Abusive head trauma is a form of child maltreatment that is most prevalent in the first year of life and is associated with high morbidity and mortality. The varying clinical presentation and findings associated with abusive head trauma can make it challenging to diagnose. This article reviews current knowledge of the epidemiology, presentation, recommended evaluation, and differential diagnosis of abusive head trauma. Outcomes after abusive head trauma, as well as the efficacy of current prevention programs are discussed with additional recommendations for opportunities for future study.
Key points
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Abusive head trauma (AHT) encompasses a multitude of mechanisms, presentations, and injuries and therefore requires inclusion in the differential followed by a thorough work-up for timely and accurate diagnosis.
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There are many conditions which may have findings similar to AHT; however, they can largely be differentiated from AHT based on history, examination findings, or imaging/laboratory results alone.
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Successful AHT prevention programs require a significant amount of resources, illustrating the need for increased maltreatment-related funding and legislatio.
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Further research into AHT mechanisms, timing, and outcomes, as well as continued refinement of clinical prediction tools may allow forreductions in diagnostic variability and bias.
| AHT | abusive head trauma |
| BESS | benign expansion of the subarachnoid spaces |
| CBC | complete blood count |
| CDR | clinical decision rules |
| CT | computed tomography |
| GA1 | glutaric aciduria type 1 |
| MBP | myelin-based protein |
| NSE | neuron-specific enolase |
| OPN | osteopontin |
| PECARN | Pediatric Emergency Care Applied Research Network |
| PediBIRN | Pediatric Brain Injury Research Network |
| PIBIS | Pittsburg Infant Brain Injury Score |
| PredAHT | Predicting Abusive Head Trauma Tool |
| VKDB | vitamin K deficiency |
| VWD | von Willebrand disease |
Background
The term abusive head trauma (AHT) refers to any violent, inflicted physical injury to the head and/or neck of an infant or young child. Various names have historically been used to describe this clinical entity, including non-accidental head trauma, shaken baby syndrome, and whiplash injury. However, as child abuse research has grown, so has the understanding that these previous descriptors do not fully encompass the wide range of traumatic mechanisms involved in inflicted head injury such as blunt force trauma, acceleration-deceleration (inertial) forces, crush injury, and asphyxiation. In 2009, the American Academy of Pediatrics began using the term AHT to better encompass these different traumatic mechanisms and the resulting range of injuries associated with them.
Epidemiology
As with other forms of child maltreatment, AHT occurs most frequently in children less than 4 years of age. While the true incidence of AHT is uncertain given the occult nature of child abuse, the standardization of definitions and the United States Centers for Disease Control and Prevention’s adoption of common ICD-9 and ICD-10 codes for AHT have allowed for better estimation and monitoring of AHT occurrence. Recent estimates suggest that AHT impacts approximately 22 to 38/100,000 children in the first year of life with the median age of patients being 4 months old, significantly younger than those children diagnosed with unintentional head injury. In children less than 2 years old, AHT is recognized as the leading cause of fatal head injuries and, in one retrospective report, was responsible for 53% of serious or fatal traumatic brain injury cases.
Risk Factors
There are numerous child and caregiver risk factors associated with AHT. Infants under the age of 12 months are particularly susceptible to this type of injury due to the unique anatomy of their head and neck, with their large heads and correspondingly weaker neck muscles preventing them from being able to withstand various traumatic forces. Furthermore, infants’ incomplete neuronal myelination increases their vulnerability to neuronal shear injury. Prematurity, congenital/developmental anomalies, male sex, and incessant crying are some of the other child risk factors shown to be associated with AHT. These child risk factors (especially crying) may compound other stressors experienced by caregivers. These caregiver risk factors include young age, history of substance abuse, mental illness, and familial violence. ,
Mechanisms and Findings
Early literature suggested shaking as the primary causative force involved in what is now called AHT. While inflicted head injury is still most commonly attributed to shaking, there is a growing understanding that AHT can result from several different mechanisms, which may involve varying magnitudes and combinations of acceleration-deceleration, torsional, and static strain forces with or without a blunt force impact. , , Injuries observed vary depending upon these forces and therefore there is no single finding, which is diagnostic of AHT. Findings which have been shown to be more common in AHT than in accidental head trauma include subdural hemorrhage (especially mixed-density, interhemispheric, and/or convexity hemorrhages), hypoxic-ischemic injury, cerebral edema, and retinal hemorrhage. By contrast, epidural hemorrhages are more significantly associated with accidental trauma. , Other frequently observed findings in AHT include subarachnoid hemorrhage, parenchymal contusions and lacerations, bridging vein thrombosis, and spinal ligamentous injury. The presence of additional extracranial traumatic injuries in a child with suspected AHT is highly suggestive of abuse.
