Purpose of this Document - NHS Networks
GuidelineInvestigation of Suspected Abusive Head Trauma in Children with subdural haemorrhages under 2 years old.ScopeTrust-wide.PurposeTo detail recommended practice for the investigation of suspected abusive head trauma (AHT) involving sub-dural haemorrhages in children under two years of age at Cambridge University Hospital Foundation Trust .Section A -To provide information, including a literature review of current papers concerning AHT involving sub-dural haemorrhage Section B - To provide general practical guidelines Abbreviations usedAPPT activated partial thromboplastin timeCSFcerebrospinal fluidCTcomputed tomographyFBCfull blood countFLAIRfluid attenuated inversion recoveryGA1glutaric aciduria type 1MRImagnetic resonance imagingAHT Abusive head traumaNon-AHT Non abusive head traumaPTprothrombin timeSDHsubdural haemorrhageTEGthromboelastogramSection AA1. IntroductionAHT involving injury to or bleeding around the brain is one of the most serious forms of physical child abuse. It carries severe consequences for the child. Recently published population studies report a mortality of 8% in AHT cases with 53% of AHT cases having persistent neurological impairment at hospital discharge. AHT is the leading cause of death, in children who have been abused and 31-45% of children who survive experience ongoing problems. ADDIN EN.CITE <EndNote><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1)We have adopted the term ”Abusive Head Trauma” inline with recent nomenclature proposed by the Committee on Child Abuse and Neglect; American Academy of Paediatrics to include an inflicted injury to the head and its contents. Brain injury may well include elements of both impact and acceleration –deceleration injury. But the term AHT does not apply causality and in reality the causal mechanism is rarely confirmed. This should be used in preference to ‘Shaken Baby Syndrome’, “intentional head injury” or “non accidental head injury”. AHT occurs most commonly in children under one year of age. It is estimated that between 20-24 per 100,000 infants under the age of one year are diagnosed with AHT in the UK. This rises to 36/100,000 in children under six months, on average a paediatrician in a district general hospital will see one case every one to two years but regional Paediatric Intensive care Units and Paediatric Neurologists will do so on a regular basis. Studies have found no association between ethnicity and AHT incidence, but AHT has been observed to be more common in lower socio-economic groups. ADDIN EN.CITE <EndNote><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1) Many children suffering AHT may have experienced previous episodes of physical abuse. Any suspicion of physical abuse of a baby or child must be fully investigated to identify the condition and prevent further abuse. However, it is also essential to give full consideration to differential diagnoses (discussed further in sections A8 and B4). 2011 guidance from the HYPERLINK ""The Crown Prosecution Service states that AHT will usually be diagnosed by ‘the Triad’ of internal head injuries, namely retinal haemorrhages, subdural haemorrhages and encephalopathy ADDIN EN.CITE <EndNote><Cite><Author>Crown</Author><Year>2011</Year><IDText>Non Accidental Head Injury cases: Legal Guidance</IDText><DisplayText>(2)</DisplayText><record><urls><related-urls><url> Accidental Head Injury cases: Legal Guidance</title></titles><contributors><authors><author>Crown Prosecution Service</author></authors></contributors><added-date format="utc">1302532840</added-date><ref-type name="Web Page">12</ref-type><dates><year>2011</year></dates><rec-number>129</rec-number><last-updated-date format="utc">1302532840</last-updated-date></record></Cite></EndNote>(2).A2. Involvement of the Professional TeamOnce a diagnosis of ‘possible AHT’ has been made, it is the duty of the consultant paediatrician responsible for the medical care to HYPERLINK ""inform the Safeguarding Children Team. If the child is on PICU then this would the Intensivist. If the child is on the ward when the possibility of AHT is raised, then this would be general paediatrician, or the paediatric neurologist if the child is under the neurosurgery team. Referral to the CYPS (Children’s Social Care) should be made as soon as possible. See HYPERLINK "" \t "_blank" \o "CHILD PROTECTION - SAFEGUARDING CHILDREN PROCEDURE"Child protection - safeguarding children procedure. Further assessment and investigations should then proceed in accordance with these guidelines, after the child has been clinically stabilised.The child’s care and investigation will ultimetaly be lead by a lead local paediatrician, they should be identified and informed on the first working day after identification of SDH, with a consultant to consultant phone call, and clear decision on who is leading the below. Relevant specialist teams should be contacted as usual with regard to the child’s clinical condition.NICE guidance recommends that “A clinician with expertise in non-accidental injuries in children should be involved in any suspected case of non-accidental injury in a child”. ADDIN EN.CITE <EndNote><Cite><Year>2007</Year><IDText>NICE Clinical Guideline 56</IDText><DisplayText>(3)</DisplayText><record><urls><related-urls><url> Clinical Guideline 56</title></titles><added-date format="utc">1302267808</added-date><ref-type name="Web Page">12</ref-type><dates><year>2007</year></dates><rec-number>109</rec-number><last-updated-date format="utc">1302534044</last-updated-date></record></Cite><Cite><Year>2007</Year><IDText>NICE Clinical Guideline 56</IDText><DisplayText>(3)</DisplayText><record><urls><related-urls><url> Clinical Guideline 56</title></titles><added-date format="utc">1302267808</added-date><ref-type name="Generic">13</ref-type><dates><year>2007</year></dates><rec-number>109</rec-number><last-updated-date format="utc">1302267808</last-updated-date></record></Cite></EndNote>(3). .The on-call neurosurgical registrar will discuss any child referred for a neurosurgical opinion with subdural haemorrhage with their neurosurgical consultant.Overall responsibility for the child protection investigation will lie with Social Care, who will liaise with relevant allied services e.g. the Police. It is essential for all medical professionals involved in the child’s care to remember that good documentation is vital, as all findings may have to bear examination in court. A list of useful contacts at CUHFT is provided in section B.A3. Identification of Suspected AHTChildren may present with clear signs of head injury, such as unconsciousness, fitting, paralysis or extreme irritability. However, some may present with less specific signs such as increased head circumference, poor feeding or excessive crying.Brain injuries may be asymptomatic but observed on radiological imaging performed if other non-accidental injury is suspected (e.g. rib fractures, unexplained bruising). Children can suffer non abusive head trauma by a variety of mechanisms. However, some features are particularly associated with AHT:Table 1 From Kemp A (34)Positive predictive values and OR for features associated with AHTPPV (97.5% CI)OR (97.5% CI), pApnoea93% (73% to 98%)17 (5 to 58), <0.001Rib fracturesHYPERLINK "" \l "fn-1#fn-1"*73% (5% to 88%)3 (0.7 to 13), 0.13Retinal haemorrhageHYPERLINK "" \l "fn-1#fn-1"*71% (48% to 86%)3.5 (1.1 to 11), 0.03Seizures66% (45% to 82%)3 (0.7 to 12), 0.13Long bone fracturesHYPERLINK "" \l "fn-1#fn-1"*59% (48% to 69%)1.7 (0.8 to 3.6), 0.14Skull fractures44% (22% to 68%)0.85 (0.3 to 2.3), >0.2Head and neck bruising37% (4% to 90%)0.8 (0.07 to 9), >0.2* Estimates in this analysis are deemed to be conservative owing to missing data as children who have head trauma from non-abusive causes rarely have complete skeletal surveys or full ophthalmology examinations. AHT, abusive head trauma; PPV, positive predictive value Subdural haemorrhage – in three studies, 63%, 54% and 82% of cases of SDH were considered to be probable AHT PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NeWhyZSBNQzwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NeWhyZSBNQzwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+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ADDIN EN.CITE.DATA (4-6).Apnoea ADDIN EN.CITE <EndNote><Cite><Author>Welsh</Author><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1, 7)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><contributors><authors><author>Welsh Child Protection Systematic Review</author></authors></contributors><added-date format="utc">1302188112</added-date><pub-location>Core Info</pub-location><ref-type name="Generic">13</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><last-updated-date format="utc">1302188112</last-updated-date></record></Cite><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1, 7) apnoea is significantly associated with AHT and appears to coincide with the fact that hypoxic ischaemic injury is commonly seen on MRISeizures – seizures have been shown to occur more frequently in AHT than Non-AHT and may exacerbate further hypoxic ischaemic damage to the brainRib fractures ADDIN EN.CITE <EndNote><Cite><Author>Welsh</Author><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1, 7)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><contributors><authors><author>Welsh Child Protection Systematic Review</author></authors></contributors><added-date