Abusive Head Trauma Often Missed in Young Children
Abusive Head Trauma Often Missed in Young Children
By Patricia McGinley, RNP, MSN
Summary—Caseload statistics from agencies offering child protective services across the United States report three children die each day as a result of abuse or neglect. Those statistics show reported cases have risen 47% over the past 10 years. A retrospective analysis of hospital records of 173 abused children revealed startling results. The diagnosis of abusive head trauma was missed in more than 31% of cases. In infants and toddlers with a presenting complaint of vomiting or irritability on the initial visit, the diagnosis was missed 56% and 65% of the time, respectively. To protect the most vulnerable members of our society, health care providers must remain alert and aware of the potential for abuse in those who cannot defend or speak for themselves.
Out of every 1,000 children in the United States, 47 are victims of child maltreatment. In the past decade, child abuse reporting levels increased by 47%.1 This increase does not necessarily reflect an actual increase in the volume of child abuse, but rather reflects an increase in public awareness and willingness to report such activities. Types of abuse include physical, emotional, sexual, and neglect. The most commonly reported abuse is neglect. Caseload reports to agencies offering child protective services across the country show that three children die each day as a result of abuse and neglect. The statistics are staggering and reflect poorly on family life in America. The numbers actually may be much higher in the infant and toddler group due to misdiagnosed abusive head trauma.
A six-year retrospective study found that 31.2% of the children who evidenced clinical symptoms of abusive head trauma were diagnosed with other conditions on the first visit.2 Clinicians missed the diagnosis of AHT in 55.6% of infants and toddlers who presented with vomiting and 65.4% of those presenting with irritability. In four cases resulting in death, abusive head trauma was not diagnosed until the second or third visit, which occurred 8-141 days after the initial visit. At that time, all four children, ages 18 months-3 years, demonstrated retinal hemorrhage, subdural hemorrhage, and diffuse brain injury. In seven cases, radiological error involving computed tomography scan, skeletal survey, or long-bone radiographs contributed to the missed diagnosis.
Abusive head trauma may result in permanent neurologic consequences or death. In a verbal child, history of head trauma can be elicited directly from the child. However, in the preverbal infant and toddler, abusive head trauma may be more difficult to diagnose. Clinicians must rely on the history obtained from caregivers as well as the more subtle signs and symptoms of abusive head trauma. These signs can be confused with less serious conditions such as colic, gastroenteritis, or seizure disorders.
Research Methodology
Researchers at the Children’s Hospital in Denver conducted a retrospective medical record review of children diagnosed with abusive head trauma over a six-year period. The hospital’s Child Advocacy and Protection (CAP) team of pediatricians, nurses, social workers, psychologists, child psychiatrists, and attorneys evaluated all potential study subjects. They investigated all cases of suspected child abuse or neglect at the Children’s Hospital and maintained a case log.
The team interviewed caretakers regarding:
• the child’s medical history;
• and purported mechanism of injury.
To confirm that abusive head trauma or other abusive behavior was indeed inflicted upon the child, team members reviewed each child’s:
• past medical records;
• physical exam findings;
• and diagnostic studies.
The team also ensured that the child’s presenting signs and symptoms were not due to organic illness.
Researchers gathered data about demographics, family and social information, presenting clinical complaints, and the clinical course. A pediatric radiologist reviewed all imaging studies conducted on the abuse victims.
The study included 173 children between the ages of 10 days and 2.9 years, with a mean age of 247 days. Researchers limited the study of head injuries to children younger than 3 years for two reasons:
• children older than 3 are less likely to sustain severe injury when shaken or struck in the head;
• and children older than 3 are more likely to describe their experiences.
Investigators defined abusive head trauma as "inflicted cranial injury" and grouped all head injuries resulting from abuse in this category. To reach a diagnosis of abusive head trauma as opposed to unintentional head injury, the CAP team considered:
• confession of intentional injury by the adult caretaker;
• a history from the caretaker that did not adequately explain the nature and/or severity of the injury;
• unexplained associated injuries such as fractures or intra-abdominal injury;
• and delay in seeking care.
Study Results
Sixty-five percent of the children were Medicaid-funded or uninsured. In addition to head trauma, the children suffered from trauma to other body parts, including fractures. Five of the 54 children died as a result of the abusive head trauma, and 15 of the 54 suffered from a reinjury following earlier misdiagnosis. Looking more closely at the demographic data, the missed cases tended to be younger patients (mean age 180 days), Caucasian (37%), and living in two-parent households (40%). Employment status of the parents, existence of private insurance coverage, sex, birth weight, and premature birth did not differ between subjects with missed as opposed to recognized abusive head trauma. Severity of presenting symptoms did play a role in who was diagnosed at first visit vs. diagnosis at subsequent visits.
Children with obvious head trauma presenting in a comatose state, with visible bruising or respiratory distress, were more likely to be diagnosed correctly at initial presentation. However, children who presented with more subtle signs and symptoms such as vomiting or irritability were missed until subsequent visits. In some cases, it took up to nine visits before the abusive head trauma was recognized and diagnosed. The most common diagnosis given to these children was viral gastroenteritis or accidental head injury. In seven cases, radiological mistakes involving computed tomography scan, skeletal survey, or long-bone radiographs contributed to the missed diagnosis.
Implications for Practice
Child abuse statistics present a sad commentary on societal and family views toward the youngest and most vulnerable members of our population. Infants and toddlers, unable to verbalize their complaints or life circumstances must rely on the keen, educated eyes and skills of the clinician to recognize abuse and make an appropriate diagnosis. With the incidence of child abuse so prevalent, the clinician must keep child abuse and neglect in the differential diagnosis for the child who presents with subtle symptoms. As seen in this research study, judgments based on a child’s socioeconomic status raise a red flag in some circumstances but may falsely lower it in others. The researchers presented several recommendations for clinicians:2
• Be alert for bruises and/or abrasions on the heads or faces of children presenting with vague, nonspecific symptoms.
• Consider head trauma in the differential diagnosis when an infant or toddler presents with nonspecific symptoms such as fever, vomiting, or irritability.
• Consult a pediatric radiologist to interpret X-ray and computed tomography images.
• If spinal fluid is collected, test for xanthochromia; if present, it can represent old blood from previous trauma (i.e. intracranial bleed).
With increased vigilance in looking for and detecting child abuse, these most vulnerable members of our society stand a better chance for a normal, healthy, protected life.
References
1. Wang C. Current trends in child abuse reporting and fatalities: The results of the 1997 annual 50-state survey. National Committee to Prevent Child Abuse, Chicago. Available on the World Wide Web: www. childabuse.org/50data97.html2.
2. Jenny C, Hymel K, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621-626.
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