The purpose of this course is to review the clinical manifestations, management, and prevention of pediatric abusive head trauma.
Upon completion of this course, the nurse should be prepared to:
- define relevant terminology and review statistics related to child maltreatment and pediatric abusive head trauma
- identify risk factors (victimization, perpetration, and community factors) and protective factors related to pediatric abusive head trauma
- describe the clinical manifestations (history and physical examination) associated with pediatric abusive head trauma
- describe the key components of evaluation and management of pediatric abusive head trauma patients
- describe mandatory reporting considerations for pediatric abusive head trauma
- identify primary and secondary prevention strategies to reduce pediatric abusive head trauma
Child maltreatment is an umbrella term encompassing four common types of maltreatment: physical abuse, sexual abuse, emotional abuse, and neglect (Maiese et al., 2021). At the Federal level, child abuse and neglect have been defined by the Child Abuse Prevention and Treatment Act (CAPTA) as any recent act or failure to act on the part of a parent or caregiver that results in serious physical or emotional harm, sexual abuse, or death to a child younger 18 (Child Welfare Information Gateway, 2019a). The definition of child abuse and neglect at the State level may vary based on civil and criminal statutes. During 2018, approximately 678,000 children were victims of maltreatment. Nationally, the child maltreatment rate is 9.2 victims per 1,000 children in the population (Administration of Children and Families, 2021).
Abusive Head Trauma
Healthcare providers have historically used shaken baby syndrome to describe a brain injury intentionally inflicted on infants or children, usually due to traumatic shaking (Hung, 2020). More recently, the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) have recommended using the term abusive head trauma (AHT) to encompass any head or brain injury of a child (<5 years of age) from a variety of biomechanical forces, including shaking and blunt trauma (Christian et al., 2009; Parks et al., 2012). AHT can include intracranial hemorrhages, retinal hemorrhages, skull fractures, and spinal injuries (Narang et al., 2020).
According to the CDC (2021c), 1,840 children died from child maltreatment in the US in 2019. The infants and children who experience child maltreatment often suffer from long-term health consequences with an estimated lifetime economic burden of $428 billion in 2015. Although any child has the potential to be a victim of child maltreatment, children living in poverty are more likely to experience abuse and neglect. The CDC (2021a) reported that children in families with low socioeconomic status are five times more likely to experience child maltreatment than children in families with a higher socioeconomic status.
Abusive head trauma is the leading cause of physical abuse death for children under 5 years and accounts for one-third of all deaths from child maltreatment (CDC, 2021b). Infants less than one year of age are at the greatest risk for AHT, with an estimated 32 to 38 cases per 100,000 children each year, with 25% of these fatal events (CDC, 2021b; Narang et al., 2020). Although AHT can occur in older children, most cases occur in children less than two years of age (Narang et al., 2020). This higher incidence rate in younger infants and children is attributed to episodes of prolonged, uncontrollable crying, which can trigger parent or caregiver shaking or abusive behavior. Not only does AHT have a high case fatality rate (25%), but two-thirds of survivors suffer significant disabilities associated with their injuries, such as visual impairments, developmental delays, physical disabilities, and hearing loss (CDC, 2021b). In the US, the medical costs associated with AHT are estimated at $69.6 million annually (Peterson et al., 2015).
AHT can result in cerebral edema, intracranial hemorrhage, spinal hemorrhage or injury, and retinal hemorrhage (Narang et al., 2020). Although the precise mechanisms for these injuries are not entirely understood, evidence supports that both rotational and contact forces play a role. Shaking or blunt trauma forces cause repetitive and rapid flexion, extension, and head and neck rotation (Joyce et al., 2021). These quick movements cause the brain to strike the skull repeatedly, resulting in the tearing of blood vessels (intracranial hemorrhage) and sheering of the nerve axons (known as a diffuse axonal injury or brain damage). Since infants have underdeveloped neck muscles, and their head size is large compared to their body, the head moves more violently when shaken. Swelling in the brain leads to increased intracranial pressure (ICP) and cellular death from a lack of oxygenation. Secondary brain injuries are characterized as an endogenous cascade of cellular and biochemical events within minutes of a primary brain injury that can continue for months. Thus, secondary brain injuries can lead to ongoing traumatic axonal injury and neural cell damage/death. Cerebral perfusion pressure is the net pressure gradient (defined as the difference between the mean arterial pressure [MAP] and the ICP) that drives oxygen delivery to the cerebral tissue (Mount & Das, 2021). Hypertension in patients with a traumatic brain injury (TBI) can also increase ICP, leading to a secondary brain injury. Similarly, hypotension can also result in inadequate CPP and potential brain cell death (Joyce et al., 2021).