Discussion
Given its complexity, the diagnosis of AHT requires careful consideration of the totality of any given patient’s history, developmental abilities, social factors, examination findings, and associated injuries. The clinical presentation of AHT typically consists of vague symptoms such as fussiness, inconsolable behavior, vomiting, and poor feeding. Symptoms may then progress to lethargy, altered mental status, seizures, respiratory compromise/apnea, and coma. Alternatively, patients may present at a time delayed from initial injury with symptoms such as increasing head circumference or developmental delay. Though the most common extracranial injuries seen in association with AHT are cutaneous injuries, skeletal injuries, and retinal hemorrhages, patients may not have any external signs of trauma. Due to the variable and sometimes subtle clinical presentation of AHT, initial diagnosis is often missed. A retrospective review of children diagnosed with AHT found that the initial diagnosis was missed in 31% of cases. AHT diagnosis was more likely to be missed in White infants less than 6 months of age from intact families and in children without respiratory compromise or seizures. As such, it is imperative that pediatric clinicians consider AHT in their differential diagnosis and complete a thorough evaluation whenever there is concern for inflicted injury.
Evaluation
The workup of AHT begins with a thorough history and detailed physical examination. Caregivers rarely spontaneously report abuse or shaking as the history of presenting illness. Rather, the most commonly reported history provided by caregivers is that of a low-height (less than 3–4 ft) fall preceding onset of symptoms or simply no history of head trauma at all (eg, the child presents due to symptoms alone). The lack of history of preceding trauma has been shown in multiple studies to have greater than 90% specificity for abuse. , Regardless of whether a traumatic mechanism is provided, medical history-taking should include a timeline of symptom onset, as well as a description of events leading up to presentation, including details of what happened, what position the child was in, the height of the fall, how the child landed, the type of surface the child landed on, and how the child acted immediately after the event. Additional history regarding the child’s birth and past medical history, history of prior trauma, developmental history, family history (especially any history of coagulopathy), and social history should also be obtained. Early involvement of a social worker for assessment of psychosocial risk factors (eg, prior maltreatment concerns, caregiver history of mental health disorders, substance abuse, domestic violence, or law enforcement involvement) is also imperative.
Once the history has been obtained, a head-to-toe physical examination must be completed to evaluate for concomitant injuries. Particular attention should be paid to the skin assessing for bruising specifically in the TEN (torso, ears, and neck) regions in any child under 4 years old, or any bruising in a child under 4 months old as this would be highly suggestive of abusive trauma. Additionally, the oral cavity should be examined especially in infants to assess for injury to the frenulum or oropharynx. Examination of the abdominal and musculoskeletal regions for malformations or trauma is also essential.
Imaging and laboratory studies provide valuable information for diagnosis and treatment of AHT. Unenhanced computed tomography (CT) of the head remains the standard to urgently assess for intracranial hemorrhage or cerebral edema, which may require acute intervention in unstable patients. This should be followed by unenhanced brain and whole-spine MRI in any child with abnormal head CT findings, persistent neurologic signs or symptoms, and/or a high index of suspicion for abuse as MRI is more sensitive for the detection of small-volume extra-axial hemorrhage, evolving parenchymal injury, and spinal ligamentous injury. , In stable patients, MRI can be used as the initial neuroimaging study if it can be completed and interpreted in a timely manner. Standard MRI sequences should be supplemented with diffusion-weighted and susceptibility-weighted imaging for increased detection of parenchymal ischemia and diffuse axonal injury. While the apparent density of blood products on neuroimaging should not alone form the basis of injury timing due to imprecision, the addition of contrast may be considered in select cases in which there is concern for potential chronic injury. Contrast allows for better visualization of intradural membranes, the presence of which would suggest an injury is at least 10 days old. , Fast MRI (motion-tolerant MRI sequences performed without sedation) has also emerged as a promising alternative for reduced radiation exposure in both stable and unstable patients, though its use is still limited by availability. , All infants and young toddlers with suspected AHT should also receive a skeletal survey. The identification of additional injuries that are suggestive of child abuse (ie, posterior rib fractures or metaphyseal fractures) has great forensic significance, even if clinical intervention is not deemed necessary. The utility of laboratory studies depends upon the patient’s clinical presentation; however, in children with suspected abusive head trauma, several screening laboratory studies may provide valuable data about occult injuries, as well as other potential contributory medical conditions. Initial screening should include a complete blood count (CBC), coagulation factors (aPTT, PT/INR), and hepatic transaminases. Factor VIII/Factor IX levels, von Willebrand panel, as well as a fibrinogen and D-dimer levels may be indicated in specific clinical scenarios.
