eMedicine Specialties > Neurology > Pediatric Neurology

Neonatal Injuries in Child Abuse

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
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

Updated: Mar 18, 2009

Introduction

Background

Child abuse is often misdiagnosed and underrecognized 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).

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.

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 ]}

For related information, see eMedicine's article Child Abuse & Neglect, Physical Abuse.

Pathophysiology

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.

The mechanism by which brain damage occurs is controversial. Traditionally, shearing forces 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.^{[5,6 ]}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.

Frequency

United States

Approximately 47.8 of every 1000 American children are mistreated. In 2006, 3.6 million cases of child abuse and neglect were reported. Of these, 905,000 cases were substantiated. In the first year of life, accidental injury occurs more often than intentional injury. The incidence of trauma in children younger than 12 months is approximately 24.4 cases per 1000 children per year.^{[7 ]}

International

Good statistical data are not available.

Mortality/Morbidity

Abuse and neglect account for 5-14% of all deaths of children. In 2006 in the United States, 1530 fatalities from child abuse were reported, and 45% involved infants younger than 12 months. In Missouri, the number of substantiated fatalities in 2006 decreased from the previous year; 27 children died as a result of child abuse or neglect in 2006, compared to 32 deaths in 2005.^{[8 ]} Shaken baby syndrome is reported to be the leading cause of death in children younger than 4 years.

• 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.
• In a series of 80 patients younger than 2 years who had head trauma and died because of the injury, 43% had evidence of child abuse.

Sex

• 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.^{[9 ]}

Age

• In 2006, 3.6 million cases of child abuse and neglect were reported. Of these, 905,000 cases were substantiated. About 14.2% of the affected children were younger than 3 years, and 24.4% were younger than 1 year.^{[7 ]}
• The typical abused child is younger than 6 months.

Clinical

History

• 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.
• 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 ]}
• 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.

Physical

• 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.

Causes

Certain risk factors increase the probability of child abuse.

• Characteristics of the child abuser include increased stress, social difficulties, and low educational achievement.
• 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.

Differential Diagnoses

Other Problems to Be Considered

Accidental trauma (eg, subdural hematoma, especially in children with enlarged extra-axial spaces)
Arteriovenous malformation
Bleeding disorders
Connective tissue disorder (ie, osteogenesis imperfecta)
Infectious subdural effusion
Metabolic disorders, especially glutaric aciduria type 1 (can cause retinal hemorrhages and intracranial lesions)

Workup

Laboratory Studies

Laboratory studies for shaken baby syndrome are nonspecific and are not diagnostic.

• Leukocytosis is seen in approximately 50% of patients.
• Serum chemistry findings are usually normal, but they may reveal evidence of acidosis.
• The cerebrospinal fluid may be bloody, possibly indicating subarachnoid hemorrhage.

Imaging Studies

• The true nature of the problem is often discovered only after CT is performed and evidence of intracranial pathology is found.
• The key to diagnosing shaken baby syndrome is neuroimaging.
  • CT scanning of the brain is sufficient to diagnose subdural hemorrhage (see Media file 1), cerebral edema (see Media file 2), and/or subarachnoid hemorrhage. CT is usually the first neuroimaging study obtained in the ED.
    
    

    

    CT scan shows a subdural hematoma.

    
    
    

    

    CT scan shows cerebral edema with loss of gray matter–white matter distinction.

    
    
  • As a follow-up study, MRI can be used to determine the extent of the neurologic injury (see Media files 3-6). MRI may be helpful for continued management and prognosis.
    
    

    

    T1-weighted MRIs reveal bilateral chronic subdural hematomas as well as severe encephalomalacia involving the parietal, occipital, and temporal lobes.

    
    
    

    

    T1-weighted MRIs show chronic bilateral subdural hematomas.

    
    
    

    

    T2-weighted MRIs show encephalomalacia after shaken baby syndrome.

    
    
    

    

    Sagittal MRIs show chronic subdural hematoma.

    
    
  • Retinal hemorrhages can be seen as early as 48 hours before any intracranial lesions can be detected on brain CT or MRI.
• As long as the fontanelle is still open, ultrasonography can be performed to identify an intracranial hemorrhage. However, a negative head sonogram does not rule out intracranial pathology.

Other Tests

• An ophthalmologic evaluation is extremely important and helpful in diagnosis.
  • A dilated eye examination is preferred. However, in the ED, all patients (regardless of the presenting complaint) should receive retinal examination with a direct ophthalmoscope.
  • Papilledema indicates increased intracranial pressure, and retinal hemorrhage strongly suggests shaken baby syndrome (see Media file 7).
    
    

    

    Funduscopic image shows intraretinal hemorrhages, subhyaloid hemorrhages, localized hemorrhagic choroid detachments, and thin retinal folds.

    
    
• All patients in whom abuse is suspected must be given a long-bone skeletal survey to check for new or healing fractures, which help in the diagnosis.

Treatment

Medical Care

Supportive care is the mainstay of treatment in child abuse.

• Blood pressure and vital signs should be supported and maintained.
• Provide mechanical ventilation as needed.
• Treat increased intracranial pressure, if present.

Surgical Care

• Intracranial monitoring may be necessary, especially when intracranial pressure is a problem.
• In the presence of subdural hematoma, surgical evacuation may be necessary.

Consultations

• Consult an ophthalmologist who is well versed in identifying eye findings in abused children. The ophthalmologist is required for the initial ophthalmic evaluation and possibly for follow-up as well.
• Appropriate referral to the state or county protective (abuse) center is necessary to identify siblings who may be at risk of abuse.
• Referral to a physician who specializes in abuse can be helpful but not mandatory.

Activity

• Physical therapy and occupational therapy can be helpful after neurologic injury.
• Speech therapy might be beneficial for patients in whom speech and/or language may be affected.

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.

Multimedia

Media file 1: CT scan shows a subdural hematoma.

Media file 2: CT scan shows cerebral edema with loss of gray matter–white matter distinction.

Media file 3: T1-weighted MRIs reveal bilateral chronic subdural hematomas as well as severe encephalomalacia involving the parietal, occipital, and temporal lobes.

Media file 4: T1-weighted MRIs show chronic bilateral subdural hematomas.

Media file 5: T2-weighted MRIs show encephalomalacia after shaken baby syndrome.

Media file 6: Sagittal MRIs show chronic subdural hematoma.

Media file 7: Funduscopic image shows intraretinal hemorrhages, subhyaloid hemorrhages, localized hemorrhagic choroid detachments, and thin retinal folds.

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.

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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

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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