’
Aspects of Abuse: Abusive Head Trauma
Tanya Hinds, MD, MS, Eglal Shalaby-Rana, MD, Allison M. Jackson, MD, MPH, and
Zarir Khademian, MD
Abusive Head Trauma (AHT) is a form of child physical abuse
that involves inflicted injury to the brain and its associated
structures. Abusive Head Trauma, colloquially called Shaken
Baby Syndrome, is the most common cause of serious or fatal
brain injuries in children aged 2 years and younger. The
American Academy of Pediatrics recommends the term Abu-
sive Head Trauma, as opposed to Shaken Baby Syndrome, as
the former term encompasses multiple forms of inflicted head
injury (inertial, contact, and hypoxic–ischemic) and a range of
clinical presentations and radiologic findings and their seque-
lae. Children diagnosed with AHT are 5 times more likely to
die compared with accidentally head-injured children, yet
Introduction
busive Head Trauma (AHT) is a form of child
A physical abuse that involves inflicted injury to
the brain and its associated structures. Abusive
Head Trauma, colloquially called Shaken Baby Syn-
drome, is the most common cause of serious or fatal
brain injuries in children aged 2 years and younger.1
The American Academy of Pediatrics recommends the
term Abusive Head Trauma, as opposed to Shaken
Baby Syndrome, as the former term encompasses
multiple forms of inflicted head injury (inertial, con-
tact, and hypoxic–ischemic) and a range of clinical
presentations and radiologic findings and their seque-
lae.2 Vigorous, repetitive shaking is one form of AHT.3
Overall, 3% of Japanese mothers of 4-month-old
infants self-reported “violent shaking while the infant
is crying” at least one time in the previous month4; 2% of
American mothers used shaking as a form of discipline
of their children aged 2 years or younger.5 A majority of
children will have non-specific symptoms following
From the Children's National Medical Center, The George Washington
University School of Medicine and Health Sciences, Washington, DC.
Curr Probl Pediatr Adolesc Health Care 2015;45:71-79
1538-5442/$ - see front matter
& 2015 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cppeds.2015.02.002
Curr Probl PediatrAdolesc Health Care, March 2015
signs and symptoms are not always obvious, and therefore
the diagnosis can be overlooked. Therefore, the American
Academy of Pediatrics has tasked pediatricians with knowing
how and when to begin an evaluation of children with signs
and symptoms that could possibly be due to AHT. Overall, a
detailed history of present illness and medical history, recog-
nition of physical and radiological findings, and careful
interpretation of retinal pathology are important aspects of
formulating the differential diagnoses and increasing or
decreasing the index of suspicion for AHT.
Curr Probl Pediatr Adolesc Health Care 2015;45:71-79
shaking, and AHT and will not require urgent medical
attention.
Among children who present for formal medical
care, 75% may present to an Emergency Department
and 17% to a primary care doctor; subsequently, 91%
of these children are admitted, with half admitted to an
Intensive Care Unit.6 A third of children who have
sustained AHT will be misdiagnosed at initial presen-
tation.7 This increases the risk for re-injury, medical
complications related to delayed diagnosis, and fatal
Abusive Head Trauma.7,8 The most frequent misdiag-
noses in missed cases of AHT include viral gastro-
enteritis or influenza, accidental head injury, ruled out
sepsis, increasing head size, otitis media, and seizure
disorder.7 Children experience a mean of 2.8 physician
visits prior to diagnosis.7 A delay of more than a week
may occur in nearly a third of patients.9 At the time of
diagnosis, 40–45% of children have clinical or radio-
logic evidence of prior brain injury.10 A majority of
children (68%) who survive AHT will have diagnosed
neurologic, visual, cognitive, behavioral, and sleep
abnormalities by 2–5 years of age.11 Mortality ranges
from 6% to 36%.11–13 For these and other reasons, the
American Academy of Pediatrics has tasked pediatri-
cians with knowing how to begin an evaluation of
children with signs and symptoms that could possibly
be due to AHT.2
71
Epidemiology pathological, and forensic data have shown that
