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The American Academy of Pediatrics Warns of Subtle Signs of Abusive Head Trauma

Cute infant with a crooked smile

Revised Policy Summarizes a Decade of Evidence Supporting Diagnosis

The American Academy of Pediatrics today warned its members of the dangers of missing subtle signs of abusive head trauma and cautioned that some courts are allowing “pseudoscientific theories" to be considered.

In a revised policy statement issued today, the AAP said pediatricians have arrived at a consensus on the validity of an abusive head trauma diagnosis and described any debate as “philosophical" rather than scientific. A 2016 study of doctors at 10 leading U.S. children's hospitals found the vast majority of physicians —93%—said abusive head trauma is a valid diagnosis.

"The science behind abusive head trauma is very strong, even more so than when we issued our last policy 10 years ago," said AAP President Sara “Sally" H. Goza, MD, FAAP. “It's our duty to distribute this information to our member pediatricians because we want to protect children, and we want accurate diagnoses. Also, medical research has greatly contributed to the growing body of science about specific injuries most likely to indicate abuse."

The authors of the policy advised pediatricians to be vigilant for signs of bruising to the torso, ears and neck in children under 4 years old, or any bruising on an infant younger than 4 months. 

The Academy recommends a skeletal survey, a series of X-rays of all bones in the body, when AHT is suspected in children under age 2, in order to identify fractures not always seen in an X-ray that need to be confirmed. So-called occult fractures occurred in 42% of cases reviewed as part of an analysis of missed diagnoses published in the Journal of the American Medical Association. 

The AAP policy highlights injuries or symptoms researchers have identified as much more common in cases of abuse versus accidental injury, such as apnea; retinal hemorrhages; and bruising on the torso, ears and neck. (A more detailed list can be found at the bottom of this release.)

The Academy reviews policies like this one every five years. It issued its policy on abusive head trauma in 2009, affirmed it in 2013, and is now issuing this substantial update. 

The policy acknowledges the serious implications this diagnosis has on families, as well as civil and criminal cases. It also reminds pediatricians that they are required by law to report when they suspect abuse or neglect, even without a definitive diagnosis. 

"Our No. 1 job is to make sure every child in our care is healthy and safe," said James Lukefahr, MD, FAAP, one of three lead authors of the revised policy and the medical director of the Center for Miracles, the child abuse medical evaluation facility at Children's Hospital of San Antonio. 

“Sadly, about 5 children die every day in America from abuse and neglect, and the greatest risk here is someone missing the signs," Lukefahr said. “This is why child abuse pediatricians routinely act as part of a multidisciplinary team before finalizing a diagnosis in suspected abuse cases, and why we undergo three years of additional training on the signs and symptoms of child abuse."

Alexis Verzal, now 13, was the victim of abusive head trauma in 2008 when she was 14 months old. (Although her in-home day-care provider was charged with severely shaking the baby and throwing her, a jury later acquitted her.)

David Hardy, MD, FAAP, a now-retired pediatric critical care specialist at Baylor Scott & White Medical Center in Temple, Texas, made the diagnosis.

"He knew all of the steps to do immediately," said Tiffany Verzal, Alexis' mother. “We were very fortunate that he was there because our precious daughter needed a pediatrician with special expertise. She needed the very best."

It wasn't the only time Alexis would be evaluated for abuse.

Eight months after Alexis was injured, she fell during physical therapy and hit her head. No one thought she was seriously hurt at the time, but she kept touching her head as if she was in pain. A scan revealed bleeding in her brain.

Once again questions were raised about whether Alexis had been abused. 

That's when the couple met Suzanne Haney, MD, FAAP, a child abuse pediatrician at Children's Hospital & Medical Center in Omaha and current chair of the AAP Council on Child Abuse and Neglect. Child abuse pediatricians are board-certified specialists with expertise in child maltreatment and the rare conditions that can mimic it. 

Haney determined that the injury was “a rebleed" that resulted from aggravation of the old injury, not current abuse. The diagnosis spared the family from further investigation and an unnecessary separation.

"I don't think any doctor has an easy job, but the work that these child abuse pediatricians do is especially demanding," Tiffany Verzal said. “They diagnose abuse and also rule it out, which is complicated work. Our family is forever indebted to these experts."

Today, Alexis lives with serious disabilities. She is visually impaired, uses a power wheelchair at school, reads at a third-grade level and has use of only her left hand.

The Verzals' experience points to an important fact: that child abuse pediatricians often rule out abuse. In one seven-year study at Yale New Haven Children's Hospital, child abuse pediatricians did not find abuse in 44% of cases referred to them by other doctors.

"Child abuse pediatricians don't set out to diagnose abuse; they set out to find out what happened," said Robert Sege, MD, PhD, FAAP, a child abuse pediatrician and current member of the AAP Committee on Child Abuse and Neglect. “We actively search for other explanations for an injury, including rare disorders, every single time. We don't go in hoping for child abuse, just like infectious disease specialists don't go in hoping to find infectious diseases. They just know what to look for in diagnosing patients."

Scientific highlights from the Academy's updated policy on abusive head trauma:

  • Abusive head trauma is devastating to babies and small children. In documented cases, nearly one fourth of babies under 1 died from their injuries. 

  • The following features have been identified by researchers as much more common in abusive head trauma than in accidental injury: 

    • Bruising on an infant younger than 4 months;

    • Apnea; 

    • “TEN-4" bruising — those on the torso, ears and neck of children younger than 4;

    • Retinal hemorrhages — specifically ones that are too numerous to count in one or both eyes, present in all layers of the retina, and extending into the retinal periphery; 

    • Traumatic retinoschisis, abnormal splitting of the retina's neurosensory layers;

    • Spinal subdural hemorrhage, an accumulation of blood that can mechanically compress the spinal cord; and

    • Oral injuries. 

  • Skeletal surveys should be read by radiologists who are experienced in these specialized imaging studies. 

  • Defense attorneys often proffer pseudoscientific theories such as short falls as a likely medical explanation for symptoms commonly seen in abusive head trauma. In a comprehensive review of short fall literature, the estimated mortality rate of short falls affecting infants and young children is <0.48 deaths per 1 million young children per year. Pediatricians should be prepared to explain in court that death from a short fall is highly unlikely.

  • The term abusive head trauma has replaced “shaken baby syndrome" because it is a more precise term that encompasses shaking and other actions that can injure a child's brain. Clinical studies continue to emphasize the importance of shaking as a cause of AHT. 

Further, a 2018 consensus statement affirmed that AHT is a scientifically non-controversial medical diagnosis that is recognized throughout the world. The statement was supported by eight medical societies representing subspecialists in a number of countries, including Norway, Sweden and Japan.

Additional Information:

3/23/2020 12:00 AM
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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