Abusive head trauma in infants and young children

Last reviewed: 2 Sep 2023
Last updated: 07 Feb 2023



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
More key diagnostic factors

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
Other diagnostic factors

Risk factors

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

Diagnostic investigations

1st investigations to order

  • cranial CT scan
  • CBC
  • liver function tests
  • toxicology screen
  • prothrombin/acticated PTT/fibrinogen/von Willebrand testing
  • urinalysis
  • cerebrospinal fluid analysis
  • cranial MRI
More 1st investigations to order

Investigations to consider

  • spinal 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
  • postmortem exam
More investigations to consider

Treatment algorithm


all patients



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

Consultant in Paediatric Intensive Care

NIHR Clinician Scientist

Birmingham Women’s and Children’s NHS Foundation Trust




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 topic.


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




AG declares that she has no competing interests.

Rebecca Moles, MD

Division Chief

Child Protection Program

UMass Memorial Medical Center




RM declares that she has no competing interests.

  • Abusive head trauma in infants and young children images
  • Differentials

    • Accidental head trauma
    • Birth trauma
    • Central nervous system infection: meningitis and encephalitis
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  • Guidelines

    • Evaluating for suspected child abuse: conditions that predispose to bleeding
    • Summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and rirst aid task forces
    More Guidelines
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