Child abuse: Evaluation and diagnosis 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
- 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 evaluation and diagnosis of abusive head injury in infants and children will be presented here. The epidemiology, mechanisms, and ophthalmologic aspects of abusive head injury in children, management of suspected child abuse, and the initial evaluation of severe traumatic brain injury in children are reviewed separately. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Eye findings in children with abusive head trauma (AHT)" and "Initial approach to severe traumatic brain injury in children" and "Physical child abuse: Diagnostic evaluation and management".)
More than 40 percent of deaths from child abuse occur among children younger than 12 months of age . Abusive head injury is the most common cause of death as the result of child physical abuse. Infants frequently present with nonspecific clinical features without a history of trauma. As a result, as many as 30 percent of children with abusive head injury may be misdiagnosed at the initial evaluation [2,3].
Identification of abusive head injury can be life-saving. In one chart review describing missed cases of abusive head injury, four of five deaths might have been prevented if the inflicted mechanism had been recognized during previous evaluations for symptoms related to head injury .
Cranial injury may be inflicted by blunt force trauma, shaking, or a combination of forces. The constellation of injuries associated with this mechanism has been referred to as the "shaken baby syndrome" (SBS), the "infant whiplash syndrome", the "shaken/impact syndrome", or more simply, as "inflicted or abusive head injury". For many young infants, crying may be a trigger for the shaking episode, suggesting that the caretakers' response to prolonged crying may be an effective target for prevention strategies [4-6]. (See 'Prevention' below.)
The significance of the diagnosis (with regard to morbidity, 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 "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Mechanisms of injury'). Some experts have suggested that the term "shaken baby syndrome" be replaced with a more generic term such as "abusive head injury" or "inflicted neurotrauma", allowing 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 [7,8].
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- CLINICAL FEATURES
- Physical examination
- - Retinal hemorrhages
- - Cutaneous bruising
- - Associated injuries
- Laboratory studies
- - Computed tomography
- - Magnetic resonance imaging
- - Skeletal evaluation
- Ophthalmologic examination
- Children with intracranial injury
- Well-appearing infants
- DIFFERENTIAL DIAGNOSIS
- Accidental injury
- Birth trauma
- Apparent life-threatening event
- Bleeding disorders
- Other diagnoses
- SUMMARY AND RECOMMENDATIONS