Perspectives on abusive head trauma in infants

Feb. 05, 2022

When asked about prevalence of abusive head trauma in infants, Mark S. Mannenbach, M.D., a pediatric emergency medicine physician at Mayo Clinic in Rochester, Minnesota, says he can't express how often this occurs. "We unfortunately see too many children with nonaccidental injuries," he says. "Providers who care for children in the acute care setting will at some point in their careers encounter situations where nonaccidental trauma is involved."

Often an infant who is abused acts fussier than usual, says Dr. Mannenbach. Meanwhile, the infant has suffered the impact injury plus secondary injury due to poor brain perfusion. He explains that infants who've been abused can be especially challenging to identify, as their presenting symptoms are often nonspecific.

Trauma and emergency provider roles with infant head trauma

A key challenge facing trauma and emergency providers with abusive head trauma in infants is recognition, particularly due to biases interfering with identification. "We as providers don't want to think someone can hurt an infant, yet determining whether an infant has an abusive injury is crucial," says Dr. Mannenbach.

When providers meet a parent bringing an injured infant to the hospital, this individual may have suspicions or gut feelings that the child has been hurt by the partner. Often the parent accompanying the infant has experienced domestic abuse. Dr. Mannenbach says about 90% of infants with abusive injury are brought in by the concerned mother, not the perpetrator, who may or may not be present. "We're not sure who's done what to the child and who's bringing the child in," says Dr. Mannenbach.

Recognizing or ruling out abuse

Infants who are abused may not have obvious injury signs, says Dr. Mannenbach. However, some clues to nonaccidental injury include:

  • Frenulum or mouth bruising or frenulum bleeding
  • Subtle scalp or other bodily bruising
  • Head circumference suddenly expanding rapidly compared with the infant's proportions

"What might seem like an innocent bruise may be an abuse marker," he says. "Any bruising in an infant less than 4 months of age should raise concern for nonaccidental injury or an underlying medical problem."

Infant assessment

Assessing infants is harder than an older child or adult, says Dr. Mannenbach. It may be difficult for providers to immediately understand the full span of an infant's injury or the significance of observations. Nonverbal status presents challenges for determining an injury's cause, and with lack of ambulation, it also increases a child's vulnerability. He offers guidelines to determine whether an infant's injury is due to abuse or another cause:

Conduct a full exam

He strongly recommends providers undress an infant, conducting a head-to-toe exam.

Look for vomiting minus accompanying symptoms

If an infant is vomiting alone without other indications of illness, causal possibilities are endless. Yet, presence of this symptom alone may indicate head trauma.

"Where the presenting symptom is only vomiting, it's easy to miss head trauma," he says. "We think it's just a bug and send them away. Yet, one or two days later, the child's still vomiting and not acting right. By the second or third visit, a provider may consider head injury as the cause of the vomiting, especially as the child becomes more ill in appearance."

Pay attention to seizures

There are many potential causes of seizure in infants, such as a seizure disorder unrelated to injury. Repetitive seizures, however, may be abuse signs.

Compare anecdotes, facts

A critical tool for determining an infant's abuse status is checking physical evidence upon examination and medical history with anecdotes offered by those accompanying the child.

He suggests using open-ended questions with family members followed by careful listening. Sometimes stories families tell providers don't add up to injury findings, or history given doesn't correspond with developmental ability. "If they say, 'He rolled off the couch,' and the child is 2 months old, the child simply doesn't have that ability," he explains. And he mentions that if there's also bruising, it's an abuse red flag.

Note multiple hospital presentations

It may take 3 to 4 presentations with an injury in an infant before its source becomes clear. "Bouncing back to the emergency department is a sign," says Dr. Mannenbach. "If you find multiple visits for vague symptoms, unexplained injuries or nonspecific vomiting, consider pursuing further testing, including imaging for injuries."

Perform a head CT scan

If you note multiple visits in an infant's medical record — especially with vomiting incidents — Dr. Mannenbach recommends a head CT, required to diagnose abusive head injury. He indicates that although pediatric associations increasingly advise imaging caution due to radiation exposure, avoiding scans can hinder abusive head injury detection.

Report suspected cases

In cases where he suspects potential abusive head trauma, Dr. Mannenbach tells the family accompanying the infant that he's required to report the injury. "I avoid terms like 'suspicion' and tell them I have a concern that what I've found so far in the child doesn't fit with what I've heard," says Dr. Mannenbach, emphasizing it's not the medical provider's job to prove abuse or identify a perpetrator.

All providers caring for children are mandated to report suspicion. These reports should be made to the local social services agency where the child lives. These resources would have any previous reports of concern for a particular child.

He says he often relays to social services that he's concerned because the family's anecdote doesn't match the physical exam. If providers report such suspicions, they are protected from downstream impact if reporting in good faith. Conversely, providers can experience repercussions by failing to report such cases.

"Remember who your patient is — the child — not parents, grandparents or anyone else — and what the law requires," he says. "You can't hand off reporting to someone else."

Abusive head injury case referral

If your medical center doesn't have facilities for an infant with suspected nonaccidental head trauma, Dr. Mannenbach encourages sending the child to a children's center providing specialty care.

Also, providers should call an ambulance to transport the infant to a higher level of care to ensure arrival. He indicates that if the family travels by car with the child, the child may never get to the facility.

Avoiding regrets

As a front-line children's provider, Dr. Mannenbach says it's possible to miss an abuse case. "The impact of child abuse goes beyond that of the child alone," he says. "Providers who care for children also are impacted greatly by the thought of someone harming a child. I unfortunately have had the experience of not promptly diagnosing abusive head trauma in an infant. I will never forget that experience, and it has stayed with me for more than 30 years after the fact. I wonder what I could have done differently at that first visit."

He says he knows professionals who've left medicine due to missing child abuse. "No one wants to miss something," he says. "Abusive head trauma is tough to find, confront, report and process after the fact if you missed something."

Dr. Mannenbach encourages trauma providers to educate themselves about child abuse to be as prepared as possible for an abuse situation.

For more information

Emergency Medicine Resources for physicians. Scroll to Child physical abuse recognition and evaluation. Mayo Clinic.

Refer a patient to Mayo Clinic.