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PEDIATRIC

ABUSIVE HEAD TRAUMA

Dana Bartlett, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and author. His

clinical experience includes 16 years of ICU and ER

experience and over 20 years of as a poison control center information

specialist. Dana has published numerous CE and journal articles, written

NCLEX material and textbook chapters, and done editing and reviewing for

publishers such as Elsevier, Lippincott, and Thieme. He has written widely on

the subject of toxicology and was recently named a contributing editor,

toxicology section, for Critical Care Nurse journal. He is currently employed

at the Connecticut Poison Control Center and is actively involved in lecturing

and mentoring nurses, emergency medical residents and pharmacy students.

ABSTRACT

Pediatric abusive head trauma has a high rate of occurrence in the

United States. It is a major cause of physical injury and death in

children. Clinicians need to be aware of the risk factors and to be

prepared to pursue a careful history and physical examination early in

the evaluation period when care has been sought to avoid serious

complications of injuries associated with abusive head trauma.

Additionally, prevention strategies and support for parents to seek help

to avoid child abuse are discussed.

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Continuing Nursing Education Course Director & Planners:

William A. Cook, PhD, Director; Douglas Lawrence, MS, Webmaster;

Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner

Accreditation Statement:

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses.

Credit Designation:

This educational activity is credited for 2.5 hours. Nurses may only

claim credit commensurate with the credit awarded for completion of

this course activity.

Course Author & Planner Disclosure Policy Statements:

It is the policy of NurseCe4Less.com to ensure objectivity,

transparency, and best practice in clinical education for all continuing

nursing education (CNE) activities. All authors and course planners

participating in the planning or implementation of a CNE activity are

expected to disclose to course participants any relevant conflict of

interest that may arise.

Statement of Need:

The statistics, risk factors and clinical characteristics associated with

pediatric abusive head trauma are necessary for health providers to

detect and manage this injury, and to promote prevention.

Course Purpose:

To provide nurses with an overview of the recognition and prevention

of pediatric abusive head trauma.

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Learning Objectives:

1. Identify risk factors for pediatric abusive head trauma.

2. Identify commonly reported signs of pediatric abusive head trauma.

3. Identify injuries that are common to pediatric abusive head trauma.

4. Identify the mechanism(s) of injury of pediatric abusive head

trauma.

5. Discuss the process of detection and diagnosis of pediatric abusive

head trauma.

Target Audience:

Advanced Practice Registered Nurses, Registered Nurses, Licensed

Vocational Nurses and Associates

Course Author & Director Disclosures:

Dana Bartlett, RN, BSN, MA, MSN, William S. Cook, PhD,

Douglas Lawrence, MS, Susan DePasquale, CGRN, MSN, FPMHNP-BC -

all have no disclosures.

Acknowledgement of Commercial Support: There is none.

Activity Review Information:

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.

Release Date: 11/11/2014 Termination Date: 11/11/2017

Please take time to complete the self-assessment Knowledge Questions

before reading the article. Opportunity to complete a self-assessment of

knowledge learned will be provided at the end of the course

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1. True or false: Very few cases of pediatric abusive head trauma go

undetected.

a. True

b. False

2. Two mechanisms of injury that can explain pediatric abusive head

trauma are:

a. Shaking and impact force.

b. Impact force and malnutrition.

c. Shaking and a coincidental systemic infection.

d. Developmental delays and short, accidental falls.

3. Which of the following increases the risk for pediatric abusive head

trauma?

a. Female gender

b. Age > 5 years

c. Male gender

d. Premature birth

4. Which of the following increases the risk for pediatric abusive head

trauma?

a. Developmental delays

b. Chronic otitis media

c. Female gender

d. Age < one year

5. True or false: Children who have abusive head trauma often have

evidence of previous abuse.

a. True

b. False

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6. Which of these injuries is commonly caused by pediatric abusive

head trauma?

a. Retinal hemorrhages

b. Pneumothorax

c. Skull fracture

d. Ruptured spleen

7. Which of these injuries commonly occurs with pediatric abusive

head trauma?

a. Liver damage

b. Rhandomyolysis

c. Subdural hematoma

d. Facial fractures

8. Which of these injuries is commonly associated with pediatric

abusive head trauma?

a. Oral trauma

b. Esophageal trauma

c. Scalp lacerations

d. Rib fractures

9. Children ≤ 24 months of age who may have suffered abuse should:

a. have cardiac enzymes and serum CK measured.

b. have a skeletal survey and a CT or MRI scan of the head.

c. have a cardiac echocardiogram.

d. have a skull x-ray and a chest x-ray.

