The research team found that children with suspected high-risk child abuse injuries had a high incidence of occult head injuries, even when their neurological examinations were otherwise normal. Those head injuries, such as scalp swelling, skull fractures and more serious intracranial injuries, were often missed by routine physical, neurological and ophthalmologic exams and skeletal surveys but were detected by brain scans, which are not universally used for screening in this high-risk population. The study, published in the June issue of Pediatrics, was the first to estimate the prevalence of occult head injury in a high-risk cohort of abused children.
"Head injury is the leading cause of death among abused children under age two years," says David M. Rubin, M.D. M.S.C.E., a physician at Safe Place: The Center for Child Protection and Health at The Children's Hospital of Philadelphia, and lead author of the study. "Because asymptomatic head injury can be difficult to diagnose, especially in young children, it is necessary to use additional measures to determine which children have sustained these injuries so we can intervene early to prevent death, long-term neurological damage or future abuse."
Children's Hospital researchers studied hospital records for 51 children under age two who presented to The Children's Hospital of Philadelphia with suspected abuse injuries between 1998 and 2001. Patients were included if they had one of the following "high-risk" characteristics or injuries: age less than six months for any abusive injury, rib fractures, more than one fracture of any type, or facial injury. The children underwent routine screening measures and a brain scan using computed tomography (CT) or magnetic resonance imaging (MRI) technology. Also, patients included in the study had normal neurological examination on admission and showed no overt signs of head injuries.
Of the 51 patient records with complete data, 19 (37%) showed signs of occult head injuries with more than half suffering from intracranial injuries. Skeletal survey alone missed 5 of the 19 children with an occult head injury. An ophthalmologic examination was performed on 14 patients to determine the presence of retinal hemorrhages, a sign of head trauma. No evidence of hemorrhage was present in any of the children, suggesting ophthalmologic exam is not an accurate screening measure for occult head injury in asymptomatic children. Children with head injury were also found to be younger than children without head injury, with all but one of the head-injured children less than one year of age.
The study results support a recommendation for universal CT or MRI screening in all children under six months of age with any signs of abuse and children under one year of age with high-risk injuries, including rib fractures, multiple fractures and facial injuries. "Additional research is also needed to help determine the presence of occult head injury in the broader population of children who are abused, and whether universal or targeted screening would be most appropriate," adds Cindy W. Christian, M.D., medical director of Safe Place and co-author of the study.
"Thanks to past research, there has for a long time been an effective universal recommendation that children under age two years who have acute head injury should be screened for hidden fractures, but no comparable guidelines have existed for head injury screening," said Dr. Rubin. "We are hopeful that this study sets the stage for new guidelines to better diagnose, treat, and protect these children."
In addition to Drs. Rubin and Christian, additional co-authors from The Children's Hospital of Philadelphia include, Larissa T. Bilaniuk, M.D., Department of Radiology, Kelly Ann Zazyczny, R.N., Department of General Pediatrics, and Dennis R. Durbin, M.D., M.S.C.E., Division of Pediatric Emergency Medicine.
The Children's Hospital of Philadelphia identifies and treats more victims of abuse and neglect than any medical institution in Pennsylvania. Safe Place: The Center for Child Protection and Health at Children's Hospital is one of the nation's most comprehensive centers dedicated to addressing the healthcare needs of neglected and abused children, and children in foster care. Staffed by an interdisciplinary team of physicians, social workers and psychologists, the Center is a major resource for clinical services, research, education and advocacy.
Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked today as the best pediatric hospital in the nation by a comprehensive Child magazine survey. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 381-bed hospital recognition as a leading advocate for children and adolescents from before birth through age 19.