Suspected Pediatric Abusive Head Trauma
by Michael R. Weinraub, MD, FAAP
For purposes of this discussion, Abusive Head Trauma (AHT) is interchangeable with Shaken Baby Syndrome (SBS).
Why consider a pediatrician to review a case of suspected abusive head trauma (AHT), when there may already be an opinion of child abuse by a pediatrician?
A pediatric review of the case is needed to ensure that a differential diagnosis was formulated, a standard of care medical workup was completed and that the diagnosis which best explains the most facts within reasonable medical certainty has been offered.
Stating that the only medical diagnosis consistent with the findings is AHT, is declaring that the single best explanation of case findings and facts within a reasonable degree of medical certainty is child abuse. The act of offering AHT as a diagnosis implies that this diagnosis was derived from the completion of a standard of care medical workup, as AHT is most often a diagnosis of exclusion. A clinically experienced pediatrician can determine whether a standard of care workup has been completed and whether the final diagnosis offered of AHT is the best explanation which encompasses the most facts within reasonable medical certainty.
In some cases, even though there was a child abuse pediatrician involved in the initial workup, the diagnosis of abuse was made primarily on an unproved hypothesis that by consensus, not by scientific proof, “a triad” of findings are pathognomonic (red flags) of intentional maltreatment: retinal hemorrhages, subdural hematomas, and cerebral edema. When the triad has been invoked as circumstantial evidence of child abuse, a pediatrician’s second opinion case review is needed to certify that a rush to judgement based on the triad has not occurred. This is accomplished by obtaining the complete medical history; then by corroborating findings on physical exams with the potential diagnoses; by reviewing the ophthalmology consultation to see whether a timely standard of care examination has been provided; by ensuring that all laboratory studies have been ordered to rule out underlying medical conditions and by consulting with a pediatric radiologist to correlate the clinical findings with the radiology findings for a reasonable interpretation.
A pediatrician’s review of the case can identify whether a diagnosis of child abuse was made before the workup was completed, whether there was a rush to judgement forming a diagnosis of child abuse based on a triad of findings, or whether there was exclusion of reasonably likely alternative medical diagnoses without a standard of care workup.
In 1971 British neurosurgeon, Norman Guthkelch, M.D., published his thoughts about his cases of several infants with subdural hematomas who were subject to admitted shaking. He never intended by this publication to develop a hypothesis considered as proof that intentional abusive shaking had occurred to cause an infant’s findings simply when “the triad” of findings was seen. This triad of findings is considered by some to be certain proof of child abuse even in cases without evidence of head impact, without skeletal fractures, without corporal bruises and even without a social history consistent with a child at risk for abuse. Dr. Guthkelch cautions in a follow-up essay written in 2012, ”Problems of Infant Retina-Subdural Hemorrhage and Cerebral Edema with Minimal External Injury,” that after 40 years of consideration the triad may legitimately be classified as a syndrome, but it is not necessarily the result of shaking, or of abusive behavior. Guthkelch, N; Houston Journal of Health Law & Policy 2012.
A multitude of medical conditions including sequellae of previous trauma, infections, genetic and metabolic disorders, anemia, coagulation disorders (bleeding disorders), thrombophilias (hyper clotting disorders), and cerebral hypoxia can result in retinal hemorrhages, subdural hematomas and brain swelling. And most importantly, two or more of these medical conditions presenting together may act synergistically and the multifactorial contribution of medical causes to the occurrence of retinal hemorrhage and subdural hematoma and brain swelling must be considered as unique to diagnosing that specific child’s case.
A pediatrician is needed to ensure that this standard of care process has been met:
- The diagnosis of AHT as the only cause of findings implies that injury from an intentional act of harm has occurred within a reasonable degree of medical certainty.
- The diagnosis of AHT indicates certainty that the findings could only be explained by abuse and that the child was previously essentially well.
The diagnosis of AHT once made indicates that medical causes and accidents have been eliminated from the differential diagnosis list by completing a medical workup.
- The diagnosis of AHT cannot be based on neuroradiology findings alone as imaging studies cannot differentiate abusive from accidental causes and medical causes of intracranial hemorrhage.
- The diagnosis of AHT cannot be based on ophthalmology findings alone, as these findings cannot differentiate abusive from medical and accidental causes of retinal hemorrhages.
A pediatrician’s second opinion comparing the caregiver’s description of events, the scene investigation, the child’s complete past and current medical history, the pattern of growth and development with the radiology and ophthalmology findings offers the standard of care approach to differentiating the diagnosis of accidental from intentional injury and/or medical causes of the findings with reasonable medical certainty.
- Was a differential diagnosis well-thought-out before a final diagnosis was formulated?
- Was a standard of care workup completed?
- Was the diagnosis chosen which best explains the most facts?
More on the questions and controversies surrounding suspected abusive head trauma cases.
Michael R. Weinraub, MD, FAAP, is a Board Certified Pediatrician with four decades of clinical practice experience.