Elizabeth E. Gilles, MD
Elizabeth E. Gilles is a pediatric neurologist with particular expertise in working with infants and children with complex neurologic disease and autonomic dysfunction, children with multiple disabilities and children after traumatic brain injury (TBI) especially early life TBI. She has extensive expertise in Abusive Head Injury in young children. Dr. Gilles has worked as a general neurologist in academic and hospital-based practices for the past 19 years.
Inﬂicted head injury, commonly called shaken baby syndrome, is a preventable form of traumatic brain injury resulting from assault that occurs typically, but not exclusively, in infants and young children less than 3 years of age. These injuries are the result of actions of parents or other caregivers. There are significant medical-legal issues that are not typical for most neurologic diseases.
Certain presentations and patterns of injury raise concerns for abuse. Emergency responders, medical providers, and hospital personnel are mandated reporters. This means they must legally report concerns about abuse and neglect to authorities. It is important to remember that a suspicion of an injury being from abuse is just a suspicion. The ultimate determination of injuries being from abuse and/or neglect is a legal determination from the trier of fact (such as a family court judge or a jury in criminal court).
Child abuse remains a significant problem nationally, despite considerable efforts at prevention. In 2012, 1,640 children died from abuse and neglect (2.2 deaths/100,000). This means 4 children died daily. Seventy percent of these were less than 3 years of age, 70% were neglected, and 44% were either only physically abused or abused in combination with another type of maltreatment. Parents caused 4/5 of deaths, alone or acting with another adult. Mothers were responsible 27% of the time, father’s 17%, both parents 21% of the time, and unrelated perpetrators were responsible 14% of the time. It is highly likely that actual numbers are higher, given that some states report no cases of fatalities due to abuse and neglect. This appears to be a function of how fatalities are reported to the state.
There are many terms used for traumatic brain injuries in young children that occur from assault. A commonly used term is shaken baby syndrome. This term was first used in the medical literature in the 1970s. However, providers now recognize the frequency of associated impact or blunt force trauma and the importance of secondary brain injury. This recognition has led to the use of other terms such as:
- non-accidental head injury
- abusive or inflicted neurotrauma
In the discussion that follows, many new terms will be presented. Definitions can be found in the Glossary section.
Abusive head injury is a distinct form of traumatic brain injury in which the history offered by the person who injured the child is biomechanically inconsistent with the severity of injury. An example is a 4 month old infant who becomes suddenly limp and stops breathing (apnea) after an alleged (stated but not proved) fall from the bed. This infant hasn’t developed enough to roll yet. The baby is in a coma (unconsciousness lasting more than 6 hours). Injuries include a complicated skull fracture, bleeding around the brain (subdural hematomas), brain swelling, bleeding into the brain and bleeding into the retina (retinal hemorrhages). The infant also has rib and arm fractures. These injuries are very severe, not found after short falls and not possible in an infant not yet rolling over. Something else has happened as there are no other disorders or diseases presenting in this manner.
There is a wide spectrum of severity of abusive head injury. Injuries range from mild to severe and can result in death. Infants with mild injuries who survive are at risk for learning and behavioral problems, incoordination and, less often, seizures. Those with severe injuries who survive often have significant problems, including:
- intellectual disability
- learning and behavioral problems
- motor problems
- persistent coma (persistent vegetative state)
Physicians are best able to clinically diagnose that abuse has occurred when the infant or child is severely injured and presents with a caregiver who gives a history that is inconsistent with the clinical, imaging and laboratory findings and the temporal course (what happens to the baby before and after hospitalization). Physicians are not making a legal determination. If any member of the treating team (social workers, nurses, providers) is concerned that the findings might be from abuse, they must report these concerns to the local social service agencies, commonly called child protective services, and law enforcement departments. The exact procedures vary by state.
Unlike unintentional trauma such as a fall from a tree, people responsible for injuring infants and children under report the scope and significance of the injury events. It is quite rare for a perpetrator to disclose what happened when the infant first presents. This means that the medical providers are trying to diagnose without a history, an essential part of the diagnostic process. The diagnosis of an abusive injury is not always possible during the acute phase of hospitalization, unlike other forms of traumatic brain injury where there are often multiple witnesses, and/or there is a clear and unchanging history that is consistent with the clinical findings.
It is not uncommon when a perpetrator does disclose what they have done that they report having repetitively injured the infant. This abuse may occur within a short time frame or over a series of weeks or months. If the infant is not severely enough injured, they may not be brought for medical care especially if the non-abusing parent is unaware there was an injury. Therefore, infants who sustain milder brain injuries (infantile concussions) are often undiagnosed.
Traumatic brain injury occurs when there is enough force applied to the head to upset how brain cells communicate and function. Its mildest form is a concussion. This is where there is a temporary loss of brain function. In older children and adolescents who sustain a mild concussion, the majority do not lose consciousness. Mild brain injuries do not result in any permanent brain damage.
In babies with concussions, symptoms are non-specific, such as:
- sleeping more
- increased irritability
- decreased response to the environment or decreased visual alertness
- a change in breathing
- decreased appetite
- nausea and vomiting
- occasionally a seizure
When greater forces are applied to the head and spine (primary injuries), more injury results. For example, a typical history in such cases is a previously healthy infant who suddenly decompensates neurologically. Symptoms include severe respiratory distress, apnea, flaccidity, longer duration of unconsciousness (including coma), trouble breathing, vomiting, seizures, pallor, and limpness.
Seizures occur in about 80% of infants. A severely injured infant cannot regulate any behavior requiring higher cortical functions, such as eating, sitting, coordinated activity, playing, laughing, or walking. Low oxygen (hypoxia) and low blood pressure (hypotension) cause a special type of secondary brain injury called hypoxic-ischemic injury (decreased oxygen-low brain blood flow), an important predictor of outcome.
Abusive injuries are due to someone assaulting the infant or child. Therefore, the injuries are not hereditary. They may occur when the caregiver reaches a point of frustration, becomes angry and lashes out either to get the infant to stop (in the case of crying) or to punish the infant.
GENERAL OVERVIEW OF ANATOMY
The brain or cerebrum consists of 2 halves called the hemispheres. Looking at the side of the brain, there are 4 distinct brain regions called lobes (Figure 1):
Figure 1. Parts of the brain
Sitting in the lower back part of the skull is the cerebellum. Connecting the brain and the cerebellum with the spinal cord is the brainstem. It runs from the base of the brain in front of the cerebellum. There are a number of different types of brain cells in the brain, of which the neurons are critical for their role in information processing.
Neurons are located in several areas of the brain, such as:
- the large folded surface layer of the brain called the cortex
- deep within the brain in areas that help control movement (basal ganglia)
- relay sensory and motor signals from the body (thalamus)
- help with memory (hippocampus)
- the cerebellum
These areas are important to the discussion about outcome.
