Combating misinformation about abusive head trauma: AAP endorses new report
Sandeep K.Narang, M.D., J.D., FAAP
Abusive head trauma remains a contentious pediatric diagnosis in the legal literature
and media. Allegations of a poor scientific base for the diagnosis, along with a purported
“shift” in the pediatric medical community’s belief about the validity of the diagnosis,
have resulted in overturned shaken baby convictions and an adverse effect on child
protection and future prosecutions.
To better educate courts and legal colleagues on misconceptions about the diagnosis
of abusive head trauma, a group of pediatric radiologists, pediatric neuroradiologists,
child abuse pediatricians, an academic law professor and a pediatric neurosurgeon
created a comprehensive evidence-based review on the subject matter. The document
Consensus Statement on Abusive Head Trauma in Infants and Young Childrenwas generated under the auspices of the Society for Pediatric Radiology and has been
endorsed by the Academy, the European Society of Pediatric Radiology, the American
Society of Pediatric Neuroradiology and the American Professional Society on the Abuse
The statement provides an evidence-based reference source on the current literature
underpinning the clinical features strongly associated with abusive head trauma. More
importantly, it arms the pediatrician with the scant evidence base for many court-proffered
alternative theories to abusive head trauma, such as cerebral sinovenous thrombosis,
hypoxic-ischemic injury and benign enlargement of the subarachnoid spaces. As many
general pediatricians may be called to testify in child protection or criminal hearings,
and consequently, may encounter these extraneous theories, this resource can assist
pediatricians in impartially educating courts and legal colleagues.
Many conclusions can be drawn from the consensus statement; the most salient ones
for the general pediatrician are the following:
Although abusive head trauma is the current, most appropriate and inclusive diagnostic
term for infants and young children who suffer from inflicted intracranial and associated
spinal injury, this does not negate shaking or shaking with impact as a significant
mechanism of injury.
Lack of history, changing history or the incompatibility of history (i.e., short falls)
with the severity of injury raise concerns for possible abusive head trauma.
Relatively few infants with abusive head trauma have isolated intracranial injury
without retinal hemorrhages, fractures or other manifestations of child abuse. These
children need a comprehensive evaluation to rule out other diseases.
No single injury is diagnostic of abusive head trauma. A compilation of injuries —
most often including subdural hemorrhage, complex retinal hemorrhage and/or retinoschisis;
rib, metaphyseal or other fractures; and soft tissue injury — leads to the diagnosis.
There is no reliable medical evidence that the following processes cause the constellation
of injuries associated with abusive head trauma: cerebral sinovenous thrombosis, isolated
hypoxic ischemic injury, lumbar puncture and dysphagic choking/vomiting.
There is no substantiation of the proposal that long-term consequences of birth-related
subdural hemorrhage can result in later collapse, coma or death due to acute rebleeding
into a previously asymptomatic chronic subdural.
Subdural hematoma is uncommonly seen in the setting of benign enlargement of the subarachnoid
space, and when present, abusive head trauma should be considered in the differential
Abusive head trauma is a medical diagnosis and is not related to the legal assertion of murder. The use of the term “triad” in courts to
confine the abusive head trauma diagnosis to three particular findings (subdural hemorrhage,
retinal hemorrhage and encephalopathy) is a legal convention/artifact.
The legal implications of this, and other, professional society consensus statements
are significant. Albeit low on the hierarchy of evidence-based medicine ratings, professional
society consensus statements represent the highest level of medico-legal evidence.
If thorough and well-conducted, they can impartially educate the court on the best
evidence-based medical literature on a particular topic. More importantly, they can
constitute prima facie evidence of “general acceptance” of a medical community’s position
on a particular topic, and thus aid the court in admissibility determinations of expert
testimony on that topic. At the very minimum, professional society consensus statements
can serve as strong cross-examination tools for hypotheses that lie outside mainstream
Thus, this consensus statement and the Academy’s endorsement of it serve an important
purpose in clarifying the most reliable literature on a purportedly contentious topic
— abusive head trauma in infants and children. The statement supports the Academy’s
mission of advocating for the protection of infants and children, and it provides
an impetus and example to other professional societies of how they can impartially
assist courts on matters outside the courts’ expertise.
Dr. Narang, a co-author of the consensus statement, is a member of the AAP Council
on Child Abuse and Neglect and the Committee on Medical Liability and Risk Management.