format="utc">1302188112</added-date><pub-location>Core Info</pub-location><ref-type name="Generic">13</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><last-updated-date format="utc">1302188112</last-updated-date></record></Cite><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1, 7) and long bone fractures have been found to be associated with AHT. The explanation for this is likely to be the fact that most cases of AHT include a combination of shaking injuries with or without impactRetinal haemorrhages (RH) are strongly associated with AHT . Most studies identified retinal haemorrhages in 80-90% of confirmed AHT. RH have also been observed in severe Non-AHT but not in trivial accidental head injuriesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EdWhhaW1lPC9BdXRob3I+PFllYXI+MTk5MjwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EdWhhaW1lPC9BdXRob3I+PFllYXI+MTk5MjwvWWVhcj48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ADDIN EN.CITE.DATA (5,8).Skull fractures are more associated with Non-AHT. As most cases of non-AHT arise from falls or impact injuries that will predispose to skull fractures. Bruises to the head and neck ADDIN EN.CITE <EndNote><Cite><Author>Welsh</Author><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1, 7)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><contributors><authors><author>Welsh Child Protection Systematic Review</author></authors></contributors><added-date format="utc">1302188112</added-date><pub-location>Core Info</pub-location><ref-type name="Generic">13</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><last-updated-date format="utc">1302188112</last-updated-date></record></Cite><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1, 7) (N.B. please refer to the Addenbrooke’s Procedure for HYPERLINK "" \t "_blank" \o "BRUISING IN CHILDREN NOT INDEPENDENTLY MOBILE"Bruising in Children not independently mobile)Further detail concerning non-accidental head and spinal injury is available at HYPERLINK ""Welsh Child Protection Systematic Review group - Neurological injuries in ChildrenNICE Clinical Guideline 89 HYPERLINK ""When to suspect child maltreatment and the RCPCH HYPERLINK ""Child Protection Companion provide useful information for identification of suspected NAHI.A4. Subdural HaemorrhageBoth accidental and non-accidental head injury can cause brain injuries of these types. The features seen in AHT include bleeding around the brain, most commonly subdural haemorrhages with or without sub-arachnoid haemorrhages. ADDIN EN.CITE <EndNote><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1)Features which may distinguish AHT from non-AHT:Multiple SDHs/SAH’s ADDIN EN.CITE <EndNote><Cite><Author>Welsh</Author><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1, 7)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><contributors><authors><author>Welsh Child Protection Systematic Review</author></authors></contributors><added-date format="utc">1302188112</added-date><pub-location>Core Info</pub-location><ref-type name="Generic">13</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><last-updated-date format="utc">1302188112</last-updated-date></record></Cite><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1,7)SDHs over both halves of the brain, or interhemispheric SDH ADDIN EN.CITE <EndNote><Cite><Author>Welsh</Author><Year>2008</Year><IDText>Neurological Injuries Review</IDText><DisplayText>(1, 7)</DisplayText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><contributors><authors><author>Welsh Child Protection Systematic Review</author></authors></contributors><added-date format="utc">1302188112</added-date><pub-location>Core Info</pub-location><ref-type name="Generic">13</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><last-updated-date format="utc">1302188112</last-updated-date></record></Cite><Cite><Year>2008</Year><IDText>Neurological Injuries Review</IDText><record><keywords><keyword>of use?Cardiff University 2008</keyword></keywords><urls><related-urls><url> Injuries Review</title></titles><added-date format="utc">1302188112</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>102</rec-number><publisher>Core Info</publisher><last-updated-date format="utc">1302534190</last-updated-date><contributors><secondary-authors><author>Welsh Child Protection Systematic Review</author></secondary-authors></contributors></record></Cite></EndNote>(1,7). Apart from in AHT, SDH in the interhemispheric fissures or posterior and middle cranial fossa has only been reported following severe accidental trauma or coagulopathy. ADDIN EN.CITE <EndNote><Cite><Author>Datta S</Author><IDText>Neuroradiological aspects of subdural haemorrhages. [Arch Dis Child. 2005] - PubMed result</IDText><DisplayText>(10)</DisplayText><record><urls><related-urls><url> aspects of subdural haemorrhages. [Arch Dis Child. 2005] - PubMed result</title><secondary-title>Arch Dis Child</secondary-title></titles><pages>947-51</pages><number>9</number><contributors><authors><author>Datta S, Stoodley N, Jayawant S, Renowden S, Kemp A.</author></authors></contributors><added-date format="utc">1302267004</added-date><ref-type name="Journal Article">17</ref-type><rec-number>107</rec-number><last-updated-date format="utc">1302267004</last-updated-date><volume>90</volume></record></Cite></EndNote>(10)Children may present with SDH’s of varying ages. Some legal cases have raised the possibility that this pattern may arise from rebleeding into older SDH’s. However, the volume of any such rebleed is considered unlikely to cause raised intracranial pressure and thus this explanation is not compatible with the usual presentation with increased ICP, encephalopathy or general unwellness. ADDIN EN.CITE <EndNote><Cite><Author>Datta S</Author><IDText>Neuroradiological aspects of subdural haemorrhages. [Arch Dis Child. 2005] - PubMed result</IDText><DisplayText>(10)</DisplayText><record><urls><related-urls><url> aspects of subdural haemorrhages. [Arch Dis Child. 2005] - PubMed result</title><secondary-title>Arch Dis Child</secondary-title></titles><pages>947-51</pages><number>9</number><contributors><authors><author>Datta S, Stoodley N, Jayawant S, Renowden S, Kemp A.</author></authors></contributors><added-date format="utc">1302267004</added-date><ref-type name="Journal Article">17</ref-type><rec-number>107</rec-number><last-updated-date format="utc">1302267004</last-updated-date><volume>90</volume></record></Cite></EndNote>(10) Symptoms/Signs of Acute SDH ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11)Encephalopathy:IrritabilityCryingInconsolabilityUnsettled behaviourLethargyMeningismDecreased or increased toneSeizuresImpaired consciousnessVomiting/poor feedingBreathing abnormalities, apnoeaPallor, shockTense fontanelleEarly post-traumatic seizuresSymptoms/Signs of Subacute or Chronic SDH ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11)Expanding head circumferenceVomitingFailure to thriveNeurological deficitsA5. Retinal HaemorrhagePresence of retinal haemorrhages is strongly associated with AHT but is not specific for the diagnosis.AHT haemorrhagic retinopathy typically causes multi-layer retinal haemorrhages throughout the retina, from the posterior pole to the ora serrata. Superficial nerve fibre layer haemorrhages are flame shaped and usually resolve within days, deeper retinal and sub-retinal haemorrhages can take weeks or months to resolve. Sub-hyaloid haemorrhages (blood trapped between the posterior vitreous face and the retina) often have a fluid level and can take many months to resolve. Vitreous haemorrhage is frequent in severe cases.Although retinal haemorrhages cannot be dated with precision, if deep retinal haemorrhages are present but no superficial nerve fibre layer haemorrhages are seen, the causative event is likely to have taken place more than 24 hours prior to the examination. ADDIN EN.CITE <EndNote><Cite><Year>1999</Year><IDText>Child abuse and the eye. The Ophthalmology Child Abuse Working Party</IDText><DisplayText>(12)</DisplayText><record><keywords><keyword>Brain Injuries/complications</keyword><keyword>Cardiopulmonary Resuscitation/adverse effects</keyword><keyword>Child</keyword><keyword>Child Abuse/ diagnosis</keyword><keyword>Child, Preschool</keyword><keyword>Eye Injuries/ etiology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Retinal Hemorrhage/etiology</keyword><keyword>Risk Factors</keyword></keywords><urls><related-urls><url> (Print)0950-222X (Linking)</isbn><titles><title>Child abuse and the eye. The Ophthalmology Child Abuse Working Party</title><secondary-title>Eye (Lond)</secondary-title></titles><pages>3-10</pages><edition>1999/07/09</edition><language>eng</language><added-date format="utc">1304969606</added-date><ref-type name="Journal Article">17</ref-type><dates><year>1999</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>135</rec-number><last-updated-date format="utc">1304969606</last-updated-date><accession-num>10396376</accession-num><volume>13 ( Pt 1)</volume></record></Cite></EndNote>(12)A recent review has concluded that the overwhelming body of literature supports the conclusion that haemorrhagic retinopathy in otherwise previously well children who have not experienced severe accidental head injury have been submitted to abusive acceleration-deceleration trauma with or without head impact. ADDIN EN.CITE <EndNote><Cite><Author>Levin</Author><Year>2010</Year><IDText>Retinal Hemorrhage in Abusive Head Trauma -- Levin 126 (5): 961 -- Pediatrics</IDText><DisplayText>(13)</DisplayText><record><urls><related-urls><url> Hemorrhage in Abusive Head Trauma -- Levin 126 (5): 961 -- Pediatrics</title><secondary-title>Pediatrics</secondary-title></titles><pages>961-970</pages><number>5</number><contributors><authors><author>Levin, A</author></authors></contributors><added-date format="utc">1302278782</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2010</year></dates><rec-number>116</rec-number><last-updated-date format="utc">1302278782</last-updated-date><volume>126</volume></record></Cite></EndNote>(13)Haemorrhagic retinopathy in NAHI can affect all retinal layers and haemorrhages of a variety of ages and stages may be present. Vitreous haemorrhage is common in NAHI, but otherwise rare. NAHI is also associated with retinoschisis, retinal detachment and dislocated lenses. ADDIN EN.CITE <EndNote><Cite><Author>Kaur B</Author><Year>1992</Year><IDText>Fundus hemorrhages in infancy.