The purpose of this course is to provide useful and pertinent info regarding pediatric abusive head trauma/injury, previously known as shaken baby syndrome (SBS).
- Briefly define terms and review national statistics related to child maltreatment, and where available, abusive head trauma
- Identify risk, protective, and preventive factors surrounding abusive head trauma
- Describe the signs and symptoms of pediatric abusive head trauma
- Describe how to assess pediatric patients in suspected cases of abusive head trauma and document the findings thoroughly
- Prepare nurses to educate caregivers to avoid accidental head trauma due to falls, accidental injuries, etc.
- Discuss the implications for nursing practice and future research
Child maltreatment, which is the umbrella term encompassing child abuse that includes physical abuse, emotional abuse, sexual abuse, or neglect, is responsible for 25% of brain injuries in children over the age of two.
Brain and head trauma is the most common cause of traumatic deaths in children under age 2. According to the National Library of Medicine, a branch of the National Institutes of Health, pediatric abusive head trauma is defined as an injury to the intracranial contents or skull of a child under the age of five as a result of shaking, blunt impact, suffocation or strangulation. It refers to a specific type of injury, and not necessarily a mechanism, and can also include dropping or throwing a child. The classic triad of abusive head trauma refers to encephalopathy, subdural hematoma, and retinal hemorrhage.
While there exists a relative lack of consistent, well documented statistics regarding this issue, the following have been established with relative certainty. The Child Maltreatment Report of 2016reports the incidence of child maltreatment in the first year of life at 24.8 per 1000 children of the same age in the US. Incidence of abusive head trauma is estimated at 35 per 100,000. The National Center for Shaken Baby Syndrome reports between 1200-1400 cases of pediatric abusive head trauma annually in the US. The CDC, which recommends the term “Abusive Head Trauma” for legal and other reasons (versus SBS), reports that abusive head trauma in pediatrics accounts for roughly 10% of the 2000 deaths annually from maltreatment. Annual medical costs are estimated at over $70 million. Sixty-five percent of patients develop significant neurological disabilities and more than 50% will be partially or completely blind. Between 5-35% of infants die from their injuries.
Risk factors for abusive head trauma can be categorized into three basic groups: characteristics of the victim, the perpetrator, and the community. Victim risk factors include inconsolable crying and/or colic (peaks at 6-8 weeks of age), disability of the child, greater than 2 siblings in the home, and living in an unrelated adult’s home. Perpetrator risk factors include a frustrated caregiver or frustration intolerance, a history of domestic violence in the home, a mental or behavioral health history, inexperienced caregiver, single parents, young parents, low education level, low socioeconomic status, lack of prenatal care and maternal smoking. Sixty-five to ninety percent of perpetrators of pediatric abusive head trauma were male, while the statistics for child maltreatment in general is more evenly split between the sexes (54% women, 45% men). Community risk factors include social isolation, lack of recreational facilities, and poverty.
The National Institutes of Health lists family support and parental concern as effective protective factors against abusive head trauma. The preventive factors for abusive head trauma include parental education programs regarding child development and parenting, social support, and parental resilience.
Evidence-based Nursing Practice
The initial management of a critically ill or unstable patient with abusive head trauma presenting to an emergency room or urgent care includes the same basic lifesaving measures you would employ for any unstable patient: Circulation, Airway management, and Breathing. Nearly 40% of abusive head trauma patients require CPR at initial presentation. Vital signs need to be taken regularly and watched closely for apnea, hypothermia/chills and bradycardia. Once the patient has been determined stable, a full history and head to toe nursing assessment/physical exam should be done.
