Chapter 40: Abusive Head Trauma

BACKGROUND

The term abusive head trauma (AHT) is used to describe the spectrum of injuries that can arise when a caregiver shakes, throws, strikes, or otherwise injures a child resulting in skull, brain, and possibly spinal cord injury. Although children of any age may be affected, typically infants and young children are at highest risk, with most cases occurring in infants less than 1 year of age with a peak incidence noted in the first few months of life. The spectrum of injury ranges from mild to fatal, with approximately 15% to 23% of children dying from their injuries.¹ The majority of children who survive have permanent disability, which may include developmental delay or intellectual disability, blindness, seizure disorder, cerebral palsy, and feeding or respiratory issues.

The nomenclature of this entity has evolved as researchers have developed a deeper understanding of the mechanisms and pathology related to AHT. This understanding is informed not only by clinical and radiologic studies and pathologic assessment of injuries, but also by direct confessions of perpetrators. Dr. John Caffey initially noted a correlation between long bone fractures and subdural hemorrhage in 1946,² and developed the language of “shaken baby/shaken whiplash syndrome” when he published a case series of these children in 1972.³ (This phenomenon was also noted by AK Guthkelch in 1971.⁴) In 1987, Duhaime and colleagues ⁵ proposed that fatal and more severe cases of inflicted brain injury were likely to involve not only shaking but also blunt force impact, leading some to coin the term “shaken impact syndrome.” In 2009, the American Academy of Pediatrics⁶ joined many experts in supporting the term “Abusive Head Trauma,” a designation which encompasses not only injury from shaking but injuries which may be sustained when a child suffers blunt trauma or crushing injury.

The incidence of AHT is estimated to be between 24 and 34 cases per 100,000 children less than 1 year of age; however, it is likely that this is an underestimate due to unrecognized cases of abuse.⁷ Milder cases may be missed if parents fail to bring children for evaluation, and more severe cases may not be recognized, but rather mistaken for meningitis or seizure disorder, accidental injury, viral gastroenteritis, or other medical disorders. The likelihood of a misdiagnosis appears to be higher if patients have mild injury or if parents are judged by providers to be “low risk”—i.e. married, white, and economically stable.⁸ Boys appear to be victimized at a slightly higher rate than girls. Male perpetrators are more common than female, with fathers, stepfathers, and boyfriends making up 60% of offenders.⁹

Brain injury seen in AHT is caused by a cascade of events. Depending on the mechanism of injury, there often is direct trauma to the brain parenchyma during violent and repetitive shaking or during the rapid acceleration/deceleration event which occurs when a child is thrown ...