Abstract
Abusive head trauma (AHT) is one of the most severe forms of child abuse due to its morbidity and mortality. However, AHT is still misdiagnosed in developing countries because of its nonspecific clinical picture and limited knowledge of it on the part of physicians. The aim of this study was to describe some characteristics of children with AHT, their families, and caregivers, as well as the clinical data that could serve as signs for its suspicion and the medical-legal resolution of the cases. Children suspect with AHT in emergency rooms in three Mexican hospitals were included after obtaining informed consent from the parents. All information was obtained from the parents by means of a questionnaire and from different clinical and radiological evaluations of the clinical records of the patients. 15 children, with a median age of 5 months and predominantly males (73.33%), were included in the study. 66% reported a history of irritability periods, and most of the patients (73.33%) had more than one habitual caregiver. The diagnosis of AHT was suspected in only 33.33% on admission in the Emergency Services. Acute symptomatology was present in 53.33%, while less severe symptoms were reported in the rest. Special attention should be paid on babies with history of irritable periods. When a child who is previously healthy and suddenly presents with a seizure or cardiorespiratory dysfunction or brought to the hospital dead, the diagnosis of AHT should be considered as a priority.
Introduction
Child abuse (CA) is characterized by the variability of its clinical expressions because of the different mechanisms that generate it (Loredo-Abdalá, 2001). The predominant modality is physical abuse (PA), not only for being the most frequent but also for causing the greatest corporal damage. Within this modality is abusive head trauma (AHT), a condition that can cause significant neurological, visual, auditory, and physical disability and, sometimes, the death of the victim (Paul & Adamo, 2014).
Although this form of PA has been described in other parts of the world, but it is not more than two decades ago that information on AHT began to arise in Mexico, mainly by pediatricians working in third-level hospitals such as National Institute of Pediatrics (INP) and occasionally in private health institutions. For this reason, the medical-social-legal information about this problem in our country is insufficient because few cases are well studied. Undoubtedly, because of this the data on this modality of CA lagged to be completely extrapolated to the entire country.
It is difficult to estimate the real incidence of this pathology due to the complexity of the causes that may trigger the problem, the varied or limited specific clinical data, the variability in the reports offered by relatives, the poor knowledge of the pathology in pediatric hospital centers in the country, and the difficulty determining the precise aggressor. In Mexico, as in other countries of the world, AHT is considered when CA is suspected; therefore, only cases that are treated in pediatric third-level-care hospitals are most likely prosecuted (Loredo-Abdalá et al., 2016).
In the United States, 60% of traumas in children that causes death have been described as traumatic brain injury and CA (Chadwick et al., 1998). Specifically speaking of AHT, it is noteworthy to indicate that 2% of American mothers have indulged in shaking their babies under 2 years of age as a form of discipline (Maker et al., 2005). In England, an annual AHT incidence of 12.8 per 100,000 has been reported (Zolotor et al., 2008). In Scotland, the incidence is 24.6 per 100,000 (Barlow & Minns, 2000). In Japan, it has been reported that approximately 3% of the mother’s resort, at least once a month, to shaking their babies in situation of tantrum (Yamada & Fujiwara, 2014).
Despite the few publications in Mexico, reported cases have indicated some variables of the victim and relevant family data, as well as the characteristic clinical picture, the morbidity and mortality in the short and medium terms (Nieto Domínguez & Fernández Guinea, 2008).
It is pertinent to point out that this type of PA constitutes a very important cause of neurological, visual, auditory and physical disabilities, as well as death in these children. However, the aforementioned alterations combined with cognitive and bone morbidity are poorly reported in the national literature, even when they have been described in up to 68% of cases (Esernio-Jenssen et al., 2011). A similar situation exists with mortality due to this condition and, which has been described in 6% to 36% (Alvy et al., 2013) without any attribute to AHT.
Hence, we believe that it is extremely necessary to highlight the different characteristics of this modality of CA in different areas of the country, the triggering condition of the aggression, and other family and social determinants that may favor the development of this problem.
Faced with this reality, the aim of this study was to prospectively analyze the problem in three medical centers in Mexico with medical personnel, trained and equipped with the knowledge, skills, and sensitivity to suspect the cases and fully attend them.