Retinal hemorrhages have been found to be present in up to 85% of cases of AHT, and as such, a dilated fundoscopic examination, preferably by a pediatric ophthalmologist, should be completed within 24 to 48 hours of suspected injury. , Retinal hemorrhages that are too numerous to count, multilayered, and extending to the ora serrata have been shown to be more common in AHT than in accidental trauma, with an odds ratio of 14.7 in one systematic review. Similarly, traumatic retinoschisis is highly specific for rapid acceleration-deceleration forces and thereby highly suggestive of child abuse.
The diagnosis of abusive head trauma is best made upon the multidisciplinary input of multiple care team members. Depending on the examination findings, laboratory results, and imaging findings, subspecialists such as Neurology, Neurosurgery, Ophthalmology, and Hematology should be involved. Additionally, a medical social worker and a child abuse trained pediatric clinician are essential for managing these complex situations. All of these different roles are helpful in correctly identifying child abuse, ruling out other potential causes of the injury, and determining next steps for the patient. Though mandated reporting statutes vary between states, in every state any reasonable concern for child abuse also requires reporting to the appropriate child welfare and/or law enforcement agency.
Differential Diagnosis
Given the variability in findings associated with AHT, each of which has a considerable differential of its own, there is a long list of alternative conditions that are often cited as mimics of AHT. , It should be noted that the vast majority of these conditions can be differentiated from AHT by a careful history, physical examination, and evaluation as detailed earlier; however, consideration of these additional etiologies is essential to a thorough abuse evaluation.
Accidental/birth trauma
Accidental trauma is one of the most commonly reported histories provided by caregivers in cases of AHT and as such, is an essential consideration in the differential diagnosis of AHT. Short falls, defined as a fall from less than 3 to 4 feet, usually result in minor injury; but have in some cases resulted in skull and clavicle fractures. Subdural hemorrhages can occur in association with accidental injury; however, they are more common with abusive mechanisms. Similarly, retinal hemorrhages observed in accidental injury are typically fewer in number and less severe than those seen in AHT. Minor accidental injury is also unlikely to result in death. Examples of household accidents that have resulted in child death include: a TV set falling on a child, a horse falling on a child, a father falling on a child and crushing him while going down the stairs, and a child being backed over by a vehicle. These cases represent the magnitude and types of force required to cause severe and life-threatening injury and are in stark contrast to the relatively trivial and benign trauma offered as an explanation for a child’s injuries in cases of inflicted injury. Complex falls, such as falls down the stairs or those involving infant walkers can cause more serious injuries, but again, rarely result in death. Multiple studies demonstrate that falls down stairs rarely involve more than one body region or result in hospital admission with critical illness.
Subdural and retinal hemorrhages have also been reported as sequelae of parturition and are more likely after deliveries that required instrumentation. These subdural hemorrhages tend to be small and located in the posterior fossa and rarely cause symptoms. Similarly, birth-related retinal hemorrhages are more likely to be localized to the posterior pole; however, they can be more extensive. Studies show that both findings resolve within 4 to 6 weeks of age, further emphasizing the need for a detailed birth history and thorough evaluation for occult injury in young infants who present with intracranial hemorrhage.
Bleeding disorders
Though rare, children with severe bleeding disorders such as Factor VIII deficiency (Hemophilia A), Factor IX deficiency (Hemophilia B), von Willebrand disease (VWD), and Factor XIII deficiency may develop intracranial hemorrhage following minor injury or even spontaneously. These patients can typically be distinguished from those with AHT using a thorough history, laboratory evaluation, and by understanding the differences in how they present. Intracranial hemorrhage from a bleeding disorder is more likely to present with parenchymal bleeding and few, if any, retinal hemorrhages, typically in the posterior pole. In a 2016 cohort of 547 babies with hemophilia, the annual prevalence of intracranial hemorrhage was approximately 4% per year. Similarly, the prevalence of spontaneous subdural hemorrhage in children under 2 years of age with type I VWD is estimated to be 1 in 59,000, and the probability of spontaneous intracranial hemorrhage in children under 2 years of age with factor XIII deficiency is estimated to be 1 in 2.7 million while the probability of suffering a spontaneous subdural hemorrhage is estimated to be 0. Coagulation studies are therefore an integral part of the evaluation in any child with suspected AHT; however, it is important to note that the presence of coagulopathy does not necessarily exclude the concomitant possibility of physical abuse.