</IDText><DisplayText>(14)</DisplayText><record><urls><related-urls><url> hemorrhages in infancy.</title><secondary-title>Surv Ophthalmol</secondary-title></titles><pages>1-17</pages><number>1</number><contributors><authors><author>Kaur B, Taylor D.</author></authors></contributors><added-date format="utc">1302343233</added-date><ref-type name="Journal Article">17</ref-type><dates><year>1992</year></dates><rec-number>118</rec-number><last-updated-date format="utc">1302343233</last-updated-date><volume>37</volume></record></Cite></EndNote>(14)Retinal haemorrhage may be unilateral or asymmetrical in terms of number and distribution, however, some victims have none at all (15-25%) ADDIN EN.CITE <EndNote><Cite><Author>Levin</Author><Year>2002</Year><IDText>Ophthalmology of shaken baby syndrome</IDText><DisplayText>(15)</DisplayText><record><dates><pub-dates><date>Apr</date></pub-dates><year>2002</year></dates><keywords><keyword>Diagnosis, Differential</keyword><keyword>Diagnostic Techniques, Ophthalmological</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Shaken Baby Syndrome/ diagnosis/physiopathology</keyword></keywords><urls><related-urls><url> (Print)1042-3680 (Linking)</isbn><titles><title>Ophthalmology of shaken baby syndrome</title><secondary-title>Neurosurg Clin N Am</secondary-title></titles><pages>201-11, vi</pages><number>2</number><contributors><authors><author>Levin, A. V.</author></authors></contributors><edition>2002/10/24</edition><language>eng</language><added-date format="utc">1304970059</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Ophthalmology, Hospital for Sick Children, Departments of Paediatrics, Genetics, and Ophthalmology, University of Toronto, Toronto, Ontario, Canada. alex.levin@sickkids.ca</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>136</rec-number><last-updated-date format="utc">1304970059</last-updated-date><accession-num>12391704</accession-num><volume>13</volume></record></Cite></EndNote>(15). In severe life threatening trauma (motor cycle, great height) retinal haemorrhage was found in less than 3%. ADDIN EN.CITE <EndNote><Cite><Author>Levin</Author><Year>2002</Year><IDText>Ophthalmology of shaken baby syndrome</IDText><DisplayText>(15)</DisplayText><record><dates><pub-dates><date>Apr</date></pub-dates><year>2002</year></dates><keywords><keyword>Diagnosis, Differential</keyword><keyword>Diagnostic Techniques, Ophthalmological</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Shaken Baby Syndrome/ diagnosis/physiopathology</keyword></keywords><urls><related-urls><url> (Print)1042-3680 (Linking)</isbn><titles><title>Ophthalmology of shaken baby syndrome</title><secondary-title>Neurosurg Clin N Am</secondary-title></titles><pages>201-11, vi</pages><number>2</number><contributors><authors><author>Levin, A. V.</author></authors></contributors><edition>2002/10/24</edition><language>eng</language><added-date format="utc">1304970059</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Ophthalmology, Hospital for Sick Children, Departments of Paediatrics, Genetics, and Ophthalmology, University of Toronto, Toronto, Ontario, Canada. alex.levin@sickkids.ca</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>136</rec-number><last-updated-date format="utc">1304970059</last-updated-date><accession-num>12391704</accession-num><volume>13</volume></record></Cite></EndNote>(15) Convulsions and prolonged CPR are very unlikely to be the sole cause of retinal haemorrhages. It has been suggested that non-NAHI-related retinal haemorrhages could occur as a result of coagulopathy. However, it appears that this occurs only with obvious severe coagulopathy. ADDIN EN.CITE <EndNote><Cite><Author>Levin</Author><Year>2010</Year><IDText>Retinal Hemorrhage in Abusive Head Trauma -- Levin 126 (5): 961 -- Pediatrics</IDText><DisplayText>(13)</DisplayText><record><urls><related-urls><url> Hemorrhage in Abusive Head Trauma -- Levin 126 (5): 961 -- Pediatrics</title><secondary-title>Pediatrics</secondary-title></titles><pages>961-970</pages><number>5</number><contributors><authors><author>Levin, A</author></authors></contributors><added-date format="utc">1302278782</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2010</year></dates><rec-number>116</rec-number><last-updated-date format="utc">1302278782</last-updated-date><volume>126</volume></record></Cite></EndNote>(13) Retinal haemorrhages are seen in up to 75% of neonates born by vacuum-assisted delivery, and in up to 33% of spontaneous vaginal deliveries. The majority of these resolve by two weeks of age, but have been seen to persist until 6 weeks of age. ADDIN EN.CITE <EndNote><Cite><Author>Emerson</Author><Year>2001</Year><IDText>Incidence and rate of disappearance of retinal haemorrhages in newborns</IDText><DisplayText>(16)</DisplayText><record><titles><title>Incidence and rate of disappearance of retinal haemorrhages in newborns</title><secondary-title>Ophthalmology</secondary-title></titles><pages>36-39</pages><number>1</number><contributors><authors><author>Emerson MV</author><author>Pieramici DJ</author><author>Stoessel KM</author><author>Berreen JP</author><author>Gariano RF</author></authors></contributors><added-date format="utc">1302279386</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2001</year></dates><rec-number>117</rec-number><last-updated-date format="utc">1302279483</last-updated-date><volume>108</volume></record></Cite></EndNote>(16) However, the series reporting the disappaearance of these by 6 weeks of age is small.If AHT is suspected, an ophthalmologist should perform a retinal examination using mydriatic drops and an indirect ophthalmoscope Ideally whilst ventilated and sedated on PICU. If retinal haemorrhages are seen, a consultant ophthalmologist with paediatric sub-specialty interest should be asked to review, document and comment on the findings. Where possible retinal digital imaging should be performed but this is usually only possible when the baby is sedated. A6. Spinal InjuryTwo patterns of spinal injury are described in the context of physical abuse: neck injuries and chest/lower back injuries.Cervical neck injuries (mean age 5 months): When children sustain neck injuries from physical abuse they often have co-existing inflicted brain injury and/or retinal haemorrhages. In many cases, spinal injury may not be immediately obvious as co-existing brain injury makes the patient difficult to assess. In some cases, the child may be reluctant or distressed when the neck is moved, indicating the underlying injury. ADDIN EN.CITE <EndNote><Cite><Author>Welsh</Author><IDText>Head and Spinal Injuries</IDText><DisplayText>(17)</DisplayText><record><urls><related-urls><url> and Spinal Injuries</title></titles><contributors><authors><author><style face="bold" font="default" size="100%">Welsh Child Protection Systematic Review Group</style></author></authors></contributors><added-date format="utc">1304459947</added-date><ref-type name="Web Page">12</ref-type><rec-number>133</rec-number><last-updated-date format="utc">1304460030</last-updated-date></record></Cite></EndNote>(17)Thoraco-lumbar (T12-L2) Chest/lower back injuries (mean age 13 months). These are predominatly fracture dislocations associated with thoracolumbar deformity, kyphosis and swelling. Spinal cord injury presenting with paraplegia and urinary retention .A recent study found a high incidence of clinically occult spinal SDHs in children with AHT on MRI. None of the spinal haemorrhages observed were surgically evacuated and all those followed up had resolved. Further work is required to evaluate potential long-term complications. ADDIN EN.CITE <EndNote><Cite><Author>Koumellis P</Author><Year>2009</Year><IDText>Spinal subdural haematomas in children with non-accidental head injury.</IDText><DisplayText>(18)</DisplayText><record><urls><related-urls><url> subdural haematomas in children with non-accidental head injury.</title><secondary-title>Arch Dis Child</secondary-title></titles><pages>216-9</pages><number>3</number><contributors><authors><author>Koumellis P, McConachie NS, Jaspan T</author></authors></contributors><added-date format="utc">1303831779</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2009</year></dates><rec-number>132</rec-number><publisher>Department of Neuroradiology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.