Method
Study Design
An observational, transversal and multicenter study was conducted in three Mexican health institutions: The National Institute of Pediatrics (INP), a third-level-care hospital, located in Mexico City; Chihuahua Specialty Children’s Hospital, Chihuahua, and General Hospital of Mexicali, Baja California, both a second-level hospital, located in northern Mexico. The study period was from September 2012 to April 2015.
Participants
Children from 1 to 24 months of age, admitted in the Pediatric Emergency Services of the three hospitals with a suspicion of or confirmed AHT during their stay in the emergency room were included in the study. The diagnosis of AHT was established mainly by the existence of brain injury (intracranial hemorrhage and hygromas), and/or retinal hemorrhage, and the clinical pictures.
Ethics
The study was approved by the Research and Ethics Committees of National Institute of Pediatrics (approval number 073/2012). Before the implementation of the study procedures, an informed consent was sought and obtained from the parents or the caretakers of the children, and to ensure the safekeeping and confidentiality of the information of the participants, all the protocols established by local legislation were strictly observed.
Procedures
The sources employed to obtain the relevant information were the review of the clinical files of the patients, a questionnaire applied directly to the parents/caretakers, compilation of laboratory and imaging data, and the available generated information on the social and legal outcomes.
Key Information Sought and Measured
Child-caregiver information
The usual caregiver(s), their age, sex, and academic level. At the time the child presented the acute symptomatology that generated the request for medical care. The relationship of the caregiver(s) with the child, family history of lawful or illicit addictions, history of imprisonment in the family of the child or of the caretakers, and recruitment in the policy of military service.
Child pathological history/behavior
Presentation of crisis of inconsolable crying by the child, history of irritability, and history of food rejection.
Clinical signs and symptoms
The manifestations that motivated the request for hospitalization and their severity, time between the onset of the manifestations and sought for medical attention/treatment, suspicion of AHT on admission and diagnosed, evaluation of the fundus oculi, by whom and the findings, and performance of radiological examinations and their findings.
Medical and legal situations
Determination of the medical outcome and the medical-legal situation of the cases and its outcome.
Data Analysis
Univariate analysis
Frequencies and percentages were analyzed for categorical variables, and the medians and range and/or mean values and standard deviation were obtained for continuous variables.
Bivariate analysis
Spearman’s correlation analysis was performed to identify variables that were correlated.
Results
Characteristics of Children
A total of 17 children were evaluated in the Emergency Departments of the three hospitals for presenting signs and symptoms suspicious of AHT. This was discarded in two cases where physical abuse was determined as the final diagnosis. The rest (15 patients) met the inclusion criteria for AHT and were included in the study. Male–female relationship showed male gender predominance (73.33% vs. 26.67%). The median age of the patients was 5 months (range 1–24 months). Table 1 shows the demographic data of the patients by hospital.
Demographic Data of 15 Patients Diagnosed With Abusive Head Trauma in Three Hospitals in the Mexican Republic From 2012 to 2015.
Note. INP = Instituto Nacional de Pediatría (National Institute of Pediatrics); HIECh = Hospital Infantil de Especialidades de Chihuahua (Chihuahua Specialty Children’s Hospital); HGM = Hospital General de Mexicali (General Hospital of Mexicali).
Pathological background of the children
An intentional search made on the behaviors of the children, which may have led to the indulgence of the aggressors to commit the aggression, revealed a history of periods of irritability in 66.66% of the children, constant rejection of food in 33.33%, inconsolable crying crises in 13.33%, gastroesophageal reflux disease in 26.66%, and sobbing spasms in one case (6.66%). However, it is pertinent to point out that these behavioral aspects established in our patients do not constitute points to regard them as blameworthy party for the commission of the aggression. Hence, adults or caregivers of children should have a control of temper.
Characteristics of Caregivers
About 73.33% of the children had more than one habitual caregiver consisting of both parents in 53.33% of the cases, only the mother in 26.66%, the father and the grandmother in 13.33%, and the mother and the grandmother in 6.66%. The median age of the caregivers was 21 years, and their educational level was basic in 53.33%, medium to superior in 26.66% and superior in 6.66%. In two cases, caregiver education information was not obtained.