rotation of the brain, with or without impact, may
Population-based studies of AHT suggest an incidence cause cardiorespiratory compromise, traumatic coma,
ranging from 14 to 40 per 100,000 children in infants less concussion, intracranial hemorrhage, diffuse parenchy-
than 1 year of age.6,9,12,14,15 While children less than 1 mal brain injury, and eye and neck injuries.23 Incon-
year of age have the highest incidence of AHT, a quarter solable infant crying is an important risk factor and
of AHTs are diagnosed in children greater than 1 year of trigger for violence.24,25 Epidemiologically, there is an
16
age. AHT has also been diagnosed in toddlers and increase in prolonged crying beginning at 2–3 weeks of
adults.17,18 In addition to age, the incidence varies based age, which peaks at 6–8 weeks and declines signifi-
on source of data (parental report, national hospital cantly in most infants by 4 months.24 Shaking and
19
discharge data, or fatality data). Shaking and Abusive other violent acts, sometimes on more than 1 day, have
Head Trauma is likely more common than suggested by been described by caregiver–perpetrators.3,4,25,26 Iner-
hospital data because of underreporting, misdiagnosis, tial brain injuries caused by shaking of the brain can be
and/or misclassification. In 2002, an anonymous tele- accompanied by radiologic evidence of blunt force
phone survey on parenting practices related to discipline impact, even in cases when there is no disclosure of
was conducted in North Carolina. Overall, 2% of mothers impact.3,25,26 Shaking and/or impact is generally fol-
or female guardians admitted to shaking their children lowed by the cessation of crying, lethargy, and
aged 2 years or younger.5 In contrast, between January sleepiness.3,26
2000 and December 2001, the incidence of AHT in There are caregiver and infant characteristics asso-
North Carolina among children aged 2 years or younger ciated with an increased risk of an infant being
was 17.0 per 100,000 person-years [95% confidence diagnosed with AHT.24 Biological fathers, stepfathers,
interval (CI): 13.3–20.7] based on prospectively collected and mother's boyfriends are the most common perpe-
data from all hospitals with a pediatric intensive care unit trators of AHT in a majority of studies.15,16,25,26 In
14
or a monitored step-down unit. children less than 1 year of age,
Children diagnosed with AHT are 5 66% of perpetrators are biological
times more likely to die compared with Children diagnosed with fathers; in children older than 1
accidentally head-injured children.12 AHT are 5 times more year, 13% of perpetrators are bio-
Mortality ranges from 6% to 36%.12–14
likely to die compared logical fathers; and 52% are mostly
A majority of children (68%) who
survive AHT will have diagnosed with accidentally head- non-parental, predominately male
caregivers.16 A study that found
motor, speech, visual, cognitive, injured children. no gender difference in AHT perpe-
behavioral, and sleep abnormalities trators, nevertheless, noted males
by 2–5 years of age.11,13,20 Of these deficits, 40% are were significantly more likely to confess, be convicted,
severe.11 More than 5 (5.7) years after infant or toddler and inflict more significant injuries compared with
AHT, nearly half of the survivors have demonstrated no females.27 Although not predictive of AHT, many
recovery in intellectual functioning and have IQs less than incidence studies document that a higher proportion of
the 10th percentile.20 Factors associated with poor neuro- male infants, children less than 6 months of age, infants
developmental outcomes include diagnosis of AHT born to young mothers, products of multiple births, and
compared with accidental head trauma, low GCS at poor and minority infants are at an increased risk of
presentation, early-onset seizures, longer duration of loss being diagnosed with AHT.6,9,12,14,15,22
of consciousness, extent and distribution of cerebral
edema, and/or infarction.1,10,13,21 Not unexpectedly,
length of hospital stay among AHT survivors is signifi-
cantly longer, a mean of 9 versus 3 days for abused versus Clinical Presentation
non-abused patients, respectively.22
History