10. True or false: Pediatric abusive head trauma is always

accompanied by external signs of trauma.

a. True

b. False

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Introduction

Pediatric abusive head trauma, once commonly known as and still

occasionally called the shaken baby syndrome, is a form of child abuse

that can result in significant morbidity and mortality. The traditional

explanation for pediatric abusive head trauma (hereinafter, simply

referred to as abusive head trauma) was that violent shaking of the

child or infant by an adult caused shearing and breaking of blood

vessels in the brain and the eyes. However, many authorities feel that

shaking alone cannot account for the damage seen in cases of abusive

head trauma. The exact mechanism or mechanisms of injury are not

known, but the injuries incurred are most likely caused by impact

force, shaking, or a combination of the two.

The peak incidence of abusive head trauma appears to be in children

less than one year of age, and frequently the victims are between the

ages of 2 to 4 months. Most of the victims and most of the

perpetrators are male. The exact incidence of abusive head trauma is

not known, but it is certainly under-diagnosed and under-detected.

However, there are no doubts about the seriousness of this type of

child abuse. Intracranial bleeding, significant ocular damage, multiple

fractures, and other serious injuries are very common consequences of

abusive head trauma. In addition, the mortality rate of abusive head

trauma has been estimated to be as high as 25% and many of the

survivors are left with permanent and significant disabilities.

Detection of pediatric abusive head trauma can be very difficult and

requires a high index of suspicion. There are some injuries that are

considered to be essentially diagnostic for abusive head trauma but in

many cases the clinical presentation is non-specific, there are no

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visible signs of injury, and there are no witnesses to the event.

Improving detection rates is critically important, as the research has

shown that children who are abused this way will almost always be

abused again.

This course provides an overview of the recognition and prevention of

pediatric abusive head trauma. Specific topics include the statistics of

abusive head trauma, mechanisms of injury, etiology of and risk

factors for abusive head trauma, the clinical characteristics and

specific injuries associated with abusive head trauma, detection and

diagnosis of this injury, and management and prevention issues.

Statistics Of Child Abuse

Child abuse includes abandonment, emotional abuse, neglect, physical

abuse, sexual abuse, and substance abuse, and it is a significant

problem in the United States. In 2011, 3.4 million referrals were made

to child protective services.1 The annual incidence of abusive head

trauma has been estimated to be approximately 24-34 cases per

100,000 children one year of age or younger.2 These statistics by

themselves are very disturbing, yet the actual number of children who

are abused is likely much higher1 as not all cases are reported and/or

detected, and the standards for reporting differ.

Definitions of child abuse vary and this has

legal, medical, and social implications. For

example, the National Incidence Study (a

U.S. government directed assessment of

child abuse and neglect) assesses the

Child protective

services are the local,

county, and state

agencies that intervene

in cases of child abuse.

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prevalence of child abuse using the Harm Standard and the

Endangerment Standard. The Harm Standard requires that an act or

omission must cause demonstrable harm to be considered abuse while

the Endangerment Standard only requires that a child be endangered

by abuse or neglect. The definition that will be used here is from the

Federal Child Abuse Prevention and Treatment Act. Child abuse, at

minimum is:

“Any recent act or failure to act on the part of a parent or

caretaker which results in death, serious physical or emotional

harm, sexual abuse or exploitation; or an act or failure to act

which presents an imminent risk of serious harm.”3

Physical abuse of children is less prevalent than many of the other

forms of child abuse. Of the over three million reports of child

maltreatment received by child protective services approximately 18%

of these involve physical abuse.4 Tragically, many of these cases of

physical abuse involve head trauma.

Abusive head trauma is a leading cause of serious, traumatic brain

injury and death in children two years of age and younger in the

United States.5,6 Abusive head trauma has been estimated to be the

cause of 50%-80% of the deaths attributable to head trauma in this

age group7 and mortality rates in abusive head trauma have been

reported to be between 15%-25%.8 Keenan et al., (2004) found that

almost 39% of children who had an inflicted brain injury required

cardiopulmonary resuscitation (CPR), over 31% had a loss of

consciousness, and almost 49% had a seizure.9 The initial injury, if

the child survived, can often cause permanent and serious behavioral,

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neurological, and physical impairments7 and approximately one-third

