From the Journals

AAP adds specifics to policy on abusive head trauma



Stay alert to subtle signs of abusive head trauma in children, the American Academy of Pediatrics said in an updated policy statement.

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Abusive head trauma (AHT) is fatal in approximately one-quarter of cases in infants during the first year of life, and less-obvious clinical signs such as vomiting and fussiness often are missed, wrote Sandeep K. Narang, MD, JD, of Northwestern University, Chicago, and colleagues on the AAP Council on Child Abuse and Neglect.

In a policy statement published in Pediatrics, the AAP cautioned physicians to remain vigilant for signs that are common in AHT cases. In particular, bruising on the torso, ears, and neck in children aged younger than 4 years, or any bruising in infants younger than 4 months should be a red flag. In addition, the most recent data indicate that apnea and retinal hemorrhages are more common in cases of abuse than in accidental injuries. The AAP also recommends a skeletal survey in suspected AHT for children younger than 2 years to identify occult fractures.

“Oral injuries in infants, such as frenulum tears, may also accompany or precede AHT,” Dr. Narang and associates said.

In addition, secondary brain injury as a result of AHT can lead to poor outcomes that may be observed. “Almost 70% of survivors of AHT have some degree of lasting neurologic impairment, including static encephalopathy, intellectual disability, cerebral palsy, cortical blindness, seizure disorders, behavior problems, and learning disabilities,” according to the statement.

Endocrine dysfunction also is common in children with a history of AHT, but might not present until years later, the authors noted.

When AHT is suspected in a patient, the policy statement recommends that a subspecialist in child abuse pediatrics or in related areas including radiology, ophthalmology, neurosurgery, neurology, and general pediatric surgery “should also be consulted when necessary to ensure a complete and accurate evaluation.”

Although falls from a height of 1.5 m or 5 feet often are used as an explanation for AHT injuries, “numerous lines of clinical research have clarified the extreme rarity of short falls as a cause of severe neurologic injury or death in young infants,” Dr. Narang and associates wrote.

Other recommendations in the updated policy encourage use of the term “abusive head trauma” in medical communications, as well as encourage caregivers to serve as a medical home for survivors of AHT or refer them to medical homes for rehabilitation and monitoring. Parents and caregivers may need to be educated about the dangers of shaking or striking an infant, shown safe ways to manage a crying baby, and given tools to manage their own stress and frustration.

Physicians are legally required to report suspected cases of child abuse or neglect, and should be prepared to educate stakeholders if you are called on to work with legal and child protective services about the science behind AHT.

“The role of the pediatric practitioner is not to apportion blame or investigate potential criminal activity but to identify the medical problem, evaluate and treat the child’s injuries, and offer honest medical information to parents, families, investigators, and attorneys and/or judges,” Dr. Narang and associates wrote.

This policy statement updates the previous policy statement issued in 2009 and affirmed in 2013. The policy had no external funding, and the authors had no financial conflicts to disclose. Dr. Narang, Amanda Fingarson, DO, and James Lukefahr, MD, have served as paid expert witnesses/consultants in cases of abusive head trauma in infants and children.

SOURCE: Narang SK et al. Pediatrics. 2020 Mar 23. doi: 10.1542/peds.2020-0203.

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