Etiology and Risk Factors A diagnosis of AHT is made by reflecting on an

individual patient's history, including past medical and
Knowledge of etiology and risk factors is critical to family history and the specific physical and radiologic
preventative rather than diagnostic efforts. Clinical, findings. History taking should be done in the same

72 Curr Probl PediatrAdolesc Health Care, March 2015

open-ended fashion that is useful for making other progression of symptoms. According to perpetrators,
medical diagnoses. Eliciting a narrative history of the 91% of children are immediately symptomatic follow-
injury event or sequence of events minimizes the ing AHT.26 The minority of cases in which symptoms
introduction of unintended bias or seem to have been delayed all
alternative explanations. Multiple involved children who were not
investigators have noted an initial Multiple investigators observed closely immediately after
history of a short fall and trivial have noted an initial his- their trauma.3,26 Signs and symptoms
trauma or no history of trauma as are non-specific and range from
the most common caregiver history
tory of a short fall and impaired consciousness, lethargy/
of present illness.1,22,25,28,29 In a trivial trauma or no his- drowsiness/falling asleep, decreased
prospective study of infants and tory of trauma as the most oral intake, vomiting, irritability, seiz-
toddlers with subdural hemorrhage, common caregiver history ures, apnea, respiratory distress or
84% of patients whose subdural sudden collapse, and vomiting to
hemorrhage was determined to be
of present illness macrocephaly and delayed develop-
due to abusive trauma had a history ment.1,3,7,9,28 Apnea discriminates
of a minor fall or no history of between AHT and accidental trauma,
trauma. Similarly, in cases where definite abuse was with a PPV for abuse of 93% and an OR of 17
defined by the presence of retinal hemorrhages, moderate (po0.001), but is not as frequently documented by
or high specificity fractures, and/or patterned skin clinicians as other signs and symptoms.31
findings, having no history of trauma had a high Recent medical visits and prior injuries to skin,
specificity (97%) and positive predictive value (92%) skeletal, and other systems should be elicited as part
for abuse.29 Among patients diagnosed with definite of a child's past medical history. At the time of
abuse, the subgroup of patients with persistent neuro- diagnosis, 40–45% of children have clinical or radio-
logic abnormality at hospital discharge who had a history logic evidence of prior brain injury.7,10 Overall, 27% of
of no or low-impact trauma had a specificity of 100% severe or fatally injured children aged less than 1 year
and a PPV of 100% for definite abuse.29 Parents of have a history of a sentinel injury (bruise, intraoral
accidentally injured children are more likely to offer a injury, or a fracture) noted at a prior medical visit.32
history of trauma (75% versus 2.5%; po0.001).1 Signs of neglect and failure-to-thrive are also possible.
When a history of a short fall or other trauma is Clinicians must seek to elicit only the level of detail
shared, it is critical to listen for events that occurred that will help with their assessment about whether
before, during, and after the fall or trauma. Fall subjective information offered by caregivers is a likely
components that should be elicited include whether explanation for clinical status, physical examination,
the child sustained a free fall, the height of the fall, how and/or radiologic findings.
the child landed, the landing surface, and the child's
and the caregiver's response to the fall. The time
Physical Examination
between the reported injury event and when formal
medical care occurred should also be elicited. After A careful, comprehensive examination may reveal
careful consideration of history in the context of other signs of possible intracranial pathology as well as
physical and radiologic findings, the short fall history cutaneous injury in some patients ultimately diagnosed
or history of trivial trauma may cause suspicion for with AHT. Suspicious cutaneous findings may include
AHT. An initial history of trauma that changes sub- a bulging fontanel, lingual or labial frenula injuries,
stantially can also be seen in patients subsequently ligature marks, bruises in pre-mobile children, and
29,30
diagnosed with AHT. Injuries blamed on home bruises in unusual locations (ears, neck, torso, geni-
resuscitative efforts are also suspicious for AHT.29 talia, hands, and feet).33 Bruising on the torso, ear, or
In lieu of a history of trauma, caregivers may provide neck (TEN) in children less than 4 years old or any
a history of symptoms such as lethargy, poor feeding, bruising in an infant less than 4 months old is
vomiting, irritability, seizures, apnea, or difficulty in predictive of abuse, with a sensitivity of 97% and a
breathing.1,29 When a history of only symptoms is specificity of 84%.34 Overall, 50% of children less than
shared, it is important to elicit when the child was last 6 months old with suspicious bruising who underwent
completely well and to listen for the onset and screening for occult injury were found to have at least

