Guidelines Issued on Management of Abusive Head Trauma in Infants and Children

Laurie Barclay, MD

April 28, 2009

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April 28, 2009 — The American Academy of Pediatrics (AAP) recommends that pediatricians be able to recognize signs and symptoms of abusive head injury in infants and children and consult with pediatric subspecialists when necessary, according to a policy statement on abusive head trauma (AHT) issued in the May issue of Pediatrics.

"Shaken baby syndrome is a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children," write Cindy W. Christian, MD, Robert Block, MD, and the AAP Committee on Child Abuse and Neglect. "Although the term is well known and has been used for a number of decades, advances in the understanding of the mechanisms and clinical spectrum of injury associated with...AHT compel us to modify our terminology to keep pace with our understanding of pathologic mechanisms....Medical and biomechanical research, clinical and pathologic experience, and radiologic advances have improved our understanding of the range of mechanisms that contribute to brain injury from AHT, yet controversy remains."

Shaking an infant can potentially cause neurologic injury, as can blunt impact or a combination of shaking and blunt impact. Poor outcomes may be aggravated by spinal cord injury and secondary hypoxic ischemic injury, with possible sequelae including death or permanent neurologic disability, static encephalopathy, mental retardation, cerebral palsy, cortical blindness, seizure disorders, and learning disabilities.

Because of the various mechanisms of trauma that may cause neurologic injury in infants and children, the AAP recommends using the more general term, abusive head trauma, when describing an inflicted injury to the head and its contents.

The AAP also recommends that pediatricians become proficient in recognizing the signs and symptoms of abusive head injury caused by shaking and/or by blunt impact and that pediatric subspecialists be consulted as needed.

Specific clinical recommendations regarding pediatric management of AHT, specifically aiming for prevention, are as follows:

• Pediatricians should be knowledgeable about and vigilant to recognize the signs, symptoms, and patterns of head trauma associated with AHT.

• Pediatricians should be trained in how to initiate a thorough, objective medical assessment of infants and children who present for medical care and who are exhibiting signs and symptoms of possible AHT.

• Subspecialty consultations, including radiology, ophthalmology, and neurosurgery, are often needed in the medical assessment to facilitate interpretation of findings and to confirm the diagnosis.

• To ensure the completeness of medical assessment and the accuracy of diagnosis, pediatricians should consider obtaining a consultation with a subspecialist in child abuse pediatrics.

• When describing the diagnosis and in other medical communications, pediatricians should use the term abusive head trauma rather than shaken baby syndrome or other term suggesting a single mechanism of injury.

• Pediatricians should continue to educate parents and caregivers regarding the dangers of shaking, striking, or otherwise inflicting trauma to an infant's or child's head. New parents and other caregivers should be instructed in safe strategies for calming and coping with crying infants.

Additional strategies for pediatricians to help prevent AHT are to participate in comprehensive community-based prevention efforts and to emphasize to parents the importance of leaving a young infant or toddler in the care of adults who can be trusted not to harm their child.

"Few pediatric diagnoses engender as much debate as AHT, in part because of the social and legal consequences of the diagnosis," the guidelines authors write. "The diagnosis can result in children being removed from their homes, parents losing their parental rights, and adults being imprisoned for their actions. Controversy is fueled because the mechanisms and resultant injuries of accidental and abusive head injury overlap, the abuse is rarely witnessed, an accurate history of trauma is rarely offered by the perpetrator, there is no single or simple test to determine the accuracy of the diagnosis, and the legal consequences of the diagnosis can be so significant."

Pediatricians have the responsibility and duty to recognize, report, and respond to suspected child abuse and neglect and the resulting medical complications. Unfortunately, clinicians do not always report to child welfare agencies injuries that are highly suspicious for abuse, thereby putting children at additional risk for injury. When child protective services or law enforcement become involved in an investigation of suspected abuse, the pediatrician must accurately interpret clinical findings using terms and explanations that are comprehensible to nonmedical professionals.

Although the diagnosis of AHT is sometimes clearly apparent, unsuspecting clinicians may fail to recognize injuries in many symptomatic infants. Injuries to multiple organ systems that could only result from inflicted trauma may clearly indicate the diagnosis early in the course of the assessment, but when the diagnosis is not as clear-cut, restraint is required until the medical workup is complete. Clinicians are legally and ethically bound to make a working diagnosis and to continue appropriate workup as indicated.

On the other hand, pediatricians must also consider the differential diagnosis in a child who appears to have findings consistent with AHT and must reach the medical diagnosis of AHT only after considering all the clinical findings.

"Pediatricians also have a responsibility to the family of the abused child," the guidelines authors conclude. "The role of the pediatrician is not to apportion blame or investigate potential criminal activity but to identify the medical problem, treat the child's injuries, and offer honest medical information to parents and families....To protect abused infants and prevent future severe neurologic injury, pediatricians must remain cognizant of the possibility of AHT in infants who present with both subtle and overt neurologic symptoms and take seriously the ethical and legal mandates to report suspected child abuse to governmental agencies for investigation."

Pediatrics. 2009;123:1409-1411.

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