Brief Communications

Shaken baby syndrome: report on four pairs of twins

To estimate associations between factors recorded in pregnancy and the first week of life and subsequent abusive head trauma.

Multicenter, retrospective case-control study of perinatal records from 142 cases of abusive head trauma and 550 controls, matched by date and hospital of birth from 1991 to 2010. Multiple logistic regression assessed the relationship between perinatal exposures and abusive head trauma.

The risk of abusive head trauma decreased with increasing maternal age (OR, 0.91 per year; 95% CI 0.85-0.97) and increasing gestational age at birth (OR 0.79 per week; 95% CI 0.69-0.91). Mothers of cases were more likely to be Māori (OR 4.61; 95% CI 1.98-10.78), to be single (OR 5.10; 95% CI 1.83-14.23), have recorded social concerns (OR 4.29; 95% CI 1.32-13.91), and have missing data for antenatal care, partner status, social concerns, and substance abuse (OR 13.53; 95% CI 2.39-76.47). Case mothers were more likely not to take supplements in pregnancy (OR 3.53; 95% CI 1.30-9.54), to have membrane rupture longer than 48 hours before delivery (OR 13.01; 95% CI 2.84-59.68), and to formula feed (OR for mixed breast and formula feeding 6.06; 95% CI 2.39-15.36) before postnatal discharge (median 3 days).

Factors associated with subsequent abusive head trauma can be identified from routine perinatal records. Targeted interventions initiated perinatally could possibly prevent some cases of abusive head trauma. However, any plans for targeted prevention strategies should consider not only those with identified risk factors but also those for which data are missing.

The youngest children, particularly in the first year of life, are the most vulnerable to physical abuse. Skeletal survey is the universal screening examination in children 24 months of age and younger. Fractures occur in over half of abused children. Rib fractures may be the only abnormality in about 30%. A repeat limited skeletal survey after 2 weeks can detect additional fractures and can provide fracture dating information. The type and extent of additional imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically occult abusive head trauma can occur, especially in young infants. Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients. Contrast-enhanced CT of the abdomen/pelvis is utilized for suspected intra-abdominal or pelvic injury. Particular attention should be paid to discrepancies between the patterns of injury and the reported clinical history. Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The rate of multiple births has increased over the last two decades. In 1982, an increased frequency of injuries among this patient population was noted, but few studies have evaluated the increased incidence of maltreatment in twins. The study aim was to evaluate the features of all multiple-birth children with substantiated physical abuse and/or neglect over a four-year period at a major children's hospital.

A Retrospective chart review was conducted of multiple-gestation children in which at least one child in the multiple set experienced child maltreatment from January 2006 to December 2009. Data regarding the child, injuries, family, and perpetrators were abstracted. We evaluated whether family and child characteristics were associated with maltreatment, and whether types of injuries were similar within multiple sets. For comparison, data from the same time period for single-birth maltreated children also were abstracted, including child age, gestational age at birth, and injury type.

There were 19 sets of multiple births in which at least one child had abusive injuries and/or neglect. In 10 of 19 sets (53%), all multiples were found to have a form of maltreatment, and all children in these multiple sets shared at least one injury type. Parents lived together in 63% of cases. Fathers and mothers were the alleged perpetrator in 42% of the cases. Multiple-gestation-birth maltreated children were significantly more likely than single-birth maltreated children to have abdominal trauma (13% vs. 1%, respectively; p < .01), fractures (83% vs. 39%; p < .01), and to be injured at a younger mean age (12.8 months vs. 34.8 months; p < .01).

Siblings of maltreated, multiple-gestation children often, but not always, were abused. In sets with two maltreated children, children usually shared the same modes of maltreatment. Multiples are significantly more likely than singletons to be younger and experience fractures and abdominal trauma. The findings support the current standard practice of evaluating all children in a multiple set when one is found to be abused or neglected.

The appropriate imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the injuries are discrepant with the clinical history. The clinical presentations reviewed consider these factors and provide evidence-based consensus recommendations by the ACR Appropriateness Criteria^® Expert Panel on Pediatric Imaging.

Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.