of all children who are victims of abusive head trauma are severely

disabled.10

The tragedy of abusive head trauma is compounded by missed

diagnoses and repetitive injuries. Jenny et al., (1999) found in their

retrospective study of head trauma that 31% of cases of abuse head

trauma were not accurately diagnosed by the physician and 28% of

children were re-injured after that missed diagnosis.11 These findings

have been reaffirmed by later researchers12 and it has also been

shown that as many as 45% of children who have suffered abusive

head trauma had been previously abused.12,13

Pediatric Abusive Head Trauma Defined

As mentioned in the introduction, abusive head trauma was originally

called shaken baby syndrome. The term shaken baby syndrome is still

used, but the American Academy of Pediatrics has recommended it no

longer be used and the term abusive head trauma used in its place.14

The Academy pointed out that shaking is a mechanism of injury of

abusive head trauma. However, the Academy also wanted clinicians to

be aware that shaking is not the only way this injury can be inflicted.

Blunt force trauma alone can cause abusive head trauma or there can

be a combination of forces. Clinicians trying to determine if a child may

be suffering from abusive head trauma or if head trauma was

accidental or inflicted could be mislead if they believe shaking to be

the sole mechanism of injury of abusive head trauma.14,15

The Centers for Disease Control and Prevention (CDC) has defined

pediatric abusive head trauma as:16 … an injury to the skull or

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intracranial contents of an infant or young child (< 5 years of age) due

to inflicted blunt impact and/or violent shaking; unintentional injuries

resulting from neglectful supervision and gunshot wounds, stab

wounds, and penetrating trauma are excluded from this definition.16

Recognizing and writing about the patterns and consequences of child

physical abuse of patterns was first done by Ambrose Tardieu in

France in the 1800s.17 In the United States, Dr. John Caffey in 1946

was the first to publish a systematic study of clinical and radiologic

evidence that suggested a syndrome of child physical abuse.18

However, although Caffey indicated that he felt the pattern of injuries

he described was caused by deliberate abuse, he only suggested it and

did not conclusively state that abuse was the cause. It was not until

1962 that Kempe et al., unequivocally described and labeled child

physical abuse as abuse.19 The authors’ term for this was battered-

child syndrome.

Guthkelch’s (1971)20 and Caffey’s (1972)21 research on the topic of

child physical abuse implicated shaking as the primary mechanism of

injury and during that time abusive head injury was occasionally

referred to as infant whiplash injury. The term shaken baby syndrome

was first used by Ludwig and Warman in 198422 and subsequently

replaced by the terms abusive head trauma or pediatric abusive head

trauma.23,24

Mechanisms Of Pediatric Abusive Head Trauma

The traditional term for pediatric abusive head trauma, shaken baby

syndrome, was first used in a case series study of 20 infants who had

suffered physical abuse22 and these authors, and several others who

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had written previously on the subject, assumed that shaking was the

primary mechanism of injury that explained the syndrome.

Subsequently, the medical community accepted both the term shaken

baby syndrome and the idea that violent shaking was the sole cause of

the neurologic, ocular, and other damage caused by this abuse. This

belief by the medical community is no longer the case. Violent shaking

causes rotation and acceleration-deceleration of the head and brain;

this can be of sufficient force to cause abusive head trauma.

An infant has a proportionally large head and relatively weak neck

muscles and the sudden, intense movement of the head that occurs

when an infant is shaken can cause shearing of blood vessels in the

brain and the eyes.6 However, there is considerable controversy as to

whether shaking alone can mechanistically explain the damage of

abusive head trauma, or if shaking plus impact are needed.6,25 As early

as 1988, Duhaime had performed biomechanical studies and concluded

the following: 26

the force of impact was far greater than the force of shaking;

shaking was not necessary to produce rotational forces;

shaking could not produce sufficient force to cause the

pathological and radiological evidence of abusive head trauma.

In 2010 Dias wrote that no convincing argument had been advanced

that supported shaking as the primary mechanism of injury in abusive

head trauma.27 Herman et al., (2010) wrote:

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“An accumulating body of evidence, however, supports the idea

that either mechanism, shaking alone or shaking with impact,

can produce the injuries that are observed clinically.”6

However, Christian et al. (2009) concluded that “. . . all the models

and theories (of abusive head trauma) have known limitations . . . “.14

Once the initial, primary injury from mechanical forces has occurred,

secondary mechanisms of injury such as hypoxia-ischemia,

inflammation, or hypoperfusion may begin.15,28,29 These secondary

mechanisms of injury appear to be more common in inflicted head

trauma in children than in accidental head trauma; and, the outcome

for the infant is likely to be very poor if hypoxia and ischemia are

present.14,29

Risk Factors Of Pediatric Abusive Head Trauma

There are specific patient, caregiver, and environmental factors that

increase the risk for abusive head trauma. Knowing what these risk

factors are helps the clinician to determine whether they are present,

and forms a critical part of the assessment of abusive head trauma.

