Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children
- Cindy Christian, MD
Cindy Christian, MD
- Professor of Pediatrics
- Perelman School of Medicine at the University of Pennsylvania
- V Jordan Greenbaum, MD
V Jordan Greenbaum, MD
- Clinical Assistant Professor
- Emory University School of Medicine
- Section Editors
- Daniel M Lindberg, MD
Daniel M Lindberg, MD
- Section Editor — Pediatric Psychosocial Emergencies
- Associate Professor of Emergency Medicine and Pediatrics
- University of Colorado Kempe Center
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Chief of Neurology
- Children’s Hospital Los Angeles
- Vice Chair of Neurology
- USC Keck School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The epidemiology, mechanisms, and types of head injury found in abused children are reviewed here.
The clinical features, evaluation, and diagnosis of abusive head trauma in infants and children, including ophthalmologic aspects, and the management of suspected child abuse are discussed separately. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children" and "Child abuse: Eye findings in children with abusive head trauma (AHT)" and "Physical child abuse: Diagnostic evaluation and management".)
Abusive head trauma includes inflicted cranial, cerebral, and spinal injuries resulting from blunt force trauma, shaking, or a combination of forces [1,2]. The injuries themselves may be primary or secondary. The classic injury pattern that is associated with shaking includes diffuse unilateral or bilateral subdural hemorrhage, diffuse multilayered retinal hemorrhages, and diffuse brain injury. This pattern has been referred to as the "shaken baby syndrome" and "shaken/impact syndrome" [3,4]. The absence of a history of trauma and a paucity of external manifestations of injury can make recognition of the inflicted nature of these injuries difficult. The AAP has recommended that the term "shaken baby syndrome" be replaced in medical records with the broader term "abusive head trauma", which allows for consideration of multiple mechanisms of injury in any child . Generic terms, such as "head injury", also serve to distinguish the diagnosis of injury from the investigation of how the injury occurred [2,5].
The mechanism of brain injury is only one factor that must be considered in making the diagnosis of abusive injury. The significance of the diagnosis (with regard to child protection and criminal prosecution) may be similar, regardless of whether injury resulted from direct blows or from shaking . In addition, much of the evidence to support the mechanism of injuries that result from shaking is retrospective and indirect. (See 'Mechanisms of injury' below and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Diagnosis'.)
Child abuse occurs most often among children less than four years of age . In one population based study, the most common mechanism of injury for infants three to five months of age was battering . Among young children, head injury, in particular, is often inflicted. This is illustrated in the following reports:
- Adamsbaum C, Grabar S, Mejean N, Rey-Salmon C. Abusive head trauma: judicial admissions highlight violent and repetitive shaking. Pediatrics 2010; 126:546.
- Christian CW, Block R, Committee on Child Abuse and Neglect, American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics 2009; 123:1409.
- Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 1974; 54:396.
- Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants--the "shaken-baby syndrome". N Engl J Med 1998; 338:1822.
- Richards PG, Bertocci GE, Bonshek RE, et al. Shaken baby syndrome. Arch Dis Child 2006; 91:205.
- Reece RM. Highlighting violent and repetitive shaking. Pediatrics 2010; 126:572.
- U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2015). Child maltreatment 2013. http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment (Accessed on December 14, 2015).
- Agran PF, Anderson C, Winn D, et al. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics 2003; 111:e683.
- Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 2004; 114:165.
- Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics 2003; 111:602.
- Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med 2000; 154:11.
- Keenan HT, Runyan DK, Marshall SW, et al. A population-based study of inflicted traumatic brain injury in young children. JAMA 2003; 290:621.
- Barlow KM, Minns RA. Annual incidence of shaken impact syndrome in young children. Lancet 2000; 356:1571.
- Talvik I, Metsvaht T, Leito K, et al. Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia. Acta Paediatr 2006; 95:799.
