ABUSIVE HEAD TRAUMA
What happens before, during
and after?
Anne-Claude Bernard-Bonnin MD,FRCP
CHU STE-JUSTINE, Université de Montréal
Montréal, Québec, Canada
Annie Stipanicic, PhD.
Université du Québec à Trois-Rivières
Trois-Rivières, Québec, Canada
NO CONFLICTS
OF INTEREST
OBJECTIVES- PLAN OF
PRESENTATION
Prevention programs: are they effective?
Clinical index of suspicion
3. Clinical and radiological features
4. Indicators distinguishing abusive vs nonabusive head trauma.
5. Short-term and long-term outcomes
1.
2.
1
PREVENTION PROGRAMS
Are they effective?
CHILD ABUSE PREVENTION
Primary prevention
Addresses a broad segment of the
population (ex: all new parents)
2. Secondary prevention
Targets a specific subset of the
population considered to be at higher risk
3. Tertiary prevention
Targets perpetrators and seeks to
prevent recidivism
1.
PRIMARY PREVENTION
PROGRAMS CRITERIA
Powerful message
Administered at the appropriate moment
Requiring very little effort or time
Targeting parents of newborn infants
‐Parents are the most common perpetrators
‐Period or greatest risk during the months after
birth
‐Contact period between parents and the health
providers
‐Contextually significant information
2
“DON’T SHAKE THE BABY”
PREVENTION PROGRAM
(J. Showers, 1992)
Educational campaign about dangers of
shaking a baby
‐ All parents of newborns in one county in
Ohio during 12 months
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“DON’T SHAKE THE BABY”
PREVENTION PROGRAM
(J. Showers, 1992)
Self-addressed stamped postcard for
responding to the materials
‐ 15 708 parents received the materials
‐ 3 293 parents (21%) returned the postcard
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PURPLE STUDY
(RG Barr et al, 2009)
‐The
Period of PURPLE Crying Program
‐Educate about the association between
infant crying and the dangers of shaking
‐Importance of sharing the information with
other caregivers
3
PURPLE STUDY
(RG Barr et al, 2009)
PURPLE materials developed by the
National Center on Shaken Baby Syndrome
P: Peak pattern
U: Unexpected timing
R: Resistance to soothing
P: Pain-like look
L: Long crying bouts
E: Evening clustering
PURPLE STUDY
(RG Barr et al, 2009)
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RCT- Two groups of mothers of newborns
Both groups received booklets and a DVD
Intervention group: PURPLE materials
Control group: injury control materials
Telephone at 5 weeks for reminding of
Baby’s Day Diary
Telephone interview at 8 weeks
PURPLE STUDY (RG Barr et al, 2009)
OUTCOMES
Primary outcomes (questionnaire)
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Crying knowledge
Shaking knowledge
Behavior for crying
Behavior for inconsolable crying
Self-talk during inconsolable crying
Shaking information
Secondary outcomes (diary)
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Measures of caregiving
Measure of frustration
Pediatric office visit frequency
4
PURPLE STUDY (RG Barr et al, 2009)
RESULTS
Knowledge scores higher in intervention
group
‐ Behavioral responses higher in intervention
group
‐ Sharing information about walking away or
dangers of shaking more often by
intervention group
‐ More minutes/day of contact with
distressed infant in intervention group
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PERINATAL SHAKEN BABY SYNDROME
PREVENTION PROGRAM-PSBSPP
(C. Goulet et al. 2009)
‐ Two hospitals
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CHU Ste-Justine (99 parents)
CH Pierre Le Gardeur (164 parents)
Focus on three main factors
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Infant crying
Parental anger and coping strategies
Lack of knowledge about SBS
PSBSPP (C. Goulet et al, 2009)
EDUCATIONAL INTERVENTION
During postnatal hospital stay
One card per main factor
‐ Action plan discussed with nurse and
signed by one/both parents
‐ Telephone interview between 6-9 weeks
postnatal
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PSBSPP (C. Goulet et al, 2009)
EVALUATION BY PARENTS
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Sample of 263 parents
98% parents appreciated the intervention
99.6% parents agreed it should be continued