For abusive head trauma patients, a major factor affecting their morbidity and mortality is timely and accurate diagnosis by the initial health care professionals they encounter, and this often means a triage nurse or similar provider in emergency rooms, urgent care centers, and pediatric clinics. The classic triad of findings for abusive head trauma includes subdural hemorrhage (usually bilateral, but could be unilateral), retinal hemorrhage (usually bilateral), and encephalopathy/cerebral edema. However, many infants will present with various and varied symptoms ranging from mild flu-like symptoms or no external injuries (35-40%) to altered level of consciousness and coma. The following are red flags that could indicate abusive head trauma or other child maltreatment:
- Unilateral or bilateral subdural hemorrhage (68%)
- Retinal hemorrhage (usually bilateral, encompassing most of the retina) (60-85%)
- Cerebral edema (39%)
- Fractures of ribs, long bones, and/or metaphyseal (22-29%)
- Skull fracture (especially complex, diastatic > 3mm, multiple, occipital, and non-parietal)
- Decreased interaction and/or lack of social smile
- Decreased level of consciousness, lethargy, or increased sleeping
- Failure to thrive or poor feeding
- Bulging fontanel
- Irritability (65%)
- Nausea/vomiting (56%)
- Bruising in a non-ambulatory child, especially under 5 months old
- Bruising around ears, neck, or torso under 4 years old
- Frenulum injuries
- Ligature marks
A complete nursing assessment, with a special focus on repeated, consistent and complete neurological exams, can provide important clues and trends that lead one to suspect abusive head trauma and lead towards the necessary tests and imaging studies to confirm that diagnosis. The majority of abusive head trauma patients present with an abnormal neurological exam.
A complete and thorough history from the adult(s) accompanying the ill child will also provide a number of important clues to indicate to the nurse that abusive head trauma should be suspected and ruled out. Within the initial history, the nurse is looking for stories that change over time, do not align with the child’s injuries and developmental stage, or are otherwise unreliable and suspicious. In several retrospective studies, no history of a traumatic event was offered in >64% of abusive head trauma cases. In fact, the lack of a history of trauma had a high specificity and high positive predictive value for abusive head injury. Injuries are often attributed to resuscitative efforts or are developmentally incompatible. Over 60% of victims of abusive head trauma were found to have a history or clinical evidence of previous abuse. The nurse should attempt to establish a clear timeline of the patient’s injuries. Open ended questions will help establish a good therapeutic communication pattern between the nurse and the caregiver, and if there are multiple adults they should be interviewed separately.
Medical work-up for these patients includes basic blood work such as CBC, CMP, platelets and coagulation studies. Urinalysis and CSF studies are sometimes done as well. Initial imaging studies include a head CT and skeletal survey, with additional follow-up imaging if needed to further clarify or elucidate any abnormal findings. Finally, an ophthalmologic consult/exam to assess for retinal hemorrhage should also be included.
Once the diagnosis of abusive head trauma has been established by the medical team, the nursing care of these patients are rooted in sound acute care and pediatric nursing data. A Glasgow coma scale score under 9 in combination with respiratory distress or hemodynamic instability should suggest the need for advanced airway management and ventilation. Intracranial pressure can rise dangerously in abusive head trauma in the presence of cerebral edema and subdural hemorrhage causing extensive secondary damage. Maintaining the head of bed at 30° and limiting environmental stimulus optimizes cerebral perfusion and decreases cerebral metabolism, simultaneously helping to reduce intracranial pressure. Sedation with barbiturates and or therapeutic hypothermia further decreases cerebral metabolism and therefore intracranial pressure. Vital signs are monitored closely, and regular neuro checks should be completely consistently, and if possible, by the same provider throughout a given shift.
Unfortunately, many patients with abusive head trauma will not survive, or will do so with extensive disability and long-term effects. The best nursing care for these children, therefore, is not optimal treatment after the fact, but rather prevention of the maltreatment beforehand. A number of studies have evaluated education efforts to reduce the family and community risk for child maltreatment, especially for abusive head trauma in infants. Thus far the primary prevention efforts, including large public education campaigns as well as hospital based campaigns, have unfortunately not shown any significant corresponding drop in hospitalizations for abusive head trauma. They aim to educate caregivers throughout the community about normal child development, parenting skills, and coping strategies for stress and frustration. One such program is the Period of PURPLE Crying program which acknowledges the frustration that can be caused by crying and gives parents and caregivers coping skills and methods to handle the crying without shaking.