Clinicians often speak of the index of suspicion when they are trying to

make a diagnosis. This simply means that the clinician uses objective

data to determine what disease, illness, or injury is most likely to be

responsible for the patient’s clinical condition. For example, if the

patient is 69 years old and has shortness of breath, cyanosis, rales,

and a past medical history of hypertension and myocardial infarction,

the index of suspicion would be high for congestive heart failure and

low for asthma.

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The clinician should consider the need for assessment of pediatric

abusive head trauma if:

the child has an acute or a chronic illness or injury and there is

no adequate explanation or an inconsistent explanation;

the child has a severe head injury or other major trauma that is

reported to have happened because of a short fall or minor

accident;

there is an unexplained head injury in a child who had previously

been well;

circumstances surrounding the injury are accompanied by risk

factors and certain patterns of injury that are associated with

abusive head trauma.

Of course, the necessary data may not be available or the data that is

available is equivocal. In cases of abusive head trauma, physical signs

or radiologic findings that are typically considered to be diagnostic of

abusive head trauma may be absent; or the results of examination, X-

rays, and scans may be too general and non-specific.

Because it is critically important to make an early and accurate

diagnosis of abusive head trauma, nurses and other health care

professionals must be aware of the risk factors associated with it. Risk

factors associated with abusive head trauma are outlined in Table 1

below. 10

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Table 1: Factors Associated with Increased Risk

for Abusive Head Trauma

Caregiver mental health disease

Caregiver substance abuse

Inconsolable crying

Intimate partner violence

Low socioeconomic status

Male caregiver

Male gender of the child

Previous abuse

Young age of the child

Young maternal age

For some of these factors the association between the risk factor and

abusive head trauma is strong and consistent. Many authors have

noted that a child’s age of less than one year is consistently associated

with abusive head trauma,5,30-34 that males are more likely than

females to be victims of abusive head trauma,5,31-33,35 and males are

the perpetrator of abusive head trauma more often than females.15

Evidence of prior abuse is also a common finding.32 Of particular

interest is the issue of crying. Abusive head trauma is much more

likely to occur in children less than one year of age, and inconsolable

infant crying is common during this period of a child’s development.

The crying can be prolonged, unpredictable, accompanied by other

behaviors that can be upsetting to caretakers, and, as the term

suggests, the infant cannot be consoled. Several authors have found

that inconsolable crying is associated with abusive head trauma.36-38

Significant traumatic injuries in a child who does not walk or is in the

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pre-cruising (walking with assistance) stage of development are also

highly unlikely, and indicative of abusive head trauma.

There are also risk factors specific to the pediatric brain and pediatric

anatomy that contribute to the neurological and ocular injuries caused

by abusive head trauma.15,39

An infant’s head is relatively large and unstable when compared

to its body. This feature of infant anatomy can mean that if an

infant is vigorously shaken, the head and the brain can rapidly

accelerate and decelerate.

An infant’s brain matter is relatively soft and has high water

content, making it softer and susceptible to injury.

An infants’ skull is soft and pliable so force is more easily

transmitted to the brain.

The base of an infant’s skull is relatively flat and this allows for

more brain movement inside the skull.

An infant’s neck muscles are relatively weak and this allows for

greater movement of the head is response to force.

A relatively high cerebral blood flow increases the potential for

bleeding and swelling in the brain.

Clinical Presentation Of Pediatric Abusive Head Trauma

Abusive head trauma should be considered as a possibility in every

child less than two years of age who has neuro-trauma or a

neurological abnormality. 47 Abusive head trauma is detected and

diagnosed through a combination of awareness or suspicion of the

possibility in a given circumstance, a carefully performed history and

physical examination, consultations (i.e., neurology, ophthalmology),

characteristic physical findings, and appropriate diagnostic testing.

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Detecting and diagnosing abusive head trauma is difficult, and for

many reasons the diagnosis of this trauma requires a high index of

suspicion.40 Some of the difficulties that hinder detection and diagnosis

of abusive head trauma are further discussed below.

