Medical Facts

By Carroll Jenny
Information on this page is not intended to replace advice by a health care professional. If you are concerned about your child's health please consult a physician.

Abusive Head Trauma can be Difficult for Physicians to Recognize

Abusive head trauma is a dangerous form of child abuse. Head injury in infants and toddlers can be difficult to diagnose, as symptoms are often nonspecific. Vomiting, fever, irritability and lethargy are common symptoms of a host of diseases seen in children, including head trauma. When caretakers do not give a history of injury, and when the victim is pre-verbal, an abusive head injury can be mistakenly diagnosed as a less serious condition.

We studied 173 cases of abusive head trauma in children less than 3 years old who were evaluated at the Childrens Hospital, Denver, Colorado, from 1990 through 1995. Since the mechanism of injury cannot always be accurately determined in child abuse cases, we studied children who had experienced shaking, impact to the head, or both.

The mean age of the 173 children was eight months. All of the children suffered serious head injuries. Thirty-one percent of the children had previously been seen by a physician who did not recognize the diagnosis of abusive head trauma. Many of the 54 children whose head injuries were missed were seen by doctors on multiple occasions after their injuries. For children whose head trauma was missed, the average length of time to diagnosis head trauma from the day of the first doctor visit was 7 days. When missed cases were compared to recognized cases, several factors were found to be significantly different.

Children with missed abusive head trauma were much younger than those in whom the diagnosis was recognized on the first physician visit. The mean age of the missed cases at the time of their first medical visit for head injury symptoms was 180 days. The mean age of the recognized cases was 278 days.

Abusive head trauma was missed significantly more often in children who were Caucasian than in children of minority races, and was more likely missed in families where both parents lived with the child. Not surprisingly, the severely injured children were more likely to be recognized as having head trauma at their first visit to the physician. At the first visit, children who were comatose, whose breathing was compromised, who were seizing or who had facial bruising were more likely to be accurately diagnosed.

We constructed a computer model based on the data to determine how likely a physician would be to recognize the correct diagnosis of abusive head trauma. We found that if a child had normal respirations, no seizures, no facial or scalp injury, and came from an intact family, the probability that abusive head trauma would be recognized was less than one in five.

We do not know how many cases of abusive head trauma are never detected. Parents who confess to shaking or hitting the heads of their children frequently report doing the same thing previously. In one of our study cases, an infant was hospitalized three times after violent shaking before someone witnessed the abuse. Infants have few ways to demonstrate illness or injury. Non-specific signs such as vomiting, fever and irritability are frequently seen in a myriad of conditions, including many minor illnesses. The difficulty, then, is to be able to tell when these signs and symptoms occurred because of serious head injuries.

Are missed cases of missed abusive head trauma inevitable? If a child's caretakers cannot or will not give an accurate history, making the correct diagnosis is extremely difficult. Physicians cannot obtain cranial CT scans on every infant and toddler who is present with vomiting, irritability and fever.

Based on this study and on our experience with these cases, we recommend the following suggestions to physicians to facilitate the diagnosis of abusive head trauma:

• Be alert for the presence of bruises or abrasions on the faces or heads of children presenting non-specific symptoms.
• When evaluating infants and toddlers with non-specific symptoms, such as vomiting, fever, or irritability, consider head trauma in the differential diagnosis. Perform a head-to-toe physical examination, check the fontanelles (soft spots) on the babies heads, measure the head size and be alert for signs of trauma.
• When doing a spinal tap, look for signs of previous bleeding or old blood in the spinal fluid.
• Pediatric radiologists should be consulted to interpret X-rays and head CTs in cases of suspected child abuse. More research should be done to find better ways of diagnosing head trauma in infants and young children. Education is also important. While it is difficult for physicians to detect all serious abusive head trauma in the clinical setting, an awareness of the signs and symptoms of abusive head trauma could increase the likelihood that more cases will be detected.

Carole Jenny, MD, MBA, is a consultant for the National Service on SBS. She has served on the faculty of the University of Washington and University of Colorado. She is the director of the Child Safe program at Hasbro Childrens Hospital and also serves as a professor of pediatrics at Brown University.

For further information please see:

Jenny, C., Hymel, KP, Ritzen, A., Reinert, SE, Hay, TC. Abusive Head Trauma:An Analysis of Missed Cases, Journal of the American Medical Association 281:621-626, 1999.