94% parents agreed about the nurses'
participation added value
Learning from the cards
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57% from the card on crying
52% from the card on anger
61% from the card on SBS
PSBSPP (C. Goulet et al. 2009)
ACTION PLAN
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98% wrote an action plan
20 different actions
The first two coping strategies were
examples on the information card
6-8 weeks later, 47% remembered one or
two actions from their plan
8% did not remember any at all
No relevance of signatures
PSBSPP (C. Goulet et al. 2009)
EVALUATION BY NURSES
CHU Ste-Justine: 42 out of 85 trained
CH Pierre Le Gardeur: 27 out of 72 trained
‐ Unanimous that intervention was
appropriate and should continue
‐ Unanimous that information cards were
important, and helpful support when
meeting parents
‐ 98% agreed intervention well received by
parents
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6
HOSPITAL-BASED PARENT EDUCATION
PROGRAM (M. Dias et al, 2005)
Comprehensive hospital-based parent education program
in an 8-county region of WNY served by the WCHOB(Buffalo)
- Provide a universal consistent education program
to parents of all newborn infants
- Assess parents’ knowledge about dangers of infant
shaking
- Track the dissemination of information through the
return of a commitment statement
- Assess the impact on regional incidence of abusive
head injuries among children < 36 months
HOSPITAL-BASED PARENT EDUCATION
PROGRAM ( M. Dias et al, 2005)
Parents received a 1-page leaflet
11 minute video
‐ Educational posters on maternity wards
‐ Both parents asked to sign a commitment
statement
‐ 10% of parents selected randomly for
telephone follow-up survey at 7 months
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HOSPITAL-BASED PARENT EDUCATION
PROGRAM ( M. Dias et al, 2005)
Regional incidence of AHT tracked prospectively
during the 66-month period of the study (Dec
1998-May 2004)
Contrasted with:
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Minimal regional incidence during the 60
months immediately preceding the program
(Dec 1992-Nov 1998)
Incidence rates of substantiated AHT in the
Commonwealth of Pennsylvania (1996-2002)
7
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HOSPITAL-BASED PARENT EDUCATION
PROGRAM ( M. Dias et al, 2005)
41.5 AHT cases per 100,000 live births during
the 6-year control period
22.2 AHT cases per 100,000 live births during
the 5.5-year study period
No comparable decrease in the Commonwealth
of Pennsylvania
35.3 AHT cases per 100,000 live births (without
signed committment statement)
15.5 AHT cases per 100,000 live births (with
signed committment statement)
PARENT EDUCATION BY MATERNITY
NURSES (RL Altman et al, 2011)
19 community hospitals
‐ 1 tertiary care academic teaching hospital
‐ Hudson Valley Shaken Baby Prevention
Initiative
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Leaflet
Video
Self-administered questionnaire
Commitment statement
6-month telephone follow-up survey
PARENT EDUCATION BY MATERNITY
NURSES (RL Altman et al, 2011)
‐Standardized
staff training in 20 hospitals
‐One single tertiary care children’s hospital
receives all transferred patients for
evaluation of suspected abusive head
injuries
‐Comparison of a 5-year historical control
period with a 3-year intervention period
8
HOME VISITATION
NURSE-FAMILY PARTNERSHIP
(DL Olds et al, 1986)
Based on theories of human ecology, selfefficacy and human attachment
‐ Improving prenatal health-related
behaviors
‐ Helping parents provide responsible and
competent child care
‐ Assisting parents to plan for their future
including subsequent pregnancies and
employment
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HOME VISITATION
NURSE-FAMILY PARTNERSHIP
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(DL Olds et al, 1986)
No previous live births
Age of mother < 19 years
Actively recruited
Single-parent status
Low socio-economic status
Any woman who asked to participate and who
was bearing a first child
Women recruited before 25 to 29 weeks of
gestation
Study carried in a semi-rural county well-served
for both health and human services
HOME VISITATION
NURSE-FAMILY PARTNERSHIP
(DL Olds et al, 1986)
Home visiting by nurses with 4 weeks of
special training before the program
Detailed visit-by-visit guidelines and
standardised protocol of visits
Average 6-9 prenatal visits
Average 21-26 visits from birth to child’s
second birthday
Visits lasted around 75-90 minutes
9
HOME VISITATION
NURSE-FAMILY PARTNERSHIP
(DL Olds et al, 1986)
Among women at highest risk for care-giving
dysfunction
Group
with NHV
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fewer instances of child abuse and neglect
less frequent punishment of children
More appropriate play material
Less frequent ER visits in 1st year
Regardless of family’s risk status
Group
with NHV
‐ Fewer ER visits in 2nd year
‐ Fewer visits for accidents and poisoning
HOME VISITATION PROGRAMS
Home-visiting programs are not uniformly
effective
Any home-visiting program should not be
assumed to reduce child abuse
Para-professional home-visiting interventions
have not been shown effective
Mac Millan HL et al (2009)
CLINICAL INDEX
OF SUSPICION
10
FEATURES RAISING SUSPICION
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Any injury to a young pre-ambulatory infant
Injuries to multiple organ systems
Multiple injuries in different stages of healing
Patterned injuries
Injuries to non bony or other unusual
locations
Significant injuries inconsistent with history
Additional evidence of child neglect
MISSED CASES OF AHT
(C. Jenny et al.1999)
Retrospective chart review of cases of AHT
over 6 years
173 children diagnosed with AHT
31.2% seen by physicians after the event,
but AHT not recognized
Mean number of visits before recognition of
AHT: 2.8 (range 2-9)
Mean length of time before recognition of
AHT: 7 days (range 0-189)
MISSED CASES OF AHT
(C. Jenny et al, 1999)
Comparison of missed cases vs recognized
cases
Missed cases are younger (180 vs 278 days)
Missed cases more frequent among minority
races
Missed cases more frequent among intact
families
More severely symptomatic children more likely
to be recognized as having head trauma at first
visit
11
MISSED CASES OF AHT
(C. Jenny et al, 1999)
Predicting factors of correct diagnosis of
AHT
1. Abnormal respiratory status
2. Seizures
3. Facial and/or scalp injury
4. Parents not living together
MISSED CASES OF AHT
(C. Jenny et al, 1999)
Outcome and consequences of missed
cases (54 cases): 4 deaths
27.8% reinjured because of delay in
diagnosis of AHT
40.7% had medical complications
• Seizure disorders
• Chronic vomiting
• Increasing head size because of increasing
untreated subdlural hematomas
SENTINEL INJUREIS
(L. Sheets et al, 2013)
Case-control retrospective study
401 infants less than 12 months seen by
Child Protection Team during a 10 year
period
‐ 4 study cohorts
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definite abuse by AHT
definite abuse with non-AHT injuries
intermediate concern for abuse
no concern for abuse
12
SENTINEL INJUREIS
(L. Sheets et al, 2013)
History of sentinel injury -63 cases
‐ 30 (30%) in the AHT cohort
‐ 25 (25%) in the non-AHT abuse cohort
‐ 8 (8%) in the intermediate concern cohort
‐ None in 101 cases in the control cohort
SENTINEL INJUREIS
(L. Sheets et al, 2013)
Description of sentinel injuries
200 infants with AHT or non-AHT abuse
55 (27.5%) had a sentinel injury
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80% had bruise
11% had an intra-oral injury
7% had a fracture
8 infants in the intermediate concern cohort
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7 bruises
1 poorly explained subluxation of the radial head
SENTINEL INJUREIS
(L. Sheets et al, 2013)
Definitely abused infants 4.4 times more
likely to have a sentinel injury than infants
with intermediate concern for abuse
‐ 23 cases with a medical provider aware of
the injury
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13 cases: no suspicion of abuse
10 cases: suspected abuse but no protection
at the end
13
CLINICAL AND RADIOLOGICAL
FEATURES
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SIGNS AND SYMPTOMS
Non-specific
• Vomiting
• Poor feeding
• Irritability
Sentinel injuries
• Bruises
• Intra-oral injuries
