As pediatricians, we are dedicated to improving the health and well being of children, including their protection from maltreatment. Abusive head trauma is one of the most serious forms of child abuse, exacting a devastating toll on our youngest patients.1"3 Inflicted pediatric neurotrauma has been linked to subdural, subarachnoid, and retinal hemorrhaging;4"7 respiratory compromise or arrest, loss of consciousness, hypotension;8"11 and secondary, diffuse, hypoxic-ischemic brain injury with swelling.2·11"13
Victims of inflicted pediatric neurotrauma frequently present with associated cutaneous injuries6'14 and fractures of the skull,4'15'16 ribs, or extremities.17 At the time of initial neuroimaging, up to 45% of young victims reveal radiological evidence of prior intracranial injuries.18 Sixty-six percent of infant homicides result from inflicted head trauma.19
The diagnosis of inflicted pediatric head trauma presents us with significant professional challenges beyond our patients' acute medical management. These additional challenges include our recognition of subtle cases; our decision to report suspected abuse to the local child protective services (CPS) divisions of state human services departments or to the police, our duty to inform parents of our suspicion of abuse and our duty to report, the need for a relevant diagnostic evaluation, and legal testimony. In this article, we review these five challenges in detail and provide guidance appropriate for pediatricians.
RECOGNITION OF SUBTLE CASES
What do the following case scenarios have in common?
* The mother of a 6-monthold discovered her baby to be blue around the lips and not breathing. With stimulation, the infant began to breathe and cry and her color returned quickly to normal. Emergency department (ED) evaluation revealed no abnormalities. The mother was reassured and the baby was sent home.
* Concerned parents brought their 1 1 -month-old into the ED because they thought he was having a seizure. The doctor in the ED reassured them that their baby's neurological examination was normal, and cranial imaging was deferred.
* At her 6-month well-child checkup, an infant's head circumference was noted to have increased dramatically and disproportionately. Developmentally, she appeared to be progressing normally. A cranial computed tomography (CT) scan confirmed an unexplained, chronic subdural hematoma.
Frequent Erroneous Diagnoses Made in Cases of Missed Abusive Head Trauma*
* A 3 -month-old girl was described as highly irritable all day and had vomited three times within the past 2 hours. Her pediatrician diagnosed acute gastroenteritis. The baby returned later to the ED in status epilepticus.
* A new mother brought her 15 -monthold into the doctor's office because the toddler had been irritable all day and had developed a low-grade fever. The baby was crying vigorously during her examination. The doctor diagnosed an early, acute, left otitis media and prescribed an antibiotic. When the child subsequently deteriorated, her cranial CT scan revealed acute subdural and subarachnoid bleeding.
* The mother of a 4-month-old picked up her infant daughter from the babysitter's after work. At home, she noticed a facial bruise. When the mother called the babysitter that evening, the babysitter denied any knowledge of the baby's bruise.
* The mother of a 2-month-old infant awoke to find her baby completely unresponsive, not breathing, blue, and cold to the touch. The infant's death was attributed initially to sudden infant death syndrome (SIDS) until autopsy revealed unexplained, traumatic, intracranial injuries.
Each of these cases describes a child's initial "presentation" for unrecognized, inflicted, intracranial injuries. As illustrated by these cases, children with inflicted head injuries present for medical care under a wide variety of circumstances and with highly variable clinical manifestations. The caregiver's explanation for a child's acute or chronic clinical signs may be incomplete, inconsistent, or fabricated. For all of these reasons, prompt and accurate diagnosis of abusive neurotrauma can be difficult. A high index of clinical suspicion is required.
