1/12/2015

Pediatric Abusive
Head Trauma
Nursing Responsibility

Inflicted traumatic brain injury

Occurs after a baby is violently shaken by the shoulders, arms, chest, and legs.
May experience a deliberate blow/s to head or may be deliberately dropped.
Can occur in a matter of seconds and a from as few as three violent shakes.
Can lead to permanent severe brain damage or death.
Also known as abusive head trauma, shaken impact syndrome, inflicted head
injury or whiplash shake syndrome.
CDC defines as child maltreatment as any act or series of acts of commission or
omission by a parent or other caregivers that result in harm, potential harm, or
threat of harm.

What is Shaken Baby

Syndrome

Past Terminology
Shaken Baby Syndrome
Shaken-Impact Syndrome

Preferred terminology since 2009

Abusive Head Trauma
Abusive Head Injury
Older terminology is for nonmedical personnel

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In 2007, Kentucky was the 1st in the nation for child abuse
death rate.
Last count Kentucky is 18th in the nation.
Kentucky averages 30-40 child deaths involving maltreatment
per year, with another 30-60 near fatalities per year.
Abusive head trauma is the most common cause of morbidity
(disability) and mortality (death) in physical child abuse.
Lead to the development of House Bill 285 in Kentucky
Mandates/recommends education for various groups in the state
who work with or care for young children. Help caregivers to
recognize early signs and prevent escalation to Abusive Head
Trauma. Provides caregivers with tools for dealing with a crying
baby.

Statistics

Is a leading cause of child abuse death and long term disability in

the United States.
Between 1,000 to 1,5000 infants per year. In 2009, 1,770 infants
died from abuse and neglect.
Most often occurs in children between 3 and 8 months of age, but is
seen in children up to 5 years of age.
80% occurred in children younger than 4 years of age, and 40% of
are younger than 1 year of age.
Medical cost associated with initial and long term range ranges
from $300,000 to one million.
60% of the victims are males.
Prematurity and/or low birth weight infants, infants with disabilities
Many times cases go undiagnosed or misdiagnosed as a virus.

Incidence

Angry or frustrated parent or caregiver

Infant that cries and are inconsolable, which is the # 1 trigger. Colic
75% are biological parents with 60% being the father.
Males 60-70%, Mothers boyfriend 34%, Babysitter 4-30%,
Mother 6.5%
Single parent, less than 18 years, did not complete high school,
poor socioeconomic status (welfare recipients), and known to
social service. Lack of parenting skills.
Bruising in babies is NOT normal.
Maltreatment can and does occur in nice families.

Risk Factors/Parental Concern

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Unrealistic expectations of babies

Stress
Domestic violence
Alcohol or substance abuse
Unstable family situations
Depression
A history of mistreatment as a child.
Twins
Unemployment
Lack of healthcare resources
Lack of social and family support

Additional Risk Factors

Crying/Whining
Toilet training
Feeding Issues
Interrupting the caregiver during an activity

Triggers

Infant has weak neck muscles and ligaments plus a large, heavy
head. Shaking overwhelms the bodys ability to manage.
Shaking makes the fragile brain to bounce back and froth inside
the skull, which is thin pliable.
The whiplash motion from continuous shaking causes internal
damage and bleeding, which destroys a childs brain cells and
prevents the brain from getting enough oxygen. They have a
higher cerebral blood flow.
They have unmyelinated brain cells which is more susceptible to
shear injuries.

Pathophysiology

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Leads to bleeding and bruising of brain tissue.

Damages causes the brain to swell, putting pressure on
blood vessels and further exacerbation brain injuries.
Increased intracranial pressure, respiratory problems ,
alterations in consciousness , rigidity or posturing, poor
feeding decreased muscle tone, seizures to coma, then
death.

Pathophysiology (cont.)

Irreversible brain damage and death

Closed head injury
Subdural hematoma and or subarachnoid hemorrhage.
Vision problems, partial or total blindness, retinal hemorrhage.
Central nervous system injury and spinal cord injuries, seizure
disorders and paralysis.
Speech and hearing loss
Learning disabilities
Fractures, particularly the long bones and ribs.
Cerebral Palsy
Cerebral edema. Associated Injuries; fractures (arms, legs & ribs),
bruising of the skin including the torso (internal injuries such as liver
and spleen), arms & legs.

Types of injuries

Decreased muscle tone

Lack of smiling and vocalization
Fontanel may show bulging or tense with increased
intracranial pressure.
Inability to lift head
Eyes may not focus or follow movement
If gone undetected when the child is in school they
exhibit behavioral problems and learning difficulties.

Signs and Symptoms

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Extreme irritability
Difficulty staying awake, lethargy
Breathing problems, periods of apnea which is the cardinal sign
of PAHT
Bradycardia
Poor eating, difficulty sucking, and/or swallowing, vomiting
Tremors and or seizures
Pale or bluish skin
Paralysis or inability to move one or more extremities.
Coma with progressive signs of neurological deterioration,
(dilatation of one or both pupils, decrease pulse and increased
intracranial pressure)

Signs & Symptoms

CT scan, particularly the head

MRI
Skeletal Survey
Ophthalmological exam
Blood Test (access clotting disorders and rule out some
other condition) CBC, PT & PTT. Liver function, ABGs,
urinalysis & Creatine Kinase which would indicate
muscle injury
Skull radiology

Test and Diagnosis

Nurse obtain a detailed history, using open ended

questions.
Exam should be performed in a well lit private room
Through head to toe assessment.
Check fontanels
Check for bruises and abrasions on face and head.
Note reason for bruises or marks, observe caregivers
explanation is it appropriate and watch for story changes.
TEN-4 Bruising Rule
Any bruising of the TORSO, EARS, NECK in children 4
years od age or younger or any bruising anywhere on a
child 4 months of age or younger.

Assessment

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Will depend on the extent of the injuries.

Placed in Pediatric Intensive Care
Placed on a ventilator to maintain airway
Surgery to stop the bleeding in the brain
Management of external injuries
Seizure management, observe for changes that indicate
increase in intracranial pressure.
Cardiac monitoring
Management involves the whole healthcare team,
physician, nurses, social workers, case management, and
respiratory therapy.

Treatment

1/3 of the victims will die from their injuries

1/3 will suffer from life-changing injuries
1/3 will suffer minor injuries.
Seizure disorders
Loss of motor control
Many may end in long term care facilities

Prognosis

Nurses have a legal and moral obligation to report suspected abuse. Mandatory
to report
Suspected child abuse be meticulously in documentation. (just the facts)
Take pictures of the injuries
Document the caregivers reaction and interaction with the child.
Promptly report suspected abuse, become familiar with your hospitals, urgent care
facilities and physicians office regarding reporting abuse.
Nurses should never leave a child alone who they suspect abuse.
It is not the nurse responsibility to decide who is to blame or investigate.
Recognize the impact this may have on the family and give them honest
information and concern for childs safety.
Take picture and document factual information.

Nursing Responsibility

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PREVENTION
IDENTIFICATION of Risk factors
EDUCATION of caregivers
After the birth of an infant assess the family environment,
parenting skills, how do they act with other children, and
do they need referral to home health services.
Is there an adequate support system
April is child abuse prevention month

Nurses Responsibilities

Talk to them about how all babies will cry and that it is
expected.
Discuss options when they become frustrated or angry.
Walk away, after checking to make sure that the infant
basic need have been met, or take the baby for a ride. Call
a friend or neighbor, but never shake your baby.
Discuss shaken baby syndrome
Never discipline your child when angry, or hold your
child during an argument
Let parents discuss their frustration with a colic baby.

Parental Education