Curr Probl PediatrAdolesc Health Care, March 2015 73

one significant (abdominal, skeletal, or intracranial)
injury.35
Although a meticulous physical
examination is important, clinically
important neurological, skeletal, and
abdominal traumas often occur with-
clinically important
out visible bruising. At presentation, neurological,
25% of AHT patients less than 20 and abdominal trau- and severe motor vehicular acci-
months of age are asymptomatic; mas often occur without dents.38,39 Repetitive inertial forces
neuroimaging reveals occult intracra-
nial injury in 75% of these neuro-
visible
logically normal patients.36 Of the
neurologically normal children less than 12 months
of age with suspicious fractures, 31% have occult
37
intracranial injury. Universal screening of neuro-
logically normal young children for occult intracranial
trauma is recommended, particularly in children aged
less than 1 year.
Ophthalmologic Examination
Using a direct, handheld ophthalmoscope, a clinician
can view the optic disc and part of the posterior retina,
through a non-dilated pupil of a cooperative child.
When the pupil is dilated, the entire posterior pole
(optic disc, blood vessels, macula, and fovea) of the
retina is visualized on direct examination with the
handheld ophthalmoscope. Non-ophthalmologists can
(and should) document the presence or absence of
retinal hemorrhages, but they should also understand
that this is not a substitute for a formal ophthalmologic
evaluation. In order to describe the number, type (pre-,
intra-, and sub-retinal), and distribution (posterior pole,
mid-periphery, periphery, and ora serrata), indirect
ophthalmoscopy, sometimes including scleral depres-
sion, by an experienced ophthalmologist is mandatory
as soon as possible. An ophthalmologist is also able to
identify other indicators of mechanical trauma such as
retinal folds and retinoschisis. Ophthalmic Imaging
(i.e., photography, optical coherence tomography, and
electroretinography) substantiates findings and helps
with management and prognosis.
Retinal hemorrhaging occurs in 78% of AHT and 5%
of accidentally injured children based on a recent
systematic review.38 In otherwise healthy children,
when retinal hemorrhages occur as a result of acci-
dental, household short falls trauma, they are few in
number and confined to the posterior pole.38 Retinal
hemorrhaging confined to the posterior pole has an
39
extensive differential that includes trauma. More
74
severe trauma will cause more severe and widespread
retinal hemorrhaging.40
Vitreoretinal traction is the prevailing
theory of causation in the too-numer-
ous-to-count, widespread, bilateral,
multilayered retinal hemorrhages that
skeletal, characterizes AHT, some crush injuries,
resulting in traumatic subdural hemor-
bruising rhage are believed to cause shearing
forces that are maximal at the macula,
along blood vessels on the retinal surface, and in the
peripheral retina behind the irises.39
Imaging
There are multiple radiologic findings associated with
injury in Abusive Head Trauma including subdural
hemorrhage (SDH).41 Trauma (birth, non-accidental,
and accidental) is the most common cause of SDH in
young children.9,28 If abuse is suspected, neuroimaging
can identify the extent of structural injury, help guide
necessary surgical intervention, and provide information
on clinical outcome and future cognitive dysfunction.42
A skeletal survey is mandatory for children less than
2 years old evaluated for physical abuse, and therefore, it
can be used as a modality for evaluating possible diffuse
physical injury.43 However, computed tomography (CT)
and magnetic resonance imaging (MRI) are the principal
imaging modalities for evaluating brain injury in infants
and young children resulting from abuse. CT is the
primary modality for evaluating traumatic brain injury. It
is available on a short notice and sensitive for evaluating
intracranial hemorrhage, mass effect, and fracture.44
MRI is sensitive in evaluating subtle brain injury that
is not detected on CT. If CT findings are normal or
indeterminate in a child with encephalopathy or worsen-
ing medical conditions, an MRI should be performed.45
MRI can also evaluate possible trauma to the cervicoc-
ranial junction.46 In the setting of trauma, MRI is helpful
for a more accurate determination of the timing of the
hemorrhage or future patient's neurologic outcome.44
Pediatricians evaluating children with possible Abu-
sive Head Trauma, and other physicians specializing in
pediatric subfields, should be cognizant that many non-
traumatic medical conditions such as collagen disease
or metabolic disorders may be presented with intra-
cranial findings similar to traumatic head injury.47
Finally, for the developing brain in infants and young
Curr Probl PediatrAdolesc Health Care, March 2015
children, trauma could have a negative impact on
maturation and future cognitive functions.48,49 Neuro-
imaging (CT and MRI) can document the trauma-
related structural changes and be a predictor of future
cognitive function.42
When Abusive Head Trauma is suspected, it is
imperative to obtain a complete radiographic skeletal
survey to elucidate fractures and soft tissue injuries that
may be present. A limited radiographic skeletal survey
performed 2–3 weeks after the initial study is sug-
gested in young infants and high-risk patients. This
follow-up survey can help reveal fractures that may be
difficult to see in the acute phase (i.e., rib), clarify
