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Abusive head trauma: evidence, obfuscation, and informed management

JNSPG 75th Anniversary Invited Review Article

Ann-Christine Duhaime and Cindy W. Christian

provide practical guidance to clinicians faced with a patient for whom an inflicted injury is a consideration. Epidemiology Abusive head trauma (AHT) is a universal phenomenon, reported and studied around the world. 15 , 52 , 53 The incidence is estimated at 20–30/100,000 children, with victims’ median age being 4 months, highlighting the vulnerability of young infants. More than 2000 hospitalized children are assigned diagnoses of AHT annually in the US using code-based definitions. 73 Perpetrator confessions suggest that some infants are handled violently on

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Scott Boop, Mary Axente, Blakely Weatherford and Paul Klimo Jr.

H ealth care providers know all too well the immediate and long-term consequences of abusive head trauma (AHT). It is estimated to account for 80% of the deaths that result from childhood maltreatment, killing more than 250 children each year in the United States. 14 Compared with patients with nonabusive head injury, children with AHT are more often younger than 1 year of age, male, and from socioeconomically disadvantaged families; they are also likely to be hospitalized longer and have higher rates of in-hospital mortality. 18 Males (i.e., fathers

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Henry Kesler, Mark S. Dias, Michele Shaffer, Carroll Rottmund, Kelly Cappos and Neal J. Thomas

A busive head trauma in children less than 36 months of age remains a significant cause of death and neurological morbidity. Most cases are thought to involve angular acceleration of the brain brought about by violent infant shaking, with or without impact injury, and have been collectively described as shaken baby or shaken impact syndrome. 1 , 2 , 10 The mortality rate ranges from 15 to 35%, 7 , 14 , 18 , 22 and 50% of survivors suffer permanent neurological and visual sequelae. 9 , 13 Abusive head trauma is a leading cause of death due to child abuse

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Miriam Nuño, Lindsey Pelissier, Kunal Varshneya, Matthew A. Adamo and Doniel Drazin

A ccording to data from the National Child Abuse and Neglect Data System (NCANDS), 49 states reported 1598 fatalities with a national estimate of 1640 child deaths from abuse and neglect in 2012. These figures equal a rate of 2.20 deaths per 100,000 children per year and an average of 4 children dying every day from abuse and neglect. 29 The NCANDS also concluded that children younger than 1 year accounted for 44.3% of fatalities. The majority of child maltreatment deaths resulted from injuries to the head, otherwise known as abusive head trauma (AHT

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Ray Bradford, Arabinda K. Choudhary and Mark S. Dias

RW : Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies . Child Maltreat 7 : 329 – 348 , 2002 17 Hymel KP , Rumack CM , Hay TC , Strain JD , Jenny C : Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma . Pediatr Radiol 27 : 743 – 747 , 1997 18 Ichord RN , Naim M , Pollock AN , Nance ML , Margulies SS , Christian CW : Hypoxic-ischemic injury complicates inflicted and accidental traumatic brain

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Nickalus R. Khan, Brittany D. Fraser, Vincent Nguyen, Kenneth Moore, Scott Boop, Brandy N. Vaughn and Paul Klimo Jr.

P ediatric abusive head trauma (AHT) is the third most common cause of head injury in children—following falls and motor vehicle crashes—and is the most common cause of serious head injury before the age of 1 year. 6 , 12 The Centers for Disease Control and Prevention has defined AHT as an injury to the skull/intracranial contents of an infant/young child aged 5 years or fewer due to intentional abrupt impact and/or violent shaking. 37 Injuries include skull fractures, cerebral contusions and hemorrhage in any compartment—epidural, subarachnoid

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Kenneth W. Feldman, Naomi F. Sugar and Samuel R. Browd

C hildren evaluated for abusive head trauma (AHT) often have acute subdural hemorrhage (SDH), chronic SDH, or both acute and chronic SDH. 1 , 6 , 8–10 , 13 In cases in which both acute and chronic SDH are present, the question often arises whether the acute SDH represents new abusive trauma or rebleeding into an area of chronic SDH, either spontaneously and/or from minor trauma. 2 , 5 , 11 , 13 Literature documenting clinical presentations and associated clinical findings for children with acute/chronic SDH (acute/chronic SDH) is sparse. 8 , 13

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Ann-Christine Duhaime

children with abusive head trauma (AHT). While acknowledging the limitations of this approach, the authors are able to provide confirmation of the findings of other groups using different methods to answer some of these questions. The results are remarkably consistent among studies. First, with respect to incidence, the figures discerned by these authors are almost identical to those found elsewhere, some of which take place in the United Kingdom. On average, for every 100,000 infants, 28.2 will suffer an inflicted head injury in their 1st year of life. The rate

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Catherine Adamsbaum

looks completely normal. The collections are never associated with evidence of subdural hematoma (hyperdensity on CT or hyperintensity on MRI) in the tentorium or interhemispheric space. The collections are clinically silent (aside from the macrocephaly), i.e., without even mild neurological signs, such as vomiting, and without fontanelle bulging. 1 As the presence of subdural collections immediately raises the concern of nonaccidental trauma, should any of the above criteria not be met, the pediatrician should seriously consider the possibility of abusive head trauma

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Cormac O. Maher

T he potential importance of cervical spine (c-spine) injury in abused children has been recognized since the initial description of the “whiplash shaken infant syndrome” by John Caffey in 1974. 1 Despite this long association, the optimal screening protocol for spine injury in children with abusive head trauma (AHT) has not been settled. In the accompanying article, Dr. Oh and colleagues examine the utility of c-spine MRI (cMRI) in these patients. 11 At their busy pediatric trauma center, a policy was instituted in 2012 that required all patients with a