An internal medicine physician approaches you at a social function and says, “I just read an article in The New York Times about a father who lost custody of his children and could face prison time after his infant son was hospitalized with subdural hematomas. The article indicated that shaken baby syndrome is now considered a controversial medical diagnosis. I was not aware of that!”
Legal cases of shaken baby syndrome highlighted in the media offer sensational narratives of wrongfully convicted individuals who spend years fighting for justice. These stories often ignore the nuanced, multifactorial nature of abusive head trauma (AHT) and oversimplify a complex medicolegal issue. As a result, they give rise to misconceptions about the causes, effects and science underpinning this serious condition.
Over the last several decades, much has been published on various aspects of the AHT diagnosis, and it can be difficult for pediatric providers to keep up with the volume and complexity of the science. A new AAP technical report provides a comprehensive review of the evidence-based literature surrounding AHT, which can help pediatricians communicate scientific information to child welfare agencies, the courts and others.
The report Abusive Head Trauma in Infants and Children was authored by a multidisciplinary group of experts from 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. It is available at https://doi.org/10.1542/peds.2024-070457 and will be published in the March issue of Pediatrics.
Consequences of controversy
While the media and legal community have questioned whether shaken baby syndrome is real, the AAP and at least 18 international professional medical societies consider it a valid diagnosis under the broader diagnosis of AHT.
The AAP adopted the term AHT in 2009 in recognition that shaking is just one of a variety of biomechanical forces that can cause inflicted head injury in children. The change in terminology has been misinterpreted by some, including those in the court system, as an indication that shaking no longer is a valid cause of injury.
A recent medicolegal study found that the rate of conviction reversals of AHT cases in the U.S. appellate system increased four-fold in the prior decade (Narang SK, et al. Child Abuse Negl. 2021;122:105380).
Additionally, recent high-level state court decisions including State of New Jersey v. Darryl Nieves have described AHT as an “article of faith” diagnosis that rests on “discredited science.”
This background and the increasing volume and complexity of AHT science make it challenging for pediatric providers to educate interdisciplinary colleagues such as child welfare agencies and courts about the diagnosis.
How technical report can support pediatricians
Although not conducted in a formalized systematic review method, the technical report, with 72 pages and 684 references, offers many supports for the pediatric provider.
First, unlike large books or chapters in books, the technical report is openly available, readily accessible and includes up-to-date scientific information.
Second, it provides an appendix of standardized definitions. Various medical terms encountered in the AHT diagnosis (i.e., acute subdural hematoma/hemorrhage, chronic subdural hematoma/hemorrhage, short distance fall, subdural hygroma, etc.) have had some definitional variance throughout the medical literature. The technical report endeavors to provide consistency by utilizing the National Institutes of Health Common Data Elements for Traumatic Brain Injury.
Finally, the technical report is organized into scientific subsections such as epidemiology, risk factors, evaluation, diagnosis, team approach to management and prevention. Takeaway points are listed at the end of each subsection. These scientific summary statements offer succinct, evidence-based responses to counter misinformation. Following are examples of some takeaway points:
- An absent trauma history, in the presence of traumatic findings, has high specificity and positive predictive values for AHT.
- Sentinel injury research has identified bruising as a key sentinel finding in babies and young infants, occurring in upwards of 28% of “definite” abuse cases.
- Bruising in the TEN-4-FACESp distribution has high sensitivity and specificity for abusive injury. This refers to torso, ear, neck (TEN), frenulum, angle of jaw, cheeks (fleshy), eyelids, subconjunctivae (FACES), patterned (p), and the 4 represents any bruising anywhere to an infant 4.99 months or younger. Thus, in general, bruising in such locations, absent a clear and consistent accidental history, warrants an evaluation for possible abuse.
- Retinal hemorrhages that are numerous, present in multiple layers of the retina and extend peripherally beyond the posterior pole are highly specific (94%) for severe head trauma and particularly AHT. Nontraumatic causes of retinal hemorrhages usually occur in patterns different from head trauma.
- Short distance falls rarely result in fatality in children.
- There is an evidence base among multiple initiatives that demonstrate AHT prevention programs improve caregiver knowledge on infant crying, the consequences of shaking an infant and AHT in general.
The controversy surrounding AHT likely will continue in legal and media realms. The emotional and psychological toll on families accused of abuse is significant. Pediatric providers stand in the unique position to counterbalance sensationalistic propositions with the sound, measured, evidence-based information provided in the technical report.
Dr. Narang is a lead author of the technical report and a member of the AAP Council on Child Abuse and Neglect.
