Pediatric Abusive Head Trauma

Excerpt

Pediatric abusive head trauma (AHT) most often involves brain injury of infants and young children. Another term for this condition is shaken baby syndrome (SBS). Shaking, blunt impact or the combination can result in neurological injury. AHT is the most dangerous and deadly form of child abuse.

Abusive head trauma typically involves injury to the intracranial contents or skull of an infant or child younger than 5 years old as a result of violent shaking or blunt impact. The outcome ranges from complete recovery to significant brain damage and death.

Brain and head injuries are the most common cause of traumatic death in children less than 2 years. Early diagnosis is essential but may prove challenging. Often the individuals responsible are evasive. Health professionals may not recognize the signs and symptoms due to the frequent lack of external signs of head trauma or abuse.

The solution to avoiding abusive head trauma is caregiver education to avoid accidental pediatric abusive head trauma and shaken baby syndrome and training health providers to recognize the signs and symptoms. Preventive mental health care is the best option to reduce child abuse. For those children that survive, the long-term financial and medical burden is extensive.

Caregivers rarely admit to the deliberate abuse of infants and children. They are usually evasive, fear repercussions, and invent “accidents” such as:

1. Falling down the stairs

2. Falling out of a crib, highchair, or bed

3. Trauma from other children

Definitions and Considerations

Unless head injuries are obvious, clinicians and healthcare providers may overlook the signs and symptoms of abusive head injury. There are patterns of injuries that suggest abusive head trauma or child abuse. Healthcare providers need to be aware of the typical injuries associated with accidents versus those associated with abuse.

Abusive Head Trauma (AHT)

1. Injury to the intracranial contents or skull of an infant or child younger than 5 years old, usually resulting from violent shaking or blunt impact.

2. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics have recommended using the term abusive head trauma for injuries from these conditions. They have included shaking, blunt impact, suffocation, and strangulation.

3. “Abusive head trauma” also includes injuries from dropping and throwing a child. The term describes the type of injury rather than the mechanism.

4. “Abusive head injury” may have legal significance as to the specific means of injury. If a provider diagnoses a child with “shaken baby syndrome,” this may preclude evidence of other types of injuries and allow for more challenges in court. The majority of abusive head trauma victims are younger than a year old, often between 3 to 8 months of age. These injuries can occur in children up to 5 years of age.

5. The perpetrator is usually a caregiver or parent, with 65% to 90% being male. The National Center for Shaken Baby Syndrome estimates that each year between 1200 to 1400 children are injured or killed by abusive head injuries annually in the United States.

6. Abusive head trauma is the primary cause of death and disability in infants and young children from child abuse. Child abuse has been identified as the major cause of brain injuries in one-fourth of children older than 2.

Pediatric Acquired/Traumatic Brain Injury (PA/TBI)

1. Traumatic causes include motor vehicle accidents, sports-related injuries, blast injuries, falls, assaults, and gunshot wounds.

Shaken Baby Syndrome (SBS)

1. Abusive head trauma with a pattern of injuries may include retinal hemorrhages and regular patterns of brain injury. Rib fractures, as well as fractures of the ends of long bones, are also seen.

2. “Shaken baby syndrome” is used to describe brain injury symptoms consistent with vigorously shaking an infant or small child. The injuries often include unilateral or bilateral subdural hemorrhage, bilateral retinal hemorrhages, and diffuse brain injury. While children can be injured by shaking alone, there is often evidence of blunt trauma, so a more inclusive term, “shaken impact syndrome,” may be used.

3. The triad of SBS refers to encephalopathy with a subdural hematoma and retinal hemorrhage. The diagnosis of pediatric abusive head trauma can only be made following a detailed medical examination and testing and should not be based on only these three findings.

Other terminologies involving shaken baby syndrome include:

1. Nonaccidental head injury (NAHI)

2. Inflicted traumatic brain injury (iTBI)

3. Nonaccidental head trauma (NAHT)

4. Shaken impact syndrome (SIS)

5. Whiplash shaken infant syndrome (WSIS)