Children with abusive head trauma (shaken baby syndrome) can present quite variably. Some children may present with poor feeding, irritability or increasing head circumference. Other children can be seizing or in cardiopulmonary arrest. The presentation can be quite subtle and can mimic other conditions. There may be no findings on physical examination.

Retinal hemorrhages should raise suspicion of inflicted head trauma in the absence of a consistent medical condition (e.g. leukemia, clotting disorder, congenital infection).

On CT, the hallmarks of abusive head trauma are subdural hematomas (described as a thin rim of bleeding around the brain) and cerebral edema.

Specific fractures are also associated with abusive head trauma. These are posterior rib fractures and classic metaphyseal fractures. The latter group consists of fractures across the growth plates of long bones. Classic metaphyseal fractures are also known as bucket handle fractures, corner fractures.

The most likely cause in the above case is abusive head trauma. Although accidental head injuries can mimic some elements of abusive head trauma, the key thing to remember is that LARGE amounts of force are required to produce this pattern of injury. A high-speed motor vehicle accident or fall from greater than two stories could mimic this type of injury. However, this was not reported in the history. In cases of abusive head trauma, caregivers may attribute the injury to a fall from a much shorter height.

Aside: The term ‘abusive head trauma’ is currently used in the child abuse literature. It is synonymous with ‘shaken baby syndrome’.

Excellent question

Bruises in an infant are concerning for physical abuse. However, they could also result from a bleeding diathesis (e.g. hemophilia), a collagen vascular disease (e.g. Ehlers-Danlos syndrome) or leukemia.

As such, the minimum investigation required for bruises that are inconsistent with the history is a CBC and a PT/PTT.

X-rays, bone scanning and skeletal surveys would not have an important role to play in the assessment of bruising (although they can be important in the assessment of fractures).

Bruise colorimetry is not an actual investigation. The colour of bruises is actually largely meaningless. Bruises sustained at the same time can have different colours. The only small bit of information that can be gleaned from bruise colour is that a yellow bruise is considered to be at least 18 hours old (since it takes at least this long for red blood cells to break down to bilirubin).

Although intranasal decongestants have a role in the treatment of mild intermittent rhinitis, they should not be used for more than 10 days at a time or more than twice a month. As such, an intranasal decongestant would not be appropriate long-term therapy.

The other options described above would be safe and effective long-term treatment options that could be used in combination.

As Jonah is tolerant of cow’s milk, he should not have been tested to milk in the first place. Jonah has shown a sensitization to milk on the skin test but this does not mean that he is allergic. He regularly consumes milk without incident – that constitutes the best test for milk allergy! Jonah has tolerance to milk despite being sensitized.

Removing milk from Jonah’s diet would be difficult and unnecessary. Worse, there is evidence that avoidance of an allergen can actually prove harmful in a patient who displays sensitization on a skin test but is clinically tolerant to an allergen. When the food in question is removed from the diet, the individual can lose tolerance and develop an allergy that is essentially iatrogenic.

A food challenge would not be necessary with this patient as he is already having a daily “food challenge” at home. In a patient who is strictly avoiding a food because of a previous reaction or positive skin or blood test, food challenges can be used in the assessment of whether a child is now tolerant to the food. To be considered a candidate for a food challenge, a child would need to have food-specific IgE levels below a cutoff point and no recent allergic reactions. If the child had asthma, it would need to be well controlled before a food challenge is considered.

UTIs in children younger than 2 years old present in a non-specific fashion. The signs and symptoms include fever, hypothermia, jaundice, poor feeding, irritability, vomiting, failure to thrive, sepsis as well as strong, foul-smelling or cloudy urine.

Flank pain, costovertebral tenderness or changes in voiding patterns, although seen with UTIs in older children and adults, would not be expected in neonates and infants.

VCUG scans are indicated when you suspect vesicoureteric reflux (VUR) or bladder outlet obstruction. VCUG scans should be performed in all children under the age of 2 who present with a first UTI. This imaging modality does not have a role in the assessment of asymptomatic proteinuria or hematuria.

Ultrasound is the imaging modality of choice to assess hydronephrosis. Hydronephrosis on ultrasound sometimes indicates VUR.

DMSA scans are used to assess renal scarring in patients with VUR or recurrent urinary tract infections.

The gross hematuria and hypertension of new onset, coupled with the dipstick urinalysis suggest an acute glomerulonephritis (GN). This easily excludes Minimal Change Disease (a nephrotic syndrome) from your differential.

Alport’s syndrome (aka Hereditary GN) is unlikely. Alport’s displays dominant, recessive or X-linked inheritance and the family history generally would have included a history of end-stage renal disease in young men (although spontaneous cases can occur). Deafness and eye abnormalities are also associated. Additionally, Alport’s is a chronic form of GN and does not present acutely. It usually presents with microscopic hematuria and proteinuria.

Postinfectious GN is a possible diagnosis. It classically occurs 10-14 days after an acute illness. There is no reason to believe that the “cold” described above was streptococcal in origin. The history of treated group A Strep A pharyngitis is too remote to be related. Hence, there is no reason to believe that this would specifically be a case of poststreptococcal GN (a specific subtype of postinfectious GN). However, post-infectious GN is possible with a upper respiratory tract infection two weeks prior to the onset of symptoms. It usually occurs 2-4 weeks post-infection and can result from any infection.

IgA nephropathy classically presents with an acute unrelated illness, not after an illness.

Hence, postinfectious GN is the most likely diagnosis given the above information.

Very good question. Thank you.

Puberty in girls normally begins between the ages of 8 and 13. The first sign of puberty in girls is the development of breast buds. Signs of puberty earlier than 8 years of age is considered precocious in a girl. Onset of puberty after the age of 13 is considered delayed puberty for a girl.

Emily is normal. There is no indication of precocious puberty. As such, no investigations are required.

Although Julie appears well, you should keep her under observation until 6-8 hours after the time of the injury have elapsed. This is the time period in which most acute intracranial bleeds would present in a patient who has lost consciousness after head trauma.

An unlikely but life-threatening possibility in the above case is an epidural hematoma. This is bleeding between the dura and the skull, generally caused by tearing of the middle meningeal artery. The tear is most often caused by a temporal skull fracture secondary to blunt head trauma. Classically, these patients lose consciousness briefly and then appear well. This does not occur in all cases of epidural hematoma.

Epidural hematomas can expand rapidly. After appearing well for a lucent period, these patients can undergo an extremely rapid clinical deterioration. If this occurs, immediate neurosurgical intervention is required. As such, it would inappropriate to immediately send Julie home so soon after the injury.