Another cause of bleeding early in life is Vitamin K Deficiency (VKDB). Clinical manifestations of VKDB include bruising, hematemesis, rectal bleeding, and intracranial hemorrhage. Infants with VKDB-related intracranial hemorrhage rarely have retinal hemorrhages. There have been no reported cases of retinal folds or retinoschisis in cases of VKDB. VKDB can be distinguished from AHT using a thorough history, birth records, coagulation studies, and a PIVKA II level, which is elevated in the absence of vitamin K.
Benign expansion of the subarachnoid spaces
Benign Expansion of the Subarachnoid Spaces (BESS) otherwise known as benign external hydrocephalus, benign extra-axial collections of infancy, and benign enlargement of extra axial fluid is a non-harmful, self-limiting condition in infants that may be linked with familial macrocephaly; however, some studies have suggested a link between enlarged subarachnoid spaces and a predisposition for intracranial hemorrhage. In one study, 2.3% of children with enlarged subarachnoid spaces had subdural hemorrhage and only 1-quarter of children with both BESS and subdural hemorrhage were found to have additional injuries concerning for abuse. This poses a diagnostic challenge when an infant presents with extensive subdural hemorrhage, possible BESS, and no other injuries after a relatively minor trauma. Thus, if BESS and subdural hemorrhage are first noted on head CT, MRI of the brain is indicated to further clarify the CNS findings; however, in the absence of additional injuries, the presence of an unexplained subdural hemorrhage in a patient with BESS would not be diagnostic of AHT.
Glutaric aciduria type 1
Glutaric aciduria type 1 (GA1) is a metabolic disorder caused by a gene defect in the enzyme glutaryl-CoA dehydrogenase that may present with intracranial hemorrhage and retinal hemorrhage. Affected children typically present with an episode of metabolic decompensation during an infection or fever. Additionally, the child may have the characteristic micro encephalic macrocephaly on physical examination and imaging, with a large head circumference despite cerebral atrophy. This characteristic cerebral atrophy may result in the relative expansion of subarachnoid spaces thereby leading to increased risk of intracranial hemorrhage. Children with GA1 typically have other distinguishing features on neuroimaging that differentiate this disease from AHT. Similarly, the pattern of retinal hemorrhage in GA1 is usually limited to the posterior pole versus the numerous and widely distributed retinal hemorrhage seen in AHT. Diagnosis is made by assessing urine and blood for elevations of specific metabolites.
Menke’s disease
Menke’s disease is a genetic disease that is a result of a defect in the copper transport enzyme, which impacts collagen and elastin formation. Children with Menke’s may have rapid neurologic degeneration, abnormal growth, and skeletal development, as well as characteristic abnormal hair morphology (pili torti: short, coiled, friable, and decreased pigment). Their blood vessels are increasingly fragile and may be prone to rupture even with routine activities, which can manifest as intracranial or intra-abdominal bleeding. Children with Menke’s frequently have bone defects that may mimic the classic metaphyseal lesion, but retinal hemorrhage has not been reported as a feature. Diagnosis is made by examining the hair under a microscope in addition to identifying decreased levels of serum copper and ceruloplasmin.
Outcomes
Outcomes after AHT have been shown to be worse than those observed after accidental head injuries. Most estimates suggest that approximately 25% of patients who experience AHT die in the acute period, approximately 15% go on to experience normal development, and the majority are left with at least 1 long-term disability. , Outcome studies vary in measures used and length of follow-up, but generally, the most commonly reported long-term disabilities reported after AHT are developmental delays, epilepsy, behavioral disorders, learning disorders, and visual impairment. , Overall, prognosis after AHT has been correlated to the severity of initial injury, as well as to the age at which the initial injury was sustained. While most AHT occurs in infants and young children, neurodevelopmental impacts are often not apparent until later in development, highlighting the need for close monitoring of children with AHT throughout their entire childhood rather than just the first few years after injury. ,
Prevention
Numerous prevention efforts have been made throughout the years to decrease child maltreatment. Some of those efforts include primary prevention, which targets the general population, such as public health education and more focused education designed for new parents. Secondary prevention programs are aimed at a particular population deemed to be at increased risk of child maltreatment, and tertiary prevention programs focus on the caregivers of children who have suffered maltreatment in an attempt to prevent recurrence or other negative complications.
