Child abuse in infants presenting with an apparent life-threatening event

Parker K, Pitetti R. Mortality and child abuse in children presenting with
apparent life-threatening events. Pediatr Emerg Care. 2011 Jul;27(7):591-5.

During the study period of 9 years, 563 patients were enrolled. The mean age of the patients was 2.6 months. Eleven patients (2%) were diagnosed with child abuse. Those diagnosed with child abuse were more likely to have focal findings on physical examination (54% vs 17%, P < 0.01). Three children died; the overall mortality rate was 0.5% (3/563). One of the 3 deaths was secondary to child abuse. The other 2 deaths were reported at autopsy to be secondary to sudden infant death syndrome. One of the 11 cases of child abuse ended in a death, which is a 9% mortality rate of child abuse victims who present with an ALTE. Although the subsequent mortality rate for children who present with an ALTE is low, child abuse was one of the identifiable causes of death and should be considered during evaluation of all children who present with an ALTE.

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Al Khushi N, Côté A. Apparent life-threatening events: assessment, risks, reality. Paediatr Respir Rev. 2011 Jun;12(2):124-32.

“We recommend that clinicians caring for infants presenting with an ALTE consider including dilated fundoscopy in their evaluation protocol even in well-appearing infants as the diagnosis of abusive head injury is a serious one that could be overlooked on standard physical examination. Again here, careful organization of follow-up with the primary care physician is essential as the diagnosis of some forms of child abuse become evident with recurrent events.”

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Guenther E, Powers A, Srivastava R, Bonkowsky JL. Abusive head trauma in
children presenting with an apparent life-threatening event. J Pediatr. 2010

Of 627 patients with ALTE, 48% were male. Nine (1.4%) were diagnosed with abusive head trauma, of whom 5 were diagnosed in the emergency department. All cases detected in the emergency department had physical examination findings indicative of abusive head trauma. Patient age, male sex, or ethnicity were not significantly different between those with and without abusive head trauma. More children with abusive head trauma had a documented 911 call (56% vs 22%, P = .029), vomiting (56% vs 19%, P = .018), or irritability (22% vs 3%, P = .033). Multivariate analysis revealed odds ratio for abusive head trauma were 4.9 with a 911 call (P = .037), 5.3 with vomiting (P = .024), and 11.9 with irritability (P = .0197). Abusive head trauma is in the differential for infants with an ALTE, although almost half of the cases are missed by current emergency department management. Vomiting, irritability, or a call to 911 are significantly associated with heightened risk for abusive head trauma.

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Vellody K, Freeto JP, Gage SL, Collins N, Gershan WM. Clues that aid in the
diagnosis of nonaccidental trauma presenting as an apparent life-threatening
event. Clin Pediatr (Phila). 2008 Nov;47(9):912-8.

In our study, a thorough history and physical exam of patients presenting with an ALTE provided clues that led to the eventual diagnosis of NAT. We recommend considering NAT in any infant who presents with an ALTE, given the serious consequences of missing this diagnosis. We would also suggest tailoring subsequent evaluation to findings identified in a complete history and physical examination. In this study, laboratory tests, radiographic evaluations, and ophthalmologic exams aided in confirming the initial suspicion. We encourage awareness of the costs and possible risks of “routine” laboratory and radiographic tests, especially when not directed by concerns raised during the history and physical exam.

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Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and
adverse neurological outcome of infants after an apparent life-threatening event.
Pediatrics. 2008 Jul;122(1):125-31.

Infants who suffer an apparent life-threatening event are at risk for subsequent child abuse and adverse neurological outcomes. Deaths were uncommon and only occurred in the setting of severe developmental delay and seizure disorders. Neurological evaluation during hospitalization for a first apparent life-threatening event is of low yield, but close follow-up is essential.

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Waseem M, Pinkert H. Apparent life-threatening event or child abuse? Pediatr Emerg Care. 2006 Apr;22(4):245-6.

Previous studies have reported that CT is unnecessary in suspected abused children with normal neurological findings. [15] Certainly, many children who are presented with an ALTE have vague or nonspecific signs and symptoms, and nonaccidental trauma can be easily missed. This condition is usually underdiagnosed for many reasons. The children may present to the emergency department with signs and symptoms that do not seem to result from trauma. These young children may not present with the history of trauma or shaking and the caretakers rarely admit shaking the infant. Diagnosis is more difficult because of the non-verbal age of these young children. Evaluation for abuse therefore must not be delayed during investigation for other underlying medical conditions. The potentially devastating consequences of missing such a diagnosis underscore the need to obtain brain neuroimaging in the evaluation of young children who experienced ALTE with nonsuggestive initial presentations. [16]

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Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005 Apr;115(4):885-93.

Although our series did not include any unsuspected cases of child abuse, we and others have previously reported ALTEs that presented without suggestive findings but were eventually linked to abusive head injury.[8–10] The potentially devastating consequences of missing such a diagnosis underscores the need for brain neuroimaging in the evaluation of ALTE patients with nonsuggestive initial presentations.

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Altman RL, Brand DA, Forman S, et al. Abusive head injury as a cause of apparent life-threatening events in infancy. Arch Pediatr Adolesc Med. 2003 Oct;157(10):1011-5.

A wide spectrum of diseases and disorders can precipitate an ALTE. Among them, abusive head injury—a recently recognized cause—occurs frequently enough to obligate its inclusion in the differential diagnosis even if the physician observes no clues suggestive of an intracranial pathologic condition. Therefore, unless the physical examination and initial test results strongly suggest another cause, the clinician should consider taking steps to evaluate a possible inflicted injury, beginning with a dilated funduscopic examination and head imaging studies.

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More PubMed results on child abuse, head trauma, and ALTEs.

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