References

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

This brief begins by explaining abusive head trauma (AHT) is a well-recognized constellation of brain injuries caused by the directed application of force to an infant or young child, resulting in physical injury to the head and/or its contents and that approximately 20/100,000 children sustain AHT annually. The decision by the American Academy of Pediatrics to use the team abusive head trauma rather than a term that implies a single injury mechanism, such as shaken baby syndrome (SBS), is then discussed, and it is noted that there is no legitimate medical debate among the majority of practicing physicians as to the existence or validity of AHT/SBS. Following sections of the brief review strategies for identification of AHT-related injuries, including subdural hematoma, retinal hemorrhages, and hypoxic ischemic encephalopathy. 61 references.

Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.

Shaken Baby Syndrome (SBS), a form of abusive head trauma, occurs when an adult or older child violently shakes a young child, sometimes hitting the baby's head on a surface such as a bed or floor. Nearly all victims of SBS have serious health consequences, such as brain injury, cerebral palsy, seizures and paralysis, and at least one of every four babies who are violently shaken dies. Most adults who admit to shaking a baby say that they became frustrated and upset when the baby would not stop crying. Evidence based research suggests that programs that teach parents and caregivers about the dangers of shaking a baby, as well as ways to cope with the stresses of caring for a child, are very effective in reducing the incidence of SBS. In New York State, all hospitals are required to offer new parents the option of viewing a video on Shaken Baby Syndrome, including ways to cope with a crying child. It is important to reach as many current or future caregivers as possible to share this important message with them:

Pediatricians have implicit and explicit racial biases that impact the health and well-being of children and their families.1,2 Similarly, effects of racism on diagnosis and reporting of suspected child abuse and neglect to child protective services (CPS) can have serious consequences. Although we and others are mandated to report suspected child abuse or neglect in all US states and territories, the threshold for reporting requires only “reasonable suspicion” of abuse or neglect.3 Pediatricians may also report families that they perceive need additional resources.

The mission of the Centers for Disease Control and Prevention is to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats (Centers for Disease Control and Prevention 2010). Among the key objectives used to achieve this mission is working with national and international partners to monitor health and detect and investigate health problems. Monitoring of population health is achieved through public health surveillance, defined as the ongoing and systematic collection, analysis, and interpretation of outcome-specific data for use in the planning, implementation, and evaluation of public health practice (Thacker and Berkelman 1988). Public health surveillance relies on uniform case definitions and data elements that facilitate the collection of data useful for monitoring trends over time and characterizing persons at risk for health outcomes of interest among different subpopulations or geographic areas. The prevention of child maltreatment and the reduction of abusive injuries and their consequences is an important priority area for CDC. As part of the public health approach in addressing child maltreatment, CDC has launched an effort to develop uniform case definitions and data elements for use in surveillance of child maltreatment and abusive head trauma. In 2008, CDC published Version 1.0 of Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements (Leeb et al. 2008), which covers all types of child maltreatment. The current report focuses on standard data elements for abusive head trauma—a specific category of child maltreatment that presents unique definitional and measurement challenges. These challenges are discussed followed by a presentation of recommended uniform operational definitions of fatal and nonfatal abusive head trauma based on International Classification of Diseases (ICD-9-CM for morbidity coding and ICD-10 for mortality coding) diagnosis and external- cause-of-injury codes (2001; 2005). Similar processes and formats to that of the Child Maltreatment Surveillance Uniform Definitions and Data Elements have been used in order to maintain consistency and facilitate ease of use.

We searched the US National Library of Medicine's PubMed, Google Scholar and the American Psychological Association's Psychinfo databases during September 2019 for citations and abstracts on abusive head trauma (AHT) and shaken baby syndrome prevention dated 1 January 2000 to 31 August 2019. We identified 53 empirical studies and performed a structured review to identify the effects of prevention, if any, on AHT. We identified three lines of investigation that have focused on: (i) strategies which teach parents how to respond to newborn crying and the dangers of shaking babies; (ii) community and public health factors; and (iii) professional education and practice. Most studies were observational, although a small number used sophisticated designs such as prospective or randomised controlled trials. We note other strengths and weaknesses of these articles and suggest future directions for research in each of these areas based on the current level of scientific inquiry.