CORE – INFO:Anafiadau pen ac anafiadau i’r cefn

ymhlith plant

Cyflwyniad

Mae’r daflen hon yn crynhoi’r hyn a wyddys ar hyn o bryd am gyflwyniad clinigol anafiadau pen ac anafiadau i’r cefn i blant yn sgil cam-drin (AHT).

Mi fydd o ddiddordeb arbennig i:

• staff damweiniau ac achosion brys• paediatregwyr; • meddygon teulu; • ymwelwyr iechyd; • cadeiryddion cynadleddau amddiffyn plant; • arweinwyr diogelu; • rheolwyr timau gwasanaethau plant; • swyddogion adolygu annibynnol; • swyddogion dynodedig awdurdod lleol; • gweithwyr cymdeithasol plant; • yr heddlu ac ymarferwyr cyfreithiol.

Mae’r wybodaeth yn seiliedig ar adolygiad systematig o’r holl waith ansawdd yn llenyddiaeth y byd am anafiadau pen ac anafiadau i’r cefn i blant yn sgil cam-drin; mae manylion llawn ar gael yn core-info.cardiff.ac.uk

Beth ydyn ni’n ei wybod am anafiadau pen i blant yn sgil cam-drin?Anafiadau pen yn sgil cam-drin sy’n anafu’r ymennydd neu’n achosi gwaedu yn y strwythurau o amgylch yr ymennydd yw’r math mwyaf difrifol o gam-drin yn gorfforol ar blant, ac mae ganddynt rai o’r canlyniadau mwyaf difrifol i les y plentyn yn y dyfodol. Dyma achos mwyaf marwolaeth ymhlith plant a fu’n destun camdriniaeth.

Gall AHT godi o anafiadau ysgwyd, ysgwyd a tharo, neu daro.Gwelir y cyflwr yn fwyaf cyffredin ymhlith plant llai na dwy flwydd oed, ac amcangyfrifir ei fod yn gyffredin mewn 1:3,000 o fabanod sy’n llai na chwe mis. Mae’n ymddangos bod bechgyn yn dioddef mwy o anafiadau pen na merched, o unrhyw achos. Ar wahân i blant sy’n marw o ganlyniad i AHT, gallai’r rheini sy’n goroesi gael anableddau tymor hir sylweddol: mae 31 i 45 y cant yn cael problemau parhaus – gan gynnwys parlys yr ymennydd, problemau golwg, epilepsi, problemau dysgu ac ymddygiadol.

Prin y bydd cam-drin corfforol yn digwydd unwaith. Mae llawer o blant sy’n dioddef AHT wedi dioddef o achosion blaenorol o gam-drin corfforol. Mae’n hanfodol yr ymchwilir yn llawn i unrhyw amheuaeth o gam-drin corfforol i faban neu blentyn ifanc iawn, er mwyn nodi’r cyflwr ac atal cam-drin corfforol mwy difrifol yn y dyfodol.

Ar ôl ei adnabod, mae’n rhaid i AHT gael triniaeth briodol ar unwaith i leihau risg marwolaeth neu broblemau tymor hir difrifol.

Anafiadau i’r pen

Sut ydw i’n gwybod a yw plentyn efallai wedi dioddef anaf pen yn sgil cam-drin?Bydd rhai plant yn cyflwyno arwyddion clir o anaf pen, hyd yn oed os nad yw’r achos yn amlwg yn syth. Byddant naill ai’n anymwybodol neu’n dangos arwyddion o anaf ymennydd fel ffitiau, parlys neu lid eithafol. Fodd bynnag, gallai rhai plant gyflwyno arwyddion llai amlwg, fel cylchedd pen mwy, bwydo gwael neu grio gormodol.

Gall plant sydd wedi dioddef anaf ymennydd trawmatig o unrhyw achos gael cyfuniad o anafiadau. Mae rhai nodweddion clinigol yn gallu bod yn arwyddion pendant o AHT. Ymhlith y rhain mae gwaedlifau retinol, torri asennod, cleisiau ar y pen a/neu’r gwddf, ac apnoea (trafferthion anadlu).