The cortex and deep collections of nerve cells look gray when a brain is examined and are called gray matter. Between these areas the brain looks white so this is called white matter. Gray matter and white matter have different densities.
Ventricles are normal holes within the brain and between the cerebellum and the brainstem. Cerebrospinal fluid is made here. Covering the brain and spinal cord are 3 membranes collectively called the meninges (Figure 2).
These layers from the side closest to the skull to the surface of the brain are the dura, arachnoid and pia. In understanding abusive injuries, the dura and arachnoid are important.
The dura mater is a thicker membrane attached to the skull at several different points. It folds in 4 places. The two most important folds are located between the 2 hemispheres of the brain (falx cerebri) and between the hemispheres and the cerebellum (tentorium cerebella). This creates different brain regions within the skull. This is important when understanding intracranial (in the skull) pressure problems.
The middle layer, the arachnoid, is the membrane overlying the subarachnoid space. This is where cerebrospinal fluid is made by the brain. It then circulates around the spinal cord and the brain before it is absorbed in special cells (called arachnoid granulations) back into the venous drainage system of the brain.
There are two types of blood vessels inside the skull:
- The arteries, which bring blood from the heart to the brain
- Two systems of veins that bring blood back to the heart
The two venous systems are the deep veins of the brain and the dural venous sinuses (channels in the dura). Blood vessels run from the dura to the surface of the brain and from the brain surface to the venous sinuses.
The infant skull consists of 8 bones that are incompletely developed and separated by fibrous membranes called the sutures (Figure 3).
Figure 3. Infant skull
This arrangement allows for some movement between the bones (allowing the baby to come through the birth canal). Looking down on the skull in the front, where the frontal bones meet the parietal bones is a soft spot, or anterior fontanelle. As the brain grows, the skull grows and these bones fuse together. By 1-2 months, the posterior fontanelle is closed in most infants. The anterior fontanelle is closed by about 9-18 months of age.
During infancy and childhood, these sutures are flexible. This allows for the rapid brain growth that occurs in the first 3 years. In the first year the brain triples in size. Having flexible sutures also protects the brain from minor injuries to the head, such as when the infant is learning to hold his head up, roll over, and sit up.
UNIQUE FEATURES OF THE INFANT
The infant is biomechanically and physiologically vulnerable to injury for many reasons (See Table 1). These features predispose the infant to greater shear strains with significant angular acceleration.
Table 1: Unique features of the Infant
* Larger head-to-body ratio
* Less developed neck and shoulder girdle musculature
* More easily disrupted respiratory drive
* Decreased synaptic density
* Decreased ischemic and seizure thresholds to trauma
* Higher brain water content
* Incomplete myelination
MECHANISM OF INJURY
Common to traumatic brain injury of all types is angular or rotational movement of the head strongly back and forth; either front to back or side to side (lateral) often striking another moving or stationary object (such as a wall). If the head does not rotate but stays in a plane with the neck, no significant brain injury can occur. An example of this is the woodpecker as they are known to peck 20 times a minute without suffering a brain injury.
Velocity is the rate at which an object changes position in space compared to speed which only describes how fast something is moving and not where it is in space. As the head moves in space, it can change its velocity and/or direction. This is called angular or rotational acceleration (speeding up). A lay term for this is shaking. Deceleration occurs as the head slows in its movement prior to moving in another direction or as the head hits an object, called impact. Impact can be either the head hitting an object (like a wall or table) or the head being hit with a hand or fist. This is also called blunt force trauma. Whiplash is a non-medical term for sudden hyperextension of the neck causing injury.
The initial injury is termed the primary injury whereas the brain and tissue reactions to the trauma are termed secondary injuries. Some reactions to injury start immediately whereas other reactions evolve over minutes to days. Blood flow changes within the brain and the brain starts to swell; pressure can begin to increase within the skull further contributing to brain damage.
When the head undergoes acceleration-deceleration, different components (the skull, dura, brain, and blood vessels) move at different rates. The gray and white matter of the brain have different densities, so movement at distinct rates causes shearing or shear strain. This strain stresses cells and their axons and can result in significant injury. Likewise blood vessels, some in the meninges, are also injured or torn during these events. This leads to blood collecting in the potential subdural space (subdural hematoma) or in the subarachnoid space (subarachnoid hemorrhage).
The skull of an infant, being more flexible, is deformed inwards with an impact. The brain continues to move, hitting the inner table of the skull. This is called the coup injury. The brain is then set into motion and collides with the opposite side. This is called the contrecoup. The latter is bigger. These are considered focal brain injuries. They can occur together or individually. Brain regions most affected are the frontal and temporal lobes. They are least common in younger infants (see Physical Abnormalities).
Injuries are not always confined to the head. Infants may be strangled, gagged, and smothered as well as being hit in other parts of the body with resultant injuries to the neck, chest, and abdomen. Some infants have broken bones, most often ribs. Some patterns are associated with abuse and not seen with other conditions. They are called pathognomonic. For instance, rib fractures to the side and back of the chest are almost always due to abuse. Pattern injuries are those that show the etiology. An example of a pattern injury is the mark left on the neck of a child that matched a watch worn by the perpetrator or the outline of a handprint on the face or body. Another is the marks on the neck from strangulation.
Physical abnormalities vary between infants. Not all injuries need to be present to make the diagnosis of abusive injury. Additionally, there is no specific lab finding that is only found in this form of trauma. It is the pattern of injury findings as a whole; within the context of an injury history, that doesn’t fit rather than a single physical finding that establishes the likelihood that an injury is abusive rather than unintentional. Again, the hallmarks of non-accidental head injury are the presenting signs and symptoms, not isolated injuries.
All of these injuries do occur in unintentional traumatic head injury, but the frequency is variable for each type of injury. For instance, retinal and optic nerve sheath hemorrhages are uncommon in unintentional injuries. While skull fractures occur in both types of injury, certain types are not seen except with abusive injury.
Impact injuries. Scalp injuries and skull fractures only occur because of direct impact of the head to or from an object. Frequency is variable. This force happens in a way that causes the tissue planes to slide against each other (called shear). This can cause:
- scalp bruising
- soft tissue swelling underneath the scalp (caput succedaneum)
- tearing of the membrane attached to the surface of the skull leading to bleeding (cephalohematoma)
- bleeding to occur in a potential space between the scalp and the skull (subgaleal hemorrhage)
It is difficult to see most scalp bruises, due to hair and skin pigmentation (Figure 4).
Figure 4. Bleeding outside the skull
Spinal trauma is rarely caused by abuse, but does occur. The spinal cord in the neck (cervical) in the region of the craniocervical junction (where the skull meets the spine) has been found to have a high rate of injury when examined in infants who have not survived their injuries.
