Abusive head trauma

Background

Current term for constellation of injuries that result from nonaccidental trauma involving forcefully shaking infant and/or any direct head impact
- may be referred to as "shaken baby syndrome" in lay press or old literature
Injuries result of repetitive acceleration-deceleration and rotational forces (akin to whip lash) as well as direct blunt trauma from impact with objects or assailant

Majority of patients <1 year old
History concerning/red flags for child abuse
Retinal hemorrhage
- Most common manifestation of abusive head trauma (as high as 85% in some retrospective reviews^[1])
- In infants, virtually pathognomonic for nonaccidental trauma, especially when numerous and multilayered
- Due to vitreoretinal traction
- May lead to retinal detachment
- May also have other eye findings (e.g. subconjunctival hemorrhage, hyphema, ecchymoses
Signs of traumatic brain injury
- SDH (most common intracranial injury), skull fracture, diffuse axonal injury
- AMS, lethargy, seizure, irritability/inconsolable crying
Cutaneous ecchymoses: to face/head and other areas where patient grabbed or sustained impact
Other injuries associated with child abuse, especially long bone and/or rib fractures

Bruising
- Mongolian spots (congenital dermal melanosis)
- Bleeding disorders
- Hemangiomas
- Phytophotodermatitis
- Malignancy
- Connective tissue disease
- Cultural healing practices (eg, coining and cupping)
- Osteogenesis imperfecta
- Vasculitis (Henoch-Schönlein purpura)
- Ink stains (e.g. caused by new clothing)
Burns
- Hypersensitivity reaction
- Friction blisters
- Impetigo (may be confused with cigarette burns)
- Phytophotodermatitis
- Dermatitis herpetiformis
- Accidental laxative ingestion
- Healing practices (eg, coining, cupping, and moxibustion)
Fractures
- Rickets
- Congenital syphilis (can cause periosteal elevation)
- Birth trauma
- CPR (rarely causes rib fractures and very rarely causes posterior rib fractures)
- Osteogenesis imperfecta
- Caffey disease
- Osteomyelitis
Subdural hematoma
- Bleeding disorders
- Vascular malformations
- Glutaric aciduria type 153
- Benign extra-axial fluid
- Menkes disease
Retinal hemorrhage
- Vasculitis
- Vascular obstruction
- Vaginal delivery (generally disappear by 4 weeks of age)
- CPR (retinal hemorrhages are rare after chest compressions and, if present, are usually in the presence of other risk factors for hemorrhage)

Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
- Skull AP and lateral view (left and right)
- Chest AP and lateral view
- Right and left oblique of the chest
- AP of the abdomen to include pelvis and hips
- AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
- AP bilateral humerus
- AP bilateral forearms
- AP bilateral femurs
- AP bilateral tibia and fibula
- Posterior view of the hands
- Dorsoplantar view of the feet
Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
- Consider CPK and platelet function studies if extensive bruising is present
- If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
Consider a dilated fundoscopic exam if under 2 years
Photograph injuries
Obtain a social work consult

↑ Morad Y, Kim YM, Armstrong DC, Huyer D, Mian M, Levin AV. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol. 2002;134(3):354-359. doi:10.1016/s0002-9394(02)01628-8
↑ Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.

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