- Spies EL, Klevens J. Fatal Abusive Head Trauma Among Children Aged <5 Years - United States, 1999-2014. MMWR Morb Mortal Wkly Rep 2016; 65:505.
- Gill JR, Goldfeder LB, Armbrustmacher V, et al. Fatal head injury in children younger than 2 years in New York City and an overview of the shaken baby syndrome. Arch Pathol Lab Med 2009; 133:619.
- Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 281:621.
- King WJ, MacKay M, Sirnick A, Canadian Shaken Baby Study Group. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. CMAJ 2003; 168:155.
- Duhaime AC, Gennarelli TA, Thibault LE, et al. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409.
- Ludwig S, Warman M. Shaken baby syndrome: a review of 20 cases. Ann Emerg Med 1984; 13:104.
- Hadley MN, Sonntag VK, Rekate HL, Murphy A. The infant whiplash-shake injury syndrome: a clinical and pathological study. Neurosurgery 1989; 24:536.
- Ettaro L, Berger RP, Songer T. Abusive head trauma in young children: characteristics and medical charges in a hospitalized population. Child Abuse Negl 2004; 28:1099.
- Keenan HT, Runyan DK, Marshall SW, et al. A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics 2004; 114:633.
- Mierisch RF, Frasier LD, Braddock SR, et al. Retinal hemorrhages in an 8-year-old child: an uncommon presentation of abusive injury. Pediatr Emerg Care 2004; 20:118.
- Salehi-Had H, Brandt JD, Rosas AJ, Rogers KK. Findings in older children with abusive head injury: does shaken-child syndrome exist? Pediatrics 2006; 117:e1039.
- Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013; 131:701.
- Starling SP, Holden JR, Jenny C. Abusive head trauma: the relationship of perpetrators to their victims. Pediatrics 1995; 95:259.
- McCabe CF, Donahue SP. Prognostic indicators for vision and mortality in shaken baby syndrome. Arch Ophthalmol 2000; 118:373.
- Ghahreman A, Bhasin V, Chaseling R, et al. Nonaccidental head injuries in children: a Sydney experience. J Neurosurg 2005; 103:213.
- Stiffman MN, Schnitzer PG, Adam P, et al. Household composition and risk of fatal child maltreatment. Pediatrics 2002; 109:615.
- Vinchon M, Defoort-Dhellemmes S, Desurmont M, Dhellemmes P. Accidental and nonaccidental head injuries in infants: a prospective study. J Neurosurg 2005; 102:380.
- Gumbs GR, Keenan HT, Sevick CJ, et al. Infant abusive head trauma in a military cohort. Pediatrics 2013; 132:668.
- Krugman, RD. Fatal child abuse: analysis of 24 cases. Pediatrician 1983-1985; 12:68.
- Barr RG, Trent RB, Cross J. Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse Negl 2006; 30:7.
- Reijneveld SA, van der Wal MF, Brugman E, et al. Infant crying and abuse. Lancet 2004; 364:1340.
- Huang MI, O'Riordan MA, Fitzenrider E, et al. Increased incidence of nonaccidental head trauma in infants associated with the economic recession. J Neurosurg Pediatr 2011; 8:171.
- Wood JN, French B, Fromkin J, et al. Association of Pediatric Abusive Head Trauma Rates With Macroeconomic Indicators. Acad Pediatr 2016; 16:224.
- Ibrahim NG, Wood J, Margulies SS, Christian CW. Influence of age and fall type on head injuries in infants and toddlers. Int J Dev Neurosci 2012; 30:201.
- Alexander R, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking. Am J Dis Child 1990; 144:724.
- Choudhary AK, Ishak R, Zacharia TT, Dias MS. Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatr Radiol 2014; 44:1130.
- Kadom N, Khademian Z, Vezina G, et al. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatr Radiol 2014; 44:839.
- Raghupathi R, Margulies SS. Traumatic axonal injury after closed head injury in the neonatal pig. J Neurotrauma 2002; 19:843.
