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儿童虐待：婴儿及儿童虐待性头部创伤的流行病学、机制和类型

Authors
Cindy Christian, MD
V Jordan Greenbaum, MD
Section Editors
Daniel M Lindberg, MD
Jan E Drutz, MD
Douglas R Nordli, Jr, MD
Deputy Editor
James F Wiley, II, MD, MPH
Translators
刘劲芳, 副教授

引言

因儿童虐待致死的儿童中有超过40%的年龄小于1岁[1]。虐待性头部创伤(abusive head trauma, AHT)是致死性儿童虐待最常见的原因。大部分2岁以下儿童的致死性头部损伤继发于虐待[2]。颅脑创伤婴儿往往表现为非特异性的临床症状，并且无明确的创伤史。因此，在初始评估时，有高达30%的虐待性头部损伤患儿可能被误诊[3]。

早期识别AHT能够挽救患儿的生命。在一项描述虐待性头部损伤漏诊病例的回顾性研究中，如果之前在对隐匿性头部创伤相关症状进行医疗评估期间能够认识到受伤机制，那么5例死亡中的4例可能被避免[3]。

本文将总结在受虐待儿童中所见头部损伤的流行病学、机制和类型。婴儿和儿童AHT的临床症状、评估和诊断，包括眼科方面的问题，以及疑似儿童虐待的治疗将单独讨论。 (参见“儿童虐待：婴儿及儿童中虐待性头部创伤的评估与诊断”和“Child abuse: Eye findings in children with abusive head trauma (AHT)”和“儿童身体虐待：诊断性评估和处理”)

定义

AHT包括由钝力创伤、摇晃或者联合暴力所造成的虐待性颅骨、脑和脊髓损伤[4,5]。损伤本身可能是原发性的，也可能是继发性的。与摇晃有关的典型损伤类型包括弥漫性单侧或双侧硬膜下出血、弥漫性多层视网膜出血，以及弥漫性颅脑创伤。这种类型被归为“婴儿摇晃综合征”或“摇晃/撞击综合征”[6,7]。缺乏外伤史和没有损伤的外在表现使得难以识别出这些损伤的虐待本质。美国儿科学会(American Academy of Pediatrics, AAP)推荐，在病历中使用更为广义的术语“虐待型颅脑创伤”来替换“婴儿摇晃综合征”，因为“虐待型颅脑创伤”这一术语使得对于任何儿童考虑到创伤的多种机制[5]。通用术语，例如“头部损伤”，也有助于从损伤如何发生的调查中区分出该创伤诊断[5,8]。

在进行虐待型创伤诊断的过程中，脑损伤机制是必须考虑到的唯一因素。诊断的意义(在儿童保护和刑事起诉方面)可能是相似的，无论损伤是由直接暴力击打还是由摇晃导致[9]。此外，许多支持受伤机制由摇晃导致的证据是回顾性和间接的。 (参见下文‘受伤机制’和“儿童虐待：婴儿及儿童中虐待性头部创伤的评估与诊断”，关于‘诊断’一节)

                   

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Literature review current through: 2017-06 . | This topic last updated: 2016-05-31.
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