The acute symptomatology was detected by the caregivers as follows: the father in 53.33% of cases (he was alone in five cases and accompanied by the mother in three) and the mother in 40% of cases (she was alone in three cases, accompanied by the father in three and with the grandmother in five) (33.33%) (Table 2). The median age of the caregivers who detected the symptoms was 25 years (range 18–59 years), and their educational level was basic in 69.2% of the cases, above average in 23.1% and higher in 7.7%. There was no correlation between the usual caregiver and the caregiver who witnessed severe symptoms (Spearman’s rho = −.239, p = .391).
Caregiver at the Time of Presentation of the Symptoms That Generated a Request for Medical Attention.
Note. INP = Instituto Nacional de Pediatría (National Institute of Pediatrics); HIECh = Hospital Infantil de Especialidades de Chihuahua (Chihuahua Specialty Children’s Hospital); HGM = Hospital General de Mexicali (General Hospital of Mexicali).
Characteristics of the Families
The children’s family structure was nuclear in 46.66% of the cases, extended in 40%, and single-parent in 13.33%. There was a history of lawful addictions in a family member in 33.33% of cases and one of illicit addictions in 20%. In three cases, history of previous imprisonment, police, and military services was found, each with one case (6.66%).
Clinical Characteristics
The clinical manifestations that motivated the caregivers to request urgent medical attention for the patient were seizures in 62.5%, vomiting in 53.3%, and acute cardiorespiratory manifestations in 33.33% (Table 3). The time between the onset of the symptomatology and treatment in the emergency department was <3 hr in eight cases (53.33%), with a range of 20 min to 3 hr. There was a correlation between the elapsed time (<3 hr) in giving care for urgent cases and the reason for this (Spearman’s rho = .707, two-sided p < .01). In the rest of children (five patients), the symptomatology was less severe, and the time between the onset of symptoms and medical attention was 24 to 48 hr in three patients (20%) and 9 to 12 days in two patients (13.33%). The diagnosis of AHT was suspected on admission to the emergency department in five cases (33.33%), out of which the trauma was initially diagnosed only in one. Table 4 summarizes the initial diagnosis made in the emergency departments of the hospitals.
Manifestations That Motivated the Caregivers to Request Urgent Medical Attention.
Note. SOS = sudden-onset seizure.
Diagnoses Established in Emergency Departments in Patients in Whom Abusive Head Trauma Was Not Initially Suspected.
With regard to the examination of fundus oculi, 10 cases (66.66%) were performed by an ophthalmologist and five cases (33.33%) by either a resident pediatric physician or an internship undergraduate. Out of the five cases diagnosed by physicians in training, only in two were the confirmation of an ophthalmologist sought (Table 5).
Results of Ophthalmologic Evaluation in Three Hospital Centers (N = 15 Cases).
Note. HGM = Hospital General de Mexicali (General Hospital of Mexicali); HIECh = Hospital Infantil de Especialidades de Chihuahua (Chihuahua Specialty Children’s Hospital); INP = Instituto Nacional de Pediatría (National Institute of Pediatrics).
In this center, all fundus oculi assessments were performed by residents/internal physicians.
Radiological Examination
Computed axial tomography scanning (CAT) of the head was performed in 14 cases (93.33%), and MRI of the head was performed in one patient. The results of these imaging studies demonstrated subdural hematoma in four cases (26.66%), subarachnoid hemorrhage in four (26.66%), hygromas in five cases (33.33), and cerebral edema in three cases (20%) (Table 6). There was a trend toward a correlation between the type of brain injury and the antecedent of an inconsolable crying crisis (Spearman’s rho = −.492, p = .062).
Tomographic Findings in Three Hospital Centers (N = 15 Cases).
Note. HGM = Hospital General de Mexicali (General Hospital of Mexicali); HIECh = Hospital Infantil de Especialidades de Chihuahua (Chihuahua Specialty Children’s Hospital); INP = Instituto Nacional de Pediatría (National Institute of Pediatrics).
In three cases, only hygromas were identified in the absence of hemorrhage or other lesions; they were identified by magnetic resonance in one case.
Extensive studies (thorax and long bone radiographs) were performed in 10 patients (66.66%), and old fractures were detected in ribs and long bones in three cases (20%).
Medical-Legal Resolution
Twelve patients survived (80%), and three (20%) died—two in Mexicali and one in the INP. Autopsy was performed in one case (Mexicali), but the report was not obtained.
