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Facial Bruising as a Precursor to Abusive Head Trauma

Hillary W. Petska, Lynn K. Sheets and Barbara L. Knox CLIN PEDIATR 2013 52: 86 originally published online 17 April 2012 DOI: 10.1177/0009922812441675 The online version of this article can be found at: http://cpj.sagepub.com/content/52/1/86

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Facial Bruising as a Precursor to Abusive Head Trauma

Hillary W. Petska, MD1, Lynn K. Sheets, MD2, and Barbara L. Knox, MD1, 3

Clinical Pediatrics 52(1) 8688 The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922812441675 http://cpj.sagepub.com

Introduction
Primary care providers may be presented with precruising infants who have unexplained bruising, a finding highly correlated with abuse.1,2 As such, primary care providers have a unique opportunity to prevent escalation of abuse if identified early and reported. The following case reports are described to emphasize the importance of recognizing bruising as a sentinel injury in precruising children.3

visit, platelet count was normal, and social and family histories were reviewed. The pediatrician documented a low suspicion for nonaccidental trauma.

Case 2
A 3-month-old male was brought to the emergency department by ambulance for evaluation of sudden-onset respiratory distress. That morning, he was left in the care of his biologic father while his mother was at work. On initial physical exam, he appeared lethargic, with a bulging anterior fontanelle and normal skin exam. Head CT was obtained and revealed a thin parafalcine subdural hematoma. While in the emergency room, multiple contusions began to evolve on his face, scalp, and left ear. Because of suspicions of abuse, the hospital CPT was consulted. Dilated ophthalmologic examination demonstrated bilateral multilayered retinal hemorrhages extending out to the ora serrata. Skeletal survey was normal. During examination by the CPT, he was noted to be seizing. Repeat head CT revealed that the subdural hematoma had enlarged and was now displaying mass effect. He was taken emergently to the operating room for neurosurgical intervention. Due to the extent of his head injury, bleeding could not be controlled and surgery was discontinued. He was transferred to the pediatric intensive care unit with palliative care measures and died the following day. After detailed questioning by law enforcement, the biological father confessed to forcefully slapping the childs head, causing the fatal injury. He was convicted of first-degree reckless homicide and is currently serving a 15-year sentence.
University of Wisconsin Hospital and Clinics, Madison, WI, USA Childrens Hospital of Wisconsin, Milwaukee, WI, USA 3 Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
2 1

Cases Case 1
A 3-month-old male was brought to the emergency department by his parents for increased irritability, poor feeding, and bruising on his forehead. History revealed that on the day of presentation, his biological father had cared for him while his mother was at work. On physical examination, he appeared sleepy but irritable, with full anterior fontanelle. There were linear contusions on his right forearm, hand, and foot. There was also bruising on his chin and bilateral cheeks. Neurologic exam was nonfocal. A head computed tomography (CT) scan was obtained and revealed a thin right subdural hematoma. Ophthalmologic exam revealed multiple intraretinal hemorrhages. Initial skeletal survey was normal. A medical diagnosis of abusive head trauma was made by the hospital child protection team (CPT). He was subsequently admitted to the pediatric intensive care unit for seizures but did not require neurosurgical intervention. He was eventually discharged to his mother. Postdischarge, he was noted to have significant developmental delays. Biological father disclosed to law enforcement that he had accidentally dropped the patient and then flexed him at the hips when he would not stop crying. He was convicted of second-degree reckless injury and is currently serving a 3-year sentence. A chart review revealed that at the 2-month wellbaby check with his pediatrician 1 month earlier, 2 small unexplained bruises were noted on his cheek. At that

Corresponding Author: Hillary W. Petska, University of Wisconsin Hospital and Clinics, 600 N Highland Avenue, Madison, WI 53792, USA Email: hpetska@uwhealth.org

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Petska et al When asked about preceding injuries, his mother reported that she had asked about recurrent facial bruising at his 2-month well-child check. At that appointment, his father stated that these bruises were self-inflicted from poking himself. The parents were reassured by the pediatrician and told to return if bruising recurred. No report to Child Protective Services was made.