Risk Factors/Protective Factors
Risk factors are characteristics (direct or indirect) that can increase the likelihood of pediatric AHT (CDC, 2021d). These risk factors can be broken down into three main categories: (a) risk factors for victimization, (b) risk factors for perpetration, and (c) community risk factors (social determinants of health [SDOH]). Although child maltreatment can affect all races, ethnicities, sexes, and socioeconomic groups, research demonstrates that some of these characteristics increase the likelihood of abuse (Joyce et al., 2021). Therefore, identifying and understanding these risk factors is essential to developing potential preventative initiatives (CDC, 2021c).
Risk Factors for Victimization
Risk factors for victimization include all individual factors about the infant or child that increase the likelihood that they will experience AHT (CDC, 2021d). The child’s age and a prior history of child maltreatment are significant risk factors for victimization. Children younger than five years of age are at increased risk for child abuse, and most cases of AHT occur in the first year of life (CDC, 2021b). Infants and children who have a history of abuse are twice as likely to experience AHT. Additional risk factors for victimization include perinatal illness, inconsolable crying (colic), male gender, and children with specials needs (CDC, 2021d). Infant crying episodes usually peak at 6 to 8 weeks of life, placing them at the greatest risk for caregiver frustration and subsequent shaking (Joyce et al., 2021).
Risk Factors for Perpetration
Risk factors for perpetration include all individual factors about the parent or caregiver that increase the likelihood of committing child maltreatment or AHT. The perpetrators of AHT are usually males, often the child’s father (Joyce et al., 2021). Individual risk factors for perpetration also include caregivers with a history of drug or alcohol use, mental illness, or a history of being abused as a child. Young caregivers, single parents, non-biological caregivers in the home, and low education are also risk factors for perpetration (CDC, 2021d).
Community Risk Factors (SDOH)
Community or population risk factors can also increase the likelihood of pediatric AHT. Community risk factors are often related to the SDOH, which are the economic and social conditions that influence health outcomes (CDC, 2021a). For example, families experiencing financial, food, or housing insecurity are at increased risk for AHT (Christian, 2021). In addition, community risk factors include high rates of violence, limited educational opportunities, high poverty rates, few community activities and supports, and easy access to drugs and alcohol (CDC, 2021d).
Although numerous risk factors increase the likelihood of AHT, there are also several protective factors. Identifying and understanding protective factors is essential to developing educational resources and initiatives to decrease the incidence of AHT. Individual protective factors include caregivers who practice nurturing parenting skills, are educated (i.e., a college degree or higher), have steady employment, and can meet the basic needs (e.g., food, shelter, and health services). Family protective factors can include robust and stable support networks, caregivers who enforce household rules and engage in child monitoring, and caring adults outside the family who serve as mentors. Finally, community protective factors include access to safe, stable housing, economic assistance, high-quality education, childcare, and healthcare services (CDC, 2021d).
A timely and accurate diagnosis of AHT is essential to ensure appropriate medical care is delivered to the infant or child, potentially reducing the severity of illness. Unfortunately, AHT can be challenging to diagnose because of misleading or inaccurate histories, variability in presentation, and a potential lack of physical signs of injury (Joyce et al., 2021). Although children or infants with AHT may present to a pediatrician’s office, caregivers are more likely to bring them to an emergency department or urgent care. The heightened use of the emergency department or urgent care settings is likely related to a delay or unwillingness to seek treatment right away, thereby resulting in more emergent symptoms. Symptoms that often lead caregivers to seek medical attention include difficulty breathing, seizures, and lifelessness (Christian, 2020). In a retrospective study, Kennedy and colleagues (2020) found that a delayed presentation for care was significantly more likely after AHT than with accidental injuries (61.8% vs. 20%).