Mae’n bwysig chwilio am anafiadau eraill – ee cleisiau, llosgiadau, cnoadau, anafiadau neu doriadau geneuol. Mae angen dehongli’r rhain yn ofalus, yn ogystal ag ymchwilio am achosion posibl eraill o anaf ymddangosiadol i’r ymennydd, yn rhan o asesiad y plentyn.

O ystyried pwysigrwydd y nodweddion hyn, os amheuir bod gan unrhyw blentyn AHT, dylai gael archwiliad trwyadl i ddiystyru anafiadau felly a oedd yn bodoli eisoes. Dylai hyn gynnwys archwiliad llygaid gan offthalmolegydd pediatrig ac arolwg sgerbwd â golygon arosgo ar yr asennau, ac ystyried arolwg sgerbwd dilynol (11-14 diwrnod wedyn) os yw’r delweddau gwreiddiol yn negyddol ac yn peri pryder.

• Apnoea – cyfnodau o anadlu diffygiol.• Gwaedlifoedd retinol – gwaedu yng nghefn y llygad.

Pa brofion y mae angen eu cynnal i nodi anaf ymennydd yn sgil cam-drin?Os amheuir AHT mewn plentyn sy’n ddifrifol sâl, dylid cynnal sgan CT, gydag adluniad 3D o’r sgan CT, i chwilio am doriadau penglog. Wrth wneud hyn, mae’n bosib y cynhelir sgan CT (asgwrn cefn serfigol) ar y gwddf hefyd. Os yw’r sgan CT yn annormal, neu os yw’n normal ond bod gan y plentyn symptomau neu arwyddion parhaus o anaf ymennydd, dylid cynnal sgan MRI. Bydd hyn yn dangos delweddau adrannol manwl o’r ymennydd ac yn rhoi gwybodaeth lawer manylach am unrhyw anafiadau ymennydd sy’n bresennol, ac efallai bydd yn helpu i ragweld amseru’r anaf (yn gyffredinol) a’r canlyniad tymor hir tebygol i’r plentyn.

Mae’r profion hyn a’u dehongli yn faes arbenigol dros ben a dylid eu hadolygu gan niwroradiolegydd â phrofiad clinigol o’r anafiadau hyn.

• Sgan CT – tomograffeg gyfrifiadurol: prawf radiolegol i nodi unrhyw anaf ymennydd acíwt neu waedu yn yr ymennydd neu o gwmpas yr ymennydd.

• MRI – delweddu cyseiniant magnetig: archwiliad radiolegol manwl i ddangos maint anafiadau i’r ymennydd, gan gynnwys anafiadau o ganlyniad i hypocsia (lefelau isel o ocsigen).

Pa ganfyddiadau ar niwro-ddelweddu sy’n awgrymu anaf ymennydd yn sgil cam-drin?Adroddir am bob math o anafiadau ymennydd mewn AHT ac anafiadau pen damweiniol. Mae astudiaethau o ganfyddiadau CT a MRI wedi dangos bod y nodweddion a welir mewn AHT yn cynnwys ardaloedd o waedu o gwmpas yr ymennydd ei hun, yn fwyaf cyffredin gwaedlifoedd islaw’r freithell (SDH), gyda gwaedlifoedd islaw’r arachnoid (SAH) neu hebddynt. Dyma’r nodweddion a allai wahaniaethu rhwng AHT ac anaf damweiniol:

• anaf hypogsig isgemig • gwaedlifoedd islaw’r freithell (SDHs) – yn arbennig os oes amryw, dros arwyneb

yr ymennydd, yn y rhigol sy’n gwahanu dau hanner yr ymennydd neu ar y cefn.

Mae niwed i’r ymennydd ei hun o ddiffyg ocsigen ac ymyrryd â chyflenwad gwaed yn fwy cyffredin mewn AHT nag anaf pen damweiniol. Mae hyn yn cyfrannu at ganlyniadau gwael i’r plant hyn. Mae gwaedlifoedd y tu allan i’r freithell yn fwy cyffredin mewn anafiadau pen damweiniol.