Secondary prevention programs have been shown to be more effective. Targeted at a specific subset that is at risk for child maltreatment, these programs include prenatal and early childhood home visitation and high school based programs run by nurses to educate caregivers. They have been shown to significantly reduce verified reports of child maltreatment (although effectiveness against preventing abusive head trauma specifically has not been established). One such program is the Nurse-Family Partnership which targets low-income first-time mothers with RN home visits that begin during pregnancy and can extend to the child’s second birthday. The visits aim to increase healthy behaviors, discourage unhealthy behaviors, recognize signs of illness in children and create safe households.
Finally, indicated prevention activities target families in which maltreatment has already occurred. It aims to prevent reoccurrence and limit the negative consequences of the maltreatment and foster healing. These often include intensive family preservation services through mental health counselors and other mental health services for children and families. One program, Triple P, covers the entire prevention continuum with various leveled programming components to enhance parenting skills and support. The CDC is currently conducting randomized clinical trials of various prevention plans to establish their effectiveness on rates of abusive head trauma and child maltreatment rates in general.
Parents of a 6 month-old female bring their daughter to the pediatric ER stating that she has been fussy and is refusing to eat. Both parents are very young, seem appropriately concerned. Vital signs indicate tachycardia and neuro exam reveals an infant crying inconsolably. Head to toe assessment reveals multiple bruises on chest, abdomen, and back. History from parents does not include any traumatic event. Imaging studies reveal rib fractures and head CT reveals a skull fracture and subdural hematoma. Infant is admitted to the Pediatric Intensive Care Unit for treatment. Father of infant seems nervous and is seen pacing in the hall. He later confesses to shaking his daughter when she would not stop crying. What are the nurse’s priorities in the care of this family?
In each state there is a list of mandatory reporters, or professionals that are required to report suspected child abuse to child welfare services. In most states, nurses are on that list. Each institution should have a policy that outlines actions to be taken when child abuse is suspected or confirmed and include who on the health care team will contact child welfare services to report the incident. To get more information about mandatory reporters and who to contact when reporting in your state use the national hotline for child abuse, Child Help USA at 1-800-4-A-Child (1-800-422-4453).
Dias, M.S., Rottmund, C.M., Cappos, K.M., et al. (2017). Association of a postnatal parent education program for abusive head trauma with subsequent pediatric abusive head trauma hospitalization rates. JAMA Pediatrics.171,223.
Hettler, J., Greenes, D.S. (2003). Can the initial history predict whether a child with a head injury has been abused? Pediatrics. 111, 602.
Keenan, H.T., Runyan, D.K., Marshall, S.W., et al. (2004). A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics. 114, 633.
King, W.J., MacKay, M., Sirnick, A., (2003). Canadian shaken baby study group. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. CMAJ. 168, 155.
Kraus, D. (2016). Why is Child Abuse Awareness Important to Trauma Nurses? Journal of Trauma Nursing, 23(3), 116-117.
Merrick, M. T., Latzman, N. E. (2014). Child maltreatment: A Public health overview and prevention considerations. OJIN: The Online Journal of Issues in Nursing. 19(1). doi:10.3912/OJIN.Vol19No01Man02.
Turner, W., Broad, J., Drinkwater, J., et al, (2017). Interventions to improve the response of professionals to children exposed to domestic abuse: A systematic review. Child Abuse Review. 26, 19-39. doi: 10.1002/car.2385.
Zolotor, A.J., Runyan, D.K., Shanahan, M., et al. (2015). Effectiveness of a statewide abusive head trauma prevention program in North Carolina. JAMA Pediatrics. 169,1126.