• Fractures
Neurologic manifestations
• Hypotonia
• Period of apnea
• Seizures
• Stupor/coma
PRIMARY INJURIES
Subdural hemorrhages
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Inertial shearing/rotational forces/abrupt deceleration
Bleeding from bridging veins in space created by
traumatic separation of arachnoid from the dura
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Subarachnoid hemorrhages
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Intraventricular hemorrhages
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Rupture of subarachnoid of pial vessels
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Large intracerebral hematoma dissolves into the
ventricle
Torn subependymal veins
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14
PRIMARY INJURIES
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Cortical contusions of superficial cortical gray
matter
Diffuse axonal injury
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Intraparenchymal hematomas
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Fiber tracts disrupted by sudden acceleration and
deceleration forces combined with rotational forces
Mainly subcortical white matter
Shearing-straining injuries due to rupture of small
intraparenchymal blood vessels
Mainly in fronto-temporal white matter
SECONDARY INJURIES
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Diffuse cerebral swelling
Hypoxia
Hydrocephalus
CSF leaks (in skull fractures)
Uncontrolled seizures
OCULAR INJURIES
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Multilayered retinal hemorrhages (60-85%)
Retinoschisis
Periorbital hematoma
Subluxed or dislocated lens
Cataracts
Glaucoma
Optic atrophy
Papilloedema
15
INDICATORS DISTINGUISHING ABUSIVE
vs NON-ABUSIVE HEAD TRAUMA
CLINICAL PREDICTION RULE
Combines predictive contributions of multiple clinical
findings or tests
‐ Predicts probability of diagnosis for an individual patient
‐ High-performance
• sensitivity > 0.95
• negative likelihood ratio <0.1
• narrow confidence limits
Three sequential phases
• derivation
• validation
• implementation
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DERIVATION OF A CLINICAL PREDICTION
RULE FOR AHT
(K. Hymel et al, 2013)
Prospective study in 14 PICUS
‐ 209 head-injured children < 3 years old
‐ 45% met one or more definitional criteria
for AHT
‐ Pretest probability (prevalence) of AHT in
the sample: 0.45
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DERIVATION OF A CLINICAL
PREDICTION RULE FOR AHT
(K. Hymel et al, 2013)
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Five discriminating and reliable variables
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acute respiratory compromise
seizures or acute encephalopathy
bruising of ears, neck or torso
interhemispheric or bilateral subdural hemorrhages
skull fractures other than isolated, unilateral, non
diastatic, linear parietal fracture
Sensitivity 97%
Negative predictive value 91%
VALIDATION OF A CLINICAL
PREDICTION RULE FOR AHT
(K. Hymel et al, 2014)
291 head-injured children < 3 years of age
14 PICUs
Prospective observational cross-sectional
study
Same definitional criteria as the derivation
study
Cluster of 4 variables
VALIDATION OF A CLINICAL
PREDICTION RULE FOR AHT
(K. Hymel et al, 2014)
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124 patients met definitional criteria for
AHT
119/124 (96%) presented with one or
more of the 4 variables (95% CI:0.90-0.99)
Specificity 0.43 (95% CI: 0.35-0.50)
PPV 0.55 (95% CI: 0.48-0.62)
NPV 0.93 (95% CI: 0.85-0.98)
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SYSTEMATIC REVIEW
(SJ Piteau et al 2012)
24 studies – OR > 1 favors abuse
- Subdural hemorrhages OR: 8.9 (95% CI 6.77-11.73)
- Cerebral ischemia: OR 4.79 (95% CI 1.84-5.46)
- Long bone fractures: OR 4.34 (95% CI: 2.52-7.49)
- Metaphyseal fractures: OR 15.06 (95% CI: 1.93-117.72)
- Rib fractures: OR: 9.84 (95% CI: 4,42-21.90)
- Retinal hemorrhages: OR: 28.24 (95% CI: 15.37-51.90)
- Apnea: OR: 4.89 (95% CI: 2.08-11.49)
- Seizures: OR: 11.24 (95% CI: 7.30-17.29)
- No adequate history: OR: 52.72 (95% CI: 12,79-217.33)
All values p<0.001