Skull fractures. These are also not specific to either unintentional or non-accidental trauma. In infants who have abusive head injury, the frequency of skull fracture varies from 25-100% (depending on how babies were identified) where less than 10% of infants who have an unintentional fall get a skull fracture. A variety of skull fractures have been reported after blunt trauma, regardless of etiology. These are simple linear fractures in the parietal or occipital region. The more complex (bilateral or multiple fractures), the more likely the injury was abusive. Skull fractures in infants with open sutures do not cross suture lines. When fractures are bilateral or multiple, there was more than one impact.
Extraaxial fluid collections. When a collection of fluid accumulates between the brain and the skull it is called extraaxial. Naming is a function of the space occupied. If below the dura, it is a subdural collection. If above, it is an epidural collection. If within the subarachnoid space, it is a subarachnoid hemorrhage (Figure 4).
Subdural hematoma. A traumatic acute subdural hematoma or hemorrhage is a venous hemorrhage that develops from shearing of the veins on the surface of the brain. It also involves the tearing of the bridging veins connecting to the dural sinuses. They can develop after surface arteries are injured. Subdural hematoma are far more common in abusive than in unintentionally injured infants with a frequency ranging from 38-100%. They are located unilaterally (one side) or bilaterally (both sides) over the front and upper sides of the brain (fronto-parietal) and/or are between the hemispheres (interhemispheric). An acute interhemispheric subdural hematoma with associated parenchymal abnormalities may be the most specific imaging pattern for non-accidental head injury in the absence of a history of a high-speed motor vehicle accident. Rare causes are metabolic disease, coagulopathies and meningitis.
Subdural effusions. This fluid collection develops from the resolving subdural hematoma within days of the injury. They consist of the fluid left as the blood forming the hematoma is breaking down. This collection is full of protein, but can also consist of spinal fluid that has leaked through a ripped arachnoid membrane, and sometimes both. Sometimes referred to as hygromas, they either resolve with time or persist when there is diffuse brain injury with secondary atrophy.
Subarachnoid hemorrhage. These occur in the potential space between the arachnoid and the pia (see Figure 2). They are generally small and patchy. When blood vessel malformations called vascular malformations rupture, extensive subarachnoid hemorrhage results.,
Epidural hematoma. These develop in the space between the dura and the skull. They are due to the injury of an artery running next to the skull. They are rare in infants who are abused.
Brain injuries. These occur due to applied primary forces (acceleration-deceleration, impact) and secondary injury (hypoxia-ischemia). However, prolonged seizures can worsen injury as can prolonged high blood sugars, often seen in infants who are severely injured.
Brain swelling. The brain does not have many ways it reacts to injury. Swelling happens both within the brain cells and in the surrounding tissue. The brain in small infants tends to develop rapid brain swelling in response to injury. It is often bilateral with or without bilateral acute subdural hematomas (Figure 5 option 2). Older infants and children may present with focal or hemispheric (half) brain swelling under an acute subdural hematoma.
Brain swelling and rapidly accumulating large subdural hematomas can both result in increased pressure inside the skull (intracranial pressure), further compromising blood flow. When intracranial pressure is very high, brain herniation may occur; where a part of the brain is squeezed to other regions of less pressure (Figure 6). This process also may cut off blood supply within the area of greatest pressure, leading to that part of the brain dying if it cannot be treated quickly. Brain swelling maximizes within 3-5 days of injury. As the skull bones are not yet closed, swelling may result in bulging of the soft spots of the skull (the anterior and sometimes posterior fontanelle) and sometimes separation of the skull bones (diastasis).
Figure 6. Types of herniation
Types of brain herniation 
1) Uncal 2) Central 3) Cingulate 4) Transcalvarial 5) Upward 6) Tonsillar
Cerebral contusions. A cortical or cerebral contusion is a bruise in the brain, although it looks different than a bruise elsewhere. They occur in older infants and children with traumatic brain injury and are thought to result from coup and/or contrecoup mechanisms. An infant less than 6 to 8 months of age is less likely to develop a contusion due to the smooth inner cranial table, greater skull compliance, incomplete myelination, and greater brain water content. The incidence of contrecoup injuries rises rapidly from later infancy to 3 years of age when it begins to approximate that of the adult. Rarely, in very small infants less than 6 months, the brain actually tears with the initial injury (called a white matter contusional tear). The presence of white matter tears or other contusions confirms that significant trauma has occurred. These develop after high-speed motor vehicle accidents and are rare after falls down stairs and have not been reported after witnessed short falls.
Diffuse axonal injury. Evidence of shearing injury can be macro in the case of the tearing of the corpus callosum (the largest fiber body connecting the 2 halves of the brain) or micro when the axons are disrupted and cell bodies damaged from diffuse axonal injury. Diffuse axonal injury occurs at the moment of injury and requires significant force to be applied. It is associated with loss of consciousness from the moment of impact and may be more common with lateral impacts to the head (such as a slap). The frequency in abusive head injury in infants is not known.
Hypoxic-ischemic (low oxygen-low blood flow) injury is a major determinant of clinical outcome. Unlike older individuals, infants are susceptible to hypoxia and ischemia. Hypoxia-ischemia most affects the neurons. Some regions of the brain are more vulnerable to the effects of hypoxic-ischemia than others, including certain layers of the cortex, the parieto-occipital cortex, the medial temporal lobe, parts of the basal ganglia and thalamus, and some brainstem structures.
In large part, the extent of hypoxic-ischemic brain damage reflects the magnitude of the initial injury and the interval from injury to resuscitation. Neuronal injury is an evolving process as brain cells become damaged by many mechanisms after the initial injury. Cells are stressed metabolically and there are many cascading biochemical and molecular events after the primary injury. Some of these cells die, whereas other cells are compromised but survive.
Infarction (stroke). Post-traumatic cerebral infarction is more common after non-accidental head injury than unintentional injury. However, the frequency remains unknown. It also develops after traumatic brain injury in older children and adults. Most often, these involve the middle parts of one or both frontal lobes, or the occipital lobe or lobes. Strokes occur deep in the brain as well, affecting the thalamus and the basal ganglia. Most of these happen because the arteries are compressed by brain swelling or herniation.
A third type of infarction is called a borderzone or watershed infarction. The blood supply to the brain comes from 2 arteries in the front of the neck (the carotids) and 2 in the neck (the vertebral arteries). The latter join together to form the basilar artery that passes into the skull in front of the brainstem. There, they join in a circle with the carotids and then send off 3 branches on each side. These arterial branches bring blood to the cerebral hemispheres. Where they branch out to smaller blood vessels there is overlap between the different regions that are supplied, the so-called borderzones. If the baby becomes hypotensive (low blood pressure) for enough time, then blood flow does not reach these overlapping areas and a stroke can occur. It is rare that strangulation results in a cerebral infarction.
