Abusive head trauma


  • Current term for constellation of injuries that result from nonaccidental trauma involving forcefully shaking infant and/or any direct head impact
    • may be referred to as "shaken baby syndrome" in lay press or old literature
  • Injuries result of repetitive acceleration-deceleration and rotational forces (akin to whip lash) as well as direct blunt trauma from impact with objects or assailant

Clinical Features

  • Majority of patients <1 year old
  • History concerning/red flags for child abuse
  • Retinal hemorrhage
    • Most common manifestation of abusive head trauma (as high as 85% in some retrospective reviews[1])
    • In infants, virtually pathognomonic for nonaccidental trauma, especially when numerous and multilayered
    • Due to vitreoretinal traction
    • May lead to retinal detachment
    • May also have other eye findings (e.g. subconjunctival hemorrhage, hyphema, ecchymoses
  • Signs of traumatic brain injury
  • Cutaneous ecchymoses: to face/head and other areas where patient grabbed or sustained impact
  • Other injuries associated with child abuse, especially long bone and/or rib fractures

Differential Diagnosis


  • Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
    • Skull AP and lateral view (left and right)
    • Chest AP and lateral view
    • Right and left oblique of the chest
    • AP of the abdomen to include pelvis and hips
    • AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
    • AP bilateral humerus
    • AP bilateral forearms
    • AP bilateral femurs
    • AP bilateral tibia and fibula
    • Posterior view of the hands
    • Dorsoplantar view of the feet
  • Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
  • Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
    • Consider CPK and platelet function studies if extensive bruising is present
    • If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
  • Consider a dilated fundoscopic exam if under 2 years
  • Photograph injuries
  • Obtain a social work consult

Inpatient Workup[2]

  • CBC
  • CMP, Mg, phos
  • PT/INR/aPTT, fibrinogen
  • PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
  • vW panel (vW AT, ristocetin cofactors, factor VIII)


  • Treat any identified injuries
  • Ophtho consult for retinal hemorrhages
  • Report abuse concerns to appropriate authority


  • Dependent on severity of injuries and safety upon discharge

See Also

External Links


  1. Morad Y, Kim YM, Armstrong DC, Huyer D, Mian M, Levin AV. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol. 2002;134(3):354-359. doi:10.1016/s0002-9394(02)01628-8
  2. Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.