Risk factors can be helpful in identifying children who are victims of

abusive head trauma. Although some of these are reliable predictors of

the possibility of abusive head trauma they are non-specific, i.e., male

gender and age less than one year (and they do not account for all

cases). There are always exceptions to identified risk factors of

abusive head trauma. Using these risk factors must be done with

caution to avoid stereotyping, over-diagnosing, and underdiagnosing.10

Of significance, there is a wide range of signs that have been observed

in children who have suffered abusive head trauma, ranging from mild

to life-threatening.10 The clinical presentation is often non-specific.40

In many cases of abusive head trauma there is no reported history of

trauma.2,40 The precipitating event is seldom witnessed, and the

perpetrator and/or the adult who brings the child for medical attention

may not be truthful about how the injury occurred.

The neurological examination may be normal, or the child may have

evidence of severe brain injury.40 Many children do not have external

evidence of injury. King et al.,41 and Keenan et al.9 noted that 54% and

40%, respectively, of the children they examined who had abusive

head trauma had no external signs of injury.

Clearly there are significant challenges in detecting and diagnosing

abusive head trauma. Because of the high morbidity and mortality rate

associated with abusive head trauma, and the high risk that infants

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who are abused once will be abused again, it is critically important that

this diagnosis not be missed. The risk factors associated with abusive

head trauma are helpful in this respect, but they are limited and can

only help as a guide for the clinician point. Its important for the

clinician to keep in mind that the clinical presentation of abusive head

trauma varies significantly and is non-specific; and, the injuries that

are considered to be part of the “typical” presentation of abusive head

trauma are not always present and may be caused by accidental

trauma, diseases, etc. Table 2, below, outlines differential diagnosis in

the determination of abusive head trauma.10

Table 2: Differential Diagnosis for Abusive Head Trauma

Accidental trauma

Benign extra-axial fluid of infancy

Benign external hydrocaphalus

Birth trauma

Bleeding disorders

Metabolic diseases

There are patterns of injury and a few clinical signs that are considered

essentially pathognomonic for abusive head trauma. Apnea, bruising of

the ears, neck, or torso, cerebral edema, certain types of skull

fractures, encephalopathy, long bone fractures, metaphyseal fractures,

skull fractures plus intracranial injury, retinal hemorrhages, and

subdural hemorrhage have all been strongly associated with, and in

some cases highly sensitive and specific for, abusive head

trauma.2,42,44 Retinal hemorrhages, subdural hemorrhage, fractures,

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and encephalopathy are considered to be the common injuries of

abusive head trauma,25 and each these will be discussed individually.

Retinal Hemorrhage and Other Ocular Damage

Retinal hemorrhages are very common in children who have abusive

head trauma. One review noted the presence of retinal hemorrhages in

almost 85% of children who had been diagnosed with abusive head

trauma,8 and other authors have confirmed the high incidence of this

ocular damage in these cases.45-47 Retinal hemorrhages also have a

high specificity and high predictive value for abusive head trauma.10,45

In addition, they are rarely caused by accidental head trauma.46 Given

that fact, and the high incidence, high specificity, and high predictive

value, retinal hemorrhages are felt to be almost pathognomonic for

abusive head trauma in very young children and infants.

The absence or presence of retinal hemorrhages cannot be the sole

criteria for diagnosing abusive head trauma.8,10 Agrawal et al. (2012)

found a 15% prevalence of retinal hemorrhages in critically ill

children,48 therefore, the absence or presence of ophthalmic findings

should only be considered as part of the diagnostic picture and must

be used in context. Table 3 below lists the differential diagnosis for

retinal hemorrhage. 10,48

Table 3: Differential Diagnosis for Retinal Hemorrhage

Anemia

Carbon monoxide poisoning

Cardio-pulmonary resuscitation

Genetic syndromes

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Glutaric aciduria - autosomal recessive metabolic disorder

Hematologic conditions, coagulopathies, and other bleeding disorders

Hypoxia

Hypo- hypertension

Infections

Intracranial hemorrhage

Perinatal retinal hemorrhage

Sepsis

Sudden Infant Death Syndrome

Tumors

Unintentional head injury

Vasculitis

Other ocular damage that can be caused

by abusive head trauma includes, but is

not limited to, hemorrhage of the optic

nerve sheath, hemorrhage of the vitreous

sheath, papilledema, perimacular folding,

and retinoschisis.8 These are less common

than retinal hemorrhage but can be highly

more specific for abusive head trauma,

i.e., perimacular folds and retinoschisis.8

Papilledema has been described a late

finding and associated with a poor

prognosis.49

The term retinoschisis

means a splitting of the

retina. A perimacular

fold is a doubling over

(folding) in the macula,

the central part of the

retina. Papillededma is

defined as optic disc

swelling caused by

increased intracranial

pressure.