Post-traumatic hydrocephalus. Cerebrospinal fluid is made continuously and flows through the ventricular system – made up of four ventricles connected by narrow passages. After trauma, this flow may be blocked due to blood in the ventricles, the passages, or in the subarachnoid space or from brain swelling. This may result in increased intracranial pressure. Not specific to non-accidental trauma.
EYE AND OPTIC NERVE FINDINGS
The eyeballs are unique in focusing light through a lens onto the receiver. The retina, where rods and cones live, contain special nerve cells that take in light from the outside world and translate the information into signals that are sent to the brain via the optic nerves. These signals are then interpreted as visual information. The retina has many layers in which the rods and cones live and the retinal blood vessels run.
Retinal hemorrhages. These are found in 50-80% of infants after abusive injury. They can be unilateral or bilateral and are found within different layers of the retina (Figures 7 a and b). They are not pathognomonic of abuse, although they are most often found in abused infants. If retinal hemorrhages within the inner layer of the retina burst into the inside of the eye, a vitreal hemorrhage occurs. If the retinal hemorrhages cover the macula, which is responsible for central vision, and fail to resolve, the infant will have central visual loss and be functionally blind. Most retinal hemorrhages resolve without intervention. Vitreal hemorrhages, if persistent, are removed by the ophthalmologist with a procedure called a vitrectomy.
Figure 7. Fundus (back of eye)
b. Retinal hemorrhages
Retinal hemorrhages are found in many conditions aside from non-accidental injury ranging from sepsis to leukemia, birth-related trauma, coagulopathies, meningitis, and in severe papilledema. They are uncommon in documented unintentional injury (0-10%). Seizures, forceful vomiting, chest compressions, and severe coughing have been documented in rare case reports (0.7%, 0-2.3%, 0% and 0% respectively). Again, in the context of severe unexplained brain injury, skull fractures and other findings of trauma, it is clinically not difficult to eliminate these other possibilities from consideration.
There are a number of other eye findings that can be seen, from retinal detachment, retinal folds and retinoschisis. None of these are pathognomonic for a non-accidental injury, although they have been documented more in such injuries.
Optic nerve sheath hemorrhages. The frequency of optic nerve sheath hemorrhages is unknown as most are identified if the infant dies. They have been reported with sudden and/or prolonged increases in intracranial pressure, such as with an adult who develops extensive subarachnoid hemorrhage after rupture of a vascular malformation, and rarely after unintentional head injury.
Injuries can be found in the head, neck, skin, chest, abdomen and extremities. In evaluating the baby, examiners look at the lips for swelling or tears, tears in the frenulum (the membrane that connects the gums to the lips and the tongue to the base of the mouth), and injuries to the teeth (if the infant is old enough). Bruising around the ears, eyes, chest, and abdomen in particular patterns tell providers specific information about how injuries occurred.
Presence of dehydration, failure to thrive, healed burns, excessive scarring, and healing or healed fractures all point to poor care and possibly previous trauma. Infants who have a large head (macrocephaly) may have chronic subdural hematomas or hydrocephalus. These infants have developmental delay and may have high tone (spasticity).
Infants sometimes present with old and new injuries. A classic presentation is that of an infant with irritability, delayed development, and spasticity who has a large head with open sutures and chronic subdural hematomas with or without hydrocephalus.
LABORATORY AND IMAGING INVESTIGATIONS
Laboratory studies include complete blood counts, chemistries to include electrolytes, blood sugar (glucose), tests of the clotting functions of the body (coagulation), kidney and sometimes liver function. A blood gas test is often obtained from the artery, but can also be taken from a vein or even capillaries (the tiny blood vessels connecting the arteries with the veins). An arterial blood gas test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. There are many other tests that may be performed depending on the clinical issues of the infant. Many of these tests are done over time.
Metabolic screening tests should be considered when infants present with somnolence, vomiting, seizures, dystonia or other movement disorder, and extraaxial collections particularly if the infant is acidotic.
Imaging. A noncontrast computerized tomographic scan (CT scan) is the initial imaging study performed at the first hospital the infant is brought. This is a specialized x-ray. Depending on the hospital protocol, magnetic resonance imaging (MRI) is performed several days after admission and may be performed if there are specific questions. This imaging technique is more sensitive than the CT scan and can help in defining the extra-axial collections, the extent of ischemic changes in the brain, and the presence of evolving infarctions. Often the MRI is repeated again over the subsequent months. The frequency of repeat imaging is clinically determined although some centers have standardized protocols.
If there is any question of spinal injury, imaging of the spine will be performed. A skeletal survey is a screening test consisting of a total body x-ray to look for fractures. Sometimes this is repeated in 10-14 days, as initially some fractures are difficult to see.
A detailed history of the circumstances of the injury will be obtained. All available caretakers will be questioned independently if at all possible. The biomechanical history of an alleged fall should include details such as the speciﬁc surface onto which the child fell, the location and type or types of injury, and the presence of corroborative witnesses.
A standardized assessment of level of consciousness in children is the Pediatric Glasgow Coma Scale. This is a neurologic scale used for the initial and subsequent assessments of neurologic arousal (see Glossary for details). This is done by paramedics in the field and again in the emergency department. A complete examination is performed with special attention to the skin, head, inside the mouth, neck, around the ears, the genital region plus the neurologic examination. Bruises and bite marks, whether they are healing or fresh, and other pattern injuries are documented.
A full neurologic examination may not be possible in a comatose infant. However, reactivity to sound, touch and noxious (q-tip wiggled in the nose) or pain (squeezing the fingertips, rubbing the chest) can be checked along with examination of the brainstem. These stimuli may trigger certain types of posturing. Flexor posturing with the arms bent and legs straight (decorticate posturing) and extensor posturing with both arms and legs held straight (decerebrate posturing) reflect severe brain and brainstem injury.
The brainstem contains critical clusters of neurons that control breathing, heart rate, arousal, and all the nerves that control the face, eye movements, hearing, swallowing, and coughing except vision and smell. There is a standardized brainstem examination that can be modified depending on the state of arousal and functional status of the infant. A dilated ophthalmologic (eye) exam is also performed by one the treating doctors or an ophthalmologist.
Many hospitals have a child abuse specialist who looks at all the available data and renders an opinion. Neurosurgeons and the intensive care doctors manage the patient. Consults from neurology, ophthalmology, pulmonary, social work, physical and occupational and speech therapy are standard, but not in all patients depending on the clinical problems.