Nurses working in an emergency department, urgent care, or primary care settings typically gather the presenting illness or injury history. Since AHT can be challenging to diagnose, the subjective information provided by the patient, parent, or caregiver is essential to delivering high-quality care and timely interventions. When performing the history-taking, the nurse should review the timeline of the injury and signs and symptoms leading up to the patient's arrival. A detailed description of events should be documented (noting any inconsistencies presented by the parent or caregiver). If more than one caregiver is present, they should be interviewed separately. Nurses should use open-ended questions when interviewing the parent or caregiver to minimize unintentional bias (Joyce et al., 2021). Research demonstrates that when AHT occurs, the parent or caregiver often reports the infant or child’s symptoms but does not disclose that an injury occurred (Christian, 2020). Based on a series of retrospective studies, researchers found that in 64% to 97% of AHT cases, no history of a traumatic event was given by the parent or caregiver. Therefore, AHT should always be considered when an infant or young child presents with fussiness, vomiting, or altered mental status (Narang et al., 2020).
Initial signs and symptoms of AHT can include irritability, decreased interaction, vomiting, insufficient oral intake, lethargy, and reduced body temperature or shivering. Late or potentially life-threatening signs and symptoms can include bradycardia, difficulty breathing or apnea, seizures, and cardiac arrest. Any indicators of child maltreatment based on the history and review of symptoms should be documented and communicated to the remainder of the healthcare team immediately (Joyce et al., 2021).
The physical examination should include vital signs and a head-to-toe assessment, including a neurological exam. The physical examination findings in AHT can also vary widely and may range from no visible injury to severe injuries. Encephalopathy, retinal hemorrhage, and subdural hematoma are the classic diagnostic triad of shaken baby syndrome (Joyce et al., 2021). With the shift from shaken baby syndrome to AHT, diagnostic injuries have also evolved. In addition to some of the signs and symptoms discussed above, the physical examination of the infant or child may also reveal retinal hemorrhages (60-85%, especially if numerous and extensive), subdural hematoma (specifically in multiple locations, along convexities, and interhemispheric), cutaneous bruising (46%), rib fractures, long bone fractures (23-29%), spinal injuries (specifically spinal subdural hemorrhage), bulging fontanel, and ligature marks (Christian, 2021). Bruising in infants and young children should alert the nurse or provider to the possibility of abuse. Particular attention should be given to linear bruising patterns and TEN-4 bruising (bruising of the torso, ears, and neck in children younger than 4 years of age or bruising anywhere in an infant younger than four months). Apnea and traumatic retinoschisis (blood accumulating beneath the internal membrane in the macula) are also associated with AHT. A thorough physical assessment and documentation of physical findings are critical in suspected or actual child maltreatment patients (Christian, 2021; Narang et al., 2020).
Evaluation and Diagnostic Workup
A detailed diagnostic evaluation should be completed if AHT is suspected in an infant or child who presents to an emergency department, urgent care, or primary care setting. According to Christian and the AAP Committee on Child Abuse and Neglect (2015), the cornerstone of AHT evaluation consists of a thorough skin assessment (noting any unusual bruising patterns as outlined above), skeletal survey, head imaging (computed tomography [CT] scan or magnetic resonance imaging [MRI]), and timely ophthalmology consultation, as subspecialty consultation may be helpful when child maltreatment is suspected. The radiographic skeletal survey is a series of x-rays capturing all the bones in the body and is the standard tool for detecting fractures. In patients with suspected AHT, skeletal trauma may not be apparent on physical examination. Therefore, a skeletal survey should be ordered for all patients with suspected AHT to rule out any hidden bone injury. Child maltreatment should be suspected if fractures are found on the skull, ribs, midshaft humerus, femur, and scapula. A fracture is a non-ambulatory infant without a clear history of trauma, or a child with multiple fractures is also suspicious for child maltreatment. In addition to the skeletal survey, all infants and children with suspected AHT require a cranial CT, brain MRI, or both. For symptomatic children, CT of the head is preferred to identify an abnormality that requires immediate surgical intervention, including acute hemorrhage or skull fracture. A brain MRI is preferred for suspected intracranial injury, cerebral hypoxia, or abnormal CT scan (Christian et al., 2015). Other than ophthalmology, additional consultations to subspecialty areas could include radiology, neurosurgery, neurology, pediatric surgery, and social work. Additional lab work might be ordered, including a complete blood count (CBC) with platelets, basic metabolic profile (BMP), liver and pancreatic function tests, and urinalysis (Narang, 2020).
