Children with AHT will present in various ways to the ED. Some presentations, such as seizures, lethargy, respiratory distress, or apnea, are obvious. The more dramatic the presentation, the more likely the diagnosis will be made.

Previous studies have shown that up to 1%-3% of acute life-threatening events are caused by abuse.^21,22 Other young infants may present with nonspecific complaints such as vomiting, crying, not eating, or respiratory symptoms. These nonspecific symptoms are also commonly seen in nonabused infants, making the diagnosis of AHT challenging.

A landmark article from 1999, “Analysis of Missed Cases of Abusive Head Trauma,” revealed how difficult this diagnosis can be.²³ The authors looked at children younger than

3 years of age who were diagnosed with AHT and then retrospectively reviewed their charts to see how frequently the child presented to a clinician before the diagnosis was made. Their results were startling. Nearly one-third of all children diagnosed with AHT were previously seen by a clinician and given a different diagnosis. Erroneous diagnoses included gastroenteritis, influenza, rule out sepsis, increasing head size, otitis media, seizure disorder, reflux, apnea, upper respiratory infection, urinary tract infection, and bruising. Given the subtlety of the presenting complaints, it is easy to see how AHT can be confused with other common pediatric conditions.

The physical exam for an infant suspected of having suffered an AHT must be detailed and thorough. Close inspection of the head, scalp, face, ears, and oropharynx is important. Is there scalp swelling or evidence of a small hematoma? Is there facial bruising? Bruising to the ear? Is there dried blood around the nose or mouth? Is there oropharyngeal trauma, such as a torn frenulum? Scalp swelling, facial or neck bruising, and oropharyngeal trauma in nonambulatory infants are all potential indicators of abuse.

Retinal hemorrhages and the neurologic exam in infants deserve special mention when considering AHT. Retinal hemorrhages are a key physical finding for AHT.24 Many, although not all, children with AHT will have retinal hemorrhages. Because the finding of retinal hemorrhage may be subtle, this exam finding should be sought by an ophthalmologist. Additionally, while a normal neurologic examination in a well-appearing infant does not exclude the diagnosis of AHT, a positive finding clearly requires further investigation.

Mimickers

It is important to note that children may have findings that appear to be from an abusive etiology but are due to genetic, nutritional, metabolic, or cultural reasons. In some of these cases, significant injury may occur with a trivial mechanism. Examples include metabolic bone diseases such as rickets, nutritional deficits such as vitamin C deficiency causing scurvy, skeletal dysplasia such as osteogenesis imperfecta, infections such as osteomyelitis, and malignancies such as leukemia.²⁵