The goal of treatment is to stabilize the baby and try to minimize further brain damage. Treatment is supportive. The head of the bed is elevated. Infants are kept quiet and any procedure or handling not essential to care is minimized. Initially the infant is not fed, but an electrolyte solution is given through a vein (intravenous line). At some point, glucose is added. Fluids are given initially through catheters into blood vessels. Infants are often put on pain medications, even if in coma.
If the infant is unable to breath on their own, a breathing tube (endotracheal tube) is inserted into the lungs through the mouth or nose and the baby is placed on a mechanical ventilator. Blood pressure is stabilized with fluids and medications to keep cerebral perfusion pressure (a pressure gradient causing optimal blood flow to the brain). Too little means the brain becomes ischemic; too much means the intracranial pressure rises too high.
Because of the high frequency of seizures, infants are often placed on anti-seizure medications immediately, even if they have not seized clinically. Because infants are minimally reactive or in coma, many pediatric intensive care units monitor brain activity with a continuous electroencephalogram (EEG).
Many neuroprotective strategies have been tried but, to date, there are no medications that stop the evolving brain injury. Mild hypothermia (- 3 to -4 degrees below normal body temperature) is neuroprotective. Many centers are now investigating head or body cooling in infants and older people. This seems to decrease the metabolic rate of the brain and decrease the secondary injury cascades.
In order to monitor the intracranial pressure, the neurosurgeon may place either an intraventricular catheter into one of the lateral ventricles of the brain (that measures intracranial pressure and allows drainage of cerebrospinal fluid) or a bolt (that only measures intracranial pressure).
The first 3-5 days are the most critical. During this time, brain swelling worsens and there is the greatest likelihood that brainstem dysfunction becomes permanent. This is called irreversible brainstem dysfunction. There is a national standardized protocol to determine whether an infant has become brain dead. This protocol is listed in the reference section.
Once the infant has stabilized, therapists begin range of motion of the extremities to prevent contractures. Sometimes orthotics (splints) are made during the intensive care unit stay and sometimes these are required later. When the infant begins to breathe over the ventilator, then a weaning process is initiated. When appropriate, the breathing tube is taken out. Later, if the infant remains unable to breathe independently and clinicians think the baby will not regain function, a tracheostomy is placed into the neck. If they remain unable to eat, a gastrostomy tube may be placed.
The majority of children who have severe unintentional head injury are older and experience better outcomes. Consequently, infants have a higher mortality rate and significant long term problems. About 10-30% of infants die from their injuries. If the infant survives, brain cells that die are cleaned up and the brain shrinks in size (atrophy). More severely injured infants have poor head growth (microcephaly – small head). Many infants have severe intellectual disability, sometimes called a general learning disability. This is manifested as significant delays in language, social development, and adaptive functioning (ability to care for themselves). The older term for this is mental retardation. There are some infants who sustained less severe injury who have better outcome.
More than 50% of the survivors have severe developmental disabilities. Many are non-ambulatory and dependent for daily care. Many never recover full consciousness. A vegetative state is a state of partial arousal, where patients are wakeful but show no other signs of awareness. If this state persists for more than 4 weeks it is called a persistent vegetative state. A permanent vegetative state lasts longer than 1 year. A minimally conscious state is when there is clear but minimal evidence of awareness.
Infants who recover enough to have wake-sleep cycles are often irritable and difficult to console. There are many strategies to help these infants. Pediatric occupational therapists can perform a sensory evaluation and help determine the best ways to help the baby. Some strategies are non-medical (positioning, massage, swings, music, and therapy). There are also medications, such as gabapentin, that help infants feel calmer without sedating them.
Behavioral problems as the infant grows are common, ranging from perseveration, oppositional behavior, and temper tantrums. These occur frequently, sometimes manifesting early on and sometimes as more task demands are made as the child reaches a functional age of 2 or so.
Surviving infants, 30-90%, have visual problems. Cerebral or cortical visual impairment (CVI) is a much greater contributor to long-term visual deﬁcits than injury to the retina. It is common to find inconsistent visual function, where the infant sometimes seems to see and sometimes does not. Another common outcome is a homonymous hemianopia. It is important to advocate for low vision specialists through early intervention and when the child starts school.
Over 50% of infants have significant motor problems. The type and location of brain injury hurts motor areas of the brain. Consequently, most infants develop a pattern of low tone (hypotonia) in the trunk and high tone (spasticity) in the extremities (quadriparesis). If brain injury was unilateral, then the other side of the body (contralateral) becomes spastic. Less commonly, the infant remains floppy (hypotonic). Sometimes infants have problems with controlling movement and are uncoordinated. These infants may develop dystonia, dyskinesia, or choreoathetosis. The same posturing (decorticate or decerebrate) seen during the hospitalization may persist.
Cerebral palsy is a common, though non-specific term used for the non-progressive movement problems that arise from damage to the motor control centers of the brain happening before age 18 months to 2 years. All of the types of movement problems detailed above are considered types of cerebral palsy.
There are many ways to help with tone problems. If an infant has many motor problems, a physiatrist, or physical medicine and rehabilitation doctor, is trained to help manage tone. They can also help with many other rehabilitation issues, like seating, best types of splints etc. Some pediatric neurologists work with infants and children after brain injury whether it is from trauma, stroke, or other brain disorders. Pediatric rehabilitation therapists (occupational and physical) are important specialists who can help as well.
ABUSIVE VERSUS UNINTENTIONAL INJURY
The scope of clinical and physical findings in abusive injury is unique to this disorder. It is important to remember the importance of scene investigation (where the infant became symptomatic) and the investigations by law enforcement and social services as critical elements in the determination that an abusive rather than an unintentional event has occurred. It is understood that falls are often offered as explanations for injury. However, large amounts of published data indicate that these are uncommon causes of the range of findings in abusive injury. Significant applied forces appear to be required. Birth injuries have also been suggested as causative, but the presentation occurs months after birth. Additionally, there is clear evidence that the injuries are acute.
In abusive traumatic brain injury, the differential alternatives (other diagnoses) for each finding must be considered along with the pattern of injuries of the nervous system and the body as a whole, along with the history of injury. For instance, there are many reasons for altered mental status or coma, including:
- trauma (both non-accidental and unintentional)
- non-convulsive continuous seizures (status epilepticus)
- heart disease
- metabolic disease including inborn errors of metabolism
In an infant who has sustained abusive injury, many of these diagnostic possibilities are eliminated early in the emergency department course either by the examination or other testing (See Laboratory and Imaging Studies).
Neurometabolic disease (problems with cell function that affect brain function) do not present with the range of findings found in abused infants. It is important to check for these when there is any question. These are rare disorders and include glutaric aciduria type 1, Menkes disease, and osteogenesis imperfecta type 1. Each of these presents with some of the many potential findings, from subdural effusions or small subdural hematomas to seizures and developmental delay.