- Raghupathi R, Mehr MF, Helfaer MA, Margulies SS. Traumatic axonal injury is exacerbated following repetitive closed head injury in the neonatal pig. J Neurotrauma 2004; 21:307.
- Case ME, Graham MA, Handy TC, et al. Position paper on fatal abusive head injuries in infants and young children. Am J Forensic Med Pathol 2001; 22:112.
- Freeman SS, Udomphorn Y, Armstead WM, et al. Young age as a risk factor for impaired cerebral autoregulation after moderate to severe pediatric traumatic brain injury. Anesthesiology 2008; 108:588.
- Bauer R, Fritz H. Pathophysiology of traumatic injury in the developing brain: an introduction and short update. Exp Toxicol Pathol 2004; 56:65.
- Finnie JW, Blumbergs PC, Manavis J, et al. Neuropathological changes in a lamb model of non-accidental head injury (the shaken baby syndrome). J Clin Neurosci 2012; 19:1159.
- Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. Brain 1974; 97:633.
- Steinbok P, Singhal A, Poskitt K, Cochrane DD. Early hypodensity on computed tomographic scan of the brain in an accidental pediatric head injury. Neurosurgery 2007; 60:689.
- Ichord RN, Naim M, Pollock AN, et al. Hypoxic-ischemic injury complicates inflicted and accidental traumatic brain injury in young children: the role of diffusion-weighted imaging. J Neurotrauma 2007; 24:106.
- Geddes JF, Hackshaw AK, Vowles GH, et al. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain 2001; 124:1290.
- Geddes JF, Vowles GH, Hackshaw AK, et al. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 2001; 124:1299.
- Harding B, Risdon RA, Krous HF. Shaken baby syndrome. BMJ 2004; 328:720.
- Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics 2012; 130:315.
- Maguire SA, Watts PO, Shaw AD, et al. Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond) 2013; 27:28.
- Agrawal S, Peters MJ, Adams GG, Pierce CM. Prevalence of retinal hemorrhages in critically ill children. Pediatrics 2012; 129:e1388.
- Binenbaum G, Mirza-George N, Christian CW, Forbes BJ. Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. J AAPOS 2009; 13:268.
- Nimityongskul P, Anderson LD. The likelihood of injuries when children fall out of bed. J Pediatr Orthop 1987; 7:184.
- Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics 1977; 60:533.
- Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics 1993; 92:125.
- Chadwick DL, Bertocci G, Castillo E, et al. Annual risk of death resulting from short falls among young children: less than 1 in 1 million. Pediatrics 2008; 121:1213.
- Tarantino CA, Dowd MD, Murdock TC. Short vertical falls in infants. Pediatr Emerg Care 1999; 15:5.
- Tzioumi D, Oates RK. Subdural hematomas in children under 2 years. Accidental or inflicted? A 10-year experience. Child Abuse Negl 1998; 22:1105.
- Wells RG, Vetter C, Laud P. Intracranial hemorrhage in children younger than 3 years: prediction of intent. Arch Pediatr Adolesc Med 2002; 156:252.
- Jayawant S, Rawlinson A, Gibbon F, et al. Subdural haemorrhages in infants: population based study. BMJ 1998; 317:1558.
- Feldman KW, Bethel R, Shugerman RP, et al. The cause of infant and toddler subdural hemorrhage: a prospective study. Pediatrics 2001; 108:636.
- Adamo MA, Drazin D, Smith C, Waldman JB. Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes. J Neurosurg Pediatr 2009; 4:414.
- Thomas AG, Hegde SV, Dineen RA, Jaspan T. Patterns of accidental craniocerebral injury occurring in early childhood. Arch Dis Child 2013; 98:787.
- Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363:846.
- Looney CB, Smith JK, Merck LH, et al. Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology 2007; 242:535.