Wrth reswm, bydd angen ymchwiliad trwyadl ar unrhyw blentyn ag anaf ymennydd heb eglurhad – ee, am gyflyrau metabolaidd neu haematolegol, cyn y gellir dod i’r casgliad mai camdriniaeth sydd wedi achosi’r abnormaleddau.

• Gwaedlifoedd islaw’r freithell (SDH) – yn gwaedu dros arwyneb yr ymennydd rhwng y freithell dew a’r arachnoid, y ddwy bilen o amgylch yr ymennydd (mae’r freithell dew o dan y benglog).

• Gwaedlifoedd islaw’r arachnoid (SAH) – yn gwaedu dros arwyneb yr ymennydd o dan yr arachnoid.

• Gwaedlifoedd y tu allan i’r freithell - yn gwaedu y tu allan i’r freithell dew.

Anafiadau Cefn

Pa anafiadau i’r cefn mae camdriniaeth yn eu hachosi?Mae mwy a mwy o adroddiadau yn y llenyddiaeth wyddonol am anafiadau a achoswyd i’r cefn mewn plant. Disgrifir dau batrwm anaf:

• anafiadau gwddf• anafiadau brest neu waelod y cefn.

Pan fydd plentyn yn cael anaf gwddf o gamdriniaeth gorfforol mae’n aml yn cael AHT a/neu waedlifoedd retinol yn cydfodoli. Adroddir am anafiadau gwddf yn fwy cyffredin ymhlith babanod iau hyd at bedwar mis. Mewn llawer o achosion, efallai na fydd yr anaf i’r cefn yn amlwg ar unwaith oherwydd gallai’r anaf i’r ymennydd olygu bod y plentyn yn anymwybodol ac anodd ei asesu. Weithiau, efallai bydd y baban yn amharod neu’n flin pan symudir ei wddf, gan nodi’r anaf sylfaenol. Mae gwaith ymchwil newydd yn awgrymu y gall babanod sydd wedi cael anaf pen yn sgil cam-drin fod wedi cael anafiadau i ewynnau’r asgwrn cefn o amgylch y gwddf hefyd.

Adroddir am anafiadau brest neu waelod y cefn ymhlith plant bach hyn, o naw mis i fyny, a law yn llaw â hwy daw naill ai arwyddion o anaf i’r cefn neu anffurfiad amlwg, fel crymedd y cefn neu chwydd yng ngwaelod y cefn. Mae llawer o’r plant hyn naill ai’n marw o ganlyniad i’w hanafiadau neu’n cael eu parlysu’n barhaol. Hefyd, cydnabyddir fwy a mwy bod gan blant ag AHT waedlifoedd islaw’r freithell cefn sy’n ymestyn yr holl ffordd i lawr i ben isaf yr asgwrn cefn.

Pa brofion y dylid eu gwneud i nodi anaf i’r cefn yn sgil cam-drin?Mae’n bwysig bod plentyn o dan ddwy flwydd oed ag unrhyw amheuaeth o gamdriniaeth gorfforol yn cael arolwg sgerbwd llawn, y mae’n rhaid iddo gynnwys pelydrau X plaen o’r asgwrn cefn - gan gynnwys golygon ochrol. Os gwelir unrhyw doriad neu os amheuir anaf i fadruddyn y cefn, dylid hefyd cynnal MRI o’r cefn. Yn sgil cydfodolaeth anaf i’r cefn ac AHT, dylai clinigwyr ystyried cynnal MRI o’r cefn fel rhan o’u hasesiad arferol.

ˇ

Goblygiadau i ymarfer

• Gall fod yn anodd ymdopi â chrio gormodol ymhlith babanod a gall eu gwneud yn fwy agored i anaf ymennydd a achoswyd. Mae angen cynghori pob rhiant sut i ymdopi os bydd eu babanod yn crio am amser hir.

• Dylai babanod ag anafiadau camdriniol – fel torasgwrn, cleisiau, llosgiadau, anafiadau geneuol neu waedlif retinol – gael niwroddelweddu am AHT posibl.

• Dylai plentyn ag anafiadau camdriniol ac unrhyw arwyddion neu symptomau o anaf ymennydd – ee, os yw’n cael trawiadau neu’n anymwybodol – gael niwroddelweddu.