Distinguishing an unintentional from an abusive head injury can be difficult and requires keeping an open mind while acquiring all possible scene, historic, physical, imaging and laboratory data. If an infant dies, a full postmortem examination (autopsy) is required. This includes examination of the eyes and possibly testing for metabolic disease. This is done through the county medical examiner or coroner’s office, depending on where the family resides.
As the majority of injuries occur when parents are stressed, the pediatrician or family practitioner plays an important role in identifying infants who are challenging to care for (severe colic, gastroesophageal reflux, previous brain injury, and irritability). Treating those infants, identifying need for parenting classes and early intervention services can make a meaningful difference. Some families have few social supports. Visiting nurse programs are often valuable community resources available to families. Community and church outreach programs also make a difference. For infants in high-risk situations, some communities have at risk nurseries where infants can receive daycare and parents can learn parenting skills.
The National Center on Shaken Baby Syndrome (http://www.dontshake.org/ ) provides Don’t Shake the Baby programs nationwide to parents and caregivers. Their web site offers information on prevention programs such as the Period of PURPLE Crying program and other prevention activities.
- The Matty Eappen Foundation: http://w.mattyeappen.org/
- Alleged: A claim or assertion about the history. Not yet proven.
- Altered mental status or level of consciousness: State of arousal that is not normal. An infant with altered mental status is not themselves. They may not seem to recognize or look towards a parent as they did before. They seem “out of it”. They may cry fitfully and not only sleep more, but be more difficult to arouse from sleep. They are not interested in eating or are unable to suck in a coordinated way. They may not be able to do motor tasks that they have already learned such as sitting, rolling, or standing.
- Angular or rotational acceleration: The change in velocity (rate of change in the position of an object) through an arc.
- Anoxia: Lack of oxygen.
- Apnea: When active breathing stops for 20 or more seconds, or shorter length of time if there is a slow heart rate (bradycardia).
- Arachnoid: A thin membrane, the middle of the 3 layers of the meninges, named because it has a spider-web appearance. It effectively acts as a barrier between the blood circulation of the dura and the subarachnoid space.
- Arachnoid granulations: Also called arachnoid villi. Small protrusions of the arachnoid that stick out into the dural venous sinuses.
- Arousable, Arousability: Ability to arouse; to waken
- Arterial blood gas: A test of blood taken from an artery
- Artery (arteries): Thicker walled blood vessels that carry blood from the heart to the body.
- Atrophy: Cerebral atrophy or shrinkage occurs when there is progressive loss of neurons and their connections. It can affect a part of the brain or be more generalized.
- Axon: The long slender projection of the nerve cell that conducts electrical impulses away from the neuron cell body to the synapse allowing transmission information between neurons, neurons and muscles, and neurons and glands.
- Basal ganglia: Multiple clusters of neurons located in the base of the brain that are interconnected with each other and with the cerebral cortex, thalamus and brainstem. Has several functions including helping control voluntary movement.
- Bilateral: Both sides.
- Blunt force trauma: Physical trauma caused to a body part by impact from physical attack.
- Capillary: The smallest of the blood vessels that connect the smallest arteries called arterioles to the smallest veins, the venules.
- Caput succedaneum: Bleeding from shearing impact below the skull and above the membrane covering the skull called the periosteum.
- Cephalohematoma: Bleeding between the skull and its membranous covering, the periosteum. Cannot cross a suture.
- Cerebral hemisphere: ½ of the cerebrum, the brain.
- Cerebral perfusion pressure: A pressure gradient that causes cerebral blood flow. Normally cerebral blood flow is constant because of the brains ability to keep cerebral blood flow stable, (cerebral autoregulation). This phenomenom is not as well developed in babies. If the arterial blood pressure is raised too high then intracranial pressure rises; if too low, then the brain becomes ischemic.
- Cerebrospinal fluid: A clear colorless fluid made by a plexus of cells within the normal holes of the brain called ventricles.
- Cerebrum: The part of the brain consisting of the 2 hemispheres including the cerebral cortex, and regions underneath including the basal ganglia and the hippocampus (localized in the temporal lobe).
- Coagulopathy: A clotting or bleeding disorder.
- Choreoathetosis: Involuntary movements consisting of irregular contractions (chorea) combined with writhing and twisting movements (athetosis).
- Coma: Means “deep sleep”. A state of unconsciousness and unresponsiveness to environmental stimuli lasting more than 6 hours. The person cannot be woken up, does not respond to painful or noxious stimuli, light, sound, no longer has a normal wake-sleep cycle and cannot initiate voluntary action. A comatose person cannot be woken up. A comatose infant will be unable to perform voluntary actions like sucking, cooing, waving hands or looking at a parent. With unconsciousness, the infant will have no tone and will be limp.
- Computerized tomographic scan (CT scan): Computer processed x-rays to produce brain slices (tomographic images).
- Concussion: From the Latin “to shake violently”. The most common type of traumatic brain injury. Also called mild traumatic brain injury, mild head injury, and minor head injury.
- Contracture: When there is permanent shortening of the muscle resulting in a contracture usually when there is prolonged spasticity (high tone).
- Contralateral: The opposite side.
- Contusion: Medical term for bruise.
- Corpus callosum: The largest bundle of neural fibers connecting the two hemispheres.
- Cortical visual impairment: A visual impairment caused by a brain problem rather than an eye problem. If severe, the child is blind.
- Coup and contrecoup injury: Coup injuries of the brain occur when the brain hits the inner side of the skull under the site of impact whereas contrecoup injuries occur when the brain rebounds and collides with the opposite side of the skull from the site of impact. These are considered focal brain injuries.
- Craniocervical junction: Where the skull meets the spine. This is where the lower part of the brainstem (the medulla) becomes the cervical spinal cord.
- Cranium: Skull
- Deceleration: The opposite of acceleration, as the speed decreases.
- Decerebrate posturing: An involuntary abnormal posturing in which the arms and legs extend (straighten out). Indicates severe brain injury.
- Decorticate posturing: An involuntary abnormal posturing in which the arms are flexed and legs extend (straighten out). Indicates severe brain injury.
- Dendrite: The branched projections of the neuron that act as receivers of the stimulus from other neurons. Passes this electrochemical stimulation to the neuron cell body, and then to the axons.
- Diffuse axonal injury: A severe type of brain injury involving the white matter. Typically damage is widespread and is a significant cause of persistent unconsciousness and coma.
- Dura mater or dura: A thick membrane that is the outermost of the 3 layers of the meninges and closest to the skull.
- Dural venous sinuses: Venous channels found within the dura mater. These receive blood from internal and external veins of the brain as well as cerebrospinal fluid from the subarachnoid space and empty into the internal jugular vein that goes back to the heart.
- Dyskinesia: A general non-specific term for an abnormal movement disorder.
