The Child and Youth Maltreatment Section of the Canadian Paediatric Society (CPS) has published a new practise Point focusing on the evaluation of children where traumatic head injury related to child maltreatment (THI-CM) is suspected.

According to the CPS, these injuries “is not rare and frequently results in significant morbidity for the child and family.” The institution emphasized the critical role of healthcare providers in these situations.

The guidance highlights the importance of “identifying and treating these children, reporting concerns of child maltreatment to child welfare authorities, assessing for associated injuries and medical conditions, supporting children and their families, and communicating medical details clearly to families and other medical, child welfare, and legal professionals.”

The Practice Point is available in Paediatrics & Child Health.

‘Red Flags‘

“studies have shown that when you involve somebody with expertise, you are more likely to get the right diagnosis.”

the CPS notes that while no single injury definitively indicates child maltreatment (CM), several “red flags” should raise suspicion for THI-CM. These include elements within the child’s history, their clinical presentation, and radiographic findings.

Past red flags include:

• absence of a reported traumatic event
• A reported injury mechanism inconsistent with the actual injury
• An injury event that doesn’t align with the child’s developmental stage
• Unexplained or undue delay in seeking medical attention
• Recurring, unexplained symptoms suggestive of head trauma

Red flags observed in the clinical presentation include:

• Head injury accompanied by apnea
• Intracranial injury with seizures
• Intracranial injury and retinal hemorrhages

Radiographic red flags include:

• Subdural hemorrhages (both intracranial and spinal)
• Cerebral ischemia, frequently enough affecting multiple areas
• Cerebral edema
• Rib fractures
• Classic metaphyseal fractures (corner or “bucket handle” fractures, particularly in infants)
• Absence or incompatibility of trauma history alongside:
  • Skull fracture with intracranial injury
  • Long bone fracture(s) with intracranial injury

The CPS also clarified that the term THI-CM “was chosen through an iterative process to reflect the current language (traumatic head injury) used by health professionals, separated from the opinion on the cause of the injury (level of concern for child maltreatment).”

The organization advises against using terms like “shaken baby syndrome,” “abusive head trauma,” “non-accidental head injury,” and “inflicted traumatic brain injury” in Canada.

Guidance When Abuse Is Suspected

The Practice Point advises clinicians to maintain objectivity, be mindful of potential biases, and show compassion toward the child and family when CM is suspected. Additional recommendations include:

• Prioritizing the patient’s medical needs while also considering medicolegal aspects.
• Recognizing that injuries can stem from trauma, medical conditions, injury mimics, or a combination thereof.
• Paying close attention to seizures during physical examinations, as they are common in infants with symptomatic head injuries from maltreatment.
• Conducting laboratory tests to evaluate medical status, screen for hidden injuries, and assess for potential medical disorders.
• Using CT scans as the primary neuroimaging choice for infants and children, with MRI as a suitable option or supplement in certain instances.

Clinicians are legally obligated to report any CM concerns to their local child welfare agency, as mandated by provincial and territorial laws.

The Practice Point emphasizes that a pediatrician specializing in CM “can help guide clinical assessment and communication with families, healthcare professionals, child welfare, and law enforcement.” It also suggests consulting with specialists in critical care, ophthalmology, neurosurgery, neurology, orthopedics, endocrinology, hematology, genetics, and rehabilitation as needed.

Suzanne Haney, MD, a professor of child abuse pediatrics at the University of Nebraska Medical Center and Nebraska Children’s Hospital, noted that the American academy of Pediatrics’ (AAP’s) guidance aligns with the CPS.

Like the CPS, the AAP uses “abusive head trauma” instead of “shaken baby syndrome” to describe suspected head trauma from abuse, according to Dr. Haney. She added, “Sometimes these kids are shaken, sometimes they’re slammed, sometimes shaken and slammed, we don’t necessarily know exactly what the forces are, but we do know that it’s abusive and was done by someone.”

Echoing the Canadian guidance, Dr.Haney recommends seeking the expertise of a child abuse specialist when CM is suspected.

She stated, “Studies have shown that when you involve somebody with expertise, you are more likely to get the right diagnosis. Most major medical centers have a child abuse pediatrician, although regrettably our numbers are far too small. We do have a number of colleagues who may not be board-certified but have a special interest or expertise in this area. So if clinicians can identify somebody in their area who has a special interest in child maltreatment, they can be very helpful.”