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 trauma". 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].
- Administration for Children & Families. Child Maltreatment 2014. Annual Report, US Government Printing Office; US Department of Health and Human Services, Washington, DC 2014 https://www.acf.hhs.gov/cb/resource/child-maltreatment-2014 (Accessed on January 04, 2017).
- Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 281:621.
- Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013; 131:701.
- 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.
- Adamsbaum C, Grabar S, Mejean N, Rey-Salmon C. Abusive head trauma: judicial admissions highlight violent and repetitive shaking. Pediatrics 2010; 126:546.
- Richards PG, Bertocci GE, Bonshek RE, et al. Shaken baby syndrome. Arch Dis Child 2006; 91:205.
- 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.
- 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.
- 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.
- Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics 2003; 111:602.
- Ludwig S, Warman M. Shaken baby syndrome: a review of 20 cases. Ann Emerg Med 1984; 13:104.
- Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants--the "shaken-baby syndrome". N Engl J Med 1998; 338:1822.
- Johnson DL, Boal D, Baule R. Role of apnea in nonaccidental head injury. Pediatr Neurosurg 1995; 23:305.
- Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics 2015; 135:e1337.
- 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.
- 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.
- Starling SP, Patel S, Burke BL, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med 2004; 158:454.
- Ricci L, Giantris A, Merriam P, et al. Abusive head trauma in Maine infants: medical, child protective, and law enforcement analysis. Child Abuse Negl 2003; 27:271.
- Oral R, Yagmur F, Nashelsky M, et al. Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse. Pediatr Emerg Care 2008; 24:816.
- Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics 2003; 111:1382.
- Laskey AL, Holsti M, Runyan DK, Socolar RR. Occult head trauma in young suspected victims of physical abuse. J Pediatr 2004; 144:719.
- Morad Y, Kim YM, Armstrong DC, et al. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol 2002; 134:354.
- 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.
- Adams G, Ainsworth J, Butler L, et al. Update from the ophthalmology child abuse working party: Royal College ophthalmologists. Eye (Lond) 2004; 18:795.
- Wygnanski-Jaffe T, Levin AV, Shafiq A, et al. Postmortem orbital findings in shaken baby syndrome. Am J Ophthalmol 2006; 142:233.
- Tung GA, Kumar M, Richardson RC, et al. Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. Pediatrics 2006; 118:626.
- Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med 1999; 153:399.
- Labbé J, Caouette G. Recent skin injuries in normal children. Pediatrics 2001; 108:271.
- Hadley MN, Sonntag VK, Rekate HL, Murphy A. The infant whiplash-shake injury syndrome: a clinical and pathological study. Neurosurgery 1989; 24:536.
- Brennan LK, Rubin D, Christian CW, et al. Neck injuries in young pediatric homicide victims. J Neurosurg Pediatr 2009; 3:232.
- Ghatan S, Ellenbogen RG. Pediatric spine and spinal cord injury after inflicted trauma. Neurosurg Clin N Am 2002; 13:227.
- Choudhary AK, Bradford RK, Dias MS, et al. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology 2012; 262:216.
- Choudhary AK, Ishak R, Zacharia TT, Dias MS. Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatr Radiol 2014; 44:1130.
- Feldman KW, Avellino AM, Sugar NF, Ellenbogen RG. Cervical spinal cord injury in abused children. Pediatr Emerg Care 2008; 24:222.
- Altman RL, Brand DA, Forman S, et al. Abusive head injury as a cause of apparent life-threatening events in infancy. Arch Pediatr Adolesc Med 2003; 157:1011.
- Hymel KP, Abshire TC, Luckey DW, Jenny C. Coagulopathy in pediatric abusive head trauma. Pediatrics 1997; 99:371.
- Carpenter SL, Abshire TC, Anderst JD, Section on Hematology/Oncology and Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluating for suspected child abuse: conditions that predispose to bleeding. Pediatrics 2013; 131:e1357.
- Berger RP, Kochanek PM, Pierce MC. Biochemical markers of brain injury: could they be used as diagnostic adjuncts in cases of inflicted traumatic brain injury? Child Abuse Negl 2004; 28:739.
- Berger RP, Dulani T, Adelson PD, et al. Identification of inflicted traumatic brain injury in well-appearing infants using serum and cerebrospinal markers: a possible screening tool. Pediatrics 2006; 117:325.
- Gao W, Lu C, Kochanek PM, Berger RP. Serum amyloid A is increased in children with abusive head trauma: a gel-based proteomic analysis. Pediatr Res 2014; 76:280.
- Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
- Demaerel P, Casteels I, Wilms G. Cranial imaging in child abuse. Eur Radiol 2002; 12:849.
- Datta S, Stoodley N, Jayawant S, et al. Neuroradiological aspects of subdural haemorrhages. Arch Dis Child 2005; 90:947.
- American College of Radiology. ACR appropriateness criteria. Suspected physical abuse - child. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedPhysicalAbuseChild.pdf (Accessed on August 06, 2012).
- Foerster BR, Petrou M, Lin D, et al. Neuroimaging evaluation of non-accidental head trauma with correlation to clinical outcomes: a review of 57 cases. J Pediatr 2009; 154:573.
- Hsieh KL, Zimmerman RA, Kao HW, Chen CY. Revisiting neuroimaging of abusive head trauma in infants and young children. AJR Am J Roentgenol 2015; 204:944.
- Girard N, Brunel H, Dory-Lautrec P, Chabrol B. Neuroimaging differential diagnoses to abusive head trauma. Pediatr Radiol 2016; 46:603.