</publisher><last-updated-date format="utc">1303831779</last-updated-date><volume>94</volume></record></Cite></EndNote>(18) there was debate as to whether cervical blood could “flow over” from posterior fossa haemorrhage, therefore the lower the blood in the spine, the more significant it is thought to be (expert group Cambridge).An MRI of the spine must be included in the standard imaging protocol when AHT is suspected (see section B1)More information concerning spinal injuries in non-accidental injury can be found at HYPERLINK ""Welsh Child Protection Systematic Review Group - Spinal injuries key messages.A7. Bony InjuriesThere is a significant association between presence of multiple fractures and abuse.In one study, 24% of children with suspected non-accidental injury had a positive skeletal survey. ADDIN EN.CITE <EndNote><Cite><Author>Day F</Author><Year>2006</Year><IDText>A retrospective case series of skeletal surveys in children with suspected non-accidental injury</IDText><DisplayText>(19)</DisplayText><record><urls><related-urls><url> retrospective case series of skeletal surveys in children with suspected non-accidental injury</title><secondary-title>J Clin Forensic Med</secondary-title></titles><pages>55-59</pages><number>2</number><contributors><authors><author>Day F, Clegg S, McPhillips M, Mok J.</author></authors></contributors><added-date format="utc">1302343551</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2006</year></dates><rec-number>119</rec-number><last-updated-date format="utc">1302343551</last-updated-date><volume>13</volume></record></Cite></EndNote>(19)In children under 4 months of age, just over 50% of fractures are suspected to be abusive, whereas over the age of 4 months the majority of fractures are accidental. ADDIN EN.CITE <EndNote><Cite><Author>Skellern CY</Author><Year>2000</Year><IDText>Non-accidental fractures in infants: risk of further abuse</IDText><DisplayText>(20)</DisplayText><record><urls><related-urls><url> fractures in infants: risk of further abuse</title><secondary-title>J Paediatr Child Health</secondary-title></titles><pages>590-92</pages><number>6</number><contributors><authors><author>Skellern CY, Wood DO, Murphy A, Crawford M.</author></authors></contributors><added-date format="utc">1302343817</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2000</year></dates><rec-number>120</rec-number><last-updated-date format="utc">1302343817</last-updated-date><volume>36</volume></record></Cite></EndNote>(20)In comparison with children with accidental injuries, children with AHT were more likely to have a SDH in the absence of a skull fracture. ADDIN EN.CITE <EndNote><Cite><Author>Myhre MC</Author><Year>2007</Year><IDText>Traumatic head injury in infants and toddlers.</IDText><DisplayText>(4)</DisplayText><record><urls><related-urls><url> head injury in infants and toddlers.</title><secondary-title>Acta Paediatrica</secondary-title></titles><pages>1159-63</pages><number>8</number><contributors><authors><author>Myhre MC, Gr?gaard JB, Dyb GA, Sandvik L, Nordhov M.</author></authors></contributors><added-date format="utc">1302191247</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2007</year></dates><rec-number>103</rec-number><last-updated-date format="utc">1302191247</last-updated-date><volume>96</volume></record></Cite></EndNote>(4) Skull fractures do not heal by callus formation and so dating of an injury is especially difficult. If the edges are round and smooth it is likely to be more than two weeks old ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11).No clear difference exists in the distribution of complex skull fractures between accidental and non-accidental injuries ADDIN EN.CITE <EndNote><Cite><Author>Kemp</Author><Year>2008</Year><IDText>Patterns of skeletal fractures in child abuse: systematic review</IDText><DisplayText>(21)</DisplayText><record><keywords><keyword>Adolescent</keyword><keyword>Arm Injuries/ etiology</keyword><keyword>Child</keyword><keyword>Child Abuse/ diagnosis</keyword><keyword>Child, Preschool</keyword><keyword>Fractures, Bone/ etiology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Leg Injuries/ etiology</keyword><keyword>Rib Fractures/ etiology</keyword><keyword>Skull Fractures/ etiology</keyword></keywords><urls><related-urls><url> (Electronic)0959-535X (Linking)</isbn><custom2>2563260</custom2><titles><title>Patterns of skeletal fractures in child abuse: systematic review</title><secondary-title>BMJ</secondary-title></titles><pages>a1518</pages><contributors><authors><author>Kemp, A. M.</author><author>Dunstan, F.</author><author>Harrison, S.</author><author>Morris, S.</author><author>Mann, M.</author><author>Rolfe, K.</author><author>Datta, S.</author><author>Thomas, D. P.</author><author>Sibert, J. R.</author><author>Maguire, S.</author></authors></contributors><edition>2008/10/04</edition><language>eng</language><added-date format="utc">1302345682</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Welsh Child Protection Systematic Review Group, Clinical Epidemiology Interdisciplinary Research Group, School of Medicine, Cardiff University, University Hospital of Wales Heath Park, Cardiff CF 2XX. kempam@cf.ac.uk</auth-address><dates><year>2008</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>122</rec-number><last-updated-date format="utc">1302345682</last-updated-date><accession-num>18832412</accession-num><volume>337</volume></record></Cite></EndNote>(21). A typical non-skull fracture of child abuse is the metaphyseal fracture caused by twisting the limb. It can also occur from birth injury (eg breech extraction). The ‘bucket handle’ and ‘corner’ type metaphyseal fractures may be suggestive of physical abuse. It is very important to target x-ray imaging on the metaphyses, as wider imaging can miss fractures ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11).More information about patterns of fractures seen in non-accidental injury is available from HYPERLINK ""Welsh Child Protection Systematic Review Group - Fractures key messages and a recent review published a list of HYPERLINK ""features associated with possible child abuse (see box 2 in the linked article).The Royal College of Radiologists recommends that a full skeletal survey must always be performed in children under 2 years when abuse is suspected. This should be the first imaging performed, unless head injury is suspected, when CT head should be performed first ADDIN EN.CITE <EndNote><Cite><Author>Royal</Author><Year>2008</Year><IDText>Standards for Radiological Investigations of Suspected Non-accidental Injury</IDText><DisplayText>(22)</DisplayText><record><urls><related-urls><url> for Radiological Investigations of Suspected Non-accidental Injury</title></titles><contributors><authors><author>Royal College of Radiologists with RCPCH</author></authors></contributors><added-date format="utc">1302424252</added-date><ref-type name="Generic">13</ref-type><dates><year>2008</year></dates><rec-number>123</rec-number><last-updated-date format="utc">1302424307</last-updated-date></record></Cite></EndNote>(22) (see section B1 for imaging protocol).Full details of the recommended skeletal survey can be found in the HYPERLINK ""Royal College of Radiologists Standards for Radiological Investigations of Suspected Non-accidental Injury. Note that a plain skull x-ray should be taken in addition to CT head, as linear skull fractures may not be identified on CT ADDIN EN.CITE <EndNote><Cite><Author>The</Author><IDText>Standard for skeletal surveys in suspected non-accidental injury (NAI) in children</IDText><DisplayText>(23)</DisplayText><record><urls><related-urls><url> for skeletal surveys in suspected non-accidental injury (NAI) in children</title></titles><contributors><authors><author>The British Society of Paediatric Radiology</author></authors></contributors><added-date format="utc">1302344216</added-date><ref-type name="Web Page">12</ref-type><rec-number>121</rec-number><last-updated-date format="utc">1302344216</last-updated-date></record></Cite></EndNote>(23). A8. Coagulation and Haematological DisordersThe investigation of these disorders in the context of AHT, is challenging, and therefore all children should, be discussed with a paediatric (if available) haematologist prior to commencing. It is essential to take a full haemostatic history of the patient and their family. A standard haematological screen is detailed in section B. This screen will exclude the most serious bleeding disorders but not all (for example factor XIII deficiency, usually seen in consanguineous families, which is not detected on the standard clotting screen and may be a cause of spontaneous intracranial haemorrhage).If bleeding is still unexplained following this screen, further tests are possible and a paediatric haematologist should be consulted.The results of these tests should be interpreted based on the age-specific normal ranges (detailed in Liesner et al, Blood Coag Fibrinolysis 2004 or on advice from Paediatric Haematology).It should be remembered that factor XII deficiency may result in dramatically prolonged APTT, but does not cause a bleeding disorder in vivo.Platelet function analysis may be performed but this is unreliable in children under 2 year of age except in the identification of severe platelet abnormalities such as Glanzmann’s thrombasthaenia. Renal and liver function tests can be useful in exclusion of acquired coagulation defects.It should be considered whether any diagnosed bleeding tendency actually relates