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  • Updated 08.24.2021
  • Released 08.08.2001
  • Expires For CME 08.24.2024

Abusive head trauma

Introduction

Overview

Abusive head trauma, formerly known as “shaken baby syndrome,” was first identified decades ago and came into the forefront of pediatric medicine in the mid-1970s with a nanny case in Massachusetts. Although many cases of abusive head trauma involve shaking of the baby, other mechanisms of injury are also important, thus, leading to the change in terminology. The injuries to physically abused babies often include skeletal fractures and bruising. However, it is the injuries to the central nervous system, especially the brain and retinas, that are often most severe and important. Abusive head trauma often mimics other common illnesses in the pediatric population. The authors discuss key features of the history, physical examination, laboratory evaluation, and imaging studies that must be sought to make the diagnosis and to distinguish abusive head trauma from accidental injury.

Key points

• Abusive head trauma is a prevalent affliction of children and occurs in approximately 38 out of every 100,000 children in the United States each year.

• Abusive head trauma often presents in a manner similar to other common pediatric ailments. For this reason, abusive head trauma should be on the differential diagnosis for all infants and young children presenting with fussiness, vomiting, and altered mental status.

• There is no single pattern of cranial or intracranial injury associated with abusive head trauma, but common findings include subdural hemorrhage, skull fracture, and cerebral edema.

• The sequelae of abusive head trauma are often severe and permanent. Survivors often require long-term, specialized pediatric medical care following their injuries.

• Educational programs for new parents may reduce or prevent the occurrence of abusive head trauma

Historical note and terminology

Recognition that subdural hematoma and multiple long-bone fractures may be due to abusive trauma was first recognized by John Caffey in 1946 (13). Caffee used the term “whiplash shaken baby syndrome” in 1972 to explain the combination of infantile subdural and subarachnoid hemorrhage, traction-type metaphyseal fractures, and retinal hemorrhages that were found in multiple injured infants in the care of a nurse maid who admitted to vigorously shaking the infants to burp them (14). It was thought that the unique anatomy and physiology of the infant's head (disproportionately large head with weak supporting neck musculature and relatively high water content of the brain) made infants vulnerable to severe injury from shaking (28).

Although the diagnosis was made on the basis of clinical and radiological findings, the term “whiplash shaken baby syndrome” implied a specific mechanism of angular deceleration as the cause of cerebral concussion and subdural hematoma. Many others reported clinical and laboratory evidence for the damaging effects of angular deceleration during this time (48; 49). Central to this concept was the idea that caretakers might inflict these injuries unwittingly, during the course of generally acceptable means of punishment or even play (15).

Eventually, it became clear that many severe head injuries of infants could not occur in the course of normal caretaking or play and that the injuries were inflicted through abuse. It was believed that inappropriate shaking was the principal mechanism of injury. This concept led to the term “shaken baby syndrome,” a term that is still widely used to describe physically abused babies today.

However, controversy exists as to the mechanism of actual injury. Shaking, impact, and suffocation have all been implicated, thus, leading to various descriptive terms including, “shaken syndrome,” “impact syndrome,” “inflicted head trauma,” “nonaccidental injury,” and “infant whiplash syndrome” (12; 21). Since 2009, the American Academy of Pediatrics has taken the position that healthcare professionals should use the term “abusive head trauma” to account for the fact that inflicted head injuries in children may result from various biomechanical forces, including shaking, blunt trauma, suffocation, and other forms of trauma and physical abuse (45).

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