Two of the more well-known primary prevention programs include the Upstate New York AHT Prevention Program and the Period of Purple Crying Program. Research has shown that crying is often a trigger for child physical abuse. These prevention programs focus on providing parents education about crying, in an attempt to normalize this behavior in infants. Additionally, they provide tips on how to decrease parental frustration, decrease infant crying, and provide information about the dangers of shaking infants. The initial pilot studies performed for both of these prevention programs showed promising results with up to a 75% decrease in abusive head trauma when compared to the previous average; however, these results have not continued as time progressed or when geographic location was changed.
On the other hand, secondary prevention programs, including the Nurse Family Partnership, have been shown to have a more long-lasting, positive impact on participants. The Nurse Family Partnership provides in-home nursing education and support for low-income first-time mothers during pregnancy, as well as in the first 2 years of life. The aim is to improve prenatal health, the health and development of the child following delivery, and mothers’ parenting. The children whose mothers received these interventions were less likely to suffer abuse when compared to control children whose mothers were not enrolled in the program. This program was the basis for the federally-supported Maternal, Infant, and Early Childhood Home Visitation Program. Researchers continue to evaluate the program, making improvements on various aspects in the hopes of increasing participant retention, and improving interventions.
A tertiary prevention program called SafeCare is a Parenting Behavioral Training Program that targets parents who have children younger than 6 years old and are in the process of reunification following removal due to child maltreatment. This in-home program provides education to parents about positive parent-child interactions, home safety, and child health. This program has been shown to decrease the rate of repeat referrals for child maltreatment when compared to families who did not participate in the program. SafeCare was transitioned to a virtual platform during the COVID-19 pandemic and research shows that even in a virtual platform, families were still able to show progress in specific skills, improving the parent-child relationships.
Overall, the most successful prevention programs appear to provide in-home, ongoing services. These programs are costly and require significant manpower. These programs must also be re-evaluated over time so that they can evolve as various social factors change. In addition, constant quality control is vital to ensure families are provided optimal support and resources as needed despite staffing changes and program growth. For continued success in abuse prevention, continued research, and policy change is necessary.
Current research/future directions
Though the AHT diagnosis has been well-established and supported by peer-reviewed medical literature and clinical experience, there is still much to learn about the mechanisms, presentation, and dating of inflicted injuries, as well as opportunities for standardization of diagnosis.
One such area of future research is in regard to occipital impacts. Though it is long-established that short-distance falls generally do not cause serious intracranial injury, it has recently been reported by Atkinson and colleagues that short-distance falls with an occipital impact may be capable of causing injuries similar to those seen in AHT. All of the patients in the Atkinson case series had witnessed short falls after which patients became immediately symptomatic, and though they were found to have varying degrees of subdural hemorrhage and retinal hemorrhage, none had any additional abusive injuries such as a skull fracture. Despite the limitations of this case series, it highlights the need for additional research regarding this particular mechanism of injury.
Another area of diagnostic variability and much-needed future research is timing of abusive head trauma. While the established literature from perpetrator confessions suggests that most infants with AHT become symptomatic close to the time of inflicted injury, several recent case reports have suggested that, while rare, some victims may experience a lucid interval. Factors associated with lucid intervals are not well-understood and therefore warrant further investigation.
Recent efforts have also been made to gain a greater understanding of biochemical and protein pathways involved in brain trauma that could aid in the diagnosis, treatment, monitoring, and recovery of traumatic brain injury. Several studies have evaluated the pathways involved in secondary brain injury in an attempt to identify differences in various biomarkers found in AHT versus accidental traumatic brain injury (TBI). Berger and colleagues compared the cerebrospinal fluid and serum levels of neuron-specific enolase (NSE), S100 B, and myelin-based protein (MBP) between children who suffered AHT and children who had no evidence of head trauma and found that NSE and MBP were somewhat sensitive and specific for AHT. This study specifically evaluated well-appearing children who presented with non-specific symptoms in the hopes that these biomarkers could be used as screens for possible AHT in infants. Newell and colleagues evaluated macrophage and T-cell activation following TBI in children and found an increase in children who had experienced TBI compared to children with no brain injury, as well as in younger patients, patients with AHT, and children with worse outcomes. Blackwell and colleagues evaluated concentrations of the neuroinflammatory marker Osteopontin (OPN) and found that the levels of OPN were higher in children who suffered AHT than in children with accidental TBI. The identification of an easily measurable biomarker of AHT would be revolutionary in the diagnosis and management of AHT, and these early efforts show significant promise, emphasizing the need for further research.
