Abusive head trauma in infants and young children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 10 Aug 2025

Last updated: 22 Mar 2024

Abusive head trauma in infants and young children is diagnosed when there is unexplained injury to the skull, brain, and/or spinal cord with no other medical explanation for their clinical presentation.

Frequently, there are other associated findings such as widespread retinal hemorrhaging, unexplained bruising, fractures and/or abdominal trauma. These additional findings are not necessary to make the diagnosis of abusive head trauma.

The clinical presentation and degree of injury occur on a spectrum from mild to severe. Management is supportive, with intervention to stop seizures and reduce intracranial pressure if needed.

Around 10% of victims die from their injuries.

Most surviving victims are at high risk of permanent neurologic damage, vision loss, and pervasive cognitive deficits and behavioral issues ranging from moderate to severe.

Children with inflicted brain injury have worse neurocognitive outcome than those with accidental head trauma.

In many cases repeated injury has occurred, as documented by the finding of old injuries such as fractures and previous head injury.

Definition

Abusive head trauma refers to the constellation of cranial, spinal cord, and brain injuries that result from deliberately inflicted injury in infants and children.[1] The term includes injuries caused by shaking and by direct trauma to the head.

Abusive head trauma may be associated with other forms of physical abuse that may result in bruising, fractures, or abdominal injury in addition to brain injury.[1][2]

History and exam

Key diagnostic factors

age <3 years
altered mental status: irritability/lethargy/coma
clinical findings inconsistent with carer history
retinal/vitreal hemorrhages or retinoschisis
apnea

Full details

Other diagnostic factors

no known history of trauma
seizure
vomiting
loss of muscle tone
brisk or asymmetric reflexes
unexplained bruising
increasing head circumference
bulging fontanelle
long-bone fractures
mucosal injury or torn labial/lingual frenulum
anogenital signs and symptoms

Full details

Risk factors

age <1 year
peak of normal crying curve
male caregiver
unrelated adult household member
male sex
socioeconomic stressors

Full details

Diagnostic tests

1st tests to order

cranial CT scan
CBC
liver function tests
toxicology screen
prothrombin time (PT)/activated PTT/fibrinogen/von Willebrand testing
urinalysis
cerebrospinal fluid analysis
cranial MRI

Full details

Tests to consider

spinal MRI
cranial ultrasound
skeletal survey
complementary imaging
blood culture
serum calcium
serum 1,25-dihydroxy vitamin D levels (calcidiol)
serum inorganic phosphorus
serum parathyroid hormone (PTH)
serum alkaline phosphatase
skin biopsy/fibroblast culture
postmortem exam

Full details

Treatment algorithm

ACUTE

all patients

Contributors

Authors

Barney Scholefield, MBBS, BSc, MSc, MRCPCH, PhD

Consultant in Paediatric Intensive Care

NIHR Clinician Scientist

Birmingham Women’s and Children’s NHS Foundation Trust

Birmingham

Disclosures

BS receives grant funding from the UK NIHR Clinician Scientist Fellowship programme.

Acknowledgements

Dr Barney Scholefield would like to gratefully acknowledge Dr Joe Brierley, Dr Gavin Wooldridge, and Dr Alice Newton, previous contributors to this topic.

Disclosures

JB, GW, and AN declare that they have no competing interests.

Peer reviewers

Amy Goldberg, MD

Attending Physician

Child Protection Team

Hasboro Children's Hospital

Assistant Professor of Pediatrics

Alpert Medical School

Brown University

Providence

Disclosures

AG declares that she has no competing interests.

Rebecca Moles, MD

Division Chief

Child Protection Program

UMass Memorial Medical Center

Worcester

Disclosures

RM declares that she has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Narang SK, Fingarson A, Lukefahr J; Council on Child Abuse and Neglect. Abusive head trauma in infants and children. Pediatrics. 2020 Apr;145(4):e20200203.Full text Abstract

Nuño M, Pelissier L, Varshneya K, et al. Outcomes and factors associated with infant abusive head trauma in the US. J Neurosurg Pediatr. 2015 Nov;16(5):515-22.Full text Abstract

National Institute for Health and Care Excellence (UK). Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication].Full text

Piteau SJ, Ward MG, Barrowman NJ, et al. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012 Aug;130(2):315-23. Abstract

Christian CW, Levin AV, Committee on Child Abuse and Neglect, et al. The eye examination in the evaluation of child abuse. Pediatrics. 2018 Aug;142(2):e20181411.Full text Abstract

American College of Radiology. Practice parameter for the performance and interpretation of skeletal surveys in children. 2021 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Accidental head trauma
- Birth trauma
- Central nervous system infection: meningitis and encephalitis
More Differentials
Guidelines
- Summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces
- Pediatric life support 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
More Guidelines
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Abusive head trauma in infants and young children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

all patients

Contributors

Authors

Barney Scholefield, MBBS, BSc, MSc, MRCPCH, PhD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Amy Goldberg, MD

Disclosures

Rebecca Moles, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice