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FROM THE AMERICAN ACADEMY OF PEDIATRICS: Cindy W. Christian, Robert Block and the Committee on Child Abuse and Neglect Abusive Head Trauma in Infants and Children Pediatrics 2009; 123: 1409-1411 [Abstract] [Full text] [PDF]

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Avoiding Mistakes

F. Edward Yazbak, Co-author Michael D Innis, Hematologist   (28 October 2009)

Making a Diagnosis of Abusive Head Trauma

Cindy W Christian, Robert Block, MD   (3 November 2009)

Avoiding Mistakes 28 October 2009
F. Edward Yazbak, Peditatrician TL Autism Research, Co-author Michael D Innis, Hematologist Send letter to journal: Re: Avoiding Mistakes tlautstudy{at}aol.com F. Edward Yazbak, et al.	In “Abusive Head Trauma in Infants and Children”1 Christian, Block and the Committee on Child Abuse and Neglect recommended that the “Shaken Baby Syndrome”2 be renamed “Abusive Head Trauma”. The authors were careful to stress that pediatricians had “a responsibility to consider alternative hypotheses when presented with a patient with findings suggestive of AHT”, that such a diagnosis is only made “after consideration of all the clinical data” and that “restraint is required until the medical evaluation has been completed” It is imperative to heed this advice as all the signs and symptoms attributed to Shaken Baby Syndrome/Abusive Head Trauma can in fact result from other causes that include a deficiency in various nutrients such as Vitamins C and K.3,4,5 Having reviewed many cases where innocent parents were suspected of child abuse and emotionally and financially ruined, we agree with the authors that as long as the infant is safe in the hospital, a rush to judgment is not justified. We believe that in addition to a very careful physical examination, a “meticulous medical history taking” must include a comprehensive review of the pregnancy, delivery and the infant’s past history including the listing of recent vaccinations. In addition, we do have concerns about diagnostic mishaps continuing to occur if screening is only “performed when indicated”. It is therefore wiser to consider the following laboratory investigations as “routine” and to perform them as early as possible in such cases: • CBC to exclude a blood dyscrasia • PTT, aPTT, PIVKA-II test and Undercarboxylated Osteocalcin to exclude Vitamin K Deficiency, a recognized cause of hemorrhage, bruising and bone lesions5,6 • Fibrin, fibrin degradation products and Factor XIII for further evidence of a coagulopathy • Serum ascorbate & blood histamine for evidence of Vitamin C Deficiency3,4 • Urinary organic acid and serum carnitine as a screen for a metabolic disorder. By doing so, everyone can be protected and terrible mistakes, at the worst possible times, can be prevented. References 1.Christian CW, Block R; Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive Head Trauma in Infants and Children Pediatrics. 2009 May;123(5):1409-11. 2. Ludwig S, Warman M. Shaken baby syndrome: a review of 20 cases. Ann Emerg Med. 1984;13(2):104–107 3. Clemetson CAB Was it “shaken baby” or a varient of Barlow’s disease? J Am Phys Surg 2004:9:78-80 4. Clemetson CA Elevated blood histamine caused by vaccinations and Vitamin C deficiency may mimic the shaken baby syndrome. Med Hypotheses. 2004;62(4):533-6 5. Innis MD. Vitamin K Deficiency Disease. Jour Orthomol Med.2008:23; 15-20 6. Rutty GN, Smith M, Malia RG. Late Form Hemorrhagic Disease of the Newborn. A Fatal Case Report with Illustrations of Investigations Which May Assist Avoiding the Mistaken Diagnosis of Child Abuse. Am J Forensic Med Path 1999;20(1):48-51 Conflict of Interest: None declared
Making a Diagnosis of Abusive Head Trauma 3 November 2009
Cindy W Christian, Pediatrician The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Robert Block, MD Send letter to journal: Re: Making a Diagnosis of Abusive Head Trauma christian{at}email.chop.edu Cindy W Christian, et al.	We thank Drs. Yazbak and Innis for their attention to the AAP policy statement "Abusive Head Trauma in Infants and Children". They correctly emphasize the primary points from the statement: a careful medical history and appropriate examinations, including laboratory and radiologic studies, will inform the final diagnosis chosen from a carefully considered differential. While the statement was not intended to review the differential diagnosis of abusive head trauma, the authors of the statement and members of the Committee on Child Abuse and Neglect are aware of both uncommon diseases that may present with symptoms similar to those of abusive head trauma, and theoretical diseases that are purported to mimic abuse despite the lack of sound science to support that contention. We must recognize that abusive head trauma often goes undiagnosed by unsuspecting physicians, putting infants and children at continued risk and further harm. Ascribing traumatic injuries to unproven hypotheses of causation can do the same. Conflict of Interest: None declared