Pediatric Abusive Head Trauma (Shaken Baby Syndrome)

Pediatric abusive head trauma (AHT) may also be called shaken baby syndrome (SBS). AHT is the various injuries or conditions that may result following vigorous shaking, slamming, or impacting an infant's or young child's head. The effects of this type of head impact or violent shaking action result in serious health issues. Children may have severe brain or cervical spine injuries, bleeding in the brain or inside the layer of the eyes, skeletal fractures, or death (Centers for Disease Control and Prevention [CDC], 2012).

AHT has been identified as a leading cause of death and long-term disability in children, especially in children younger than 12 months of age. Timely diagnosis is often delayed at initial presentation and evaluation due to nonspecific clinical features and caregiver reports of absent physical trauma. Consequently, victims of AHT may not receive prompt treatment and, therefore, have an increased risk of long-term disability or fatal injuries. Identifying risk factors and consequences, providing family and caregiver education and support, and addressing the safety of other children in high-risk homes can decrease and prevent the incidence of AHT.

Pediatric abusive head trauma is a severe form of child abuse that is the most common cause of death and long-term disability due to physical child abuse. AHT commonly occurs when a caregiver is frustrated or upset with the child's incessant crying.In response, the caregiver shakes the infant or child uncontrollably or hits the infant/child's head with an object to cease the crying (CDC, 2012). Using physical force, including shaking, throwing, hitting, or hurting, is never the correct way to stop an infant or child from crying.

According to the National Center on Shaken Baby Syndrome, in the United States, there are approximately 1,300 cases reported annually, and 25 % of the cases are fatal. AHT is the leading cause of physical child abuse deaths in children under age five in the United States (CDC, 2012). The incidence of AHT in the United States has been estimated to be 29.7 per 100,000 persons, resulting in 80 deaths per year, the majority occurring in children under the age of three (Song & Jain, 2022).

However, the accuracy and inconsistency of identifying and reporting child fatality due to physical abuse present a challenge in determining the actual incidence rate (CDC, 2012). It is suspected that AHT rates are underreported related to:

• Lack of timely recognition
• Variation in death investigation systems
• A previously inconsistent definition of AHT
• Variation in the state's child fatality review and reporting processes
• Miscoding in death certificates due to inaccurate determination in the manner of death
• Lack of coordination or cooperation among different agencies and reporting jurisdictions

Although the exact number of children affected by AHT annually is unknown, the prevalence of identified physical child abuse remains a serious problem in the United States.

Infants and children presenting with AHT may have a severe brain injury, often in the absence of significant trauma and with minimal or no external injury (Christian, 2024). Distinguishing features of AHT include subdural hemorrhage, diffuse multi-layered retinal hemorrhages, and diffuse brain injury or edema (Christian, 2024). The physical mechanisms associated with shaking include rapid and repetitive flexion, extension, and head and neck rotation, which have been proposed to explain this injury pattern. Visible signs of injury may not always be apparent. With impact, a more notable physical injury may be present, such as bruising, broken bones, lacerations, or bleeding. Additional findings may include lethargy and irritability.

Due to the physical nature of infants' and children's anatomy, they are more vulnerable to injury due to angular (rotational) deceleration when compared to adults. It has been identified that the following features contribute to pediatric AHT injury susceptibility (Christian, 2024):

• The infant's head is large, heavy, and unstable relative to the infant's body. The larger head and weak neck muscles permit greater movement when the head is met with an acceleration-deceleration force.
• Infants' skulls are not fully developed and, in trauma, may compress the brain when impacted.
• Infants and young children have soft brains with high water content, and the newborn central nervous system is not completely myelinated and is less able to autoregulate blood flow after injury, resulting in higher susceptibility to injury.

Primary injuries associated with AHT include brain contusions, skull fractures, and various hemorrhages. Secondary injuries of AHT include swelling of the brain, herniation, and strokes (Hung, 2020).

They are identifying AHT in children through an objective, thorough history, physical examination, laboratory tests, imaging studies, and a retinal exam. Commonly, the pediatric patient will present for medical care related to symptoms of their injury without a history of preceding trauma. In cases of child abuse, the history provided by the caregiver is often inconsistent, incomplete, or incorrect. Some children may present with mild or nonspecific symptoms such as vomiting or fussiness and may be misdiagnosed, only to return with severe or fatal injuries (Christian, 2024). Therefore, awareness and understanding of the clinical presentation and associated findings in pediatric AHT can aid in early identification and treatment.

