ThinkstockPhotos-510903253In recent years, the diagnosis of abusive head trauma (AHT), historically referred to as shaken baby syndrome, has been the focus of great debate in court rooms and media headlines across the country. The debate has focused on a few key questions: Does AHT really exist? Can shaking really cause brain injury or death in infants?

“Having people believe that abusive head trauma doesn’t exist and that shaking an infant is harmless is a public health danger,” said Dr. Carole Jenny, a child abuse physician in Seattle Children’s Protection Program and at Harborview Medical Center, who has more than 30 years of child protection experience. “Parents and caregivers need to be aware that abusive head trauma as a result of shaking is a real thing that can happen – it does happen – and it has devastating, lifelong or fatal consequences.”

Dr. Christopher Greeley, who is a child abuse expert and associate professor at the University of Texas Medical School at Houston, said that it comes down to this: “Would you shake your newborn baby?”

What is AHT?

Abusive head trauma is a diagnosis that describes injury to a child’s brain that is a result of a parent or caregiver vigorously shaking a child or striking a child’s head against a hard surface (blunt impact). In 2009, the American Academy of Pediatrics (AAP) issued a policy statement recommending the diagnosis of shaken baby syndrome be replaced with AHT because shaking is just one of the mechanisms that can cause abusive brain injury.

AHT can result in blindness, seizures, learning or physical disabilities, or death. The anatomy of infants puts them at greatest risk for this injury: they have weak neck muscles as well as fragile, undeveloped brains; violently shaking a baby forces the head to whip back and forth, which damages blood vessels in the brain and eyes and causes them to bleed. The majority of victims of AHT are younger than age 1, and the highest rate of occurrence is in infants between 3 and 8 months old, when babies tend to cry the most.

There are an estimated 1,200-1,400 cases of AHT each year, according to the National Center on Shaken Baby Syndrome. About 80 children per year die as a result of this abuse and as many as 80% of survivors have significant, lifelong brain injuries. Critics of AHT often state that injuries are caused by commonplace infant activities like bouncing a baby on your knee, tossing a baby in the air or short falls.

“If that were the case, we would see these injuries in the emergency department every day,” said Jenny, who is widely considered a national expert on abusive head trauma.

Diagnosing AHT

Common signs and symptoms of AHT include hemorrhages in the retinas of the eyes, subdural hematomas (bleeding around the brain), swelling and injury of the brain, skull fractures, fractures in the ribs or extremities, injury to the neck or spine, and/or bruises around the head, neck or chest.

“When we have a suspected AHT case, our team looks at the patient’s full clinical picture,” said Jenny. “We embark on an exhaustive process where we compile copious amounts of information and data to rule out any possible organic disease or accidental cause that could explain the injury, leaving no stone unturned.”

Jenny said the investigative process includes interviewing the family to get a thorough family history, consulting with specialists and other members of the child’s care team, examining the child’s diagnostic tests and reviewing X-rays with radiologists to rule out signs of abuse. The team looks for any possible disease or condition that could cause brain bleeds like leukemia, brain tumors, severe dehydration, severe clotting disorder or metabolic diseases.

The history and the explanation from the family is key in the investigation, said Jenny. With pediatric patients, especially those who are non-verbal, physicians must rely on the parents to provide the details.

“Often in abuse cases we’ll hear, ‘I don’t know what happened; I just found my baby unconscious in his crib,’” said Jenny. “Some people will also report their baby had a simple fall. We have seen thousands of babies who have rolled off couches and they don’t lose consciousness. They don’t have major fractures and they don’t have brain damage.”

If abuse is suspected, the medical team assembles a group of experts who consult Child Protective Services and law enforcement. All parties must be in agreement before any charges are brought against the family.

“These decisions are not made lightly and they don’t happen in a vacuum,” said Jenny. “No one jumps to any conclusions. We spend an enormous amount of time to ensure we have the right answer. The worst outcome is when we find the presence of abuse. We’re ecstatic when we find another cause for the injury and we can send the child home knowing they are safe.”

How do we know AHT is real?

According to the AAP, few pediatric diagnoses have garnered as much debate as AHT, in part because of the social and legal consequences of the diagnosis. However, for protection experts like Greeley and Jenny, there is no doubt that this diagnosis is real.

“Research studies with good animal models have shown us that shaking or blunt impact can cause the injuries and symptoms we see in AHT cases,” Jenny said. “Research has also shown that the combination of injuries usually present in AHT can’t be explained by a natural illness or condition. Additionally, there is a large body of evidence from parents who have admitted to shaking their baby. Their confessions paint the exact picture of how and why this condition presents in kids.”

“Witnesses of this trauma and those who have admitted to shaking their baby always report a similar situation: They lost control because their baby wouldn’t stop crying and they either shook the baby for a few seconds or slammed them down, which led to the baby breathing funny, getting sleepy, collapsing in their arms or having a seizure,” Jenny said.

When critics note that the injuries seen in AHT are the result of a natural process or disease, Jenny makes the point that if they’re caused by a natural process, we’d expect to see this occur everywhere, all the time.

“If the injuries we see are a result of a natural process and not abuse, we’d see them occur in common settings where a child is around a lot of people – like at the mall or grocery store,” said Jenny. “But interestingly, we see these injuries are most common when the baby is isolated with a single caregiver. And these injuries are much more common when a male caregiver is present, which is also a red flag because we know women are more commonly the primary caregiver.”

What Parents Should Know

Jenny advises parents to be aware of the Period of PURPLE Crying, which is a term used to describe what happens between about 2 weeks and 4 months of age, when babies cry the most. Parents should be aware of and follow tips for how to deal with the frustration that may arise from frequent crying.

“Parents need to understand how vulnerable babies are and that they require special care,” Jenny said. “Be very cautious about who you leave your child with and ensure they also know the dangers of shaking a baby. Babies will cry. They will cry a lot. Most parents can probably agree that it will be frustrating at times. Just understand how to deal with those emotions, when to walk away and take a deep breath, so you prevent doing something that will have lifelong consequences for your child.”

Greeley recently presented on “The Science of Abusive Head Trauma: Lifelong Impacts to Children” at a Seattle Children’s Provider Grand Rounds and you can watch his presentation here.

Professional organizations with position and/or affirmation statements on AHT/SBS:

Additional resource for caregivers: