Inflicted Traumatic Brain Injury in Child Abuse
Abusive Head Trauma may Initially go Undetected
Sep 29, 2009
Despite its seriousness, the diagnosis seems to be missed frequently as a result of the non specificity of the child’s presentation to the clinician. Up to 30% of cases of abusive head trauma may initially go unrecognized (Center on Child Abuse Prevention Research Fact Sheet, 2007).
In an 10-year study of America's emergency departments entitled “Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma,” it was found that children injured by abuse sustain more severe injuries, utilize more medical services, and have worse outcomes than children with accidental injuries.
Intracranial Injury
Children injured by child abuse were more likely to have retinal hemorrhages (27.8% vs 0.06%) than children with unintentional injuries. Abused children were more likely than unintentionally injured children to sustain intracranial injury (42.2% vs 14.1%) and thoracic (12.5% vs 4.5%) and abdominal (11.4% vs 6.8%) injuries; to sustain very severe injuries (22.6% vs 6.3%); and to be admitted to the intensive care unit (42.5% vs 26.9%).
The mean length of stay for children who were abused was significantly longer (9.3 vs 3.8 days) and the survival to discharge from the hospital was significantly worse (87.3% vs 97.4%) than for those unintentionally injured. Among the survivors, children who were abused developed extensive functional limitations more frequently than those unintentionally injured (8.7% vs 2.7%).
Blunt Trauma
In more than half of the cases of child abuse treated in America, children sustain head, face and neck injuries (Center on Child Abuse Prevention Research Fact Sheet, 2007). Blunt Trauma injuries were found to be commonly inflicted with an instrument, eating utensils, hands, or fingers or by scalding liquids or caustic substances.
Common dental injuries include cuts on the tongue, damaged soft and hard palate, fractured teeth, facial bone and jaw fractures, and burns. Multiple injuries, injuries in different stages of healing, injuries inappropriate for the child's stage of development, or a discrepant history should arouse suspicion of abuse.
The skull may or may not be fractured, even in cases with extensive intra-cranial damage. The infant's skull is more flexible than the adult and for a given impact relative to the thickness and size of the skull, is less likely to fracture, as deformity can resolve more readily.
Children with inflicted TBI have been reported to have worse short and long term outcomes than children with non-inflicted TBI. Factors strongly related to poor outcome are young age, duration of unconsciousness, and low Glasgow coma scale. Clinicians need to be aware of the possibility of child abuse in any case of traumatic head injury without history of antecedent trauma.
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