Educational paper: Abusive Head Trauma part I. Clinical aspects

Abstract

Abusive Head Trauma (AHT) refers to the combination of findings formerly described as shaken baby syndrome. Although these findings can be caused by shaking, it has become clear that in many cases there may have been impact trauma as well. Therefore a less specific term has been adopted by the American Academy of Pediatrics. AHT is a relatively common cause of childhood neurotrauma with an estimated incidence of 14-40 cases per 100,000 children under the age of 1 year. About 15-23% of these children die within hours or days after the incident. Studies among AHT survivors demonstrate that approximately one-third of the children are severely disabled, one-third of them are moderately disabled and one-third have no or only mild symptoms. Other publications suggest that neurological problems can occur after a symptom-free interval and that half of these children have IQs below the 10th percentile. Clinical findings are depending on the definitions used, but AHT should be considered in all children with neurological signs and symptoms especially if no or only mild trauma is described. Subdural haematomas are the most reported finding. The only feature that has been identified discriminating AHT from accidental injury is apnoea.

Conclusion: AHT should be approached with a structured approach, as in any other (potentially lethal) disease. The clinician can only establish this diagnosis if he/she has knowledge of the signs and symptoms of AHT, risk factors, the differential diagnosis and which additional investigations to perform, the more so since parents seldom will describe the true state of affairs spontaneously.

Fig. 1

Two-month-old boy, victim of abusive head trauma. The CT shows an interhemispheric subdural haematoma along the falx cerebri. Subdural haematomas in children often extend along the falx cerebri and this should not be confused with calcification, which is seen at an older age

Fig. 2

a Four-month-old boy admitted with a large subdural haematoma with clinical symptoms. No trauma was described. A bite mark was found on the left shoulder. Unfortunately no measuring tape has been used while taking the picture. b Chest radiograph obtained 2 weeks after the initial CT scan shows a series of posterior rib fractures on the left side with callus formation (arrow)