to an injury or bruise, and it should also be remembered that children with bleeding diatheses may also have been abused.A9. Differential DiagnosesThere are many reported causes and associations of subdural haemorrhage, which must be considered in the production of a differential diagnosis. These include ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11):Accidental traumaTraumatic labourNeurosurgical complicationsCranial malformation (aneurysm, arachnoid cyst)Cerebral infectionsCoagulation and haematological disordersMetabolic disorders (glutaric aciduria, galactosemia, Menkes)Biochemical disorders (hypernatraemia)Traumatic labour – prospective examination of a cohort of neonates showed that presence of unilateral or bilateral SDH was not necessarily indicative of excessive birth trauma i.e. some babies with normal vaginal deliveries may have SDH. All haematomas had completely resolved by 4 weeks of age in one small seriesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaGl0Ynk8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxJ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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaGl0Ynk8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxJ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ADDIN EN.CITE.DATA (24). Arachnoid cysts/external hydrocephalus – SDH is an extremely rare complication of arachnoid cyst, and there is no generally acknowledged agreement that external hydrocephalus predisposes to SDH. For these diagnoses to be applicable, there must be evidence that the putative causative lesion was present prior to the development of the symptomatic SDH. This is obtainable by correct interpretation of imaging and head circumference measurements ADDIN EN.CITE <EndNote><Cite><Author>Punt</Author><Year>2005</Year><IDText>Mechanisms and Management of Subdural Haemorrhage</IDText><DisplayText>(25)</DisplayText><record><titles><title>Mechanisms and Management of Subdural Haemorrhage</title><secondary-title>Shaking and Other Non-accidental Head Injuries in Children</secondary-title></titles><contributors><authors><author>Punt, J</author></authors></contributors><added-date format="utc">1302425959</added-date><ref-type name="Book Section">5</ref-type><dates><year>2005</year></dates><rec-number>125</rec-number><publisher>Mac Keith Press</publisher><last-updated-date format="utc">1302426045</last-updated-date><contributors><secondary-authors><author>Minns RA</author><author>Brown JK</author></secondary-authors></contributors></record></Cite></EndNote>(25). Glutaric aciduria type 1 (GA1) – this is a rare inborn error of metabolism which is associated with acute SDH and chronic subdural collections. Children with SDH int his condition do not have associated injuries such as fractures. It has been recommended that screening for GA1 should be added to the standard array of investigations for suspected NAHI. This screen involves urine organic analysis, glutarylcarnitine measurement on blood spots and plasma total and free carnitine estimations, (followed by confirmatory enzymology ADDIN EN.CITE <EndNote><Cite><Author>Hartley LM</Author><Year>2001</Year><IDText>Glutaric Aciduria Type 1 and Nonaccidental Head Injury</IDText><DisplayText>(26)</DisplayText><record><urls><related-urls><url> Aciduria Type 1 and Nonaccidental Head Injury</title><secondary-title>Pediatrics</secondary-title></titles><pages>174-175</pages><number>1</number><contributors><authors><author>Hartley LM, Khwaja OS, Verity CM</author></authors></contributors><added-date format="utc">1302426620</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2001</year></dates><rec-number>126</rec-number><last-updated-date format="utc">1302426620</last-updated-date><volume>107</volume></record></Cite></EndNote>(26), if indicated by expert opinion) . Menkes disease, is a severe neurological disorder that produces severe neurodegeneration in children over 6 months of age (normally occurs earlier). Therefore caeruloplasmin levels may be considered in children under 6 months and over that age with a previous history of neurological or developmental difficulties. Copper analysis is complex and is only done on recommendation of a consultant paediatric neurologist. The ‘Unified Hypothesis’ - This states that SDH in infants could arise from a combination of factors as a ‘phenomenon of immaturity’ in the absence of head trauma ADDIN EN.CITE <EndNote><Cite><Author>Geddes</Author><Year>2003</Year><IDText>Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'?</IDText><DisplayText>(27)</DisplayText><record><keywords><keyword>Diagnosis, Differential</keyword><keyword>Dura Mater/blood supply/ pathology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Intracranial Hemorrhages/ etiology/pathology</keyword><keyword>Retrospective Studies</keyword><keyword>Shaken Baby Syndrome/ complications/ pathology</keyword></keywords><urls><related-urls><url> (Print)0305-1846 (Linking)</isbn><titles><title>Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'?</title><secondary-title>Neuropathol Appl Neurobiol</secondary-title></titles><pages>14-22</pages><number>1</number><contributors><authors><author>Geddes, J. F.</author><author>Tasker, R. C.</author><author>Hackshaw, A. K.</author><author>Nickols, C. D.</author><author>Adams, G. G.</author><author>Whitwell, H. L.</author><author>Scheimberg, I.</author></authors></contributors><language>eng</language><added-date format="utc">1302270065</added-date><pub-location>England</pub-location><ref-type name="Journal Article">17</ref-type><auth-address>Department of Histopathology, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK. j.f.geddes@qmul.ac.uk</auth-address><dates><year>2003</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>112</rec-number><last-updated-date format="utc">1302270065</last-updated-date><accession-num>12581336</accession-num><volume>29</volume></record></Cite></EndNote>(27). However, subsequent papers have concluded that unexplained SDH according to the unified hypothesis was ‘an extreme rarity’ and that NAHI was the most common cause of SDH in children <1 year.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXRzY2hrZTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXRzY2hrZTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+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ADDIN EN.CITE.DATA (28)Further details of differential diagnoses and recommended investigations are detailed in section B.A10. Timing of InjuryIn court, the paediatrician may be asked to give an estimate of the age of the injury. It must be appreciated that only approximations can be given. It is not possible to accurately age a subdural haematoma on MRI scans ADDIN EN.CITE <EndNote><Cite><Author>Rajaram</Author><Year>2011</Year><IDText>Neuroimaging in non-accidental head injury in children: an important element of assessment</IDText><DisplayText>(29)</DisplayText><record><titles><title>Neuroimaging in non-accidental head injury in children: an important element of assessment</title><secondary-title>Postgrad Med J</secondary-title></titles><contributors><authors><author>Rajaram, S</author><author>Batty, R</author><author>Rittey, CDC</author><author>Griffiths, PD</author><author>Connolly DJA</author></authors></contributors><added-date format="utc">1302429119</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2011</year></dates><rec-number>127</rec-number><last-updated-date format="utc">1302429208</last-updated-date></record></Cite></EndNote>(29) alone. Accurate ageing of a subdural haematoma on CT scan is not possible after 1 week. There may some visible characteristics on CT which can suggest the age of a haematoma: acute (1-5 days) haematomas appear hyperdense relative to grey matter, whereas subacute (7-20 days) haematomas appear isodense and chronic (over 20 days) haematomas appear hypodense ADDIN EN.CITE <EndNote><Cite><Author>Demaerel P</Author><Year>2002</Year><IDText>Cranial imaging in child abuse.</IDText><DisplayText>(30)</DisplayText><record><urls><related-urls><url> imaging in child abuse.</title><secondary-title>Eur Radiol</secondary-title></titles><pages>849-857</pages><number>4</number><contributors><authors><author>Demaerel P, Casteels I, Wilms G.</author></authors></contributors><added-date format="utc">1302541141</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2002</year></dates><rec-number>131</rec-number><last-updated-date format="utc">1302541141</last-updated-date><volume>12</volume></record></Cite></EndNote>(30). However, other studies have shown that SDHs may remain hyperdense up to 11 days after injury, so this method of ageing injuries is not accurate ADDIN EN.CITE <EndNote><Cite><Author>Rajaram</Author><Year>2011</Year><IDText>Neuroimaging in non-accidental head injury in children: an important element of assessment</IDText><DisplayText>(29)</DisplayText><record><titles><title>Neuroimaging in non-accidental head injury in children: an important element of assessment</title><secondary-title>Postgrad Med J</secondary-title></titles><contributors><authors><author>Rajaram, S</author><author>Batty, R</author><author>Rittey, CDC</author><author>Griffiths, PD</author><author>Connolly DJA</author></authors></contributors><added-date format="utc">1302429119</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2011</year></dates><rec-number>127</rec-number><last-updated-date format="utc">1302429208</last-updated-date></record></Cite></EndNote>(29). Advice should be sought from an experienced neuroradiologist.Spectophotometry of subdural aspirate can identify presence of bilirubin, which suggests that bleeding occurred 24 hours – 3 days prior to aspiration ADDIN EN.CITE <EndNote><Cite><Author>Tallur</Author><Year>2005</Year><IDText>Is timing of haemorrhage by spectrophotometry similar for haemorrhages in the subdural and subarachnoid space?