What are the American Academy of Pediatrics (AAP) guidelines for diagnosing shaken baby syndrome?

American Academy of Pediatrics Guidelines for Diagnosing Shaken Baby Syndrome

The American Academy of Pediatrics does not currently provide specific guidelines for diagnosing "shaken baby syndrome" as this terminology has been replaced by the more comprehensive term "Abusive Head Trauma" (AHT).

Diagnostic Approach to Suspected Abusive Head Trauma

Key Clinical Findings to Evaluate

• Retinal hemorrhages - A hallmark finding, particularly when extensive, multilayered, and extending to the periphery of the retina 1, 2
• Intracranial hemorrhages - Particularly subdural and subarachnoid hemorrhages 1, 3
• Brain injury - Including cerebral edema, hypoxic-ischemic injury, or diffuse axonal injury 4
• Absence of external signs of trauma or inadequate trauma history to explain the severity of injuries 3
• Age of child - Most commonly under 1 year of age, with highest risk under 6 months 3

Essential Diagnostic Workup

1. Neuroimaging

   • MRI of the brain is preferred for detailed assessment of brain injury patterns
   • CT scan for acute evaluation to identify hemorrhages and increased intracranial pressure
   • Consider follow-up imaging to document evolution of findings

2. Ophthalmologic Examination

   • Complete dilated fundoscopic examination by an ophthalmologist experienced in pediatric retinal examinations
   • Document extent, pattern, and location of retinal hemorrhages

3. Skeletal Survey

   • Complete skeletal survey to identify occult fractures
   • Follow AAP recommendations for skeletal survey in children under 2 years with suspected abuse 5
   • Consider follow-up skeletal survey in 2 weeks to identify healing fractures

4. Laboratory Studies

   • Coagulation studies to rule out bleeding disorders
   • Consider metabolic screening to rule out inborn errors of metabolism
   • Evaluate for other medical conditions that might mimic AHT

Differential Diagnosis Considerations

• Medical conditions that may mimic AHT:

  • Bleeding disorders
  • Metabolic disorders
  • Osteogenesis imperfecta (when fractures are present) 6
  • Glutaric aciduria type 1
  • Menkes disease

• Accidental trauma - Carefully evaluate history for consistency with injuries and developmental capabilities of the child

Documentation Requirements

• Detailed documentation of history, including:
  • Who provided the history
  • Exact description of reported events
  • Any changes in the history over time
  • Developmental capabilities of the child
• Comprehensive physical examination findings
• Results of all diagnostic studies
• Assessment of consistency between history and clinical findings

Multidisciplinary Approach

• Consultation with child abuse pediatrics specialists when available
• Involvement of neurosurgery, ophthalmology, and radiology specialists
• Social work and child protective services involvement

Red Flags Highly Suggestive of AHT

• Discrepant or changing history
• Delay in seeking medical care
• History inconsistent with child's developmental stage
• History inconsistent with severity or pattern of injuries
• Presence of other injuries suggestive of abuse (bruising, fractures)
• Severe retinal hemorrhages with severe brain injury

Reporting Requirements

• Suspected cases of AHT must be reported to child protective services as mandated by law
• Documentation should be objective and focus on medical findings rather than accusations

Remember that the diagnosis of AHT requires a careful, thorough evaluation of all medical findings and consideration of the differential diagnosis. The goal is to ensure both appropriate protection of children at risk and fair assessment of the circumstances.