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Subdural Hemorrhage

Subdural hemorrhages have been reported in 77%-90% of patients

who have suffered abusive head trauma.32 A serious intracranial injury

is rarely caused by low impact trauma,15 and a subdural hematoma is

a very unusual occurrence in children unless the child was involved in

a motor vehicle accident or a high fall.15,50 Short, accidental falls rarely

cause serious harm or death in children.15,50-54

The presence of a subdural hemorrhage in an infant or child should

prompt clinicians to investigate the possibility of abusive head trauma.

Intraparenchymal bleeding, epidural hemorrhage, subarachnoid

hemorrhage or some combination of these can also be caused by

abusive head trauma.15 A subdural hemorrhage is a collection of blood

between the dura mater and the arachnoid mater. The dura mater is

the outermost of the three meninges (fibrous membranes) that

surround the brain and the spinal cord, and the arachnoid mater in the

middle meninge.

A subarachnoid hemorrhage is a collection of blood between the

arachnioid meninge and the innermost meninge, the pia mater. As

with retinal hemorrhages, a subdural hematoma is highly suggestive

of, but not diagnostic for abusive head trauma. Clinicians must

consider other possible causes for this injury:

“While the majority of the available literature seems to accept

that the presence of any unexplained SDH (subdural hematoma)

or SDH not related to a comorbid condition in a young child

should raise the suspicion of NAT (non-accidental trauma), the

data supporting this conclusion are difficult to interpret.”55

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Table 4 includes a list of possible conditions for the clinician to

consider in the differential diagnosis of subdural hematoma.10,40

Table 4: Differential Diagnosis of Subdural Hematoma

Fractures

Fractures are not uncommon in cases of abusive head trauma.56 Rib

fractures, long bone fractures, metaphyseal fractures, radius and ulna

fractures, and tibia or fibula fractures appear to be typical sites of

injury; and, rib fractures are mentioned most often in the literature as

being associated with abusive had trauma2,10,42,57-61

Fractures are a common childhood injury, but multiple fractures

(especially of the ribs) appear to occur more often as a result of abuse

than from accidental trauma. A fracture in a child less than one year of

age is often caused by abuse.59 Skull fractures are uncommon in cases

of abusive head trauma.2,9,15,42,55,60,62

Encephalopathy

Encephalopathy is defined as a disorder or disease of the brain.

Children who have sustained abusive head trauma present with a wide

range of behavioral and neurological problems. Some of these are

Birth trauma

Coagulopathies

Genetic syndromes

Infections

Metabolic diseases

Trauma

Tumors

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relatively minor, such as the child might be irritable or lethargic.

Others are very severe. The victims of pediatric abusive head trauma

may suffer from epilepsy, seizures, motor weakness, and visual,

cognitive, and sensory impairments,63 and one author estimated that

neurological damage sustained as a result of pediatric abusive head

trauma was permanent in more than 80% of the victims.64 It is also

possible that a child who has suffered pediatric abusive head trauma

may appear to be normal and the trauma is found after computed

tomography (CT) or magnetic resonance imaging (MRI) scanning.65,66

Diagnostic Testing And Consultation

Differentiating between accidental injuries and inflicted trauma is

difficult in the case of abusive head trauma. Detecting abuse is also

very difficult in the absence of obvious signs and symptoms and/or a

confession by a parent or a caretaker.67 Child abuse and pediatric

abusive head trauma are relatively common, but the detection rate of

these problems by health care facilities is presumed to be very low,

even when health care professionals have been trained to use

systematic screening tools designed to detect abusive head

trauma.68,69 Diagnostic testing, i.e., X-rays, scans, and laboratory

testing, and neurologic and ophthalmologic consultations, can be very

helpful in detecting cases of abusive head trauma, and some of these

are considered mandatory.