A physical exam of the patient may raise suspicion for abuse when noting multiple injuries at different healing stages or injuries that do not correlate with the child's developmental level. For example, bruising is uncommon in an infant that is not ambulating. Other varied symptoms may include mild flu-like symptoms, altered consciousness, and coma. A complete nursing assessment focusing on neurological exams can provide pertinent clues that lead to necessary testing to confirm the diagnosis. As reviewed, symptoms may be nonspecific and may include:

• Poor feeding
• Lethargy
• Apnea
• Bulging fontanels
• Failure to thrive
• Vomiting
• Respiratory difficulty
• Decreased level of consciousness
• Seizure activity
• Stiffness
• Irritability
• Ligature marks
• Bruising
• Decreased interaction
• Bradycardia

Additional diagnostic studies for these patients include blood work such as a complete blood count (CBC), comprehensive metabolic panel (CMP), platelets, and coagulation studies. Urinalysis and toxicology screening may also be considered in evaluating child abuse.Necessary imaging studies include a computed tomography (CT or CAT) scan for diagnosis of intracranial injury and a skeletal survey for additional bone examination. Possible follow-up imaging, such as magnetic resonance imaging (MRI), for further diagnosis and clarification of findings. Finally, an ophthalmologic exam to assess for retinal hemorrhage is expected. Eye findings are noted in 85% of AHT cases (Song and Jain, 2022).

With injuries that are inconsistent with the history, further history-taking should be performed. When there are multiple injuries at various healing stages, a full head-to-toe physical examination is necessary. A suspicious fracture in any child under the age of two necessitates X-rays of long bones, the spine, etc. Intracranial injuries necessitate a head CT. For confirmation of injuries and to determine the extent of the child's injuries, an MRI is necessary (Hung, 2020).

Although no single physical finding definitively identifies pediatric AHT, there are hallmarks of child abuse and AHT. Combinations of clinical conditions or injuries can help accurately identify patients with a high likelihood of pediatric AHT. These conditions include, but are not limited to:

• Irreversible brain damage
• Retinal hemorrhage
• Cerebral palsy
• Spinal cord injury
• Seizures
• Blindness
• Eye damage
• Paralysis
• Learning disability
• Hearing loss
• Central nervous system injury
• Subdural hematoma
• Rib fracture
• Closed head injury

Depending on the facility, AHT can be graded. Grade I indicates a skull fracture without any soft tissue injuries. Grade IIa indicates intracranial hemorrhage and/or cerebral edema that does not require surgery. Grade IIb represents intracranial hemorrhage and/or cerebral edema that does not require surgery, but a brain infarction is present. Grade IIIa indicates intracranial hemorrhage and/or cerebral edema requiring surgery or when the patient dies. Grade IIIb indicates intracranial hemorrhage and/or cerebral edema requiring surgery or when the patient dies, and when a brain infarction is present (Hung, 2020).

Injuries can also be classified as mild, moderate, or severe. Some of the variables that help to predict or classify this injury include acute respiratory compromise prior to coming to the hospital, bilateral subdural hematomas, bruising of the neck, ears, or torso of the body, and complicated skull fractures (Joyce et al., 2023).

Treatment of pediatric AHT is dependent on the extent of the condition. First, managing the airway, breathing, and circulation is pertinent. Managing acute severe head trauma requires oxygenation and measurement of intracranial pressure. Continuous EEG monitoring is helpful for patients expected to or currently experiencing seizures. It is important to take measures to prevent hypoxic brain injuries in these patients (Hung, 2020). Last, a third-tier therapy, if necessary, includes a decompressive craniectomy, specifically for signs of herniation and deterioration. It relieves pressure and allows for swelling to occur (Joyce et al., 2023).

Unfortunately, many cases of pediatric AHT do not survive or do extensive damage, resulting in long-term disabilities. One of every four infant cases of AHT dies from this form of child abuse (CDC, 2012). Major disability has been observed in two-thirds of pediatric AHT cases. Observed disabilities can manifest as developmental delays, sensory deficits (hearing or blindness), motor impairments, attention deficits, feeding difficulties, seizures, intellectual and educational difficulties, and behavioral issues (CDC, 2012).

The long-term medical burden has a significant economic impact. Care of the surviving child with pediatric AHT may be lifelong, including physical, occupational, speech-language, and educational therapies, and, in severe cases, long-term nursing care. Pediatric AHT presents a significant financial burden to society. Estimated on the reported 4,824 cases in 2010, the total financial impact was $13.5 billion. This accounts for medical expenses and loss of potential societal productivity (Iqbal O'Meara et al. 2020).

Specific long-term complications of pediatric AHT include the following (Joyce et al., 2023):

• Blindness
• Weakness
• Learning disabilities/developmental delays
• Hearing loss
• Hydrocephalus
• Seizures

Risk factors associated with AHT have been identified through observational studies and can be categorized into infant/child, situational, and caregiver. Through healthcare providers taking the time to assess and identify areas of risk, the provider is more accurately equipped to identify patients at risk for pediatric AHT or provide resources in education or support to reduce the risk of pediatric AHT. See Table 1 below.

The American Academy of Pediatrics states that AHT is largely preventable (Christian, 2024). Evidence from the CDC's formalized efforts for consistently tracking AHT and evaluating interventions focused on prevention has demonstrated a decline in AHT rates after 2009. By identifying risk factors, clinicians can provide focused, formalized interventions to support families and caregivers in preventing AHT. Parenting programs focused on the awareness of AHT are the most common preventive intervention, with the goal of many programs focused on helping parents cope with an infant's inconsolable crying, the primary trigger of AHT (Chang et al., 2024).