questionable findings on the initial x-ray, as well as
occasionally help retroactively date fractures from the
pattern of healing seen (i.e., classic metaphyseal
lesions).50,51 CT imaging of the abdomen should be
limited to those cases with clear physical signs of
abdominal injury and those patients with abnormally
elevated liver enzymes (AST and ALT).
Assessment
Differential Diagnosis
Subdural hemorrhaging has an extensive differen-
tial.23 Most diagnoses can be differentiated from
Abusive Head Trauma by history, examination, labo-
ratory, and/or radiologic evaluations (Table 1). The
AAP recommends that clinicians begin evaluation and
consult with Child Abuse Pediatricians, Ophthalmolo-
gists, Radiologists, and Neurosurgeons.2 Accidents,
birth trauma, and coagulopathies are among the most
important entities to be excluded.
Accidents
Household falls are a common history among both
children not suspected to be abused and abused
children. However, short household falls from beds,
TABLE 1. Conditions Associated with Subdural and Retinal Hemorrhaging
 Non-accidental Trauma
 Accidental Trauma
 Birth Trauma
 Bleeding disorders, Vitamin K deficiency
 Leukemia
 Meningitis
 Osteogenesis Imperfecta
 Glutaric Aciduria Type 1
Curr Probl PediatrAdolesc Health Care, March 2015
sofas, and arms rarely cause severe or fatal brain
injury, even among pre-mobile infants.52 Based on
parental self-report, less than 1% of 3357 falls in 2500
infants aged 6 months or younger resulted in serious
injury (fracture or concussion).52 No SDH was
reported. Generally, benign outcomes following short
falls in delivery rooms and hospitals have been well
documented. Further, discrepancies in injury severity
between independently witnessed versus sole-care-
giver reported uncorroborated short falls have also
been well documented.53,54 While SDH is possible
following household trauma, systematic reviews of
abundant fall literature suggest severe intracranial
injury including SDH is an unusual outcome. Further,
the risk of infant or toddler death from a fall less than
4.9 feet is less than 1 per 1 million children per year.53
Birth Trauma
As many as 46% of healthy, term newborns have
asymptomatic subdural hemorrhage; infants with ceph-
alohematomas and prolonged and or complicated
labors may be at an increased risk of intracranial
hemorrhage.55 Most birth-related SDH resolve by 1
month of age.55 Retinal hemorrhaging may be present
in up to 52% of infants, of which infants born of
instrumented vaginal deliveries are most likely to have
retinal hemorrhages.56 In one-third of infants, birth-
related retinal hemorrhaging can be severe, potentially
mimicking AHT. However, 83% of retinal hemor-
rhages resolve within 10 days of birth and 97% by 42
days of age.56
Bleeding Disorders
Mucocutaneous, gastrointestinal, intracranial, and
retinal bleeding may be manifestations of both trauma
and bleeding disorders. Vitamin K deficiency and
moderate to severe hemophilia can present with intra-
cranial, including subdural, hemorrhage during
infancy, as can more rare disorders such as Factor
XIII deficiency and severe deficiencies of fibrinogen.57
Vitamin K deficiency-related subdural hemorrhage has
been misdiagnosed as child abuse.58 Conversely, mild
PT prolongation may be secondary to parenchymal
brain injury rather than a congenital bleeding disor-
der.59 The AAP has published guidelines to minimize
the possibility of misdiagnosis and explain the proba-
bilities of specific bleeding disorders causing intra-
cranial hemorrhage.60 Of interest, retinal hemorrhaging
75
in children with bleeding disorders is typically con- is no substitute for neuroimaging (CT or MRI). If
fined to the posterior pole and not associated with either the presence of retinal hemorrhaging or an
retinal schisis.39 abnormal skeletal survey is used as a criterion to order
neuroimaging, traumatic intracranial injury will not be
Management detected in 10–26% of patients.1,61
Mandated reporting of suspicion of
Initial attention is focused on AHT to child protective services
assessing the clinical status of the The involvement of CPS (CPS) should not be delayed while
suspected AHT patient and determin- should occur simultane- subspecialty consultation or definitive
ing whether surgical intervention, ously with the medical testing is pending. The involvement
intracranial pressure monitoring, evaluation once reason- of CPS should occur simultaneously
and/or seizure prophylaxis are with the medical evaluation once
needed. This is typically followed able suspicion for AHT reasonable suspicion for AHT exists.
by screening for extracranial occult exists Beyond the acute period, an important
(skin, eye, skeleton, and abdominal) aspect of management is the develop-
injury and potential medical explanations for finding ment of a long-term plan of care with neurodevelop-
(s). At each point in this process, there is constant mental subspecialists. A comprehensive hematologic
reflection about whether findings are compatible with evaluation is often completed on an outpatient basis
the caregiver(s) statements (Table 2). Additionally, when the child is relatively well. The CPS should be
several published frameworks help with initial clinical kept informed of long-term medical recommendations.
assessments and coherent synthesis of physical and It may incorporate medical recommendations into a
radiologic data.23,28,30 It is important to note that there CPS–family contract. The CPS may also help mitigate