SYSTEMATIC REVIEW
( SA Maguire et al 2009)
Sample of 1655 children
779 with inflicted brain injury (iBI)
‐ Discriminatory features for iBI
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apnea (PPV: 93%, OR: 17.06 P<0.001)
retinal hemorrhage (PPV: 71%, OR: 3.504
P≈0.03
NEUROIMAGING-SYSTEMATIC
REVIEW (AM Kemp et al, 2011)
- 21 studies / 2353 children
- 893 abusive head trauma /1460
accidental
- 18 studies – children < 3 years of
age
18
NEUROIMAGING-SYSTEMATIC
REVIEW (AM Kemp et al, 2011)
Features significantly associated with abusive head
trauma
‐ SDH (OR: 8.2, 95% CI 6,1-11)
‐ Multiple SDH (OR: 6,95% CI 2.5-14.4)
‐ Convexity SDH (OR: 4.9,95% CI 1.3-19.4)
‐ Interhemispheric SDH (OR: 7.9, 95% CI 4.7-13)
‐ Posterior fossa SDH (OR: 2.5,95% CI 1-6)
‐ Hypoxic ischemic injury (OR: 3.7,95% CI 1.4 ≈10)
‐ Cerebral edema (OR: 2.2,95% CI 1.0-4.5)
‐ Closed head injury (OR: 4.6,95% CI 2.9-7,5)
RETINAL HEMORRHAGES SYSTEMATIC
REVIEW
(SA Maguire et al, 2013)
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998 children (504 AHT)
Retinal hemorrhages 78% AHT vs 5% nAHT
Bilateral 83% AHT vs 8.3% nAHT
Peripheral extension 63% AHT vs 9% nAHT
Large numbers 83% AHT vs none nAHT
Head trauma and RH
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OR: 14.7 (95% CI: 6.39-33,62)
Probability of AHT: 91% (95% CI 48%-99%)
POOLED ANALYSIS
(SA Maguire et al, 2011)
14 high quality comparative studies (results
published in 2009)
‐ Authors contacted →6 studies all published
since 2003
‐ Anonymized individual level patient information
‐ Individual – patient data pooled analysis to
relate combinations of clinical features to AHT
or nAHT
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POOLED ANALYSIS
(SA Maguire et al, 2011)
1053 children (348 AHT vs 705 nAHT)
‐ Other features considered
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apnea
retinal hemorrhage
rib fractures
long bone fractures
seizures
head and/or neck bruising
POOLED ANALYSIS
(SA Maguire et al, 2011)
Child with intracranial injury and 1 or 2 of the
6 features
→ PPV of AHT varies from 4% to 97%
‐ Apnea OR: 6.89 (95 % CI: 2.08‐22.86)
‐ Rib fractures or retinal hemorrhages with any 1 of
other features
→ OR for AHT >100 (PPV > 85%)
‐ Any combination of 3 or more of the 6 features
→ OR for AHT > 100 (PPV > 85%)
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VALIDATION OF A PREDICTION TOOL
(LE Cowley et al, 2015)
Two sites - Children < 36 months
65 AHT vs 133 nAHT
If ≥ 3 features present,
• Probability AHT > 81.5% (95 CI: 63.3% - 91.8%)
• Sensitivity 72.3% (95% CI: 60.4% - 81.7%)
• Specificity 85.7% (95% CI: 78.8% - 90.7%)
• PPV 71.2% (95% CI: 59.4% - 80.7%)
• NPV 86.3% (95% CI: 79.5% - 91.2%)
• Area under ROC curve: 0.88 (95% CI: 0.823% 0.926%)
20
SHORT-TERM OUTCOMES
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Death in 25% - 30% of cases
Early post-traumatic seizures in
30% to 50% of cases
Electrographic-only seizures are
common
LONG TERM OUTCOMES
COGNITIVE SEQUELAE
SCHOOL-AGED VICTIMS
(A Stipanicic et al, 2008)
- 11 children diagnosed with SBS
- 11 control children (paired on age,
gender, SES, family
composition)
- Mean age of testing: 7.5 years
21
COGNITIVE SEQUELAE
SCHOOL-AGED VICTIMS
(A Stipanicic et al, 2008)
Significant weaknesses of the clinical
group
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Intellectual performance
Working memory
Shared attention
Reasoning
Mental organization/planning
Mental alternation and inhibition
LONG TERM OUTCOMES
Some other studies will be presented and
discussed by Dre Annie Stipanicic
KEY POINTS
Parental education during prenatal courses
and on maternity wards is of utmost
importance
‐ Home-visiting programs should target at-risk
families
‐ Development and evaluation of future
prevention efforts must be evidence-informed
‐ Physicians and other health professionals
should be alert for sentinel injuries or nonspecific symptoms of possible head trauma
‐
22
KEY POINTS
Early recognition of AHT may prevent
negative medical outcomes due to further
injury or lack of appropriate medical
treatment
‐ Some clusters of clinical features have a
higher probability of AHT, but none is 100%
diagnostic.