With the most common incident leading up to AHT being infant crying, educating caregivers on safe interventions and where to find support is an important intervention in preventing AHT (CDC, 2012). After over 40 years of research, the American Academy of Pediatrics supports the idea that early infant crying follows a period of increased and then decreased crying, starting at about two weeks and lasting until the third or fourth month of life. Educating parents and caregivers that this crying is a normal stage of development and unrelated to infants having a disease or physical problem or parents having different caregiving styles may be helpful (Narang et al., 2020).Healthcare providers have an important role in recognizing and preventing abuse. Clinicians can educate caregivers regarding the following:

• Anticipatory guidance around the dangers of shaking or impact injury
• Methods to deal with the frustration and anger of a crying infant
• Stress the importance of leaving children in the care of trusted caregivers
• Community resources as identified for risk factors
• Supportive environments
• Healthcare and social services access

Each state has mandatory reporting requirements for professionals that are required to report suspected child abuse. For information on reporting in your state, use the national hotline for child abuse, Child Help the USA, at 1-800-4-A-Child (1-800-422-4453).

In Kentucky, the law states that it is the duty of everyone with reasonable cause to believe that a child is dependent, abused, or neglected to report this information. Additionally, the following persons, but not limited to, are required to submit a more detailed/written report: physician, nurse, teacher, school personnel, social worker, coroner/medical examiner, childcare personnel, resident, intern, optometrist, dentist, EMT/paramedic, or healthcare professional.

• Kentucky's statewide Child Abuse Hotline:
  • 1-877-597-2331
• Online Child Reporting System:
  • Monday – Friday 8a-4:30p for non-emergency reports here
• If a child is in imminent danger, call 911

Six-month-old Emelia presents to the emergency department via EMS. She presents status post-seizure, limp and unresponsive. After acute stabilization, the physical assessment reveals scattered bruising at different stages of healing. A CT scan reveals a serious head injury and a subdural hematoma, and a skeletal survey suggests two fractured ribs. It was later diagnosed as AHT resulting from shaking without head impact. Social work is notified.

Think about:

• What signs and symptoms are the patient presenting with?
• What additional history is important to gather from the caregivers?
• What is the most likely cause?
• What studies confirm the diagnosis?
• What are the next steps?

Once the father arrives, he provides a more detailed history of events. Emelia's mother, who has a history of substance abuse, has recently been incarcerated. In order to work, he has been sending Emelia to a neighbor's house for childcare. He received a call from the child-caregiver explaining that Emelia had been very irritable and seemed sick and that he needed to pick her up. The father reports that the caregivers told him she had been lethargic, with flu-like symptoms, including vomiting and decreased intake. Upon arriving at the in-home childcare, he noticed Emelia having a seizure and called 911.

Think about:

• What are some of the risk factors in this case?
• What is reportable in this situation?
• Who in the care team is responsible for reporting the event?
• What resources may the father need?

The in-home childcare provider was reported to the state of Kentucky's child abuse hotline by calling 1-877-597-2331. Emelia is transferred to the ICU for further medical care. Social work coordinates efforts with the father to determine what further support he will need.

AHT is a form of child abuse that can result in the death of the child. Pediatric AHT is more common in younger children, especially during the crying phases. Symptoms of AHT can vary; there may or may not be visible external injuries. Patients may also present with life-threatening and severe symptoms, such as intracranial hemorrhages and seizures. In many situations, pediatric patients who do survive experience long-term impacts. Early identification is crucial and may potentially prevent death. Healthcare providers should conduct a thorough assessment and become skilled in recognizing signs and symptoms of AHT.

• Centers for Disease Control and Prevention (CDC). (2012). Pediatric Abusive Head Trauma: Recommended Definitions for Public Health Surveillance and Research. Centers for Disease Control and Prevention. Visit Source.
• Chang, H. Y., Chang, Y. C., Chang, Y. T., Chen, Y. W., Wu, P. Y., & Feng, J. Y. (2024). The effectiveness of parenting programs in preventing abusive head trauma: A systematic review and meta-analysis. Trauma, Violence & Abuse, 25(1), 354–368. Visit Source.
• Christian, C. (2024). Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children. UpToDate. Visit Source.
• Hung, K. L. (2020). Pediatric abusive head trauma. Biomedical journal, 43(3), 240–250. Visit Source.
• Iqbal O'Meara, A. M., Sequeira, J., & Miller Ferguson, N. (2020). Advances and future directions of diagnosis and management of pediatric abusive head trauma: A review of the literature. Frontiers in Neurology, 11, 118. Visit Source.
• Joyce, T., Gossman, W., & Huecker, M. R. (2023). Pediatric abusive head trauma. In StatPearls. StatPearls Publishing. Visit Source.
• Narang, S. K., Fingarson, A., Lukefahr, J., & COUNCIL ON CHILD ABUSE AND NEGLECT. (2020). Abusive head trauma in infants and children. Pediatrics, 145(4), e20200203. Visit Source.
• Song, H. H. & Jain, S. F. (2022). Update on Non-accidental Trauma. In: Ramasubramanian, A. (eds) Pediatric Ophthalmology. Current practices in ophthalmology. Springer, Singapore. Visit Source.