Certain chemicals in the blood may indicate brain injury

Researchers at Children's Hospital of Pittsburgh have found that increased levels of certain proteins in the blood or spinal fluid may signal brain injury in infants with vomiting, fussiness and several other common symptoms.

Infants with shaken baby syndrome (SBS) - the most common cause of severe traumatic brain injuries in young children - are often misdiagnosed because doctors rarely receive a history that an infant has been shaken, the patients are too young to talk, and the symptoms such as vomiting and fussiness are common in many childhood illnesses. Infants who are misdiagnosed may be inadvertently returned to a violent caretaker and be re-injured, sometimes with fatal consequences.

Rachel Pardes Berger, MD, MPH, of Children's Child Advocacy Center, in collaboration with P. David Adelson, MD, of the Division of Pediatric Neurosurgery, and Patrick M. Kochanek, MD, of the Department of Pediatric Critical Care Medicine, both at Children's, have found that biomarkers may able to assist in identifying infants who have a brain injury that might otherwise be missed and who would benefit from additional evaluation with a head computed tomography (CT) scan. Identifying cases of SBS that might otherwise be missed has important implications for decreasing morbidity and mortality.

The findings are published in the February issue of Pediatrics, the official journal of the American Academy of Pediatrics.

"Proper diagnosis of inflicted traumatic brain injury, or shaken baby syndrome, is often difficult even for experienced and astute physicians because caregivers rarely provide a history of trauma, children present with nonspecific symptoms such as vomiting, and the physical examination can be completely normal," said Dr. Berger, who also is an assistant professor of Pediatrics at the University of Pittsburgh School of Medicine. "As a result, misdiagnosis is common and can have catastrophic medical consequences."

Dr. Berger added, "The ability to identify infants who have inflicted traumatic brain injury and might otherwise have received a misdiagnosis would allow health care providers to limit medical complications as a result of delayed diagnosis and minimize re-injury to infants by preventing them from returning to an unsafe environment. This also can help protect siblings who may be living in the same violent environment."

The study involved 98 infants who presented to Children's Hospital of Pittsburgh's Emergency Department with one of the following symptoms: an apparent life-threatening event (near-SIDS), vomiting without diarrhea, a seizure, fussiness or irritability.

Infants had their blood or spinal fluid drawn as part of their medical evaluation, and any leftover was frozen so that the biomarker concentrations could later be measured. The infants were then tracked until 1 year of age to determine whether any were subsequently diagnosed as being abused. Researchers were then able to determine how well the biomarkers established which children had SBS, which mostly likely had a routine childhood illness, and which were possible cases of missed SBS.

"One of the interesting aspects of the study was that in many of the children who were ultimately identified as having SBS, the caretaker who brought the child to the hospital for evaluation did not know that the child had been shaken," said Dr. Berger. "It is so important for physicians to realize that the adult who brings a child to the Emergency Department may have no idea that the child is being abused by another family member, babysitter, family friend or nanny."

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