The American College of Radiology recommends that children who are

24 months of age or younger who may have suffered physical abuse

should receive a skeletal survey.70 The skeletal survey includes: 1)

frontal and lateral views of the skull; 2) lateral views of the cervical

spine (if not included on the lateral view of the skull) and the

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thoracolumbosacral spine; and, 3) single frontal views of the long

bones, chest, and abdomen.70 Oblique views of the ribs should also be

done; and, for the best quality and diagnostic accuracy, separate

views of each arm, forearm, foot, hand, leg, and thigh should be

done.70 Bone scans should be done if the X-rays are negative but the

clinical examination suggests a high index of suspicion for abuse.70

Computerized axial tomography and magnetic resonance imaging

scanning should be used to detect intracranial damage such as a

subdural hematoma.40 If the child has a skull fracture or clinical signs

and symptoms of intracranial injury a CT scan should be done

immediately.70 An MRI should be done if the CT scan does not detect

damage that requires immediate surgical intervention but the clinician

has determined that further assessment is necessary.70 If the child has

no physical or clinical signs of intracranial injury but there is reason to

believe that the child may have suffered abusive head trauma, it is

better to err on the side of caution and perform a CT scan or MRI scan

as “ . . . clinicians should have a relatively low threshold for

performing either CT or MRI of the head in children with suspected

abuse.”70

Laboratory tests that may be useful are a complete blood count and

(possibly) coagulation studies,71,72 and a urine drug screen to detect

the presence of illicit drugs. Consultations with a pediatric neurologist

and a pediatric ophthalmologist should be considered mandatory.

Management And Prevention

Nurses have the responsibility to document the clinical condition of the

child who may have suffered abusive head trauma, provide care to the

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child, and report confirmed or suspected cases to the appropriate

agencies. Precise and detailed documentation is obviously critically

important. Deciding that abusive head trauma has or has not occurred

is a process that requires the involvement of many people.

Determining that such an injury has occurred would not be the sole

responsibility of the nurse or within the scope of practice of the nurse;

the safety of the child and reporting abuse are primary nursing

responsibilities.

A comprehensive discussion about when, how, and to whom to report

confirmed or suspected abusive head trauma is beyond the scope of

this learning module. However, nurses must report confirmed and

suspected cases, child protective services should be notified, and a

social service consultation obtained. Because the consequences of

abusive head trauma are so serious, it is recommended that these

referrals be made as soon as possible. All states require nurses and

other health care professionals to report child abuse; the state by

state specifics for mandatory reporting, i.e., who is required to report,

when to report and to whom can be found using the online resource:

Child Welfare Gateway. U.S. Department of Health and Human

Services. Mandatory Reporters of Child Abuse. 2014.73

https://www.childwelfare.gov/systemwide/laws_policies/statutes/man

da.pdf.

Specific treatment will depend on the injuries sustained and the

appropriate medical and surgical consultations should be obtained.

Pediatric abusive head trauma is likely to happen in certain

circumstances and there are risk factors that appear to increase the

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possibility of its occurrence. But even if these circumstances and risk

factors are present, pediatric abusive head is not inevitable.

Prevention programs are a key part of the approach to the problem of

abusive head trauma and there is evidence that they can be

successful.

Dias et al. (2005) and Altman et al. (2001) provided educational

programs to parents and caretakers that focused on infant crying,

coping strategies, and the dangers of abusive head trauma; and, the

authors concluded that these interventions reduced the incidence of

abusive head trauma.74,75 Prevention programs have also been shown

to increase parent and caretaker awareness of the problem of abusive

head trauma and increase awareness of coping strategies to deal with

inconsolable crying.76-80

The Period of Purple Crying® is a prevention program that has been

assessed and proven successful at increasing awareness of abusive

head trauma and the use of coping strategies for inconsolable

crying.76,80-84 Purple is an acronym that describes the features of

inconsolable crying:

Peak of crying (the pattern slowly reaches a peak)

Unexpected crying

Resists soothing

Pain-like face (the infant appears to be in pain)

Long-lasting (crying can last for 5 hours or more)

Evening (the infant typically cries in the evening or at night)

Parents who are educated about these aspects of inconsolable crying

will, hopefully, be less likely to harm their children and more likely to

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use effective coping strategies or seek help. More information about

The Period of Purple Crying® and be found on the organization’s

website, www.purplecryinginfo.org.85

SUMMARY

Abusive head trauma is a significant cause of infant and child

morbidity and mortality. Abusive head trauma was originally called

shaken baby syndrome. It was thought that the primary mechanism of

injury was violent shaking by an adult that caused rotational forces

and acceleration-deceleration of the head, resulting in shearing and

breaking of blood vessels in the brain and eyes. In recent years the

validity of this theory has been intensely debated and the current

thinking is that shaking is unlikely to be the sole mechanism of injury

in abusive head trauma; and, the American Academy of Pediatrics

discourages use of the term shaken baby syndrome.