Infants and young children who have suffered acute (accidental or inflicted) traumatic intracranial injuries may manifest specific signs of brain dysfunction (eg, apnea, loss of consciousness, seizure) that facilitate rapid and accurate diagnosis. On the other hand, physicians frequently fail to diagnose cranial injuries in very young children presenting with milder, nonspecific clinical signs (eg, irritability, recurrent vomiting, fever, loss of appetite).20
In their 1999 analysis of missed cases of abusive head trauma, Jenny and colleagues20 listed a wide variety of erroneous diagnoses made in 54 cases of missed abusive head trauma during 98 clinical visits (Table). The authors demonstrated that the clinician's failure to diagnose abusive head trauma places young victims at significant risk for subsequent injury or death. Very likely, failure to consider inflicted head trauma is the primary explanation for failure to diagnose it, particularly in children presenting with mild, nonspecific clinical signs.
Irritability, recurrent vomiting, loss of appetite, and fever are seen in a wide variety of benign, self-Hmited pediatric illnesses. Clinicians cannot order cranial imaging studies for every young child presenting for evaluation of such mild, nonspecific signs. However, when routine history and physical examination fail to reveal an obvious explanation, we must consider trauma, perform a meticulous secondary physical examination, and consider additional diagnostic studies.
REPORTING SUSPECTED ABUSE
Diagnostic errors regarding child abuse carry potentially grave consequences. Unprotected and abused children frequently suffer repetitive injury.20,21 Conversely, some children have been taken away from their nonabusive parents. Understandably, these observations cause some pediatricians to hesitate to report suspected child abuse.
However, laws in all 50 states require pediatricians and other healthcare providers to report any suspicion of child abuse or neglect to the appropriate child protection or investigative agency. Healthcare providers are not mandated, trained, or qualified to investigate child abuse, to estimate the risk of ongoing abuse in a family, or to establish a legal burden of proof. These tasks fall to law enforcement, child protection, and legal professionals, respectively.
The comprehensive and objective evaluation of suspected child maltreatment requires a multidisciplinary response. As pediatricians, our role within that multidisciplinary team is to provide medical treatment, to report promptly any suspicion of abuse, and thereafter to initiate a relevant diagnostic evaluation. These tasks require clinical competence, objectivity and basic familiarity with the child abuse medical literature.
In some cases, suspicion of inflicted pediatric head trauma will seem straightforward. Whereas most young victims of moderate to severe accidental head trauma present for medical care with an unambiguous and consistent history of a significant head injury event (eg, a motor vehicle colusión), young victims of moderate to severe, inflicted head trauma often present for care with an absent, changing, or inconsistent history of a trivial head injury event (eg, a short-distance fall).4·6·22·23
In other cases, the differentiation between accidental and inflicted head trauma will prove more difficult. Under what circumstances should we reasonably suspect inflicted pediatric trauma, and therefore promptly report our suspicion? Although few injuries or circumstances can be considered independently diagnostic of child abuse, experience has taught us that some specific injuries or circumstances should lead to a suspicion of inflicted pediatric trauma (Sidebar 1, seepage 361).
When in doubt, pediatricians should consult another physician. Thereafter, if a consensus regarding the suspicion of child abuse cannot be achieved, we should err on the side of child protection and make a report. Remember that the mandated reporting laws require only a suspicion of abuse or neglect.
Suspected child abuse or neglect should be reported to the appropriate child protection agency serving the region where the child resides and to the law enforcement agency in the jurisdiction where the abuse most likely occurred. Anyone who reports suspected abuse or neglect in good faith is immune from liability for making the report. On the other hand, failure to comply with the child abuse reporting laws can result in fines or imprisonment. In addition, failure to report suspicion of abuse as required by law could subject the clinician to civil lawsuits for damages if the child is re-injured in the abusive environment.
Some pediatricians find it difficult to inform parents of their decision to report, leaving that task to their nurse or to the CPS caseworker. They view this encounter as an inevitable confrontation, rather than as an opportunity to educate and assist parents during a very stressful situation.
