Neonatal Injuries in Child Abuse Workup

  • Author: Nitin C Patel, MD, MPH; Chief Editor: Amy Kao, MD   more...
 
Updated: Aug 29, 2011
 

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.
  • Obtain urine for organic acids to rule out a diagnosis of glutaric acidemia.
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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 the first image below), cerebral edema (see the second image below), and/or subarachnoid hemorrhage. CT is usually the first neuroimaging study obtained in the ED. CT scan shows a subdural hematoma. CT scan shows a subdural hematoma. CT scan shows cerebral edema with loss of gray matCT 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 the images below). MRI may be helpful for continued management and prognosis. T1-weighted MRIs reveal bilateral chronic subduralT1-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 hT1-weighted MRIs show chronic bilateral subdural hematomas. T2-weighted MRIs show encephalomalacia after shakeT2-weighted MRIs show encephalomalacia after shaken baby syndrome. Sagittal MRIs show chronic subdural hematoma. 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.
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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 the image below).Funduscopic image shows intraretinal hemorrhages, 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.
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Contributor Information and Disclosures
Author

Nitin C Patel, MD, MPH  Professor of Clinical Neurology and Child Health, Department of Child Health, 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 Riggins, RN, MSN, CPNP  Pediatric Nurse Practitioner, Department of Pediatric Neurology, University of Missouri Health Care Hospitals and Clinics

Robin D Riggins, RN, MSN, CPNP is a member of the following medical societies: American Association of Neuroscience Nurses and National Association of Pediatric Nurse Practitioners

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.

Specialty Editor Board

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 School of Medicine; 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Chief Editor

Amy Kao, MD  Attending Neurologist, Children's National Medical Center

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.

References

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CT scan shows a subdural hematoma.
CT scan shows cerebral edema with loss of gray matter–white matter distinction.
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.
Funduscopic image shows intraretinal hemorrhages, subhyaloid hemorrhages, localized hemorrhagic choroid detachments, and thin retinal folds.
Flair and T2 images reveal intrahemispheric bleeding.
 
 
 
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