Pediatric Abusive Head Trauma (Shaken Baby Syndrome)

Pediatric abusive head trauma (AHT) may also be referred to as shaken baby syndrome (SBS). AHT is defined as the various injuries or conditions that may result following vigorous shaking, slamming, or impacting the head of an infant or young children. The effects of this type of head impact and/or violent shaking action results in serious health issues. Children may have severe brain or cervical spine injuries, bleeding in the brain or back inside layer of the eyes, skeletal fractures, or death.¹

It has been identified as a leading cause of death and long-term disability in children, increasingly so in children less 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 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 as a result of 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 into an object in an effort to cease the crying.¹ The use of physical force, including shaking, throwing, hitting or hurting, is never the correct way to stop infant or child crying.

Greater than 49 percent of deaths from child abuse occurs in children less than one year of age and AHT is the leading cause of physical child abuse deaths in children under age 5 in the United States.^{1, 2} Between 1999-2014, the National Vital Statics System data was utilized to examine trends in fatal AHT; mortality numbers were estimated as high as 2,250 in children less than five years of age, residing in the United States.³

However, accuracy and inconsistency of identifying and reporting child fatality due to physical abuse present a challenge in determining the actual incidence rate.¹ It is suspected that AHT rates are underreported related to:

• Lack of timely recognition
• Variation in death investigation systems
• A previously inconsistent definition of abusive head trauma
• Variation in State 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 agency 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.

Infant and children presenting with AHT may have a severe brain injury, often in the absence of significant trauma and with minimal or no signs of external injury.⁷ Distinguishing features of AHT include subdural hemorrhage, diffuse multi-layered retinal hemorrhages, and diffuse brain injury or edema.⁸ Additional injuries may include those of the spinal cord, ligamentous, vertebral and paraspinal soft tissues.^{9, 10} The physical mechanisms associated with shaking include rapid and repetitive flexion, extension, and rotation of the head and neck which have been proposed to explain this pattern of injury. Visible signs of injury may not always be apparent. Whereas 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 infant and children’s anatomy, they are more vulnerable to injury as a result of angular (rotational) deceleration than that of adults.⁸ It has been identified that the following features are contributors to pediatrics AHT injury susceptibility^11,12,13:

• The infant's head is large, heavy, and unstable relative to the infant body. The larger head and weak neck muscles permit greater movement when the head is met with an acceleration-deceleration force.
• Infant 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.^{14, 15}

Identification of AHT in children is through an objective, thorough history, physical examination, laboratory tests, and imaging studies, including 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 and may be misdiagnosed, only to return with more several or fatal injuries.⁴ Therefore, awareness and understanding around the clinical presentation and associated findings in pediatric AHT can aid in early identification and treatment.

Physical exam of the patient may raise suspicion for abuse when noting multiple injuries at different stages of healing or injury that does not correlate with the developmental level of the child. 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. By providing a complete nursing assessment, with a focus on neurological exam, it can provide pertinent clues leading towards 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

Additional diagnostic studies for these patients include blood work such as CBC, CMP, platelets and coagulation studies. Urinalysis and toxicology screening may also be considered in the evaluation of child abuse. Necessary imaging studies include 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 an MRI, for further diagnosis and clarification of findings. Finally, an ophthalmologic exam, to asses for retinal hemorrhage is to be expected.

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 who have 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

Unfortunately, many cases of pediatric AHT do not survive or do with extensive damage resulting in long-term disabilities. Major disability has been observed in two-thirds of pediatric AHT cases. Observed disabilities can manifest as developmental delays; sensory deficits (hearing impairment or blindness); motor impairments; attention deficits; feeding difficulty; seizures; intellectual and educational difficulties; and behavioral issues.¹

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. According to the Centers for Disease Control and Prevention year 2008 data, the total lifetime cost associated with just one year of confirmed cases of child maltreatment is approximately $124 billion.¹⁶

Risk factors associated with AHT have been identified through observational studies and can be categorized into infant/child, situational, and caregiver, see table 1 below.^1,5,6 Through healthcare providers taking the time to assess and identify areas of risk, the provider more accurately is equipped to identify patients at risk for pediatric AHT and/or provide resources in education or support to reduce the risk of pediatric AHT.

The American Academy of Pediatrics states that AHT is largely preventable.⁴ Evidence from the Centers for Disease Control and Prevention formalized efforts for consistent tracking of AHT, evaluation of interventions focused on prevention has demonstrated a decline in AHT rates after 2009. AHT rates in 2013 and 2014 were 0.41 per 100,000 children less than five years of age and 0.43 per 1000,000, respectively, the lowest rates during the 16-year data collection.³ Through identifying risk factors, clinicians can provide focused formalized interventions in supporting families and caregivers to prevent AHT.

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.¹ In over 40 years of research, the American Academy of Pediatrics supports 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.¹⁷

Healthcare providers have an important role in recognizing and preventing abuse. Clinicians can educate caregivers regarding:

• Anticipatory guidance around the dangers of shaking or impact injury
• Methods to deal with 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 USA at 1-800-4-A-Child (1-800-422-4453).

In Kentucky, the law states that it is the duty of everyone who has reasonable cause to believe that a child 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, child care personnel, resident, intern, optometrist, dentist, EMT/paramedic, or healthcare professional.

• Kentucky’s statewide Child Abuse Hotline:
  • 1-877-597-2331 or 1-800-752-6200
• Online Child Reporting System:
  • Monday – Friday 8a-4:30p for non-emergency reports here
• If a child is in imminent danger, call 911

Six months 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, a subdural hematoma and skeletal survey suggests two fractured ribs. It was later diagnosed as abusive head trauma as a result of 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 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 child care 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 in determining what further support he will need moving forward.

1. Centers for Disease Control and Prevention Website. Preventing Abusive Head Trauma in Children. Published February 26, 2019. Retrieved January 4, 2020. Visit Source.
2. Child Welfare Information Gateway. Child Maltreatment 2017: Summary of Key Findings. Published May, 2019. Retrieved January 2020. Visit Source.
3. Spies, E. L., & Klevens, J. Fatal Abusive Head Trauma Among Children Aged <5 Years - United States, 1999-2014. Published August 24, 2017. Retrieved January 4, 2020. Visit Source.
4. Christian, C. W., AAP Committee on Child Abuse and Neglect, & AAP Section on Child Abuse and Neglect. Understanding Abusive Head Trauma in Infants and Children: Answers from America's Pediatricians. Published June 1, 2015. Retrieved January 4, 2020. Visit Source.
5. Vinchon, M., Defoort-Dhellemmes, S., Desurmont, M., & Dhellemmes, P. (2005). Accidental and nonaccidental head injuries in infants: a prospective study. J Neurosurg, 102:380.
6. Gumbs, G. R., Keenan, H. T., & Sevick, C. J. (2013). Infant abusive head trauma in a military cohort. Pediatrics, 132:668.
7. Piteau, S. J., Ward, M. G., Barrowman, N. J., & Plint, A. C. (2012). Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics, 130:315.
8. Christian, C. Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children. UpToDate. Published June 11, 2019. Retrieved January 3-4, 2020. Visit Source.
9. Choudhary, A. K., Ishak, R., Zacharia, T. T., & Dias, M. S. (2014). Imaging of spinal injury in abusive head trauma: a retrospective study. Pedaitric Radiology, 44:1130.
10. Kadom, N., Khademian, Z., Vezina, G., & al., e. (2014). Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatric Radiology, 44:839.
11. Caffey, J. (1974). The whiplash shaken infant syndrome: manual shaking by the extremities with whiplashed-induced intracranial and intraocular bleedings, link with residual permanent brain damage and mental retardation. Pediatrics, 54:396.
12. Duhaime, A. C., Gennarelli, T. A., Thibault, L. E., & al., e. (1987). The shaken baby syndrome: A clinical, pathological, and biochemical study. Journal of Neurosurgery, 66:409.
13. Case, M. E., Graham, M. A., Handy, T. C., & al., e. (2001). Position paper on fatal abusive head injuries in infant and young children. American Jounral of Forensic Medical Pathology, 22:112.
14. Freeman, S., Udomphorn, Y., Amstead, W., & al., e. (2008). Young age as a risk factor for impaired cerbral autoregulation after moderate to severe pediatric traumatic brain injury. Anesthesiology, 108:588.
15. Bauer, R., & Fritz, H. (2004). Pathophysiology of traumatic injury in the developing brain: an introduction and short update. Exp Toxicol Pathol, 56:65.
16. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. Child abuse and neglect cost the United States $124 billion. CDC Newsroom. Published January 24, 2012. Retrieved January 4, 2020. Visit Source.
17. American Academy of Pediatrics. (2020, January). Child Abuse and Neglect: Abusive Head Trauma/Shaken Baby Syndrome. Published January 2020, Retrieved January 2020. Visit Source.