children and Families [serial online]. Chapter 3:Accessed September 23, 2008. Available at http://www.acf.hhs.gov/programs/cb/pubs/cm06/chapter3.htm.

  8. Missouri Department of Social Services Children's Division. Child Abuse and Neglect in Missouri: Report for Calendar Year 2006: Research and Evaluation. Available at http://digitalarchive.oclc.org/da/ViewObject.jsp?objid=0000020618&reqid=9295. Accessed November 2007.

  9. Bates B. Abused Moms Are More Likely to Spank Infants. Pediatric News. July 2008;Behavior PediatricsChild Abuse Introductionhttp://www.emedicinehealth.com/Articles/9844-1.asp: 22. Available at www.pediatricnews.com.

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

  11. Ludwig S, Warman M. Shaken baby syndrome: a review of 20 cases. Ann Emerg Med. Feb 1984;13(2):104-7. [Medline].

  12. Wilkinson WS, Han DP, Rappley MD, Owings CL. Retinal hemorrhage predicts neurologic injury in the shaken baby syndrome. Arch Ophthalmol. Oct 1989;107(10):1472-4. [Medline].

  13. Alexander R, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child. Jun 1990;144(6):724-6. [Medline].

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  22. Giardino AP, Christian CW, Giardino ER. A Practical Guide to the Evaluation of Child Physical Abuse and Neglect. Thousand Oaks, Calif: Sage; 1997.

  23. Hahn YS, Raimondi AJ, McLone DG, Yamanouchi Y. Traumatic mechanisms of head injury in child abuse. Childs Brain. 1983;10(4):229-41. [Medline].

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  26. Manning SC, Casselbrant M, Lammers D. Otolaryngologic manifestations of child abuse. Int J Pediatr Otorhinolaryngol. Sep 1990;20(1):7-16. [Medline].

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  28. Spaide RF, Swengel RM, Scharre DW, Mein CE. Shaken baby syndrome. Am Fam Physician. Apr 1990;41(4):1145-52. [Medline].

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  30. US Department of Health an 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://www.acf.hhs.gov/programs/cb/publications/cmreports.htm.

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Further Reading

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Keywords

shaken baby syndrome, shaken-baby syndrome, SBS, shaking, neurologic injury in child abuse, battered child syndrome, battered-child syndrome, child abuse, shaken infant, shaking impact syndrome, shaking-impact syndrome, retinal hemorrhage

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Contributor Information and Disclosures

Author

Nitin C Patel, MD, MPH, Associate Professor of Clinical Neurology and Child Health, Department of Child Health, Interim Division Chief for Developmental Pediatrics and Child Neurology, Specialist in Pediatrics/Neurology, University of Missouri Hospital and Clinics at Columbia
Nitin C Patel, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, and Child Neurology Society
Disclosure: Nothing to disclose.

Coauthor(s)

Robin D Davenport, BS, MSN, Pediatric Nurse Practitioner, Department of Pediatric Neurology, University of Missouri Health Care Hospitals and Clinics
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.

Medical Editor

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; Chair-Elect, Child Neurology Section, American Academy of Neurology
Robert Stanley Rust Jr, MD, MA is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, American Neurological Association, Child Neurology Society, International Child Neurology Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Neurology, Department of Neurology, Oregon Health and Science University; Consulting Staff, Shriners Hospital for Children
Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

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