TABLE 2. Medical Evaluation of Abusive Head Trauma

HISTORY  None Document history in quotes when possible.

 Trauma (Minor, Major, Changing
and/or Developmentally Incompatible)
 Symptoms (onset and progression)
 Past Medical Diagnoses (including skin,
mouth and other injuries)
 Familial Conditions (including
consanguinity)

EXAM  Dysmorphic features Measurements, written and photo documentation aid peer
 Frenula injuries review.
 Bruising location, size and shape
 Ligature, bite, slap, grab and other
patterned marks

RADIOLOGY  Non Contrast Brain CT Intracranial hemorrhage, fractures and abdominal trauma
 Brain MRI frequently occur without cutaneous injury or focal
 Spine MRI examination findings.
 Skeletal Survey(s)

LABS  CBC, PT/PTT, CMP, Urinalysis Additional testing is guided by subspecialists.

CONSULTATIONS  Child Protective Services Subspecialty evaluation does not need to be complete in order
 Child Abuse Pediatrics to make a report to CPS.
 Ophthalmology
 Neurology
 Neurosurgery
 Radiology
 Hematology
 Developmental and Rehabilitation
Specialists

76 Curr Probl PediatrAdolesc Health Care, March 2015

psychosocial stressors that could potentially affect
adherence to medical recommendations. Overall, a
detailed history of present illness and medical history,
recognition of physical and radiologic findings, and
careful interpretation of retinal pathology are important
aspects of formulating differential diagnoses and
increasing or decreasing index of suspicion of AHT.
Prevention/Resources
A caregiver's frustration, anxiety, and anger about
inconsolable infant crying is a risk for shaking and
other forms of infant AHT.24 Shaking can stop infant
crying.3,26 However, because of the potential detri-
mental effects of AHT, clinicians should discuss the
normalcy of crying and importance of carefully
thought-through babysitting arrangements at primary
care visits. The AAP website (aap.org) links to
valuable resources on infant crying and colic. The
National Center for Shaken Baby Syndrome website
(dontshake.org) offers a brief, structured primary
prevention educational intervention for new parents
(the Period of PURPLE Cryings program), AHT-
related training opportunities for clinicians, and addi-
tional medical literature on AHT.
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