For an infant or child presenting with life-threatening signs and symptoms, basic life support (BLS) measures should be started immediately as per current American Heart Association (AHA) BLS, advanced cardiac life support (ACLS), and pediatric advanced life support (PALS) standards. Life-threatening signs and symptoms could include abnormal vital signs, a Glasgow Coma Scale (GCS) less than 9, or respiratory distress. Once the patient has been stabilized, more injury and symptom-specific management can be initiated. Most of the care provided to infants and children with AHT is supportive and involves regular and frequent monitoring of vital signs and neurological checks. Their management can be broken down into three tiers of therapy (Joyce et al., 2021).
As discussed above, the initial management of an infant or child with AHT is maintaining their airway, breathing, and circulation (Joyce et al., 2021). Intubation may be necessary if the infant or child exhibits respiratory distress or arrest, a GCS of less than 9, or is hemodynamically unstable (defined as low blood pressure resulting in inadequate perfusion to vital organs in the body). Blood pressure should be closely monitored to maintain a low ICP while ensuring adequate cerebral perfusion pressure (CPP). Hypotension should be treated with intravenous fluid boluses. In addition to monitoring blood pressure, oxygenation should be monitored closely as hypoxemia also leads to secondary brain injury. Supplemental oxygen should be administered if oxygen saturation falls below 92% to ensure adequate oxygenation (Joyce et al., 2021).
Timely and effective management of the initial head injury can prevent many conditions that can exacerbate a secondary brain injury. The conditions that aggravate secondary brain injuries include coagulopathy, elevated ICP, enlarging hematomas, hypoxemia, hypotension, hypercarbia or hypocarbia, hyperglycemia or hypoglycemia, hyperthermia, seizures, and electrolyte abnormalities. If available, capnography (end-tidal carbon dioxide) is recommended during initial monitoring of a TBI to avoid excessive hyperventilation and hypocarbia, leading to vasoconstriction and decreased cerebral perfusion. PaCO2 should be maintained between 35 and 40 mmHg. In addition, elevating the patient’s head to at least 30º can optimize cerebral perfusion pressure and decrease ICP (Joyce et al., 2021).
Second-Tier and Third-Tier Therapy
Second and third-tier therapies are often used for more severe AHT injuries. As ICP increases, intracranial hypertension can occur. More invasive and aggressive interventions may be needed to decrease ICP to help prevent secondary brain injuries and long-term neurological consequences. Barbiturates can lower ICP by reducing cerebral metabolism and cerebral blood flow. Therapeutic hypothermia is another second-tier intervention that involves controlled cooling to 35º C to reduce inflammation, seizures, cerebral metabolic demands, and cell death. A neuromuscular blockade is used with controlled cooling to prevent shivering (which can also increase ICP). For patients with neurologic deterioration or signs of herniation, a surgical decompressive craniectomy can be performed as a third-tier therapy (Joyce et al., 2021).
As healthcare providers, it can be mentally and emotionally challenging to care for an infant or child when abuse is suspected. The Child Abuse Prevention and Treatment Act (CAPTA) passed in 1974 mandated reporting of actual or suspected child abuse. In addition, CAPTA requires each state to have procedures for the mandatory reporting of actual or suspected child abuse by all or selected individuals. Despite the mandate to report any suspicion of abuse to the appropriate local or state agency, many healthcare providers are uncomfortable or reluctant to report. The mandatory reporting laws, including who must report and the standards for making the report, vary by state. These variations can contribute to the lack of confidence and reluctance of healthcare providers to make a report. As healthcare providers, nurses are designated as mandatory reporters in all states. To review mandatory reporting requirements by state, the Child Welfare Information Gateway (2019b) posts a state statutes document on their site (www.childwelfare.gov). In addition, nurses should be aware of all organizational policies regarding mandatory reporting, as they may provide more specific guidance. All mandatory reporters must supply the facts and circumstances that led them to suspect abuse. Mandatory reporters are not required to prove that the abuse occurred (Child Welfare Information Gateway, 2019b).