- Dystonia: A neurologic muscle disorder that can be either genetic or acquired; it is associated with sustained muscle contractions causing twisting and repetitive movements and posturing. When specific brain damage results in dystonia, it is considered a secondary dystonia.
- Edema: Swelling. There are different kinds of edema. Some affect body parts, such as pitting edema of the lower legs. Cerebral edema is when fluid accumulates outside brain cells. As it is difficult to differentiate extracellular from cellular swelling, most clinicians use the general term brain swelling.
- Electroencephalogram (EEG): Recording of brain electrical activity from the surface of the skull.
- Encephalopathy: Encephalo = brain; pathy = not working right.
- Endotracheal tube: A catheter inserted into the breathing tube called the trachea to maintain the airway.
- Epidural hematoma: A collection of arterial blood between the dura mater and the skull. Occurs infrequently in non-accidental trauma. Tends to accumulate quickly.
- Executive function: Umbrella term for regulation of cognitive functions such as working memory, reasoning, problem solving, and attention regulation. The prefrontal areas of the frontal lobe are especially important, though not the only areas involved in carrying out these functions.
- Extraaxial fluid collection: A fluid collection outside the brain and inside the skull.
- Falx cerebri: Referred to as the falx. This is a infolding of the dura between the two hemispheres of the brain. It extends down towards the corpus callosum.
- Fontanelle: Soft spots located in the top front and back of the skull. The two main fontanelles are the anterior and the posterior fontanelle. Both are present at birth but the most obvious one is the anterior fontanelle. When the pressure in the skull is too high and the anterior fontanelle is still open, it appears to bulge up from the skull surface.
- Frenulum: A small fold of tissue. Found in several body areas. In the mouth, there is one under the tongue, another inside the upper and also lower lip. There are also buccal frena connecting the cheeks to the gum. A torn frenulum is sometimes a sign of physical abuse.
- Gastrostomy tube: A tube placed into the stomach for feeding when a baby cannot take food orally.
- Glasgow coma scale: A scoring system to reliably and objectively assess the patient’s state of consciousness. Scores range from 3 (severe coma) to 15 (normal). The scale consists of scoring for eye, verbal and motor response.
- Glutaric aciduria type 1: Also called glutaric academia type 1. An inherited metabolic disorder where the body cannot break down specific amino acids. Intermediate breakdown products build up and accumulate in the brain, especially the basal ganglia. There are two stages, before the encephalopathic crisis and after. Before infants have large heads (macrocephaly) even from birth. After an infant has become symptomatic they may have movement problems, muscle spasms, jerking, and either rigidity or decreased muscle tone and muscle weakness. Rare case reports document infants who developed acute or chronic subdural hematoma and retinal hemorrhage.
- Gray matter: Part of the brain that appears gray. It consists of brain cells (neurons) and support cells (glial cells). It is located in the surface of the brain (cerebral cortex), deep inside the brain, cerebellum, and brainstem.
- Hemiparesis: Weakness of the arm and leg on one side.
- Herniation: The dural folds (the falx and the tentorium) and dural attachments to the skull create relative regions within the skull consisting of the hemisphere on either side of the falx, and the posterior fossa (the inside back part of the skull). The pressure inside the skull (the intracranial pressure) is a function of the brain, blood in blood vessels and amount of cerebrospinal fluid. When the brain is swollen or there is significant bleeding within or around the brain or when there is too much spinal fluid, the intracranial pressure goes up. If the pressure goes up too much, then brain moves (is squished) to areas within the skull that have less pressure (like under the falx to the other side or through the hole at the base of the skull (the foramen magnum). This is called herniation.
- Homonymous hemianopia: Each eye has a visual field that overlaps with that of the other eye. The left half of the brain receives the visual pathways for the right hemifield of both eyes and the right half of the brain receives the visual pathways for the left hemifield of both eyes. If the brain is injured badly along the visual pathway on one side, the consequence can be visual loss of half of the eye, a homonymous hemianopia.
- Hypotension: Low blood pressure
- Hypothermia: Decreased core temperature.
- Hypotonia: Decreased tone from the normal state of mild tension (not strength).
- Hypoxia: Low oxygen.
- Impact injuries: Injuries resulting from contact, such as the head hitting a wall.
- Inborn error of metabolism: A large class of genetic diseases involving problems in cell metabolism.
- Infarction: Stroke.
- Interhemispheric: Between the hemispheres of the brain. The falx cerebri is the fold of dura that extends interhemispherically.
- Intracranial: Inside the skull.
- Intracranial hemorrhage: Bleeding inside the skull. Includes subdural and subarachnoid hemorrhages.
- Intracranial pressure: The pressure inside the skull, normally 7-15 mm Hg. Upper limit of normal is 20-25 mm Hg.
- Lethargy: Mildly depressed level of consciousness or alertness. Can arouse with little difficulty.
- Level of consciousness: Refers to a person’s level of arousal (alertness) and reactivity to environmental stimuli. A decreased or depressed level of consciousness is any level of arousal other than normal.
- Magnetic resonance imaging (MRI): An imaging technique that use strong magnetic fields and radiowaves to form images of the brain. No exposure to x-ray (ionizing radiation) or iodine contrast is used in this technique.
- Meninges: The covering sac of the brain and spinal cord.
- Menkes disease: An abnormality of metabolism that leads to copper deficiency in the body. More common in males as it is an x-linked recessive disorder.
- Microcephaly: Small head that is more than 2 standard deviations below the mean for age and gender. May be congenital (present at the time of birth) or acquired.
- Myelin: Myelin forms a layer around the axon of some neurons in the central and peripheral nervous system. It is essential for the brain working normally.
- Myelinization: When the infant is born, the brain is incompletely myelinated. During the course of development, the brain becomes myelinated. The most rapid period of myelinization is occurring during the first year of life.
- Neuron: The brain cell that is vital to receiving, processing and transmitting information through electrical and chemical signals.
- Neurometabolic: Genetic metabolic disorders that affect the brain and nerves.
- Obtunded: A more depressed level of consciousness. Cannot be fully aroused.
- Optic nerve sheath hemorrhage: The optic nerve sheath covers the optic nerve as it courses from the eyeball to the brain where it connects to the optic nerve tracks that run bilaterally back to the primary visual area in the back of the brain (the occipital lobe). The sheath is covered by the meninges.
- Osteogenesis imperfect type 1: A genetic disorder associated with brittle bones. Because some infants have fractures and easy bruising, this may be in the differential of possible disorders to consider. Rarely children with OI have presented after mild trauma with subdural hematoma and with or without retinal hemorrhages. Extremely rarely, nontraumatic subdural hematomas have been reported in older adults.
