Abusive head trauma—injury to the skull or intracranial contents of an infant or child under age 5 from inflicted blunt impact and/or violent shaking—is the third leading cause of death in this age group. There are about 1,300 cases reported each year, and children who survive these injuries may face lifelong physical challenges and brain damage.
The American Academy of Pediatrics (AAP) provides a comprehensive literature review in support of evidence-based medical evaluations to diagnose abusive head trauma in children in a new technical report, "
Abusive Head Trauma in Infants and Children."
Examining the evidence to rule out maltreatment
"When presented with a case of suspected abuse, a team of medical professionals works together and follows a methodical, evidence-based approach," said Sandeep K. Narang, MD, JD, FAAP, lead author of the report.
"Child abuse pediatricians receive three years of additional training to identify the signs and symptoms of maltreatment—and many times pediatricians rule out child abuse," Dr. Narang said.
A complex diagnosis
An abusive head trauma diagnosis is complex. It carries medical, social and legal implications that add to the emotional distress experienced by families.
In its report, the AAP breaks down the evidence by fields of medical expertise and disciplines to reflect the broad scope of research. It observes misunderstandings about the diagnosis that are perpetuated in court cases. It also notes geographic variances where abusive head trauma cases are reported, with the highest incidences reported in the Midwest and the lowest in the Northeast.
Different possible diagnoses, such as accidental trauma, bleeding disorders and birth trauma are discussed. In addition, the AAP sorts through alternative medical hypotheses that are not supported by research.
The need for thorough evaluations
"When child abuse is suspected, we make a medical diagnosis the same way we diagnose any other medical condition: based on the history provided by the family, the physical examination, medical testing and proven medical science," said a co-author of the report, Suzanne Haney, MD, MS, FAAP, with Children’s Nebraska and University of Nebraska Medical Center.
"For instance, it is incredibly rare for an infant who can’t even crawl to have bruising or broken bones. Such a presentation should raise concern for possible abuse and prompt a pediatrician to do a thorough evaluation," Dr. Haney said.
"Drawing on up-to-date evidence, the report includes clear and detailed guidance on virtually every aspect of head trauma in which abuse may be a consideration, including diagnosis, management, outcomes and prevention," said Ann-Christine Duhaime, MD, FAAP, a pediatric neurosurgeon at Mass General for Children and and co-author of the report. "It explains the rationale, context, and evolution of the science behind its recommendations."
Preventing abusive head trauma
The AAP also reviews the efficacy of prevention programs that seek to improve caregiver knowledge and behavior about abusive head trauma and emotional-behavioral responses to infant crying.
"Preventing abuse is really about building relationships and supporting others who are struggling. For instance, any of us can relate to how quickly a crying baby can easily frustrate the best-intentioned among us," said Dr. Narang, who is a physician with the Medical College of Wisconsin and Child Advocacy and Protection Services, Children’s Wisconsin.
"Family members, friends and neighbors can make a difference by extending a hand to new parents or anyone who is overextended. We all share a goal of creating happy, safe and loving environments for children and families."
The technical report was authored by the AAP Council on Child Abuse and Neglect, Section on Ophthalmology, Section on Radiology and Section on Neurological Surgery; Society for Pediatric Radiology; American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; and American Academy of Ophthalmology. Experts in these organizations specialize in evaluating and treating children with traumatic brain injury.
Technical reports created by AAP reflect the latest evidence in the field, and go through several rounds of peer review before being approved by the AAP Board of Directors and published in Pediatrics. The process is described here.
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