</IDText><DisplayText>(31)</DisplayText><record><keywords><keyword>Hematoma, Subdural/ diagnosis</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Spectrophotometry</keyword><keyword>Subarachnoid Hemorrhage/ diagnosis</keyword><keyword>Time Factors</keyword></keywords><urls><related-urls><url> (Electronic)0003-9888 (Linking)</isbn><titles><title>Is timing of haemorrhage by spectrophotometry similar for haemorrhages in the subdural and subarachnoid space?</title><secondary-title>Arch Dis Child</secondary-title></titles><pages>1203</pages><number>11</number><contributors><authors><author>Tallur, K. K.</author><author>Belton, N. R.</author><author>Stephen, R.</author><author>Minns, R. A.</author></authors></contributors><language>eng</language><added-date format="utc">1302429635</added-date><pub-location>England</pub-location><ref-type name="Journal Article">17</ref-type><dates><year>2005</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>128</rec-number><last-updated-date format="utc">1302429635</last-updated-date><accession-num>16243888</accession-num><electronic-resource-num>10.1136/adc.2003.036061</electronic-resource-num><volume>90</volume></record></Cite></EndNote>(31). CSF cytology and assessment of macrophage markers provide further tests for timing of bleeding. These investigations may be useful in assessing the consistency of a given injury with a reported/suspected cause e.g. birth trauma/accidental injury ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11).Xanthochromia from physiological jaundice of the newborn may persist in the CSF for up to 6 weeks ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11).A11. Legal Implications and GuidelinesRecent guidelines have been issued by HYPERLINK ""The Crown Prosecution Service regarding the prosecution approach to non-accidental head injuries ADDIN EN.CITE <EndNote><Cite><Author>Crown</Author><Year>2011</Year><IDText>Non Accidental Head Injury cases: Legal Guidance</IDText><DisplayText>(2)</DisplayText><record><urls><related-urls><url> Accidental Head Injury cases: Legal Guidance</title></titles><contributors><authors><author>Crown Prosecution Service</author></authors></contributors><added-date format="utc">1302532840</added-date><ref-type name="Web Page">12</ref-type><dates><year>2011</year></dates><rec-number>129</rec-number><last-updated-date format="utc">1302532840</last-updated-date></record></Cite></EndNote>(2). The salient points are listed below:AHT cases will usually be diagnosed by a triad of internal head injuries, “the Triad”, consisting of subdural haemorrhages, retinal haemorrhages and encephalopathy.Proof of AHT usually requires the triad of injuries plus supporting evidence (see CPS guidelines for details of supporting evidence).CPS policy is to resist challenges to the Triad diagnosis based on the ‘Unified Hypothesis (see ADDIN EN.CITE <EndNote><Cite><Author>Geddes</Author><Year>2003</Year><IDText>Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'?</IDText><DisplayText>(27)</DisplayText><record><keywords><keyword>Diagnosis, Differential</keyword><keyword>Dura Mater/blood supply/ pathology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Intracranial Hemorrhages/ etiology/pathology</keyword><keyword>Retrospective Studies</keyword><keyword>Shaken Baby Syndrome/ complications/ pathology</keyword></keywords><urls><related-urls><url> (Print)0305-1846 (Linking)</isbn><titles><title>Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'?</title><secondary-title>Neuropathol Appl Neurobiol</secondary-title></titles><pages>14-22</pages><number>1</number><contributors><authors><author>Geddes, J. F.</author><author>Tasker, R. C.</author><author>Hackshaw, A. K.</author><author>Nickols, C. D.</author><author>Adams, G. G.</author><author>Whitwell, H. L.</author><author>Scheimberg, I.</author></authors></contributors><language>eng</language><added-date format="utc">1302270065</added-date><pub-location>England</pub-location><ref-type name="Journal Article">17</ref-type><auth-address>Department of Histopathology, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK. j.f.geddes@qmul.ac.uk</auth-address><dates><year>2003</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>112</rec-number><last-updated-date format="utc">1302270065</last-updated-date><accession-num>12581336</accession-num><volume>29</volume></record></Cite></EndNote>(27)).Careful and efficient documentation of all findings is essential.The diagnosis of ‘suspected AHT’ has to be confirmed or rebutted on the basis of subsequent investigations. The degree of suspicion will then be qualified by a degree of certainty ADDIN EN.CITE <EndNote><Cite><Author>Parker</Author><IDText>Guideline: Non-accidental Head Injury (Children), Version 1</IDText><DisplayText>(11)</DisplayText><record><titles><title>Guideline: Non-accidental Head Injury (Children), Version 1</title><secondary-title>Paediatric Neurology, Women's and Children's Directorate</secondary-title></titles><contributors><authors><author>Parker, Alasdair</author></authors></contributors><added-date format="utc">1302269047</added-date><ref-type name="Book Section">5</ref-type><rec-number>111</rec-number><last-updated-date format="utc">1302269155</last-updated-date></record></Cite></EndNote>(11):Probable (on a balance of probabilities, greater than 50% chance)Possible/questionable (legally not provable at the time)Not AHT(suspicion not sustained)Section B – A Practical Guide to InvestigationAs always, the first objective on acute presentation is clinical stabilisation of the child. Following stabilisation, if AHT is suspected social care should be informed at the earliest available opportunity via telephone and followed up in writing within 24 hours. Care should be taken to inform Social Care of any other children living within the same household and if possible their current whereabouts. Within working hours the HYPERLINK ""Safeguarding Children Team should be informed. The following protocol for investigation followed. Relevant specialist teams should be contacted as normal with regard to the child’s clinical condition. Remember that good documentation is essential. A ‘checklist’ to assist with tracking of investigations is provided in appendix 2, which can be attached to the patient’s notes to provide a quick-glance overview of what investigations have been performed.Concerns that AHT is a possibility should be shared with key professionals at the earliest opportunity, this includes Childrens Social Care, the Safeguarding Children team at CUHFT, Police and the local District Paediatrician (see section A2.i). Strategy discussions will be held in accordance with the wishes of The Social Care department and Police. Trust staff may be invited to participate in these discussions. The responsible paediatrician will be asked for an opinion about the nature of the injuries and may need to introduce the subject with specific mention of the 14 day investigation period, it should be established at that time whether interim reports are required . It is the responsibility of the consultant in charge of the patient to liaise with social care and police on a regular daily basis whilst safeguarding procedures continue. The allocated Social worker may convene a further strategy meeting to be held in the hospital setting in order to gather more information and plan further investigations. A senior member of the medical team caring for the patient should attend to represent CUHFT or ensure that up to date information is available and comprehensible to the relevant team members. B1. Imaging ProtocolThe protocol for head imaging recommended in guidelines published by the Royal College of Radiologists in association with the Royal College of Paediatrics and Child Health is shown below ADDIN EN.CITE <EndNote><Cite><Author>Royal</Author><Year>2008</Year><IDText>Standards for Radiological Investigations of Suspected Non-accidental Injury</IDText><DisplayText>(22)</DisplayText><record><urls><related-urls><url>rcr.ac.uk/</url></related-urls></urls><titles><title>Standards for Radiological Investigations of Suspected Non-accidental Injury</title></titles><contributors><authors><author>Royal College of Radiologists with RCPCH</author></authors></contributors><added-date format="utc">1302424252</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>123</rec-number><last-updated-date format="utc">1302533843</last-updated-date></record></Cite></EndNote>(22):It is important to perform diffusion-weighted MRI as this is capable of detecting secondary ischaemic sequelae of NAHI which may be occult on routine sequences ADDIN EN.CITE <EndNote><Cite><Author>Royal</Author><Year>2008</Year><IDText>Standards for Radiological Investigations of Suspected Non-accidental Injury</IDText><DisplayText>(22)</DisplayText><record><urls><related-urls><url>rcr.ac.uk/</url></related-urls></urls><titles><title>Standards for Radiological Investigations of Suspected Non-accidental Injury</title></titles><contributors><authors><author>Royal College