Clinical decision rules (CDR) are another recent diagnostic advancement, which can aid in determination of the likelihood of AHT diagnosis given specific combinations of physical examination, laboratory, and imaging findings. It is important to note that PECARN (Pediatric Emergency Care Applied Research Network), a well-known traumatic brain injury prediction rule, does not apply to infants in which AHT is a concern and misapplication of PECARN likely contributes to missed AHT diagnoses. , The PediBIRN (Pediatric Brain Injury Research Network) CDR has been validated in the pediatric intensive care, inpatient, and emergency settings and is perhaps the most widely known and used prediction tool in clinical practice. There is a 3-variable (respiratory compromise; torso, ear, neck bruising; bilateral or interhemispheric subdural hemorrhage) and 4-variable version of the tool (adds skull fracture other than simple linear parietal skull fracture). The PediBIRN-4 performed with a sensitivity 96% and specificity 43% in both its original intensive care-based validation study and in a more recent external validation study that applied broader inclusion criteria of all young children admitted with head injuries. The sensitivity was similar in the ED but had lower specificity than inpatient/intensive care settings. , The Predicting Abusive Head Trauma Tool (PredAHT) is another tool used to predict the probability of AHT, in this case in children <3 years old based on 6 clinical factors: head/neck bruising, apnea, rib/long bone fractures, and retinal hemorrhages. The PredAHT version 2 enables a probability calculation when any of the 6 clinical factors are absent. Consistent with original predictions, when 3 or more features were present in a child with intracranial injury the estimated probability of AHT was 81.5%. The sensitivity of the tool was 72.3% and the specificity was 85.7%. , The Pittsburg Infant Brain Injury Score (PIBIS) is a clinical prediction rule that was initially used to help physicians decide when to obtain neuroimaging in infants who were at high-risk for AHT. The PIBIS tool is a 5-point scoring system based on: dermatologic findings (2 points), age greater than or equal to 3 months (1 point), head circumference greater than the 85th percentile (1 point), and serum hemoglobin less than 11.2 g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% and 53%, respectively. Further refinement and validation of these various tools is necessary to allow for widespread adoption.
Another important area of future research relates to bias and equity. A sentinel study conducted by Jenny and colleagues demonstrated that infants who presented with milder, less-specific symptoms, and were from a White family were more likely to have a missed initial diagnosis of AHT. Subsequent studies have shown that these disparities persist. One retrospective study using the administrative data from a national database of infants with non-motor vehicle-associated TBI found that Black race and uninsured status were both associated with increased diagnosis of child abuse. Analysis of combined data from the PediBIRN network also showed that patients of minority race were 2 times as likely to be evaluated and reported for suspected AHT when compared to White patients. These race-based differences in evaluation, diagnosis, and reporting of suspected abuse may ultimately impact outcomes as these disparities could be perpetuated within the child welfare system. Further study of these disparities and the role of tools such as CDRs in combating bias are essential to achieving health equity.
Summary
Abusive head trauma is associated with high mortality in young children, but can be challenging to diagnose due to its disparate mechanisms, subtle clinical presentations, and variable findings. The diagnosis of AHT is best made following a thorough evaluation, ideally by multiple subspecialists, including a pediatric clinician with expertise in child abuse who can fully assess for potentially confounding conditions such as accidental/birth trauma, coagulopathy, or genetic syndromes. Further research into mechanisms of AHT, timings of injury, and outcomes after injury, as well as continued work on clinical prediction tools and biochemical markers may allow for improvement in diagnostic variability and reduction of bias. Continued support for families and development of prevention programming is essential in reducing rates of this severe form of maltreatment.
Clinics care points
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The clinical presentation of AHT is variable and most often consists of vague symptoms such as fussiness, irritability, or feeding difficulty. Alternatively, patients may present at a time delayed from the initial injury with symptoms such as increasing head circumference or developmental delay.
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While there is no single finding which is diagnostic of AHT, the identification of subdural hemorrhage, cerebral edema, retinal hemorrhage, and/or hypoxic-ischemic injury in an infant without any known history of significant trauma should raise concerns and prompt further evaluation for child abuse.
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The diagnosis of abusive head trauma is best made upon the multidisciplinary input of multiple care team members. Early involvement of a medical social worker and a child abuse trained pediatric clinician is essential.
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