Medical assessment of suspected traumatic head injury due to child maltreatment (THI-CM)

The identification of subdural hemorrhage may be the impetus for considering child maltreatment. Trauma is the most common cause of subdural hemorrhage and this may result from birth, impact, or inertial forces (sudden deceleration, or acceleration/deceleration forces). When there is no clear accidental traumatic explanation, the most common cause of subdural hemorrhage is THI-CM^[5][7]. However, it is important to consider a broad differential diagnosis to avoid missing other, rarer causes. Medical disorders such as coagulation abnormalities, inborn errors of metabolism (particularly glutaric aciduria type 1), and anatomic abnormalities (e.g., enlarged subarachnoid spaces, blood vessel malformations) are associated with subdural hemorrhages, though rarely^[8].

Other findings that raise concern for child maltreatment, such as rib fractures or retinal hemorrhages, have a differential diagnosis that should be carefully considered^[6][9]. 

Medical assessment of THI-CM

Approach

When concern for child maltreatment exists, clinicians should:

• Approach the case with an open mind, awareness of possible bias, and compassion for the child and family
• Manage the patient’s medical needs first, while also considering medico-legal steps
• Identify and document visible injuries and look for occult injuries using clinical assessment and testing
• Recognize that the differential diagnosis for injuries includes trauma, medical conditions, mimics of injury, or any combination of these
• Consider whether the injuries may have resulted from birth, medical interventions, the child’s actions, or the actions of another person (or a combination of these)
• Consider whether there are reasonable grounds to suspect child maltreatment and report to the local child welfare agency in accordance with provincial or territorial laws
• Take a multidisciplinary approach as early as possible, diagnose and document medical findings, and refrain from diagnosing abuse based on medical information alone
• Communicate with family and authorities as appropriate and document findings, opinions, and interactions clearly and objectively
• The clinical assessment and any information or opinions provided should stay within the individual clinician’s scope of expertise based on training and experience. Consult specialists as needed.

History

In cases of traumatic head injury and possible child maltreatment, taking a comprehensive paediatric history is essential. Details regarding onset and progress of symptoms, and the specifics of any injury-related event(s) reported are important for assessing etiology (medical or traumatic).

Physical examination

A detailed physical examination is essential and may indicate signs of a medical condition or trauma. However, in THI-CM the examination can be normal when a head injury is present^[10]. Therefore, the physical examination cannot be solely relied upon to exclude the possibility of head injury.

Following acute assessment and resuscitation, a focused physical examination should include:

• Growth parameters, including head circumference, compared with previous measurements
• Head and scalp, noting status of anterior fontanelle
• Mouth, including the frenulae (tongue and lips)
• Neurologic examination
• Musculoskeletal examination
• Full skin examination, including ears, neck, chest, back, abdomen, buttocks, and genitalia^[11].

Be especially vigilant for seizures, which are common in infants who have sustained a symptomatic head injury due to maltreatment. Often seizures may be electrographic with no obvious clinical correlate. A low threshold for early or continuous electroencephalogram (EEG) monitoring is recommended for symptomatic infants, those with specific imaging findings, and those requiring critical care^[12].

A dilated eye examination by an experienced paediatric ophthalmologist is indicated for infants and children with intracranial hemorrhage. Documentation should include the number, type, location, and extent of retinal hemorrhage and associated findings, such as retinoschisis (i.e., traumatic split in the layers of retinal tissue). This examination should be completed as soon as possible, ideally within 72 hours of injury because hemorrhages can resolve quickly. Where the technology is available, documentation using specialized retinal photographic equipment is recommended^[13].

Laboratory evaluation

Laboratory testing can help assess for medical status and disorders that may be contributing to clinical findings. 

Coagulation testing should include:^[11][15]

• CBC, differential, blood smear
• International normalized ratio (INR), partial thromboplastin time (PTT)
• Fibrinogen
• Factor VIII, von Willebrand antigen, platelet-dependent von Willebrand activity
• Blood group (for interpretation of von Willebrand results)
• Factor IX, XIII

Metabolic testing should include:

• Review newborn screening results
• Consider urine organic acids and acylcarnitine profile

Screening for other injuries should include:

• Blood urea nitrogen (BUN), creatinine
• Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lipase (or amylase if lipase is unavailable)

Local factors (such as expertise, equipment, personnel, and pre-test probabilities) and clinical judgment may influence the medical evaluation, with additional testing based on clinical assessment (e.g., infection workup, metabolic testing, D-dimer) or the presence of other injuries^[9][11][14].

