0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Book Reviews and Other Media |

Shaking and Other Non-Accidental Head Injuries in Children

Kenneth Feldman, MD, Reviewer
Arch Pediatr Adolesc Med. 2007;161(1):108-109. doi:10.1001/archpedi.161.1.108.
Text Size: A A A
Published online

Extract

Drs Minns and Brown provide a broad review of inflicted head injuries (IHIs) from medical, epidemiological, legal, and social viewpoints. The most extensively treated topics, clinical (neurological) manifestations and biomechanics of infant and toddler head injury, consume the first third of the text. The text expands on the 2005 article by Dr Minns1 on the same topic. In both, he postulates 4 different clinical presentations for IHI. Six percent of IHIs are attributed to a “hyperacute encephalopathic or cervico-medullary syndrome,” in which acute cervicomedullary injury results in immediate apnea, leading to death or severe hypoxic-ischemic injury. Here the pathologic studies of Geddes et al2 are referenced. They observed children with IHI to have microscopic or gross evidence of injury at the cervicomedullary junction but little evidence of traumatic axonal injury. These observations were very helpful in redirecting our thinking to the role of such injuries and apnea as a cause of morbidity. Unfortunately, they jumped from there to totally unsupported conclusions that these injuries might result from minor traumatic events. Additionally, they postulated that the apnea with accompanying hypoxia might be the cause of the subdural and retinal hemorrhages seen in these children, instead of a direct result of the original trauma. They have subsequently recanted their “unified hypothesis,” but not until after it had severely damaged child protection.3 The second pattern is an “acute encephalopathic” one, with extensive symptoms of intracranial and retinal bleeding and cerebral dysfunction. Dr Minns placed 53% of the cases in this category and attributed it to shaking or repetitive whiplash injury, with or without accompanying impact. A third group of 21% of the victims had a “subacute nonencephalopathic” presentation, with intracranial bleeding and extracranial evidence of abuse but without the severe neurological symptoms. Finally, 20% had a “chronic extracerebral presentation” of enlarging head size from chronic subdurals and variable symptoms of increased intracranial pressure, but they lack other signs of abuse. The earlier mentioned figures are from a Scottish database, extensively reported in the text. Although these clinical formulations are presented as discrete scenarios, I feel they are more likely extremes, while most children have some blend of these patterns. For example, we often see children with chronic subdurals, picked up by increasing head sizes, who in retrospect have a postnatal jump in head size, simultaneous with a period of irritability and vomiting. Many, on skeletal survey, are also found to have healing rib or other fractures. It is naive to assume these children did not sustain severe head injuries with immediate concussion simply because no one is admitting it or no one recognized the cause of the symptoms at the time.

Topics

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Figures

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Jobs
brightcove.createExperiences();