Abusive head trauma refers to the constellation of cranial, spinal cord, and brain injuries which result from inflicted injury in infants and young children.
Diagnosis rests on the finding of unexplained injury to the skull, brain, and/or spinal cord in an infant who has no other medical explanation for their clinical presentation.
Frequently, there are other associated findings such as widespread retinal haemorrhaging, 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.
Around 16% to 38% of victims die from their injuries.
Most surviving victims are at high risk of permanent neurological damage, vision loss, and pervasive cognitive deficits and behavioural 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.
'Shaken baby syndrome' is the lay term used to describe the constellation of injuries resulting from violent shaking of an infant by an adult or adolescent. This injury is better classified as abusive head trauma, which is described by the American Academy of Pediatrics as a serious and common form of child abuse. Abusive head trauma includes not only shaking, but direct trauma to the head, which may occur when a child is thrown or slammed against a surface. With shaking, the resultant rotational and repetitive force can lead to a spectrum of injuries, ranging from mild to fatal, and may cause subdural haemorrhage, retinal haemorrhage, and brain injury from contact injuries and hypoxic/ischaemic injury cascades. In most cases, there is also blunt force trauma. The forces that result from blunt force trauma (described as an acceleration-deceleration injury) are much higher than forces from shaking alone; thus some clinicians feel that in children with severe brain injury there has likely been not only shaking but direct head trauma. 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.
History and exam
- no known history of trauma
- loss of muscle tone
- brisk or asymmetrical reflexes
- unexplained bruising
- increasing head circumference
- bulging fontanelle
- long-bone fractures
- mucosal injury or torn labial/lingual frena
- anogenital signs and symptoms
- cranial MRI
- cranial ultrasound
- skeletal survey
- bone scintigraphy
- 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
- post-mortem examination
Barney Scholefield, MBBS, BSc, MSc, MRCPCH, PhD
Consultant in PICU
Senior Research Fellow
Birmingham Children’s Hospital
BS receives grant funding from the UK NIHR Clinician Scientist Fellowship programme.
Dr Barney Scholefield would like to gratefully acknowledge Dr Joe Brierley, Dr Gavin Wooldridge, and Dr Alice Newton, previous contributors to this monograph. JB, GW, and AN declare that they have no competing interests.
Amy Goldberg, MD
Child Protection Team
Hasboro Children's Hospital
Assistant Professor of Pediatrics
Alpert Medical School
AG declares that she has no competing interests.
Rebecca Moles, MD
Child Protection Program
UMass Memorial Medical Center
RM declares that she has no competing interests.
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