Abusive head trauma refers to the constellation of cranial, spinal cord, and brain injuries that result from inflicted injury in infants and young children.
Diagnosis generally 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 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.
Abusive head trauma describes head injuries that are deliberately inflicted on infants and children. The term includes injuries caused by shaking and by direct trauma to the head.
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
Other diagnostic factors
- no known history of trauma
- 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
- age <1 year
- peak of normal crying curve
- male caregiver
- unrelated adult household member
- male sex
- socioeconomic stressors
1st investigations to order
- cranial CT scan
- liver function tests
- toxicology screen
- prothrombin/acticated PTT/fibrinogen/von Willebrand testing
- cerebrospinal fluid analysis
- cranial MRI
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
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.
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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