The following was adapted from the Canadian Paediatric Society's statement on "Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma." Please see the full statement for the full recommendations from the Canadian Paediatric Society. For more information, please see our PedsCases podcast on "Physical Abuse in Children."
Abusive Head Trauma (AHT) is a specific form of traumatic brain injury, defined with a constellation of signs, symptoms, laborratory investigations, imaging and pathologic findings that are consequence of violent shaking, impact or a combination of the two. AHT usually is seen in infants and young children but can occur in older children. The name AHT has been adopted in favour of past terms including Shaken Baby Syndrome as a more precise descriptor of the range of possible injuries.
Presenting features of AHT are often non-specific. There may be no external signs of injury so it is important to consider AHT in the differential in any child with altered level of responsiveness without a clear etiology. Presenting features may include:
Characteristic injuries which may be seen on examination or imaging include:
The identification, investigation and management of AHT is complex and requires a multidisciplinary approach. These guidelines outline the role of each discipline, and include overall guiding principles for managing this complex subject. This summary, targeted for learners in medicine, will focus on the role of the health sector. For more details on the complexity of this issue please see the complete statement.
The following general principles apply to all professionals involved in a suspected case of AHT:
The health sector team involved may include medical, surgical and nursing staff. Primary responsibilities of this team include diagnosis and management of medical concerns.
A complete history and physical exam should be completed. It is important to note that the accompanying caregiver may have no knowledge of the injury and/or may not give a complete or accurate history. The physical exam should look for any associated injuries with special attention to examination of the nervous system and eyes.
Every child should be assessed by an experienced opthalmologist with an indirect opthalmoscope and dilated pupils. A child with diffuse multilayered retinal hemorrhages suggests AHT. The documentation of retinal findings is essential, with photographs if possible.
Imaging of the head is necessary in all suspected cases of AHT. A CT scan is indicated acutely, and an MRI may be used later to provide additional information. Findings of a subdural hematoma or cerebral edema support a diagnosis of AHT.
A skeletal survey is required to detect bony injury. A bone scan may be used to identify some subtle and acute bony injuries.
Investigations should include a CBC and coagulation studies. Additional tests may be indicated to confirm or rule out other diagnoses.
Consultations with the following physicians may be required (preferably with pediatric expertise):
These guidelines do not discuss detailed medical management of a child with AHT, however the level of care may vary widely depending on the severity of the injury.
In the event of a child's death, the post-mortem examination should be conducted according with local legislations for deaths of children under suspicious circumstances.
The roles of other professionals include, but are not limited to:
For more details on the roles of other professionals, please see the complete statement.
Last updated by PedsCases: May 8, 2015