Pediatric Abusive Head Trauma
Child Abuse Prevention: Shaken Baby Syndrome

CONTACT HOURS: 3

Copyright © 2022 Wild Iris Medical Education, Inc. All Rights Reserved.

BY: 

Dana M. Cox, MA, BSN, RN, CIMI

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will be better prepared to recognize and help prevent pediatric abusive head trauma (AHT). Specific learning objectives to address potential knowledge gaps include:

  • Define “pediatric abusive head trauma.”
  • Recognize the risk factors for head injuries resulting from abuse.
  • Describe the mechanisms of injury, clinical presentation, history gathering, physical assessment, and diagnosis of pediatric AHT.
  • Distinguish between accidental and abusive head trauma in the pediatric population.
  • Identify immediate and long-term treatments and interventions for children presenting with pediatric AHT.
  • Discuss resources for prevention of pediatric AHT.
  • Summarize reporting requirements for suspected child abuse and neglect.

TABLE OF CONTENTS

  • Introduction
  • Risk Factors for Abusive Head Trauma
  • Assessment and Diagnosis of Pediatric Abusive Head Trauma
  • Intervention for Pediatric AHT Patients
  • Prevention Strategies for Abusive Head Trauma
  • Reporting Child Abuse and Neglect
  • Conclusion
  • Resources
  • References

INTRODUCTION


Child abuse and neglect continue to pose serious threats to the health and well-being of children. In 2020, Child Protective Service (CPS) agencies received approximately 3.9 million referrals from across the country alleging maltreatment. The largest referral sources were legal and law enforcement (20.9%), education personnel (17.2%), and medical personnel (11.6%). These reports found there to be approximately 618,000 victims of child abuse and/or neglect, or 8.4 per 1,000 children in the population. Children younger than 1 year old had the highest rate of victimization at 25.1 per 1,000 children of the same age in the national population (USDHHS, 2022).

According to the CDC (2021), pediatric abusive head trauma (AHT) is a preventable and severe form of physical child abuse that results in an injury to the head or brain of a child. It is caused by violent shaking (often referred to as shaken baby syndrome) and/or blunt impact. AHT includes a range of injury mechanisms and clinical outcomes, from subtle presentations to infants with severe and life-threatening injuries.

The diagnosis of AHT should be made by a multidisciplinary team based on an aggregate of physical, radiographic, and laboratory evidence that cannot be explained by the provided history or is incongruent with the developmental stage of the child (Choudhary et al., 2018; O’Meara et al., 2020). Subspecialists in radiology, ophthalmology, neurosurgery, neurology, general pediatric surgery, and other fields should also be consulted when necessary to ensure a complete and accurate diagnostic evaluation (AAP, 2020).

AHT continues to be leading cause of physical abuse–related death in children and the leading cause of death from injury in infants. The fatality rate is significant for AHT and has been estimated to exceed 20%, with significant disability for nearly two thirds of the survivors. Deaths due to abusive head trauma peak at 1 to 2 months of age, most likely due to higher physiologic vulnerability (see also “Risk Factors” below) (CDC, 2022, 2021).

For children in the first year of life, the majority of serious head injuries result from abuse, and this peak incidence and rapid decrease with age are thought to be related to episodes of prolonged, inconsolable, and unpredictable crying. Such crying can be both a developmentally typical way for infants to communicate their basic needs, but it also can be related to a variety of other health and/or developmental causes that can be identified through medical examination. Regardless of the etiology, it is important to aim prevention strategies toward supporting parents and caregivers in dealing with crying.

Although there has been tremendous focus on AHT, many challenges remain both in gaining accurate statistics and in overcoming misconceptions related to AHT that may defer caregivers from seeking medical services for infants and children. The good news is that much more is now known about recognizing and preventing AHT.

TERMINOLOGY

Abusive Head Trauma (AHT): The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) have recommended using the term abusive head trauma for injuries due to shaking, blunt impact, suffocation, and strangulation, recognizing that inflicted head injury to children can involve a variety of biomechanical forces.

Pediatric Acquired/Traumatic Brain Injury (PA/TBI): This term includes traumatic causes such as those sustained as a result of motor vehicle accidents, sports-related injuries, blast injuries from war, assaults/child abuse, gunshot wounds, and falls.

Shaken Baby Syndrome (SBS): SBS refers to a form of abusive head trauma caused by shaking and with a characteristic pattern of injuries that may include retinal hemorrhages, certain fractures (in particular, ribs and the ends of long bones), and recognizable patterns of brain injury, often including thin subdural hemorrhages and sometimes diffuse axonal injury.

The change in terminology (from “shaken baby syndrome” to “abusive head trauma”) was misinterpreted by some in the legal and medical communities as an invalidation of the diagnosis and the mechanism of shaking as a cause of injury. However, the AAP continues to affirm the dangers and harms of shaking infants and embraces the “shaken baby syndrome” diagnosis as a valid subset of an AHT diagnosis and for parental education and community preventative efforts to caution against the detrimental effects of infant shaking (AAP, 2020).

COVID-19 PANDEMIC AND PEDIATRIC AHT

The COVID 19 pandemic has had a significant adverse impact on families and communities in the United States and worldwide, both in terms of increasing risk for child abuse and the possibility that cases of abuse may go unreported and undiagnosed. It is believed that heightened stress, school closures (with educators formerly being the most frequent referral source for suspected child abuse and neglect), loss of income, and social isolation have increased the risk.

There have been mixed findings on the incidence of child abuse and AHT specifically. Maassel and colleagues (2021) reported that both referrals to CPS agencies and emergency department visits for maltreatment have decreased during the pandemic, leading to concerns that children were not being brought to care. This study revealed a significant decrease in AHT admission in children under 5 years of age across 49 children’s hospitals in the United States. However, Loma Linda University Children’s Hospital reported a rise in abusive head trauma rates in pediatric patients since stay-at-home orders were initiated in early 2020 compared to the same timeframe for the previous year (Brandon, 2021).