Pediatric AHT is a preventable public health problem that can lead to lifelong physical and psychological health consequences (Hung, 2020). Victims may have permanent neurological deficits, physical disabilities, and developmental delays. Long-term effects also include an increased risk for depression, substance abuse, and other mental health disorders; decreased cognitive function; and poor academic abilities. Pediatric AHT also carries significant long-term financial implications for society, as many of these children need lifetime medical and potentially nursing home care. Based on the significant physical, psychological, and economic impact, prevention strategies are essential to reduce AHT incidence (Joyce et al., 2021).
Effective child abuse prevention strategies should target the identified risk and protective factors at the individual, relational, community, and societal levels. The CDC (2021c) recommends that prevention strategies focus on modifying policies, practices, and societal norms to create safe relationships and environments. These strategies can be broken down into primary and secondary initiatives.
Primary prevention strategies are interventions designed to target a broad population (Christian, 2021). These are appropriate for pediatric AHT because any infant or child, regardless of sex, race, ethnicity, or other characteristics, could be a victim of this type of abuse. Primary prevention strategies include large-scale public education campaigns and hospital-based programs. Unfortunately, broad, large-scale primary prevention initiatives have shown minimal impact on the incidence of AHT. However, establishing the effectiveness of these initiatives can be difficult, so these primary prevention strategies should not be abandoned (Narang et al., 2020).
In a literature review of pediatric AHT, Lopes and Williams (2018) evaluated the effectiveness of 34 primary prevention initiatives. Of the 34 identified studies, 5 were focused on interventions to reduce infant crying, 3 were focused on interventions to improve caregiver’s emotional regulation, and 12 were aimed at enhancing parent and caregiver awareness of AHT. The interventions aimed at increasing awareness were most effective. More specifically, the researchers suggested educating parents and caregivers on infant crying patterns and the risks of shaking a baby (Lopes & Williams, 2018). Similarly, the CDC (2021b) recommends educating parents and caregivers about infant crying patterns and strategies to prevent shaking. In addition, as nurses working closely with parents and caregivers, the following teaching points can be routinely discussed during healthcare visits (CDC, 2021b):
- Infant crying is worse in the first few months of life and improves as the child grows.
- Try calming a crying baby by swaddling in a blanket, gentle rocking, talking a walk in a stroller, speaking in a soft voice, or offering a pacifier.
- If the infant continues to cry, check for signs of illness, and seek care if needed.
- If you are getting frustrated, try calming yourself down. Set the infant down in a safe place for 5 to 10 minutes. Never shake a baby.
- Call a friend, family member, or healthcare professional for additional support.
- Never leave an infant with someone who is easily upset and has a history of violence.
Although it has been difficult to establish the effectiveness of large-scale primary prevention initiatives, some studies have been compelling (Narang et al., 2021). For example, Dias and colleagues (2005) implemented and evaluated a hallmark comprehensive, regional, hospital-based parent education program about violent infant shaking. The program was administered to all parents or caregivers of all newborns before discharge from the hospital. Parents or caregivers were given a one-page leaflet focused on preventing AHT developed by the AAP. In addition, parents and caregivers watched an 11-minute video discussing the dangers of violent shaking, which offered strategies to handle persistent crying. The researchers found that during the first 5 years of the study, AHT incidence decreased by 47%, from 41.5 cases per 100,000 live births to 22.2 cases per 100,000 live births (Dias et al., 2005).