• Rhaid i unrhyw blentyn yr amheuir bod ganddo AHT gael archwiliad llygaid gan offthalmolegwr, a chael arolwg sgerbwd llawn i ddod o hyd i unrhyw dorasgwrn sydd wedi’i guddio, fel torri asen neu asgwrn hir.

• Dylid hefyd cofnodi’n benodol a yw’r plentyn wedi dioddef o apnoea neu ffitiau.• Dylai plentyn ag anaf pen a amheuir gael ei weld ar unwaith gan feddyg, fel

y dylai unrhyw blentyn â phoen heb eglurhad, nam niwrolegol, chwydu neu anaf cysylltiedig.

Canllawiau cenedlaethol

• Standards for radiological investigations of suspected non-accidental injury. Coleg Brenhinol y Radiolegwyr, Coleg Brenhinol Pediatreg ac Iechyd Plant. 2008.

• Head Injury: triage, assessment, investigation and early management of head injury in children, young people and adults. Y Sefydliad Cenedlaethol dros Iechyd a Rhagoriaeth Glinigol. 2014

Rhagor o gymorth gan yr NSPCC

Os ydych chi’n poeni am blentyn, mae’r NSPCC yma i helpu 24 awr y dydd, saith niwrnod yr wythnos, yn rhad ac am ddim.

Ffôn 0808 800 5000E-bost help@nspcc.org.ukNeges destun 88858 (Anfonwch neges destun i 07786 200001 yn yr Ynysoedd y Sianel - cyfraddau galwadau safonol)Neu ewch i nspcc.org.uk/help

Gwasanaeth gwybodaeth NSPCCLlyfrgell yr NSPCC yw’r casgliad mwyaf cynhwysfawr o adnoddau arbenigol yn ymwneud ag amddiffyn plant yn y DU. Mae’n cynnwys dros 40,000 o gofnodion a gallwch gael mynediad ato yn nspcc.org.uk/inform

Gallwch hefyd danysgrifio i CASPAR, sef gwasanaeth newyddion sy’n eich cyfeirio at y polisïau, yr ymarfer a’r ymchwil diweddaraf ym maes amddiffyn plant.

Cofrestrwch yn nspcc.org.uk/inform

I lwytho’r daflen hon oddi ar y we am ddim, neu i gael copïau caled ohoni, ewch i nspcc.org.uk/core-info i gael manylion prisiau.

Adolygiad systematig o anafiadau niwrolegol – diweddarwyd Gorffennaf 2013. Adolygiad systematig o anafiadau i’r cefn – diweddarwyd Tachwedd 2013. Taflen Core-info – diweddarwyd Mai 2014.

I gael y wybodaeth ddiweddaraf am yr adolygiad hwn ac am adolygiadau systematig eraill y prosiect, ewch i wefan Core info: core-info.cardiff.ac.uk

Gallwch gael rhagor o fanylion am yr adolygiad hwn drwy sganio’r cod QR isod.

Mae hwn yn brosiect ar y cyd rhwng Rhaglen Ymchwil y Blynyddoedd Cynradd, Sefydliad Gofal Sylfaenol ac Iechyd y Cyhoedd Cochrane, Ysgol Feddygol, Prifysgol Caerdydd a’r NSPCC.

© NSPCC a Phrifysgol Caerdydd, 2012. © 2014 NSPCC – cedwir pob hawl. J20141089. Ffotograffiaeth gan Paul Close, ystumiwyd gan fodelau. Rhifau elusen gofrestredig NSPCC 216401 a SC037717.

CORE – INFO:Head and spinal

injuries in children

Introduction

This leaflet summarises what is currently known about the clinical presentation of abusive head trauma (AHT) and spinal injuries in children.

It will be of particular interest to:

• emergency department staff• paediatricians• general practitioners• health visitors• child protection conference chairs• safeguarding leads• children’s services team managers• independent reviewing officers• local authority designated officers• children’s social workers• police• legal practitioners.

The information is based on a systematic review of all the quality work in the world literature about abusive head trauma and spinal injuries in children (1950-2013); full details are available at core-info.cardiff.ac.uk

What do we know about abusive head trauma in children?Abusive head trauma, involving injury to the brain or bleeding within the structures around the brain is the most serious form of physical child abuse, and these have some of the most severe consequences for the child’s future wellbeing. AHT is the leading cause of death among children who have been abused.