87 considered in infants presenting with unexplained bruising. These cases demonstrate likely missed abuse in 3 infants who later suffered abusive head trauma. In all 3 cases, the pediatricians were aware of the facial bruising, had low or no suspicion of abuse, and did not make reports to Child Protective Services. Unfortunately, cases such as these are not uncommon, as bruising prior to the severe abusive event is missed in 39% of fatal or near-fatal cases of abuse.4 In one study, 30% of infants hospitalized with abusive head trauma had a prior history of sentinel injuries such as bruising, one third of which were known to a medical provider.3 In another study on missed diagnoses of abusive head injury, Jenny et al.5 found that 37% of the missed cases had facial or scalp injuries at the time of initial presentation. Because of the missed diagnosis, 27.8% of the missed cases were reinjured. In general, facial/head bruising in children younger than 6 months is highly suspicious for abuse. In a systematic review by Maguire et al.,2 the head, and in particular the face, was the most common site for abusive bruises. Although a recent study by Pierce et al.6 found that facial and head bruising did not reliably differentiate accidental and nonaccidental trauma, the mean age of the subjects was approximately 12 months, and any bruising in infants younger than than 4 months was documented as concerning for abuse. Timely intervention is crucial in these cases as the mean interval between sentinel injury and abusive head trauma may be only 1 to 2 months.3 Children younger than 4 months are at particular risk of escalation, as 2 months of age is the peak period of crying in infants, which often acts as the triggering event for abusive injury.3,7 Pediatricians play a key role in prevention of further maltreatment by recognizing concerning injuries. In 2007, the American Academy of Pediatrics released practice guidelines for the evaluation of suspected physical abuse in a child.A thorough history and physical exam should be performed with photo documentation of physical findings when suspicious injuries are detected. Further evaluation may also include head CT, initial and repeat skeletal surveys, dilated ophthalmologic exam, assessment for hematologic disorders, and screening labs for abdominal injury. A number of factors may contribute to missed diagnoses of child abuse. Despite a growing body of literature on bruising in precruising children, pediatricians may be unfamiliar with the research or may not have received adequate training during residency in child abuse and neglect, making them less confident in their diagnoses.8,9 Even for trained providers, bruising may be subtle and easily missed. Pediatricians may also be falsely reassured by their preceding relationships with families.10 Moreover, providers may be reluctant to

Case 3
A 4-month-old female was brought to the emergency department by ambulance in cardiorespiratory arrest after reportedly falling off of a couch. Earlier that day, she had been left in the care of her female babysitter. On physical exam, she was unresponsive to painful stimuli. Pupils were fixed and dilated, and there were multiple developing contusions on her scalp, face, torso, and extremities. Head CT was performed and demonstrated right greater than left subdural hematomas, diffuse cerebral edema, and multiple skull fractures consisting of a stellate fracture of the right parietal bone and linear fractures of the left parietal and occipital bones. Skeletal survey also revealed a healing fracture of the left tibia. Dilated ophthalmologic exam revealed extensive intraretinal and preretinal hemorrhages bilaterally, with extension to the ora serrata as well as retinoschisis of the right macula. She was evaluated emergently by neurosurgery, but no intervention was performed as exam at presentation was consistent with brain death. Serial exams remained consistent with brain death, and life support was withdrawn the next day. The case was diagnosed by the CPT as abusive head trauma. The babysitter reported that she had dropped the child in the middle of the night and that the child had struck her head on a bedside dresser. The babysitter is currently in jail awaiting trial on first-degree intentional homicide charges. During the medical interview, the childs mother reported a history of poorly explained bilateral bruises on the babys nasal bridge. The mother stated that these were observed by the pediatrician at the 4-month wellchild check and that the pediatrician reassured her the babys nose was not broken and no further workup was necessary.

Discussion
Bruising is uncommon in children who are not yet mobile and occurs in less than 1% of children younger than 6 months.1,2 Although bruising is not inherently life threatening, it is the most common presentation of child abuse2 and often a precursor injury to abusive head trauma.3 As such, physical abuse must be strongly

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88 report based on perceived lack of response by Child Protective Services from prior experiences, given that reporting may result in removal from care or family disruption.8-10

Clinical Pediatrics 52(1)

suggestive of abuse? a systematic review. Arch Dis Child. 2005;90:182-186. 3. Sheets L, Leach M, Nugent M, Simpson P. Sentinel injuries precede abusive head trauma in infants. Paper presented at: The Annual Meeting of the Ray Helfer Society; September 2008; Tuscon, AZ. 4. Pierce MC, Kaczor K, Acker D, et al. Bruising missed as a prognostic indicator of future fatal and near-fatal physical child abuse E-PAS2008:634469.46. http://www.abstracts2view.com/pasall/. Accessed February 27, 2012. 5. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;282:621-628. 6. Pierce MC, Kaczor K, Aldridge S, OFlynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125:67-74. 7. Lee C, Barr RG, Catherine N, et al. Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking? J Dev Behav Pediatr. 2007;28:288-293. 8. Goad J. Understanding roles and improving reporting and response relationships across professional boundaries. Pediatrics. 2008;122(suppl 1):S6-S9. 9. Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics. 2008;122:611-619. 10. Jones R, Flaherty EG, Binns HJ, et al. Clinicians description of factors influencing their reporting of suspected child abuse: report of the Child Abuse Reporting Experience Study Research Group. Pediatrics. 2008;122: 259-266.

Summary
Three cases of infants with diagnoses of abusive head trauma are described. Although these children had previously presented to their pediatricians with reports of facial bruising, no interventions were made and each progressed to more serious abuse. These cases emphasize the importance of recognizing bruising as a sentinel injury in abused infants and intervening to prevent further morbidity or mortality. Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

References
1. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who dont cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153:399-403. 2. Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or

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