A 1-month-old male infant was brought into A&E by his parents and maternal grandmother. The grandmother was concerned that the infant was unusually drowsy and hard to rouse for feedings.
Age of mother?
Gravida 1 / Parity 1 – e.g. this child is her only pregnancy
Gestational age at delivery?
Spontaneous vaginal delivery
9 and 10 at 1 and 5 minutes, respectively.
Complications during pregnancy, delivery or postpartum?
Regular prenatal care was received throughout the pregnancy.
Morphology scan was normal.
There was a history of domestic violence during the pregnancy and the mother was treated for a chlamydia infection.
No postnatal complications were documented. Mother and baby spent two days on the maternity ward and were discharged home with no issues.
Medication use during pregnancy?
Prenatal vitamins and folic acid supplementation.
Alcohol and drug use?
The mother denied any alcohol or drug use during the pregnancy.
How long has the infant been lethargic?
Initially the parents stated that the infant had been drowsy for 1-2 days. After speaking with the grandmother, it became apparent that the infant had been lethargic for over two weeks and had vomited several times over the last week.
Do the parents have any other concerns about the infant?
Nil concerns voiced by the parents.
The parents denied any fevers, vomiting, seizures, or accidental injury. However the child’s father mentions to you in the corridor after your initial discussion that he had accidentally dropped the infant in his crib a week ago and wondered if that might be related to the infant’s current presentation.
How is the infant feeding?
The infant is breastfed and feeding 10-12 times a day, but falls asleep during feeds. Mother needs to wake him up for feeds. She denied any issues with breastfeeding and is receiving support from a lactation consultant.
Opening bowels regularly.
5-6 wet nappies a day.
Sleeps all night. Mother needs to wake him for feedings. Often sleeps in bed with the parents.
How are the parents coping?
Mother is exhausted and appears depressed. She is slow to process information and has difficulty answering questions.
Father states he couldn’t be happier and is enjoying spending time with his son.
Maternal grandmother is very proud and supportive of her daughter.
No known allergies.
No immunisations yet, but appropriate vaccination appoint has been booked for when the child is 8 weeks old.
Any relevant family history?
Nil congenital heart disease, autoimmune disorders, bleeding/clotting disorders, congenital anomalies, genetic syndromes, learning disabilities, perinatal death, SIDS, eye problems, or other health issues.
Both parents are currently unemployed but the father is currently looking for some work.
Alcohol, tobacco, and drug use?
The mother drinks 5-10 units a week of alcohol but does not smoke or use recreational drugs.
The father drinks 10-15 units a week of alcohol and does occasionally smoke cannabis.
Current living situation?
Both parents and the infant are living with the infant’s maternal grandmother.
Domestic violence has previously been reported during the pregnancy, but the mother denies any recurrence of this recently.
Inconsistent history, delay in seeking medical treatment, and suspicious mechanism of injury are all red flags for non-accidental injury. Poor feeding, vomiting, and lethargy are all non-specific findings, but can indicate head trauma. Signs of brain injury may include seizures, altered mental status, and apneic episodes and should not be missed.
In young children the history is not as useful for narrowing down the differential diagnosis as the infant can not report symptoms and signs are generally non-specific (e.g. crying, poor feeding). As a result a full screen of all systems should be adopted to reduce the risk of missing pathology.
Basic observations & measurements
Vital signs are within normal limits.
- Weight: 3.8kg (10th-25th percentile)
- Length: 54cm (25th-50th percentile)
- Head circumference: 38cm (25th-50th percentile)
The infant is sleeping on general inspection with no obvious evidence of injury, no abnormal posturing and no signs of distress. There is normal child-caregiver interaction.
Systems based physical exam
- Normal head size and shape
- No bulging fontanelle
- No dysmorphic features
- Very difficult to elicit spontaneous eye opening
- Extraocular movements were not assessed for this reason
- Eyes were of normal shape and symmetrical
- Red reflex present
- No subconjunctival hemorrhage or discharge
- Fundoscopy – extensive bilateral retinal hemorrhages
- No skin tags or pits
- Normal pinna shape and position
- Otoscopy was not performed
- No hard or soft palate abnormalities
- Normal rooting reflex
- No goiter, cysts, or neck webbing
- Full range of movement
- Innocent flow murmur
- No heaves
- BP equal in both limbs
- Pulses were regular and equal – CRT <2s
- Peripheries were warm and well perfused
- Normal chest expansion
- Equal breath sounds bilaterally
- No abnormal sounds
- No signs of respiratory distress
- No distention or masses
- Bowel sounds present
- No signs of infection around the umbilical stump
- Normal genitalia with descended testes
- Passing urine and feces
- No swelling or point tenderness of extremities
- Normal passive ROM
- Barlow and Ortolani tests were negative
- No additional digits or palmar/plantar creases
- Normal tone
- Primitive reflexes present
- Deep tendon reflexes were normal
- Drowsy and lethargic
- No rashes or birthmarks noted
- Normal curvature of spine
- No hair patches
- No visible signs of trauma
When non-accidental injury, specifically head trauma, is suspected, the clinician should be looking for signs of raised intracranial pressure, such as bradycardia, decreased respiration rate, apneic episodes, and bulging fontanelles.
The presentation of this infant was not particularly dramatic, which increases the chances that the correct diagnosis will be missed. Additionally, the presentation was relatively non-specific (as is often the case), which makes the diagnosis more difficult. Fortunately in this case, there were elements in the history of presenting complaint and pregnancy history that immediately lead to suspicions of non-accidental injury. Lastly, this infant was only one month old and there is good evidence that non-accidental head trauma in very young infants is often missed, despite them being at a higher risk of being abused.
At this stage, acute and reversible causes of the infant’s altered mental status need to be investigated.
- Full blood count – normal
- Serum biochemistry – normal
- Coagulation studies – normal
- LFTs – normal
- CRP – normal
- Lactate – normal
- Capillary blood glucose – normal
- Urine MC&S – normal
- CT Head – small left subdural haematoma – no midline shift
- A skeletal survey – 2 posterior rib fractures
Shaken baby syndrome
When the infant is being shaken by their caregiver, posterior rib fractures and intracranial haemorrhages can result if enough force has been applied. Subdural hemorrhages are most commonly seen, but subarachnoid hemorrhages can occur as well. Neurological signs that point towards raised intracranial pressure secondary to bleeding and/or brain swelling include vomiting, apneic episodes, seizures, irritability, and altered mental status. An absence of these signs does not rule out non-accidental head trauma. Retinal hemorrhages are seen in 80% of these cases, and are highly suggestive of non-accidental injury. Mandatory reporting and further workup is required. The clinical presentation was highly suspicious of non-accidental injury. The infant should be admitted to hospital where you know he will be safe. Clinicians are required to report suspected child abuse. Child protective services should be contacted immediately. Supportive care is the mainstay of treatment.
When the infant is being shaken by their caregiver, posterior rib fractures and intracranial haemorrhages can result if enough force has been applied. Subdural hemorrhages are most commonly seen, but subarachnoid hemorrhages can occur as well. Neurological signs that point towards raised intracranial pressure secondary to bleeding and/or brain swelling include vomiting, apneic episodes, seizures, irritability, and altered mental status. An absence of these signs does not rule out non-accidental head trauma. Retinal hemorrhages are seen in 80% of these cases, and are highly suggestive of non-accidental injury. Mandatory reporting and further workup is required.
The clinical presentation was highly suspicious of non-accidental injury. The infant should be admitted to hospital where you know he will be safe. Clinicians are required to report suspected child abuse. Child protective services should be contacted immediately. Supportive care is the mainstay of treatment.