AHT may arise from shaking, shaking and impact, or impact injuries.The condition occurs most commonly in children younger than two years of age, with an estimated prevalence of 1:3,000 in babies younger than six months. Boys appear to suffer more head injuries than girls, from any cause. Apart from children who die as a result of AHT, those who survive may have significant long-term disabilities: 31 to 45 per cent experience ongoing problems – including cerebral palsy, visual problems, epilepsy, learning and behavioural problems.

Physical abuse is rarely a single event. Many children who suffer AHT have suffered from previous episodes of physical abuse. It is vital that any suspicion of physical abuse to a baby or very young child is fully investigated to identify the condition and prevent future physical abuse of greater severity.

Once recognised, AHT must receive prompt and appropriate treatment to minimise the risk of death or serious long-term problems.

Head injury

How do I know if a child may have suffered from abusive head trauma?Some children will present with clear signs of head injury, even if the cause is not immediately obvious. They will either be unconscious or show signs of brain injury such as fitting, paralysis or extreme irritability. However, some children may present with less obvious signs, such as increased head circumference, poor feeding or excessive crying.

Children who have suffered a traumatic brain injury from any cause may sustain a combination of injuries. Some clinical features are particularly indicative of AHT. These include rib fractures, bruising to the head and/or neck, seizures and apnoea (breathing difficulties).

It is important to look for other injuries, such as retinal haemorrhages, bruises, burns, bites, oral injuries or fractures. These need careful interpretation, as well as investigations for other possible causes of apparent brain injury, as part of the child’s assessment.

Given the importance of these features, it is essential that any child where AHT is suspected should have a thorough examination to exclude such co-existing injuries. This should include an eye examination by a paediatric ophthalmologist and a skeletal survey with oblique views of the ribs, and consideration of a follow up skeletal survey (11-14 days later) if the original imaging is negative and concerns remain.

• Apnoea – periods of impaired breathing.• Retinal haemorrhages – bleeding at the back of the eye.

What tests need to be performed to identify abusive head trauma?If AHT is suspected in a child who is acutely unwell, then a CT scan should be performed, with a 3D reconstruction of the CT scan, to look for skull fractures. When performing this, a CT scan of the neck (cervical spine) may also be conducted. If the CT scan is abnormal, or it is normal but the child has ongoing symptoms or signs of brain injury, then an MRI scan should be performed. This will show detailed sectional images of the brain and give much more detailed information about any brain injuries present, and perhaps assist in predicting the timing of the injury (in broad terms) and the likely long-term outcome for the child.

These tests and their interpretation are highly specialised and should be reviewed by a neuroradiologist with clinical experience of these injuries.

• CT scan – computerised tomography: a radiological test to identify any acute brain injury or bleeding in or around the brain.• MRI – magnetic resonance imaging: a detailed radiological investigation

showing extent of brain injuries, including injuries due to hypoxia (low oxygen levels).

What findings on neuroimaging suggest abusive head trauma?Brain injuries of all types are reported in AHT and accidental head injury. Studies of CT and MRI findings have shown that the features seen in AHT include areas of bleeding around the brain itself, most commonly subdural haemorrhages (SDHs), with or without subarachnoid haemorrhages (SAHs). The features that may distinguish AHT from accidental injury are:

• hypoxic ischaemic injury• SDHs – particularly if multiple, over the surface of the brain, in the

groove separating the two halves of the brain (interhemispheric), or at the back (posterior).

Damage to the brain itself from lack of oxygen and interrupted blood supply is more common in AHT than accidental head injury. This contributes to poor outcomes for these children. Extradural haemorrhages are more common in accidental head injuries.

Any child with an unexplained brain injury will, of course, require a thorough investigation – eg, for metabolic or haematological conditions, before it can be concluded that the abnormalities are due to abuse.

• Subdural haemorrhages (SDH) – bleeds over the surface of the brain between the dura mater and the arachnoid mater, the two membranes that surround the brain (the dura mater underlies the skull).