- Kemp AM, Jaspan T, Griffiths J, et al. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Arch Dis Child 2011; 96:1103.
- Hymel KP, Stoiko MA, Herman BE, et al. Head injury depth as an indicator of causes and mechanisms. Pediatrics 2010; 125:712.
- Slovis TL, Strouse PJ, Strauss KJ. Radiation Exposure in Imaging of Suspected Child Abuse: Benefits versus Risks. J Pediatr 2015; 167:963.
- Barnes PD, Robson CD. CT findings in hyperacute nonaccidental brain injury. Pediatr Radiol 2000; 30:74.
- Suh DY, Davis PC, Hopkins KL, et al. Nonaccidental pediatric head injury: diffusion-weighted imaging findings. Neurosurgery 2001; 49:309.
- Morad Y, Kim YM, Mian M, et al. Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. J Pediatr 2003; 142:431.
- Levin AV. Retinal hemorrhage in abusive head trauma. Pediatrics 2010; 126:961.
- Minns RA, Jones PA, Tandon A, et al. Prediction of inflicted brain injury in infants and children using retinal imaging. Pediatrics 2012; 130:e1227.
- 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, Kemp AM, Lumb RC, Farewell DM. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics 2011; 128:e550.
- Cowley LE, Morris CB, Maguire SA, et al. Validation of a Prediction Tool for Abusive Head Trauma. Pediatrics 2015; 136:290.
- Goldstein B, Kelly MM, Bruton D, Cox C. Inflicted versus accidental head injury in critically injured children. Crit Care Med 1993; 21:1328.
- Trokel M, Discala C, Terrin NC, Sege RD. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care 2006; 22:700.
- Hymel KP, Armijo-Garcia V, Foster R, et al. Validation of a clinical prediction rule for pediatric abusive head trauma. Pediatrics 2014; 134:e1537.
- Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Pediatrics 2016; 138.
- Lindberg DM, Runyan DK. Improving Clinical Judgment in Abuse Case Finding. Pediatrics 2016; 138.
- David TJ. Non-accidental head injury--the evidence. Pediatr Radiol 2008; 38 Suppl 3:S370.
- Feldman KW, Bethel R, Shugerman RP, et al. The cause of infant and toddler subdural hemorrhage: a prospective study. Pediatrics 2001; 108:636.
- Hughes LA, May K, Talbot JF, Parsons MA. Incidence, distribution, and duration of birth-related retinal hemorrhages: a prospective study. J AAPOS 2006; 10:102.
- 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.
- Laghmari M, Skiker H, Handor H, et al. [Birth-related retinal hemorrhages in the newborn: incidence and relationship with maternal, obstetric and neonatal factors. Prospective study of 2,031 cases]. J Fr Ophtalmol 2014; 37:313.
- Hobbs C, Childs AM, Wynne J, et al. Subdural haematoma and effusion in infancy: an epidemiological study. Arch Dis Child 2005; 90:952.
- Pitetti RD, Maffei F, Chang K, et al. Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event. Pediatrics 2002; 110:557.
- Kulkarni R, Soucie JM, Lusher J, et al. Sites of initial bleeding episodes, mode of delivery and age of diagnosis in babies with haemophilia diagnosed before the age of 2 years: a report from The Centers for Disease Control and Prevention's (CDC) Universal Data Collection (UDC) project. Haemophilia 2009; 15:1281.
- Agrawal S, Peters MJ, Adams GG, Pierce CM. Prevalence of retinal hemorrhages in critically ill children. Pediatrics 2012; 129:e1388.
- Klinge J, Auberger K, Auerswald G, et al. Prevalence and outcome of intracranial haemorrhage in haemophiliacs--a survey of the paediatric group of the German Society of Thrombosis and Haemostasis (GTH). Eur J Pediatr 1999; 158 Suppl 3:S162.
- 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.
- Shein SL, Bell MJ, Kochanek PM, et al. Risk factors for mortality in children with abusive head trauma. J Pediatr 2012; 161:716.
- Sills MR, Libby AM, Orton HD. Prehospital and in-hospital mortality: a comparison of intentional and unintentional traumatic brain injuries in Colorado children. Arch Pediatr Adolesc Med 2005; 159:665.
- Bonnier C, Nassogne MC, Evrard P. Outcome and prognosis of whiplash shaken infant syndrome; late consequences after a symptom-free interval. Dev Med Child Neurol 1995; 37:943.
- Barlow KM, Thomson E, Johnson D, Minns RA. Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. Pediatrics 2005; 116:e174.
- Feldman KW, Brewer DK, Shaw DW. Evolution of the cranial computed tomography scan in child abuse. Child Abuse Negl 1995; 19:307.
- Gilles EE, Nelson MD Jr. Cerebral complications of nonaccidental head injury in childhood. Pediatr Neurol 1998; 19:119.
- van Rijn RR, Spevak MR. Imaging of neonatal child abuse with an emphasis on abusive head trauma. Magn Reson Imaging Clin N Am 2011; 19:791.
- Flaherty EG, Stirling J Jr, American Academy of Pediatrics. Committee on Child Abuse and Neglect. Clinical report—the pediatrician’s role in child maltreatment prevention. Pediatrics 2010; 126:833.
- Showers J. "Don't shake the baby": the effectiveness of a prevention program. Child Abuse Negl 1992; 16:11.
- Dias MS, Smith K, DeGuehery K, et al. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics 2005; 115:e470.
- Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA 1997; 278:637.
- 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