The presentation of abusive head trauma is very variable. The victim

may not have external evidence of injury or there may be clear signs

of trauma. Some children who have suffered abusive head trauma may

appear relatively well while other may be apneic and comatose. In

addition, the abuse is seldom witnessed and the perpetrator is unlikely

to admit guilt. As a result of these issues, detecting and diagnosing

abusive head trauma is very difficult. Detection and diagnosis is critical

as the evidence clearly shows that abuse is seldom an isolated

occurrence. If the abuse has happened once it will likely happen again.

However, knowledge of the risk factors and injuries that are associated

with abusive head trauma can be helpful in this regard. Children less

than one year of age and males are more likely to be victims and

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intracranial bleeding, retinal hemorrhages, and certain types of

fractures are common. Although risk factors and patterns of injury can

be very suggestive of abusive head trauma none of them alone are

diagnostic of this trauma. The diagnosis of abusive head trauma

requires careful consideration of all of the evidence. The specific tests

that are needed will depend on the circumstances of each case, but in

most instances of suspected abusive head trauma a skeletal survey, a

CT scan or MRI scan of the head, and consultations with a neurologist

and an ophthalmologist would be considered mandatory.

Specific treatment will depend on the injuries sustained and the

appropriate medical and surgical consultations should be obtained.

Nurses are required by law to report of confirmed or suspected cases

of abusive head trauma: child protective services and a social service

should be notified.

Please take time to help the NURSECE4LESS.COM course planners evaluate

nursing knowledge needs met following completion of this course by

completing the self-assessment Knowledge Questions after reading the

article. Correct Answers, page 30.

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1. True or false: Very few cases of pediatric abusive head trauma go

undetected.

a. True

b. False

2. Two mechanisms of injury that can explain pediatric abusive head

trauma are:

a. Shaking and impact force.

b. Impact force and malnutrition.

c. Shaking and a coincidental systemic infection.

d. Developmental delays and short, accidental falls.

3. Which of the following increases the risk for pediatric abusive head

trauma?

a. Female gender

b. Age > 5 years

c. Male gender

d. Premature birth

4. Which of the following increases the risk for pediatric abusive head

trauma?

a. Developmental delays

b. Chronic otitis media

c. Female gender

d. Age < one year

5. True or false: Children who have abusive head trauma often have

evidence of previous abuse.

a. True

b. False

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6. Which of these injuries is commonly caused by pediatric abusive

head trauma?

a. Retinal hemorrhages

b. Pneumothorax

c. Skull fracture

d. Ruptured spleen

7. Which of these injuries is commonly occurs with pediatric abusive

head trauma?

a. Liver damage

b. Rhandomyolysis

c. Subdural hematoma

d. Facial fractures

8. Which of these injuries is commonly associated with pediatric

abusive head trauma?

a. Oral trauma

b. Esophageal trauma

c. Scalp lacerations

d. Rib fractures

9. Children ≤ 24 months of age who may have suffered abuse should:

a. have cardiac enzymes and serum CK measured.

b. have a skeletal survey and a CT or MRI scan of the head.

c. have a cardiac echocardiogram.

d. have a skull x-ray and a chest x-ray.

10. True or false: Pediatric abusive head trauma is always

accompanied by external signs of trauma.

a. True

b. False

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Correct Answers:

1. B

2. A

3. C

4. D

5. A

6. A

7. C

8. D

9. B

10. B

Footnotes:

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characteristics associated with abusive and non-abusive head trauma: a

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4. Petska HW, Sheets LK Sentinel injuries: subtle findings of physical abuse. Pediatr Clin North Am. 2014;61:923-35.

5. Niederkrotenthaler T, Xu L, Parks SE, Sugerman DE. Descriptive factors of abusive head trauma in young children--United States, 2000-2009. Child Abuse Negl. 2013;37:446-55.

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7. Parks SE, Kegler SR, Annest JL, Mercy JA. Characteristics of fatal abusive head trauma among children in the USA: 2003-2007: an

application of the CDC operational case definition to national vital statistics data. Inj Prev. 2012;18:193-9.

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Crying, an abusive head trauma prevention program. J Obstet Gynecol

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of newborns: a randomized, controlled trial. Pediatrics. 2009;123:972-80.

85. The Period of Purple Crying®. Retrieved December 3, 2014 from www.purplecryinginfo.org.

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