• Subarachnoid haemorrhages (SAH) – bleeds over the surface of the brain underlying the arachnoid mater.

• Extradural haemorrhages – bleeds outside the dura mater.

Spinal injury

What spinal injuries are caused by abuse?There are increasing reports in the scientific literature of spinal injuries from physical abuse. Two patterns of injury are described:

• spinal neck injuries • chest or lower back injuries.

When a child sustains a spinal neck injury from physical abuse they often have co-existing AHT and/or retinal haemorrhages. Neck injuries are more commonly reported in younger infants up to four months. In many cases, the spinal injury may not be immediately obvious as the injury to the brain may leave the child unconscious and difficult to assess. In some cases, the baby may be reluctant or distressed when its neck is moved, indicating the underlying injury. New research suggests that infants with abusive head trauma may have sustained injuries to the ligaments of the spine in the neck area also.

Spinal injuries to the chest or lower back are reported in older toddlers, from nine months upward, and are accompanied either by signs of spinal injury or an obvious deformity, such as spinal curvature or swelling of the lower back. Some of these children either die as a result of their injuries or are left with permanent paralysis. In addition, it is increasingly recognised that children with AHT have co-existing spinal subdural haemorrhages which extend all the way down to the lower end of the spine.

What tests should be done to identify spinal injury from physical abuse?It is important that a child under two years with any suspected physical abuse has a full skeletal survey, which must include plain X-rays of the spine – including lateral views. If any fracture is seen or spinal cord injury is suspected, an MRI of the spine should also be performed. In light of the co-existence of spinal injury with AHT, clinicians should consider performing an MRI of the cervical spine as part of their routine assessment.

Implications for practice

• Excessive crying in babies can be difficult to manage and may make them more vulnerable to inflicted brain injury. All parents need to be advised on how to manage episodes of prolonged crying.

• Infants with abusive injuries – such as fractures, bruises, burns, oral injuries or retinal haemorrhage – should have neuroimaging for possible AHT.

• A child with abusive injuries and any signs or symptoms of brain injury – eg, if they have seizures or are unconscious – should have neuroimaging performed.

• Any child with suspected AHT must have their eyes examined by an ophthalmologist, and undergo a full skeletal survey to identify any possible occult fractures, such as rib or long bone fractures.

• Explicit recording of whether the child has suffered from apnoea or seizures should also be made.

• A child with a suspected head injury should be seen promptly by a doctor, as should any child with unexplained pain, neurological impairment, vomiting or associated injury.

National guidelines

• Standards for radiological investigations of suspected non-accidental injury. Royal College of Radiologists, Royal College of Paediatrics and Child Health. 2008: (undergoing revision 2014).

• Head Injury: triage, assessment, investigation and early management of head injury in children, young people and adults. National Institute for Clinical Excellence. 2014

Further support from the NSPCC

If you are worried about a child, the NSPCC is here to help, 24 hours a day, seven days a week, free of charge.

Phone 0808 800 5000Email help@nspcc.org.ukText 88858 (Text 07786 200001 in Channel Islands, standard call rates apply)Or visit nspcc.org.uk/help

NSPCC’s information serviceThe NSPCC’s library is the most comprehensive collection of specialist resources relating to child protection in the UK. It contains over 40,000 records and you can access it online at nspcc.org.uk/inform

You can also subscribe to CASPAR, a news service that signposts you to the latest policy, practice, and research in child protection.

Sign up at nspcc.org.uk/inform

To download this leaflet for free, or for printed copies of this leaflet, please go to nspcc.org.uk/core-info for price details.

Neurological injuries systematic review updated July 2013. Spinal injuries systematic review updated November 2013. Core-info leaflet updated May 2014.

For the most up to date information on this review and the project’s other systematic reviews visit the Core info website core-info.cardiff.ac.uk

Further details of this review can be found by scanning the QR code below.

This is a collaborative project between the Early Years Research Programme, Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University and the NSPCC.

© NSPCC and Cardiff University, 2012. © NSPCC 2014 - all rights reserved. J20141089. Photography by Paul Close, posed by models. NSPCC registered charity numbers 216401 and SC037717. Stores code: NS/1578.