of Radiologists with RCPCH</author></authors></contributors><added-date format="utc">1302424252</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>123</rec-number><last-updated-date format="utc">1302533843</last-updated-date></record></Cite></EndNote>(22). An MRI of the spine should be performed.A full skeletal survey should also be performed, including a plain skull x-ray. ADDIN EN.CITE <EndNote><Cite><Author>Royal</Author><Year>2008</Year><IDText>Standards for Radiological Investigations of Suspected Non-accidental Injury</IDText><DisplayText>(22)</DisplayText><record><urls><related-urls><url>rcr.ac.uk/</url></related-urls></urls><titles><title>Standards for Radiological Investigations of Suspected Non-accidental Injury</title></titles><contributors><authors><author>Royal College of Radiologists with RCPCH</author></authors></contributors><added-date format="utc">1302424252</added-date><ref-type name="Web Page">12</ref-type><dates><year>2008</year></dates><rec-number>123</rec-number><last-updated-date format="utc">1302533843</last-updated-date></record></Cite></EndNote>(22). Full details of the views to be taken are available from the HYPERLINK ""Royal College of Radiologists Standards for Radiological Investigations of Suspected Non-accidental Injury (p20) along with further details and guidance concerning head imaging.A repeat chest x-ray should be performed at 14 days from putative injury date.If a child with confirmed NAHI has a sibling under 2 years of age, a skeletal survey for the sibling should be considered ADDIN EN.CITE <EndNote><Cite><Author>The</Author><IDText>Standard for skeletal surveys in suspected non-accidental injury (NAI) in children</IDText><DisplayText>(23)</DisplayText><record><urls><related-urls><url> for skeletal surveys in suspected non-accidental injury (NAI) in children</title></titles><contributors><authors><author>The British Society of Paediatric Radiology</author></authors></contributors><added-date format="utc">1302344216</added-date><ref-type name="Web Page">12</ref-type><rec-number>121</rec-number><last-updated-date format="utc">1302344216</last-updated-date></record></Cite></EndNote>(23).Radiation risk: a recent study found a small, statistically non-significant increase in risk for all cancers following diagnostic radiography in early infancy.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYWphcmFtYW48L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy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=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYWphcmFtYW48L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy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=
ADDIN EN.CITE.DATA (32)B2. Haematology ProtocolA haemostatic history is essential and should include the following:History of bleeding in the child (ask specifically about circumcision or other surgery, particularly ENT or dental procedures)History of bleeding disorders in the familyHistory of menorrhagia in the mother or other female members of the familyHistory of consanguinityEssential tests in children under 2 years of age. These will exclude most serious bleeding disorders but not all:FBC and blood film‘Coag screen’ PA, APTT,TT, FibrinogenFactor assays: FII, FV, FVII, FVIII, FIX, FX, FXI, (FXII), FXIII, vWFTEGBlood group (essential for interpretation of vWF results)PFA Note the interpretation of the PFA and TEG is difficult under the age of 2yrs, and must always be done in discussion with the paediatric haematologist. Minimum volumes required (all citrate samples) are as follows:Coagulation screen – 1.2mlFactor assays – 1.2-2.4mlTEG (for α2 antiplasmin) 1.2ml.PFA – ideally 4ml (must be analysed within 4 hours)These may need to be done in stages.It is important to ensure that there is no contamination with heparin (potentially problematic e.g. if drawn from arterial lines in PICU)Ideally, send 6x1.4ml citrate (green) bottles before any blood products are given or as soon as possible and send to haematology lab within four hours for spinning and freezing.Results of these tests should be based on the age-specific normal ranges, which can be found in Liesner et al, Blood Coag Fibrinolysis 2004, or on request from Paediatric Haematology.If bleeding is still unexplained after these tests, discuss with the consultant paediatric haematologist who will recommend further tests. The laboratory does have a standard NAI screen which can be requested.Please discuss with the Specialist Haemostasis lab before taking samples to arrange suitable time for lab to process tests, usually within normal working hours. If child is moribund or situation dictates that samples cannot wait, then arrange with lab for samples to be spun down and frozen immediately, to be analysed at a later date.B3. OpthalmologyAn ophthalmologist should perform a retinal examination using mydriatic drops and an indirect ophthalmoscope.If retinal haemorrhages are seen, a consultant ophthalmologist with paediatric sub-specialty interest should be asked to review, document and comment on the findings. Where possible retinal digital imaging should be performed but this is usually only possible when the baby is sedated and so the ophthalmology team should be contacted quickly (as this may be easiest to perform before a child leaves PICU).It is important to remember that all children will require referral for follow up with the local ophthalmologist at discharge.B5. Multidisciplinary social assessmentThis should include input from the following people:Consultant paediatrician and teamWell Child nurseNursing staffSocial workerMember of The Safeguarding TeamPolice Child Abuse investigation TeamEssential points for the chair of the meeting to establish:A clear history of the presenting symptoms. The nature of any witnessed fall, including the height and surface of contact must be established.Who has had contact with the child in the time during which the injury may have occurred.Who is allowed to visit and care for the child on the ward, and whether they should be chaperoned (and if so by whom). This should be carefully and clearly documented in the notes.Whether other children are in the household, and whether appropriate measures are in place to protect them.Social Care will be responsible for ensuring the safety of other children within the home, but it is the responsibility of the medical team to ensure that Social Care are aware of the existence of such children and concerns about their safety.Any written agreement made with parents and / or carers should be included within the child’s notes.B6. List of Useful ContactsDr Louise Allen – Consultant Paediatric OphthalmologistDr Mike Gattens – Consultant Paediatric HaematologistDr Lucy Preston, Dr Elaine Lewis , Named Doctors and Pam Wear, Named Nurse – HYPERLINK ""Safeguarding Children Team Dr Justin Cross – Consultant RadiologistB7. Related DocumentsAddenbrooke’s Policy - HYPERLINK "" \t "_blank" \o "CHILD PROTECTION - SAFEGUARDING CHILDREN POLICY"Child protection - Safeguarding children policyAddenbrooke’s Procedure- HYPERLINK "" \t "_blank" \o "CHILD PROTECTION - SAFEGUARDING CHILDREN PROCEDURE"Child protection - safeguarding children procedureAddenbrooke’s Procedure - HYPERLINK "" \t "_blank" \o "BRUISING IN CHILDREN NOT INDEPENDENTLY MOBILE"Bruising in Children not independently mobileNICE Clinical Guideline 89 - HYPERLINK ""When to suspect child maltreatment 2009Department for Children, Schools and Families guide - HYPERLINK ""Working Together to Safeguard Children 2010‘Core Info’ Key Messages HYPERLINK ""leaflets from the Welsh Child Protection Systematic Review Group (covering HYPERLINK ""Head and Spinal Injuries, HYPERLINK ""Oral injuries and Bites, HYPERLINK ""Burns, HYPERLINK ""Fractures and HYPERLINK ""Bruising).B8. Monitoring Guideline ComplianceThe content of this document will be audited on a three-yearly basis by the Paediatric (Children’s Services) Department. Results of the audit will be fed back to the Paediatric Department.B9. Audit StandardsChildren with SDH should have the following:Full multidisciplinary social assessment Head imaging as detailed in section B1Skeletal survey as detailed in section B1Ophthalmoscopy as detailed in section B2Coagulation screen as detailed in section B3Clear documentation in notes especially the initial history.Plain skull x-ray performed as part of the skeletal survey.The on call neurosurgical registrar at Addenbrooke’s Hospital will discuss with the neurosurgical consultants all the children under two years with subdural haemorrhages referred for an opinion.B10. References ADDIN EN.REFLIST 1.Neurological Injuries Review. Core Info; 2008; Available from: HYPERLINK "" \l "Apnoea" CP. Non Accidental Head Injury cases: Legal Guidance. 2011; Available from: HYPERLINK "" \l "a08" Clinical Guideline 56. 2007; Available from: HYPERLINK "" MC GJ, Dyb GA, Sandvik L, Nordhov M. Traumatic head injury in infants and toddlers. Acta Paediatrica. 2007;96(8):1159-63.5.Duhaime AC, Alario AJ, Lewander WJ, Schut L, Sutton LN, Seidl TS, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992 Aug;90(2 Pt 1):179-85.6.Jayawant S RA, Gibbon F, Price J, Schulte J, Sharples P, Sibert JR, Kemp AM. Subdural haemorrhages in infants: population based... [BMJ. 1998] - PubMed result. BMJ. 1998;317(7172):1558-61.7.Review WCPS. Neurological Injuries Review. Core Info2008.8.Ewing-Cobbs L, Kramer L, Prasad M, Canales DN, Louis PT, Fletcher JM, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics. 1998 Aug;102(2 Pt 1):300-7.9.Minns R, Brown J. Neurological Perpectives of Non-Accidental Head Injury and Whiplash/Shaken Baby Syndrome: an Overview. In: RA M, JK B, editors. Shaking and Other Non-accidental Head Injuries in Children: Mac Keith Press; 2005. p. 1-106.10.Datta S SN, Jayawant S, Renowden S, Kemp A. Neuroradiological aspects of subdural haemorrhages. [Arch Dis Child. 