A medical-legal notification was made in all the 15 cases (100%). Eleven were presented in the Public Ministry Agency (the public body that represents the interests of society by exercising the powers of direction of the investigation of the facts that characterize crime), and four in the Office of the Attorney General for the Defense of Children and the Family. The legal outcome of the 12 surviving children were as follows: eight were returned to their parents (in five of these cases, a family support network was established), and four were placed in a temporary shelter. The abuser was prosecutor in only one case (the child’s mother).
Discussion
AHT is a series of signs and symptoms of sudden appearance, usually seen in children under the age of 1 year, who are predominantly male and apparently healthy. The damage is a consequence of violent and repeated shaking of the head, and sometimes, bashing the skull against a hard surface. In this study, the age and gender of the victims were similar to what has been widely reported in the literature (Alvy et al., 2013).
One of the most important aspects of this work is to guide pediatricians by highlighting the existence of a pathology whose clinical manifestation in a minor could lead to lose control by the caregiver (the aggressor) and made him or her to attack the child. The international and national literature indicates that the triggers of this violence include a history of crises of inconsolable crying, periods of irritability, and/or persistent rejection of food. In the United States, of a total of 5,195 children diagnosed with this pathology, 85.5% were infants with ages between 0 and 11 months. Out of these infants, 61.6% were males. The overall mortality was 10.8% with a rate of 16.5% in those from 12 to 23 months of age. Despite the high incidence of AHT among infants during the first months of life, a higher mortality was documented in those aged between 12 and 23 months. In the study of Nuño et al. (2015), it was found that retinal bleeding and shaking baby syndrome were secondary diagnosis associated with a higher mortality in children.
In Mexico, AHT commonly occurs in boys, infants, and children under 2 years of age (Loredo-Abdalá et al., 2014). This evidence suggests that the male babies have 1.5 times more risk of being victims of AHT than the female babies (King et al., 2003). Díaz-Olavarrieta et al. (2011) indicated in his study that the low socioeconomic status, being a young father, and a father with substance abuse were associated with the diagnosis of AHT. Moreover, as pointed out by Brown and Eisenberg (1995), unwanted pregnancy, in addition to being a global public health problem due to its association with bad results in the health of the mother and the child, has a link with AHT. In this work; the mothers, aggressors of AHT, were mostly younger women who confirmed during a face-to-face interview that their children resulted from an unwanted pregnancy.
Boop et al. (2016) reported that the annual incidence rate of AHT witnessed an astronomical increased from 19.6 cases per 100,000 in the population under 5 years of age in 2009 to 47.4 cases per 100,000 in 2014. In Japan, from 2010 to 2013, the average incidence of AHT per 100,000 children aged under 12 months was reported to be 7.2 (95% confidence interval [CI] = [7.18, 7.26]) for presumptive cases and 41.7 (95% CI = [41.7, 41.8]) for possible cases. The age distributions in months for both presumptive and possible AHT had a peak around 2 and 8 months (Yamaoka et al., 2020). Based on the above-recorded data, it is proven that the worldwide incidence of AHT is found in children under 2 years of age, with a higher prevalence in infants aged 12 to 24 months.
In this study and at all the centers, periods of irritability were present in 11 out of 15 cases, constant rejection of food in five out of 15, and crises of inconsolable crying in three out of 15. Hence, when a child under 2 years of age appears in the emergency department with these symptoms, prompt and diligent search for AHT should be made. The second condition required by pediatricians to diagnose these cases is the establishment of their etiology. Among the predominant medical problems are reflux disease (Baeza-Herrera et al., 2014), intolerance to cow’s milk protein (Miquel & Arancibia, 2012), and lactose intolerance (Vandenplas, 2015).
In this study, the only antecedents found were gastroesophageal reflux disease (four in 15) and sobbing spasms (one in 15). Therefore, it is extremely important that when physicians identify the existence of these antecedents in children, should properly treated them a as a true medical urgency to prevent the consequences such as AHT.
Once the diagnosis of AHT is established, it is very important to specify the characteristics of the main caregiver (age, gender, economic-cultural characteristics, and educational characteristics), because initially it is very difficult to establish the identity of the aggressor. Esernio-Jenssen et al. (2011) emphasized that most of the time the aggressor is likely a male. In this series, only a mother was established as the cause of the problem. Other variables analyzed were not found to be an important factor in the genesis of the problem.
