Abusive head trauma in infants and young children

Case history

A previously well 2-month-old male infant presents to the accident and emergency department with a seizure and difficulty breathing. His father reports that he put the child down for a nap and then discovered him having a seizure 1 hour later. He called his wife at work to ask her what he should do, and she told him to call the emergency services. When the paramedics arrived they found the infant to be pale and bradycardic. They instituted basic life support and gave lorazepam to control the seizures. In the accident and emergency department, the child requires further antiseizure medications. Examination is unremarkable except for brisk reflexes and a paediatric Glasgow Coma Scale of 10 (or V on the AVPU [alert, voice, pain, unresponsive] scale). Bilateral multilayer retinal haemorrhages are seen on fundus examination. Skeletal survey reveals multiple rib fractures and several classic metaphyseal fractures.

Other presentations

Abusive head trauma may present in a variety of ways, and diagnosis can be delayed due to an incomplete history from the carer.

Mild inflicted traumatic brain injury from shaking can present with increasing head circumference noted by a primary care physician, or with mild symptoms such as vomiting, sleepiness, or irritability with no underlying illness. Patients may also present with much more obvious signs of brain injury such as apnoea or seizure.

Abusive head trauma may be mistaken for accidental head trauma, or meningitis/encephalitis or other causes of cerebral oedema.

Severe abusive head trauma can result in death almost immediately, and presentation may initially be confused with sudden infant death syndrome until a post-mortem examination is performed.

Some infants may present to medical care for a non-related medical complaint and have a work-up that incidentally identifies signs of inflicted injury.