In our experience, parents who find themselves in this uncomfortable situation respond appropriately when concerns about abuse are presented in a direct, respectful, and nonaccusatory manner. For example: "I am concerned that someone might have hurt your child. Listen very carefully to what I am about to tell you. I do not suspect child abuse in every situation, but in this case, I do. I am sure that you would want to know if someone has hurt your child. I am required by law to report any suspicion of child abuse to child protective services. Although I am very concerned about your child's safety, it is not my responsibility to determine who might have hurt your child. As your pediatrician, I will keep you fully informed. Now, I would like to take a few minutes to tell you exactly what I am going to tell the representative from CPS about your child's injuries and my suspicion of abuse. I believe that you have a right to hear this information first."
CONDUCTING A RELEVANT DIAGNOSTIC EVALUATION
When child abuse is suspected, an appropriate diagnostic evaluation is required. The primary goal is to ascertain the nature, extent, and severity of the child's injuries or medical condition. The initial report of suspected child abuse to CPS should not be delayed until this evaluation is complete.
The evaluation should start with a thorough medical history, taken separately from each of the injured child's caregivers, using the traditional medical model (Sidebar 2, see page 363). Although the pediatrician should not function as an investigator, a complete medical history may prove to be important forensically
For example, careful documentation regarding the onset of the child's clinical signs and symptoms may help investigators estimate the timing of inflicted cranial injury and identify a perpetrator. Furthermore, meticulous documentation of the caregiver's initial explanation for the child's head injuries may facilitate recognition of subsequent inconsistencies over time that are suspicious for abuse.
If feasible, the clinician should speak to the injured child in isolation, working to establish rapport. Sitting at the child's level, speaking gently, and avoiding any outward display of emotion in response to the child's answers are important. Pediatricians must be careful to avoid asking questions that suggest specific answers, using open-ended questions instead. Relevant statements by the child and the caregivers should be documented in their own words, noting to whom those statements were made. Use of direct quotations is preferable whenever possible.
Multiple injuries are common in cases of abusive head trauma. Therefore, the physical exam should include a head-totoe examination that combines careful visual inspection with meticulous palpation of soft tissues, skeletal structures, and the abdomen. Careful examination of the eyes, retinas, and body orifices is essential (Sidebar 3, see page 364).
Additional diagnostic tests can help confirm or exclude inflicted pediatric neurotrauma and related abusive injuries (Sidebar 4, see page 365). Although CT scan is more sensitive than magnetic resonance imaging (MRI) for identifying skull fractures (Figure 1, see page 367) and subarachnoid hemorrhage (Figure 2, see page 367), MRI is the most sensitive imaging modality for identifying intracranial pathology, including subdural hemorrhage.21'24'25 The CT appearance of an older chronic subdural hemorrhage can approach cerebral spinal fluid (CSF) in density. To differentiate between chronic subdural hemorrhage and CSF, MRI that includes proton density or FLAIR (fluid attenuated inversion recovery) sequences is necessary (Figure 3, see page 368).
The information summarized in Sidebar 4 can help clinicians select the most relevant diagnostic studies for each patient. Many young victims of inflicted pediatric neurotrauma require diagnostic evaluation and treatment at a tertiary trauma center, where pediatric specialists in trauma, child abuse, intensive care, neurosurgery, neurology, orthopedic surgery, hematology, ophthalmology, radiology, and neuroradiology are more readily available for guidance and assistance.
The diagnostic evaluation may lead the clinician to consider alternate, nontraumatic medical conditions that have occasionally been misdiagnosed as child abuse. Many of these conditions are listed in Sidebar 5 (see page 369) and Sidebar 6 (see page 370). Most can be excluded or confirmed readily with careful history and physical examination, radiographic imaging, laboratory testing, or appropriate consultations.
Figure 1. Head CT of inflicted skull fractures.
Figure 2. Head CT of left frontal subarachnoid hemorrhage (red arrow) and right occipital subdural hematoma (green arrow). (Courtesy Joseph Zenel, MD)
At the time of the initial report, the CPS caseworker may request copies of the child's medical records or additional written documentation of the suspicion of abuse. When the diagnostic evaluation is complete, the pediatrician should expect to provide child protection, investigative, and legal professionals with a more comprehensive verbal and written summary of clinical impressions (Sidebar 7, see page 370).
