What are the effects of abusive head injuries on young children?

Today's guest blogger is Jeffrey Campbell, MD, Director of the Nemours Neuroscience Center and a pediatric neurosurgeon at Nemours/Alfred I. duPont Hospital for Children.

Child abuse has once again come to the attention of our region with two horrific fatal beating cases in the past two weeks, one in Delaware and the other in Pennsylvania. In both cases, young children were involved, and the extent of the abuse was unusual. Unfortunately, abuse is far more frequent than we realize.

Thousands of infants and toddlers suffer brain injuries every year due to shaking or abuse, many of whom die or are disabled for life. In a study released online today from Pediatrics, a group of researchers reviewed data and collected questionnaires to estimate how many young children suffered abusive head injury in a year as well the long term consequences of disabilities and shortened lives.

In 2009, they found 4,824 abusive head trauma cases in children ages 0-4, which included 334 deaths within 30 days of the injury, according to data from 2009 Vital Statistics mortality data and hospital admissions from the 2009 Healthcare Cost and Utilization Project Kids' Inpatient Database. To better understand the longer term consequences of these injuries, they surveyed caregivers of children who had confirmed abusive head injuries to document what happens to these children after they leave the hospital.

On average, these children live 7.6 fewer years than their peers with most of the additional deaths occurring during childhood. In addition, the amount of disability suffered by these children is similar to them losing an additional 5.7 years of normal life. Over half of the children with severe injuries will die before their 21st birthday. The results are disturbing when you think about lost lives and lost potential.

Other studies have estimated medical costs for these children, but the overall cost to society are much greater with things like the need for special education and lost years at work for parents and a child who may never be independent. The emotional toll on the family and community cannot be measured in dollars but can be devastating.

The bottom line from this very carefully done statistical work is that abusive head trauma can have terrible long lasting consequences for children and families. Any parent can relate to feeling frustrated with a crying child. An adult in a fit of rage might shake a baby or hit a child, not realizing the permanent damage they might be doing to their brain. A moment of anger can result in permanent blindness, physical and mental disability, shorter lifespan, or even death.  Unlike portrayals in film, in which the person wakes up from a coma and recovers, it can be far more permanent and devastating.

Denial of the permanence and long term consequences of brain injury are deep in our culture. It has taken years and countless examples to understand the toll of seemingly minor head injuries in athletes, and even now it is not fully appreciated.  It was not long ago that even children were encouraged to shake off "getting their bell rung" because it was felt to have no long term consequences. This is simply not true. Even concussion and minor brain injury can bring about long lasting problems that may never to fully recover.

Another study released online in Pediatrics today involves developing a judgment tool to help doctors decide if a brain injury in a child under the age of five is likely from abuse or an accident. After reviewing medical records from hospitals, they suggest that specific types of injuries occur much more commonly with abuse than with non-intentional injuries, giving doctors guidance on which families and children require further investigation.

Abuse situations are complicated in the emergency departments of local hospitals where they are often first uncovered. In these very busy departments, medical and nursing staff have to attend to the injuries of the child while providing comfort and reassure the caregivers. At the same time, they must gather data and report to family service agencies of their state if abuse is suspected. This decision can be vital since a child that has been abused once is much more likely to suffer even greater harm if this is not discovered. The child who was recently killed in Delaware suffered previous injuries prior to her death. Her death might have been prevented if this pattern of abuse was discovered earlier. On the other hand, incorrectly accusing families of abuse can create enormous emotional toll and a fear of seeking medical help even when it is needed.

What is striking in reading these studies are the numbers involved. Thousands of children are abused each year and since these injuries can be life changing, the immediate question arises as how to prevent this from happening.  There are good programs that are effective. The Shaken Baby Syndrome Prevention & Awareness Program developed by Dr. Mark Dias at Penn State involves counseling the parents while they are in the hospital with a new baby. The Practicing Safety program by Diane Abatemarco, PhD, MSW, at Nemours includes counseling during early well child visits, home visiting programs by nurses.

Early infancy is stressful. Babies sometimes cry and cannot be consoled and adults lose their temper. We have the ability to teach families how to successfully get through those first few critical months. It is time to do that work.

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