‐ Outcomes may be severe with death or longterm disabilities, mainly in the cognitive
sphere, but also many impacts on adult
health status and chronic diseases
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23
Abusive Head Trauma: what happens before, during and after?
Annie Stipanicic, PhD, University du Quebec a Trois-Rivieres (Montreal, QB, Canada)
Anne-Claude Bernard-Bonnin, MD (FRCPC), CHU Ste-Justine Montreal/ University of Montreal
(Montreal, QB, Canada)
Abstract
Abusive head trauma (AHT) is a tragedy for the victim, his family, and the community. The AHT studies
report rates of death from 13 to 36% and the majority of the survivors will experiment sequelae and
deficits which will alter their development at various levels. According to estimations, the already too high
number of victims could be up to a hundred times higher than the official diagnoses we known of today
(Theodore et al., 2005, Turz et al., 2005). This represents a huge cost for our medical and social services.
And yet, this condition is preventable. Besides being aware of large scale prevention programs,
pediatricians and other child and youth health professionals should be familiar with red flags. These flags
can make a huge difference for the infant and family if they are addressed appropriately. The investigation
for a suspicion of AHT should be performed according to evidence-based guidelines. Knowledge about
possible sequelae either short term or long term will allow a better screening in AHT survivors and earlier
rehabilitation interventions. The preliminary results of a project about the developmental cognitive and
behavioral pathways of the AHT will be shown. Thirty children from 2 to 16 years of age were tested with
an extended neuropsychological battery. Many cognitive functions were screened, such as intellectual
performance, attention, memory, executive functions, etc. Each child’s were evaluated once or twice in
the last three years. Children’s affective and adaptive behaviors were tested as well, using some hetero
reported questionnaires. Some relationship between the children characteristics, neuropsychological
results and behavioral profiles will be explained.
Biography
Professor Annie STIPANICIC Ph.D is professor at the department of psychology of the University du
Quebec a Trois-Rivieres. She is also a child neuropsychologist since more than 20 years. She has 15 years
of experience in neurodevelopemental research on cognitive and neuropsychological sequelae in victims
of abusive head trauma. She is first-editor of Le syndrome du bébé secoué (Traumatisme crânien non
accidentel) published by Les Presses de l’Université du Québec in 2010. She has presented on many
occasions for various audiences and at International Conferences on Shaken Baby Syndrome.
Dre Anne-Claude BERNARD-BONNIN MD (FRCPC) is a professor of pediatrics at the CHU Ste-Justine
Montreal/ University of Montreal. She has 25 years experience in child abuse. She is membre of the
working group on Multidisciplinary Guidelines on the Identification, Investigation and Management of
Suspected Abusive head Trauma published Jointly by CPS and Health Canada in 2008. She has presented
on many occasions on child abuse for various audiences and regular medical lectures on child abuse.
Objectives
Objective 1: Identify the red flags and satellite lesions that place infants at risk of AHT.
Objective 2: Select appropriate laboratory and imaging studies in cases of AHT.
Objective 3: Analyze short term and long term neuropsychological sequelae.