- Dias MS, Backstrom J, Falk M, Li V. Serial radiography in the infant shaken impact syndrome. Pediatr Neurosurg 1998; 29:77.
- Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics 1998; 102:300.
- Shugerman RP, Paez A, Grossman DC, et al. Epidural hemorrhage: is it abuse? Pediatrics 1996; 97:664.
- Forbes BJ, Cox M, Christian CW. Retinal hemorrhages in patients with epidural hematomas. J AAPOS 2008; 12:177.
- Hymel, KP. Child Maltreatment 1998; 3:116.
- Gennarelli TA. Mechanisms of brain injury. J Emerg Med 1993; 11 Suppl 1:5.
- Gennarelli TA, Thibault LE, Adams JH, et al. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 1982; 12:564.
- Sinal SH, Ball MR. Head trauma due to child abuse: serial computerized tomography in diagnosis and management. South Med J 1987; 80:1505.
- Gilles EE, Nelson MD Jr. Cerebral complications of nonaccidental head injury in childhood. Pediatr Neurol 1998; 19:119.
- Kemp AM, Joshi AH, Mann M, et al. What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review. Arch Dis Child 2010; 95:355.
- Barber I, Perez-Rossello JM, Wilson CR, et al. Prevalence and relevance of pediatric spinal fractures in suspected child abuse. Pediatr Radiol 2013; 43:1507.
- Choudhary AK, Bradford RK, Dias MS, et al. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology 2012; 262:216.
- Koumellis P, McConachie NS, Jaspan T. Spinal subdural haematomas in children with non-accidental head injury. Arch Dis Child 2009; 94:216.
- Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ 2008; 337:a1518.
- Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics 2009; 123:e247.
- Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child 1993; 147:87.
- Meservy CJ, Towbin R, McLaurin RL, et al. Radiographic characteristics of skull fractures resulting from child abuse. AJR Am J Roentgenol 1987; 149:173.
- Harwood-Nash DC, Hendrick EB, Hudson AR. The significance of skull fractures in children. A study of 1,187 patients. Radiology 1971; 101:151.
- Albert MJ, Drvaric DM. Injuries resulting from pathologic forces: Child abuse. In: Pediatric Fractures: A Practical Approach to Assessment and Treatment, MacEwen GD, KasserJR, Heinrich SD (Eds), Williams & Wilkins, Baltimore 1993. p.388.
- Hobbs CJ. Skull fracture and the diagnosis of abuse. Arch Dis Child 1984; 59:246.
- Arnholz D, Hymel KP, Hay TC, Jenny C. Bilateral pediatric skull fractures: accident or abuse? J Trauma 1998; 45:172.
- Atwal GS, Rutty GN, Carter N, Green MA. Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases. Forensic Sci Int 1998; 96:215.
- Merten DF, Osborne DR, Radkowski MA, Leonidas JC. Craniocerebral trauma in the child abuse syndrome: radiological observations. Pediatr Radiol 1984; 14:272.
- Lazoritz S, Baldwin S, Kini N. The Whiplash Shaken Infant Syndrome: has Caffey's syndrome changed or have we changed his syndrome? Child Abuse Negl 1997; 21:1009.
- Caffey J. On the theory and practice of shaking infants. Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child 1972; 124:161.
- Kleinman PK. Diagnostic Imaging of Child Abuse, 2nd ed, Mosby, St. Louis 1998.
- Maguire S, Pickerd N, Farewell D, et al. Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Arch Dis Child 2009; 94:860.
- Prior history of abuse
- Risk factors
- MECHANISMS OF INJURY
- Primary injury
- Secondary injury
- TYPES OF INJURY
- Retinal hemorrhages
- Intracranial bleeding
- - Subdural hemorrhage
- - Epidural hemorrhage
- - Subarachnoid hemorrhage
- - Parenchymal injuries
- Spinal and paraspinal injuries
- Skull fractures
- Skeletal fractures