Frequently, civil actions to protect children from future abusive acts require the testimony of medical professionals. Thus, the injured child's treating physician may be subpoenaed to testify as a factual witness regarding the cause, timing, nature, and severity of the patient's injuries.
If by training or experience a clinician possesses greater knowledge than the judge or jury regarding the issues under debate, then he or she may be qualified as an expert entitled to offer an opinion related to the ultimate issues at trial (eg, "Was the child abused?") These opinions must be offered "to a reasonable degree of medical certainty." Alhough difficult to define precisely, a "reasonable degree of medical certainty" is that required by a competent medical provider to reach a specific medical diagnosis and to formulate an appropriate treatment plan.
Medical testimony can be a time-consuming, uncomfortable, and humbling experience. Before testifying, clinicians should consider several recommendations.
Prepare adequately. Read the case file. Understand it completely. Discuss the case with the attorney who issued the subpoena. Know why you are testifying. Review the relevant medical literature. Consider alternative hypotheses or explanations. Understand the limitations of your opinions and conclusions. Consult other medical experts, if necessary.
Expect the testimony to take longer than anticipated. Ask the attorney who issued your subpoena to estimate the time and duration of your testimony. Ask the attorney to place you "on call" and then respond promptly. Recognize that your role in the courtroom is to educate. Effective education requires repetition and time. If necessary, inform the attorney who issued your subpoena that you will require compensation for your time away from your practice.
Figure 3. Head MRI FLAIR demonstrating different appearances of bilateral frontal chronic subdural hemorrhages (red arrow), a small acute right occipital subdural hemorrhage (green arrow), and CSF in the lateral ventricles (yellow arrow). (Courtesy Joseph Zenel, MD)
Make sure that your curriculum vitae is completely accurate and up to date. Inaccuracies on your resume may be revealed in the courtroom in an attempt to cast doubt upon your integrity or your attention to detail.
When testifying, keep it simple. Use simple language. Consider using helpful illustrations. When possible, direct your answers to the jury, not to the attorney who asked you the question. Make eye contact with the jury members to try to determine if they understand what you are saying. Avoid a long answer when a short answer will suffice. Recognize that jurors tend to remember what they hear first and last.
Maintain a professional demeanor. Never argue with an attorney in the courtroom. Control the pace of the questioning. Pause and think before you answer a question. If the attorney is asking questions too rapidly, pause even longer.
Maintain humility. Jurors do not react well to pomposity.
Demonstrate confidence. Do not allow yourself to be intimidated or to concede points that are not justified. Clarify misstatements implicit in the attorneys' questions. Do not allow an attorney to confine or restrict your answer to a simple "yes" or "no" if such an answer obscures important complexities. If necessary, refuse to discuss a medical journal article without asking for a recess to review it. Speak in a loud and clear voice. Make eye contact when speaking.
Tell the truth, the whole truth, and nothing but the truth. It is the attorneys' job to win the case, not the clinician's. Your ultimate opinion should not dictate your answer to a specific question. Acknowledge mistakes, oversights, or limitations of your opinion. Concede reasonable points; it enhances your ultimate credibility. Do not look to an attorney for help during your cross-examination. This is your opportunity to "make your case." Above all else, maintain your professional integrity.
The accurate diagnosis and successful management of pediatric abusive head trauma present pediatricians with many unique challenges. To overcome these challenges requires a high index of clinical suspicion; a willingness to report any suspicion of abuse; knowledge of the relevant medical literature; a direct, nonaccusatory, and supportive approach with parents; thorough history taking; meticulous physical examination; and most important, professional objectivity and integrity. Your patients deserve no less.
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Frequent Erroneous Diagnoses Made in Cases of Missed Abusive Head Trauma*