- Papilledema: Swelling of the optic disc (where the optic nerve enters the eye ball). Retinal hemorrhages occur as part of more severe papilledema. If a baby has papilledema and retinal hemorrhages, the retinal hemorrhages should not be considered in the diagnosis of abusive injury.
- Pathognomonic: Characteristic for a particular disease.
- Pattern injuries: An injury that has a tell-tale marker for the tool or manner in which the injury was inflicted.
- Pediatric Glasgow Coma Scale: A modification of the Glasgow Coma Score for children that accounts for less developed language. A pediatric GCS of ≥13-15 is considered mild brain injury, 8-12 moderate and <8 severe.
- Eyes opening 4 – Spontaneous 3 – To Verbal 2 – To Pain 1 – No response
- Verbal 5 – Smiles, Orients to sounds, Follows objects 4 – Cries but consolable, inappropriate interactions 3 – Inconsistently inconsolable, moaning 2 – Inconsolable, agitated 1 – No response
- Motor 6 – Moves spontaneously and purposefully 5 – Withdraws from touch 4 – Withdraws from pain 3 – Abnormal flexion to pain 2 – Abnormal extension to pain 1 – No response
- Perpetrator: A perpetrator is the person who is responsible for the abuse or neglect of a child.
- Pia: The innermost layer of the meninges that is firmly attached to the brain and spinal cord surface.
- Posttraumatic hydrocephalus: The blockage of the normal flow of cerebrospinal fluid due to bleeding into the ventricles or from compression of the brain leading to increased intracranial pressure.
- Primary injury: The initial insult due to the initial forces applied to the head and spine with resultant displacement of the physical structures of the brain.
- Quadriparesis: Diffuse weakness of all limbs.
- Retina: A light sensitive multilayered lining of tissue covering the inner surface of the eye ball (globe).
- Retinal hemorrhage: Bleeding within the layers of the retina in the globe of the eye.
- Retinoschisis: Refers to abnormal splitting between retinal layers.
- Retinal folds: Also called perimacular retinal folds. A buckling of the retina seen in some infants who have had a severe abusive head injury.
- Rods and Cones: Photoreceptor cells within the photoreceptor layer of the retina. Cones are responsible for color vision and rods are important for night vision.
- Secondary brain injury: Indirect result of the primary injury as it comes from the processes initiated by trauma. Includes brain hypoxia, ischemia, brain swelling, hypotension, changes in brain blood flow, and increased intracranial pressure among others.
- Seizure: A seizure is due to abnormal electrical activity of the brain, often used interchangeably with convulsion. There are many types of seizures, some involving the brain bilaterally (both sides) called generalized and those that involve one part or side of the brain that are called partial. Motor seizures involve jerking (clonus) or stiffness (tonic) or both. Staring or absence seizures are uncommon in infants. Seizures are associated with rhythmic eye movements, drooling or frothing at the mouth, and loss of bladder or bowel control.
- Sepsis: A severe illness caused by an infection that has spread into the blood.
- Spasticity: Also termed hypertonia, an unusual unidirectional tightness or stiffness in the muscles. This results in excessive contraction of muscles. Associated with increased deep tendon reflexes.
- Status epilepticus: When seizures continue without stopping or they stop intermittently but the infant does not recover consciousness between seizures lasting 30 minutes or more.
- Stuporous: Altered level of consciousness in which person is in a sleep-like state from which they cannot be aroused.
- Subarachnoid hemorrhage: Bleeding into the subarachnoid space.
- Subdural hematoma: Bleeding into the potential space between the dura and the arachnoid.
- Subdural hygroma: Two definitions. A subdural collection of cerebrospinal fluid or the protein rich breakdown product of a subdural hematoma.
- Subgaleal hemorrhage: Bleeding in the potential space between the skull covering, the periosteum, and the dense fibrous tissue that covers upper and back part of the skull, called the galea aponeurotica.
- Sutures: The edges where the bones meet.
- Synapse: Where the neuron communicates with either another neuron or a different cell type such as a muscle cell.
- Tentorium cerebelli: Also called the tentorium.
- Thalamus: Bilateral brain structures deep in the brain above the brainstem. Important in the relaying of sensory and motor signals to the cerebral cortex and in consciousness, sleep and alertness.
- Tracheostomy: A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). (See websites)
- Unilateral: One-sided.
- Unintentional: Newer term in injury literature. Same as accidental.
- Vegetative state: A problem of consciousness where patients who have had severe brain damage are in a state of partial arousal but are not aware.
- Persistent: Four weeks in a vegetative state
- Permanent: A year after a traumatic injury in a vegetative state
- Ventricle: A “hole” that is normally part of the ventricular system of the brain that is filled with cerebrospinal fluid. There are four ventricles, one in each hemisphere shaped like a C, that connect with one that is between the two hemispheres, that in turn connects to one in the cerebellum.
- White matter: Consists mostly of myelinated axons and other non-neuronal brain cells.
- Binenbaum G, Christian CW, Ichord RN, Ying GS, Simon MA, Romero K, Pollack AN, Forbes BJ. Retinal hemorrhage and brain injury patterns on diffusion-weighted magnetic resonance imaging in children with head trauma. J AAPOS 2013 17(6):603-8.
- Huh, JW, Raghupathi, R. New concepts in treatment of pediatric traumatic brain injury. Anesthesiol Clin 2009 27(2):213-40.
- Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF. A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics 114(3):633-39.
- Matschke J, Herrmann B, Sperhake J, Körber F, Bajanowski T, Glatzel M. Shaken baby syndrome. A common variant of non-accidental head injury in infants. Dtsch Arztebl Int. 2009 106(13): 211-17.
- Sieswerda-Hoogendoorn T, Boos S, Spivack B, Bilo RAC, van Rijn RR. Abusive head trauma Part 1. Clinical aspects. Eur J Pediatr 2011 171(3):415-23.
- Togioka BM, Arnold MA, Bathurst MA, Ziegfeld SM, Nabaweesi R, Colombani PM, Chang DC, Abdullah F. Retinal hemorrhages and shaken baby syndrome: an evidence based review. J Emerg Med 2009 37(1):98-106.
Child Welfare Information Gateway https://www.childwelfare.gov/responding/mandated.cfm
Determination of brain death in infants. http://pediatrics.aappublications.org/content/128/3/e720.full
The Child Abuse Prevention Center http://www.thecapcenter.org/showpage.asp?page_id=1
Gastrostomy tube information: http://www.nlm.nih.gov/medlineplus/ency/article/002937.htm
National Center on Shaken Baby Syndrome http://www.dontshake.org/
The Shaken Baby Alliance http://sba.aquaelephant.com/about-us/ 877-636-3929
Tracheostomy information: http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm
United Cerebral Palsy http://ucp.org/
U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2013). Child Maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment.