Abusive Head Trauma

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Abusive Head Trauma — Santa J. Bartholomew M.D.

Shaken Baby Syndrome (SBS) is often the term used interchangeably with abusive head trauma (AHT) having been coined in a seminal paper by Ludwig and Warman in 1972. They evaluated 20 infants and children injured by shaking and first made known the catastrophic injuries that can be inflicted by acceleration and deceleration of the brain inside the skull. What was not recognized at the time was the contribution of impact to head injury.

Over the last 50 years there have been enormous advances in this body of work with biomechanical modeling helping show the injuries suffered by these unfortunate children. And although biomechanical modeling has been very helpful in determining mechanism of injury, in recent years it has become understood that despite all of our complex modeling, we still do not understand each and every traumatic injury’s precise mechanism. Not only are mechanisms misunderstood but there are also medical diseases that can mimic abusive head trauma (AHT) and therefore physicians and health care workers need to be very cautious and thorough in their investigations and conclusions. This diagnosis is to be made with care and careful thought as it can result in children being removed from their home, parents losing parental rights and adults being imprisoned.

The Alarming Statistics

AHT has the highest mortality of all forms of child physical abuse with an estimated fatality rate of 20%. Survivors often have irreversible brain injury that can range from mild behavioral issues to significant neurologic devastation, seizures, blindness and paralysis. The incidence of AHT is 39.8/100,000 children in the United States and most often occurs in children under 2 years old. In 80% of these children subdural hemorrhage is found that is intra-hemispheric, posterior and often layering over the tentorium and/or a thin subdural hematoma over one or both convexities. But subdural hematoma is not pathognomonic (only ever associated with) abusive head trauma and so one must be methodical in assessing the cause of these injuries, ruling out all other possible causes.

Although, additional injuries do not need to be present for a child to have an abusive head injury we often see retinal hemorrhages, retinal schisis or tearing, posterior rib fractures and metaphyseal fractures, bruising to the scalp or other parts of the body. Children typically present with symptoms of brain injury: vomiting, irritability, seizures but often symptoms can be very subtle, not wanting to eat, crying when touched, increased quietness or somnolence.

What is required to make the diagnosis? A high index of suspicion! Such as, a story that does not match the injury pattern or many stories over time, a constantly changing history, et al. Once there is an index of suspicion then several studies help: CT head, retinal examination by an expert, bruising over the body, bony fractures: especially posterior ribs or long bones, MRI of the neck looking for ligamentous injuries from the acceleration-deceleration forces. See pictures below.

Abusive Head Trauma has the highest mortality of all forms of child physical abuse with an estimated fatality rate of 20%.

abusive-head-trauma-01
abusive head trauma indicators
abusive head trauma indicators

Treatment is dependent on the injury pattern but close attention and care to the injured brain takes priority over fractures and other injuries unless they are life-threatening in an of themselves (like a ruptured spleen or liver). The best treatment is prevention.  Focusing on parental education about how to deal with a crying child, community supports, such as drop off centers, and identifying support systems.

Resources
  1. Paul, A. R., & Adamo, M. A. (2014). Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Translational pediatrics, 3(3), 195–207. https://doi.org/10.3978/j.issn.2224-4336.2014.06.01
  2. Joyce T, Gossman W, Huecker MR. Pediatric Abusive Head Trauma. [Updated 2021 May 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499836/
  3. Glick Jill, Lorand Michele, Bilka Kristen. Physical Abuse in Children Peds Review 37 (4):146-158
  4. Christian Cindy, Block Robert Abusive Head Trauma in Infants and Children Pediatrics 2009;123:1409–1411
  5. Glaser Danya Child Abuse and Neglect and the Brain- A review. J Child Psychol Psychiat Vol 41 (1): 97-116
  6. Hung, Kun-Long Pediatric Abusive Head Trauma Biomed J 43(2020): 240-250
  7. Greeley Christopher Spencer. Abusive Head Trauma: A  Review of the Evidence Base.  AJR 2015;204:967-973
  8. https://www.childwelfare.gov/topics/responding/reporting/how/
  9. https://www.cdc.gov/violenceprevention/childabuseandneglect/resources.html
  10. https://www.childhelp.org/story-resource-center/shaken-baby-syndrome/
  11. https://www.cdc.gov/violenceprevention/childabuseandneglect/Abusive-Head-Trauma.html

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