However, it is important to identify and consider the demographic variables of the person who detected the seriousness of the problem, because this person is almost always male, and considering their physical strength, it is very probable that this individual caused the aggression (Kelly et al., 2009). In this context, it has been described that the biological father, the stepfather, or the partner of the mother may be the perpetrator, as has been specified in some cases during legal trials (Esernio-Jenssen et al., 2011).
The existence of some family and social determinants such as addiction, history of child maltreatment, and being or having been in prison may be elements associated with the existence of AHT. In this study, eight relatives reported alcohol consumption, three reported illicit drug use, and one reported having been in prison or belonging to a police corporation. A limitation in this study is the size of the sample, which does not allow statistically significant conclusions to be drawn; nevertheless, there is a clear and critical necessity to search for these determinants and to extend the sociocultural knowledge about this pathology. Nevertheless, there should not exist only one victim for this problem. It should be understood that children are the least to be guilty of these events because they do not have other ways of expressing what they feel. Hence, they manifest their problems or disagreements about their health and comfort only by such behaviors. Therefore, parents and guardians should learn to interpret and to know their children, so as to deduce their afflictions and problems and avoid an attack of anger which only leads to emission of violence on the least defenseless and the least guilty of the problem.
Although the world literature has widely defined the acute clinical picture and the characteristics of AHT infant victims, we insist that the emphasis should continue to be placed on pediatric emergency medical personnel on infants younger than 1 or 2 years old. When an infant who was previously healthy suddenly presents with a seizure or cardiorespiratory dysfunction or arrives dead at the hospital, the diagnosis of AHT should be considered as a priority.
The diagnosis of AHT depends on an immediate search for specific clinical data and their confirmation through the correct use of imaging studies. Among the first priorities is an examination of the fundus oculi to locate the existence of retinal hemorrhage (uni- or bilateral) and any other alterations. Any ocular findings should be confirmed by an ophthalmologist. The existence of this damage is a cornerstone for the establishment of a precise diagnosis.
It is important to note that the time elapsed between the onset of severe manifestations and when the child receives medical care ranges from 20 min to 3 hr. Performing a CAT scan of the head or magnetic resonance imaging will help to determine the existence and severity of cerebral edema, subarachnoid hemorrhage, subdural hematoma, and hemorrhage in the cerebral parenchyma or hygromas. The first four alterations indicate an acute picture, and the presence of hygromas suggests previous aggression. In cases of external damage, such as fractures of the skull, limb bones, clavicles, or ribs, the radiographic study will support the most severe form of the problem. In all cases, a differential diagnosis should be made with the following pathologies: febrile convulsive crisis, meningitis, carbon monoxide poisoning, glutamic acidemia, or any hemorrhagic disorder (Laurent-Vannier et al., 2009).
Having established a precise diagnosis, it is mandatory to conduct medical-legal notification with the objective of establishing the legal status of the minor and the family and, if possible, the probable aggressor. In all 15 cases in this study, this action was taken; however, the legal decisions were that eight children should be returned to the mother or a relative and four to a temporary shelter. When children are returned to a family member when the aggressor has not been established, there is a risk that they will be revictimized.
One issue that could not be addressed in this study was the medical-forensic management of the three deceased children, because no autopsy was performed in two cases, and the final results were not obtained in the case in which an autopsy was performed. This is a problem that favors the establishment of death certificates with misdiagnoses such as sudden infant death syndrome or accidental death. In this way, when the diagnosis is not specified, the aggressor escapes prosecution.
It was also not possible to specify, in the medium term, the physical and emotional sequelae in the minors and their subsequent management, situations that must be addressed in all cases.
Currently, it is very important to specify the economic cost required for the medical care of these patients. The purpose is to make public officials, health professionals, and society in general aware of the financial resources invested in this type of potentially preventable abuse.
Footnotes
Acknowledgments
The authors thank Arturo Fonseca Andere for his help with English revisions and Dr. Eduardo Cázares Ramírez for reporting suspected Abusive Head Trauma cases at the Instituto Nacional de Pediatría. The study was approved by the Research and Ethics Committees of National Institute of Pediatrics (approval number 073/2012).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by Fiscal Appeal from the National Institute of Pediatrics.
