NEW ORLEANS — Abusive head trauma is misdiagnosed in almost a third of children who are brought to the emergency department, Dr. Denis R. Pauzé said at the annual meeting of the American College of Emergency Physicians.
A missed diagnosis of abusive head trauma (AHT), also known as inflicted head trauma or shaken baby syndrome, can have tragic consequences, he said. Most infant homicides are caused by AHT, with the highest incidence occurring in babies less than 6 months old, said Dr. Pauzé of Inova Fairfax Hospital, Falls Church, Va.
“Failure to diagnose these infants and children leaves them at high risk for repeat abuse, which can lead to learning disabilities, permanent brain damage, or death. Just 5–20 seconds of shaking can kill,” Dr. Pauzé said. But making the diagnosis can be difficult. A child who has been shaken often presents with nonspecific symptoms, such as poor feeding, vomiting, diarrhea, irritability, and fever. “We therefore must have a high index of suspicion in order to diagnose inflicted head trauma,” he said.
An article published in the Journal of the American Medical Association (1999;281:621–6) is “must reading” for emergency department physicians, he said.
In a chart review, the researchers studied the characteristics of unrecognized AHT in children less than 3 years old. They found that nearly one-third of abused children who presented after AHT had their initial diagnosis missed. The average delay in diagnosis was 7 days.
The most common erroneous diagnoses made were gastroenteritis, influenza, accidental head injury, rule-out sepsis, increasing head size, otitis media, seizure disorder, reflux, and apnea. Misinterpretation of the CT scan or radiograph also caused a delay in diagnosis, which ranged from 1 to 174 days.
On the horizon to help emergency physicians make the right diagnosis in a timely manner are traumatic brain markers. Many organs, including the liver, pancreas, kidney, and heart, have serum biomarkers that act as guides to organ injury. The hope is that a biomarker for brain injury will become a bedside test for AHT in the future.
Until then, a complete and thorough history and physical exam are needed to diagnose AHT, Dr. Pauzé said.
Conflicting histories, delay in seeking medical care, or repetitive injuries should make physicians suspicious. Other red flags include injuries that are not consistent with the history given or with the developmental age of the infant or child.
A head-to-toe physical exam must be done, including checking for macrocephaly and inspecting for scalp, facial, or neck bruises. Examine the ribs and extremities for signs of tenderness or deformity and, if possible, perform a funduscopic exam for retinal hemorrhages.
'We … must have a high index of suspicion in order to diagnose inflicted head trauma.' DR. PAUZÉ