2005] - PubMed result. Arch Dis Child.90(9):947-51.11.Parker A. Guideline: Non-accidental Head Injury (Children), Version 1. Paediatric Neurology, Women's and Children's Directorate.12.Child abuse and the eye. The Ophthalmology Child Abuse Working Party. Eye (Lond). 1999;13 ( Pt 1):3-10.13.Levin A. Retinal Hemorrhage in Abusive Head Trauma -- Levin 126 (5): 961 -- Pediatrics. Pediatrics. 2010;126(5):961-70.14.Kaur B TD. Fundus hemorrhages in infancy. Surv Ophthalmol. 1992;37(1):1-17.15.Levin AV. Ophthalmology of shaken baby syndrome. Neurosurg Clin N Am. 2002 Apr;13(2):201-11, vi.16.MV E, DJ P, KM S, JP B, RF G. Incidence and rate of disappearance of retinal haemorrhages in newborns. Ophthalmology. 2001;108(1):36-9.17.Group WCPSR. Head and Spinal Injuries. Available from: HYPERLINK "" P MN, Jaspan T. Spinal subdural haematomas in children with non-accidental head injury. Arch Dis Child. 2009;94(3):216-9.19.Day F CS, McPhillips M, Mok J. A retrospective case series of skeletal surveys in children with suspected non-accidental injury. J Clin Forensic Med. 2006;13(2):55-9.20.Skellern CY WD, Murphy A, Crawford M. Non-accidental fractures in infants: risk of further abuse. J Paediatr Child Health. 2000;36(6):590-92.21.Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518.22.RCPCH RCoRw. Standards for Radiological Investigations of Suspected Non-accidental Injury. 2008.23.Radiology TBSoP. Standard for skeletal surveys in suspected non-accidental injury (NAI) in children. Available from: HYPERLINK "" EH, Griffiths PD, Rutter S, Smith MF, Sprigg A, Ohadike P, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet. 2004;363(9412):846-51.25.Punt J. Mechanisms and Management of Subdural Haemorrhage. In: RA M, JK B, editors. Shaking and Other Non-accidental Head Injuries in Children: Mac Keith Press; 2005.26.Hartley LM KO, Verity CM. Glutaric Aciduria Type 1 and Nonaccidental Head Injury. Pediatrics. 2001;107(1):174-5.27.Geddes JF, Tasker RC, Hackshaw AK, Nickols CD, Adams GG, Whitwell HL, et al. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'? Neuropathol Appl Neurobiol. 2003;29(1):14-22.28.Matschke J, Voss J, Obi N, Gorndt J, Sperhake JP, Puschel K, et al. Nonaccidental head injury is the most common cause of subdural bleeding in infants. Pediatrics. 2009;124(6):1587-94.29.Rajaram S, Batty R, Rittey C, Griffiths P, DJA C. Neuroimaging in non-accidental head injury in children: an important element of assessment. Postgrad Med J. 2011.30.Demaerel P CI, Wilms G. Cranial imaging in child abuse. Eur Radiol. 2002;12(4):849-57.31.Tallur KK, Belton NR, Stephen R, Minns RA. Is timing of haemorrhage by spectrophotometry similar for haemorrhages in the subdural and subarachnoid space? Arch Dis Child. 2005;90(11):1203.32.Rajaraman P, Simpson J, Neta G, Berrington de Gonzalez A, Ansell P, Linet MS, et al. Early life exposure to diagnostic radiation and ultrasound scans and risk of childhood cancer: case-control study. BMJ. 2011;342:d472.33.PD M, JD A, G S, AM OG, JP. F. Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse. ANJR Am J Neuroradiol. 2006;27(8):1725-8.34. Kemp A. Abusive head trauma: recognition and the essential investigation. Arch Dis Ed Pract Ed: published online Sept 26, 2011. doi:10.1136/adc.2009.170449Appendix 1: Exclusion of Differential DiagnosesWhilst the investigations listed above comprise the essential protocol for suspected NAHI, some further, more specific investigations may be performed for exclusion of specific differential diagnoses. Such differential diagnoses, the investigations to elucidate them, and some guidance regarding results suggestive of NAHI are given in the table below. Many of the investigations will already have been performed as part of the basic essential protocol. Differential diagnoses for considerationInvestigations to be performedWarning signs for NAI(* = sign of neglect)Differential Diagnosis of SDH/encephalopathy:Adequate accidental traumaBirth traumaVP shunt or neurosurgeryCardiopulmonary bypassDetailed clinical history to be taken from parents/other carers. This is the primary responsibility of the lead local paediatrician.Full, detailed physical examinationHigh-quality photography of lesions (after consent, using digital camera with date and time)Illustrations on body chart if indicated or if child too unwell for photography.Absent or minor traumatic explanation*Inconsistent or changing history*Delayed presentation*Acknowledged/witnessed NAIBruising of different agesSubgaleal haemorrhageSigns of neglectMalicious injury (burns, bites, cuts, whip marks)Drugs/vitamin K deficiencyClinical historyCoagulation screen (section B3)Kawasaki diseaseMedical history and examinationFBC, ESR, CRPMenke’s disease Clinical examination for phenotypeAlagille syndromeLiver function testsCoagulopathyITPLeukaemiaDICDehydrationRenal failureMeningitisHSVFull blood countBlood filmCoagulation screen (section B3)Urea and electrolytesBlood culture (if unwell/indicated)CSF virology and PCR (if unwell/indicated)Benign SDH with benign enlargement of sub-arachnoid spaces ADDIN EN.CITE <EndNote><Cite><Author>McNeely</Author><Year>2006</Year><IDText>Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse.</IDText><DisplayText>(33)</DisplayText><record><titles><title>Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse.</title><secondary-title>ANJR Am J Neuroradiol</secondary-title></titles><pages>1725-8</pages><number>8</number><contributors><authors><author>McNeely PD</author><author>Atkinson JD</author><author>Saigal G</author><author>O'Gorman AM</author><author>Farmer JP.</author></authors></contributors><added-date format="utc">1302536592</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2006</year></dates><rec-number>130</rec-number><last-updated-date format="utc">1302536669</last-updated-date><volume>27</volume></record></Cite></EndNote>(33)Compare previous head imaging if available.All scans to be reviewed by neuroradiologistMultiple SDHsInterhemispheric SDHHigh neurological morbidity/mortalityGlutaric aciduriaUrine organic analysisGlutarylcarnitine measurement on blood spots Plasma total and free carnitine estimationsConfirmatory enzymology if indicatedDifferential Diagnosis of retinal haemorrhagePapilloedemaLeukaemiaThrombocytopaeniaVasculitisGalactosaemiaFundoscopy by paediatric ophthalmologist with pharmacological papillary dilation (if possible: discuss with neurosurgeon)Retinal photography or detailed drawingsDocument location of haemorrhages and layers involved.Coagulation screen (section B3)Multi-layer retinal haemorrhageVitreous haemorrhageRetinal detachmentLens dislocationRetinoschisisDifferential Diagnosis of Skeletal LesionsInjuryFull skeletal survey (section B1)Detailed history of injuriesMultiple rib fracturesFemoral fracturesMid-shaft fractures of the humerusInconsistent/changing historyOsteogenesis imperfecta Investigation after expert medical opinion onlyOsteoporosisInvestigation after expert medical opinion onlyVitamin C deficiencyFBCClinical history and examinationSerum ascorbic acid level if clinically indicated after discussion with paediatric haematologist.Sickle cell anaemiaFBC, blood filmAppendix 2: Quick-Glance Checklist for Investigation of Suspected NAHIPlease print/copy these pages and attach to the notes of a patient with suspected NAHI. The purpose of this page is to provide a quick-glance summary of the investigations which have been performed. Not all of the investigations listed will be appropriate for all cases, and are not necessarily listed in the order in which they will be performed. Some cases will require additional investigations. It is helpful if such additional investigations are added to the form.Further details of these investigations are available in the guideline “Investigation of Suspected Non-Accidental Head Injury in Children”. Investigation/ActionDate Safeguarding Children team informed Date Name Lead Consultant Paediatrician at CUHFT identifiedLead Consultant paediatrician at DGHDate results receivedInitial CT head (acute presentation)Initial MRI/CT head (non-acute presentation)Initial MRI head (3-5 days post acute presentation)MRI spineRadiological skeletal surveyInitial FundoscopyFundoscopy (by consultant ophthalmologist)Retinal photographyInitial FBC, U&E, LFT, CRP, CaeruloplasminClotting screen and platelet studiesMultidisciplinary social assessmentUrine organic acid analysisFurther investigations (e.g. repeat imaging)Strategy MeetingCase ConferenceMedical ReportReferral to local ophthalmologist ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- purpose of rule of law
- purpose of report of contact
- purpose of school vs purpose of education
- the purpose of this report
- purpose of nasw code of ethics
- purpose of board of nursing
- the purpose of the oath of enlistment
- purpose of certificate of incorporation
- purpose of or purpose for
- happiness is the meaning and the purpose of life the whole aim and end of human
- the purpose of each article of constitution
- the purpose of the blood of jesus