Justine Jorgensen – Abusive Head Trauma in Developmentally Delayed Children

Non-accidental trauma is associated with injuries such as head trauma, abdominal injuries, fractures, bruising, bites, and burns. Abusive head trauma (AHT) is the leading cause of brain injury and death in children under the age of 2. AHT can result in primary injuries directly related to the traumatic forces applied to the head. Retinal hemorrhage, skull fracture, intracranial hemorrhages, parenchymal injuries and spinal cord injuries all fall under the classification of primary injuries. Secondary injuries occur as complications of primary injuries related to hypoxia, ischemia, or edema.

The mortality rate with AHT is 20-25% and outcome is typically extremely poor. The incidence rate is estimated to be 14 to 29.7 infants per 100,000. Delayed psychomotor development, motor deficits, epilepsy, visual impairment, language disorders, and cognitive, behavioral, and sleep disorders are all extremely common in patients following abuse. Compared to accidental traumatic brain injury, children with AHT have significantly less impact injury, lower initial Glasgow Coma Scale scores, and more frequent signs of acute cardiorespiratory compromise, to name a few.

We conducted a retrospective chart review on AHT patients treated at Children’s Hospital of New Orleans. The study included 91 children who underwent treatment and management for brain injuries and various other injuries due to abuse between January 2012 and March 2018 at Children’s Hospital of New Orleans. In this population there were 50 males (55%) and 41 females (45%) all 5 years of age or younger at the time of the abuse. 5 out of the 91 children in the study were diagnosed with some type of developmental delay prior to the abuse. All of the children studied had a diagnosis of Shaken infant syndrome, Shaken baby syndrome, Child physical abuse (suspected), or Child physical abuse (confirmed).

Only patients who were seen at Children’s Hospital of New Orleans and then were handed over to the Audrey Hepburn CARE Center were included in the study to ensure accuracy among suspected child physical abuse cases. Factors such as Glasgow coma scale (GCS), consciousness upon arrival, length of hospital stay, intubation, length of rehabilitation, developmental delay after abuse, and new medications needed after AHT were all included in the study. Approximately 73% of our cohort was under the age of 1 at time of trauma. Only 1 of the 91 patients died while in the hospital, and the remainder of the subjects went home with a parent (50%), went home with other family members (12%), or were discharged in state custody (37%).

One interesting thing I found was the nine patients with midline shift on average had longer hospital stays, presented with a GCS of 8 or below, and were all intubated during their hospital stays. In terms of disposition after leaving the hospital, all but 1 were noted to have developmental delays or disabilities of some kind and 66% left on seizure medications in addition to other medicines. Some of the disabilities these patients were diagnosed with resulting from abuse were presenting non-ambulating and non-verbal, cerebral palsy, spasticity, and the need for feeds through a g-tube.

Another interesting point to note is that 37 patients (41%) were either brought into the hospital for seizures or had a seizure during their stay. When analyzing this group of patients their average hospital stay was 34 days, of the known GCS only 11 patients had a GCS of 13 or higher, 27 of them were intubated at some point during their stay, and 25 of them were noted to have developmental delay after being discharged. An interesting find was that of the 9 patients with midline shift noted in the study, 8 of them had seizures while in the hospital, and the 1 patient who did not had been started on seizure prophylaxis.

At the beginning of the study my hypothesis was “that a significant relationship exists between the diagnosis of developmental delay before abuse and the risk of abusive head trauma.” I was surprised when only 5 of the 91 patients had been previously diagnosed with developmental delay prior to the abuse but I think there are a few possible explanations. One thing to note was the ages of those previously diagnosed with delay were three 2 year olds, an 11 month old and a 4 month old. It appears that many children who are diagnosed with different developmental delays including autism, motor or speech delays, or others, are diagnosed as a toddler. This would make sense as about 3/4th of patients in our cohort were under the age of 1, so even if they may have had some sort of delay, there is a good possibility it wasn’t diagnosed yet, and therefore may likely not be a major factor predicting risk of abuse. This is not to say developmental delay can’t correlate with increased risk of abusive head trauma but at least in our cohort it appears that is not the case. The aspect of midline shift correlating with patients who not only presented in a worse condition initially and seemed to correlate with worse outcome long term was interesting and an aspect I would like to further examine.

This grant really helped me to be able to carry out this research project that I am very passionate about and am so grateful to have done. I not only enjoyed doing a project that was organically my idea from start to finish, but all the amazing doctors and staff at Children’s Hospital that I had the opportunity to work with was also a major highlight of my time at Tulane. While my Neuroscience classes have been great, being able to take my knowledge from the classroom into a setting where I could apply it and expand it even further was by far an amazing experience. In addition, as this school year has started I have also been finding my work this summer has greatly helped in my neuroscience classes for this semester as I have a better understanding of the brain as a whole as well as the way it affects every single aspect of the way we function. It has given me a much greater appreciation of the brain and our bodies as a whole and how certain diseases or events can cause life changing problems due to the delicacy and amazing work that our brains perform.

Written by Justine Jorgensen, Dean’s Grant recipient, 2018