Another primary prevention program to demonstrate effectiveness in reducing AHT admissions was the Period of PURPLE Crying (POPC) program. The POPC was started in British Columbia Children’s Hospital in 2007 and focused on parental education on normal infant behaviors, such as crying. The acronym PURPLE stands for
- Peak (crying peaks at 2 months and decreases as the child grows)
- Resistant (to any soothing)
- Painlike (the infant’s facial expression)
- Long (bouts of crying)
- Evening (the most common time for crying)
The program has been widely implemented in 800 hospitals in the US, Canada, Japan, and Australia. Specifically, in an 8-year implementation period in Canada, researchers found the POPC program was associated with a 35% reduction in infant AHT admissions (Barr et al., 2018).
Secondary prevention programs are directed towards a specific subset of the population determined to be high-risk for child maltreatment (Christian, 2021). These targeted interventions can significantly impact the individual, family, and community risk factors outlined by the CDC (2021b). Since SDOH are associated with an increase in risk for AHT, secondary prevention programs that specifically target these risk factors could significantly impact the rates of child maltreatment and AHT (CDC, 2021c; Christian, 2021). According to the CDC (2021c), the following interventions to address these risk factors and create stable, safe relationships and environments are recommended:
- strengthen economic support for families (including family-friendly work policies and strengthening financial security)
- change social norms to support parents and positive parenting (public education campaigns)
- provide quality care and education early in life (preschool enrichment and quality childcare)
- enhance parenting skills to promote healthy child development (early childhood home visitation and parenting skill approaches)
- intervene to lessen harms and prevent future risks (enhanced primary care and behavioral parent training programs) (CDC, 2021c)
The Nurse-Family Partnership (2021) is a secondary prevention program that effectively reduces child maltreatment cases. The program includes trained nurses regularly visiting young, first-time mothers-to-be, starting in early pregnancy and continuing until the child’s second birthday. Expectant mothers receive specialized support, care, and education from the nurses in the home setting. These one-to-one visits help establish a trusting relationship between the nurse and mother-to-be. Throughout the partnership, the nurse provides the new mothers with education and skills to create a safe, healthy environment for the child. The Nurse-Family Partnership program has been established for over 40 years and has well-developed implementation resources for healthcare organizations to utilize (Nurse-Family Partnership, 2021).
Olds and colleagues (1997) conducted a hallmark randomized controlled trial to evaluate the long-term effects of prenatal and early childhood home visits by nurses on the incidence of child abuse. Unmarried mothers from a low-income, rural community in New York received a mean of 9 pregnancy and 23 postpartum home visits through the child’s second birthday. These families were then followed for 15 years. The researchers found a 48% reduction in child abuse and neglect in women who received nurse home visits during pregnancy and infancy compared to women who did not. Although the results are promising, more randomized controlled trials are needed to establish the effectiveness of nurse home visits on the incidence of AHT (Olds et al., 1997).
Pediatric AHT has been well established as a public health concern that requires effective primary and secondary preventative strategies (CDC, 2021c). Nurses are well-positioned as direct care providers to identify, assess, and evaluate infants and children who present with signs or symptoms consistent with AHT. The information provided in this educational activity can be used as a resource for clinical manifestations, evaluation, and management of AHT patients. In addition, nurses play a pivotal role in patient, parent, and caregiver education related to preventing child maltreatment and AHT. Although both primary and secondary prevention strategies are effective, more rigorous research is needed to establish the best approach. While primary prevention strategies are often easier and more cost-effective to implement, it is difficult to establish the direct impact on AHT incidence. Secondary prevention strategies can be the most impactful in addressing individual, family, and community risk factors. However, they are more costly, time-consuming, and challenging to complete (Narang et al., 2020).
Advancements in research have focused on preventing AHT and understanding the etiologies, clinical presentations, and outcomes of AHT. Consensus has been established that clinical features such as subdural hematoma, retinal hemorrhage, cerebral edema, and “TEN-4” bruising are more common in AHT cases than accidental injuries. In addition, clinical prediction tools have been developed to establish the probability of AHT given specific combinations of findings (physical examination, radiographic, and laboratory findings). Research has also begun to determine if serum biomarkers can identify intracranial hemorrhage in infants with nonspecific clinical symptoms. Although these advancements have shown initial success in the diagnosis of AHT, further research is needed before widespread use (Narang et al., 2020).
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