Diagnostic imaging

Neuroimaging indications in suspected THI-CM include:

• Neurologic signs and symptoms, including unexplained macrocephaly or abnormal increase in head circumference
• Visible signs of head injury (bruising, scalp hematoma), particularly in infants  
• History raising concern for head injury (e.g., reported shaking or impact, particularly in infants)
• Inadequately explained injuries, especially skull fracture, retinal hemorrhages, rib, or classic metaphyseal fractures, or bruising in pre-mobile infants^[5].

Decision tools (e.g., the Pediatric Emergency Care Applied Research Network (PECARN)) for head imaging have not been validated for child maltreatment. When head imaging is indicated for acute or symptomatic trauma, a computerized tomography (CT) scan is the test of choice^[5]. Magnetic resonance imaging (MRI) is an appropriate alternative in some non-acute cases and is frequently used as an adjunct to clarify or add information. A paediatric radiologist may advise regarding specific techniques for CT (3D skull reconstruction) and MRI (magnetic resonance angiography/magnetic resonance venography/ magnetic resonance spectroscopy (MRA/MRV/MRS) to optimize imaging. Head ultrasound is not recommended as the sole imaging modality in THI-CM because of its reduced sensitivity for detecting hemorrhage and parenchymal injuries^[8].

An MRI of a child’s full spine may identify additional injuries, particularly in cases where symptomatic intracranial hemorrhage is present or there is concern for neck injury, vertebral fractures, or multiple rib fractures.

A skeletal survey is indicated in cases of suspected physical abuse in children under 2 years of age and should include images of each body area as outlined in published protocols^[16]. A “babygram” or bone scan (or both) are insufficient to detect occult fractures in this context. Bedside or portable X-ray machines are likewise insufficient for skeletal survey imaging. In critically injured children the skeletal survey should be delayed until they are stable enough to have the imaging completed in the diagnostic imaging department. In most cases, the skeletal survey should be repeated approximately 14 days after the first imaging to identify acute injuries that may not have been visible on X-ray initially^[16]. 

Abdominal imaging by CT is recommended for infants with an abnormal abdominal examination, abdominal bruising, or elevated transaminases or lipase or amylase^[14]. 

Documentation

It is recommended that clinicians document the history and physical examination findings clearly, objectively, and in detail for cases of suspected maltreatment. Documentation should include specific findings (e.g., subdural hemorrhage, skull fracture, or cerebral edema), differential diagnoses considered, and diagnostic conclusions (e.g., traumatic head injury). Following diagnosis, a qualifying statement should be made that indicates the clinician’s concern for child maltreatment, including reasons.   

Consultation

Consultation with a paediatric tertiary care centre is often appropriate to manage acute care needs or facilitate subspecialist involvement. A paediatrician specialized in child maltreatment can help guide clinical assessment and communication with family, health care professionals, child welfare, and law enforcement. Consultation with other specialists (e.g., critical care, ophthalmology, neurosurgery, neurology, orthopedics, endocrinology, hematology, genetics, rehabilitation) can assist as needed.    

Clinicians must report concerns of child maltreatment to appropriate authorities and ensure that recommended medical evaluations in suspected THI-CM cases are completed. Health care providers who are unfamiliar with the medical literature and the legal implications of providing expert opinions in child maltreatment cases should be cautious about communicating a definitive medico-legal opinion regarding the likelihood of child maltreatment in suspected THI-CM cases. A paediatrician specializing in child maltreatment may be consulted to support communication of opinion in such cases.

Conclusion

Traumatic head injury due to child maltreatment (THI-CM) is a form of physical abuse with serious consequences. Because identifying THI-CM can be challenging, clinicians must be alert to possible signs, symptoms, and ‘red flags’. Assessment follows a standardized, objective process that considers medical and traumatic etiologies. Clinicians have an essential role in identifying and managing THI-CM, supporting families, and working with child welfare professionals.