Long-term impact of abusive head trauma in young children: Outcomes at 5 and 11 years old

Published:February 19, 2021DOI:


      • Abusive head trauma imposes long-term burden on children and their caregivers.
      • Long-term neurodevelopmental disability increased as children aged to 11 years.
      • Age at time of abusive head trauma was associated with an increased risk of long-term disability.
      • Efforts to improve comprehensive follow-up throughout childhood is imperative.



      : Abusive head trauma (AHT) is a leading cause of morbidity and mortality among young children. We aimed to evaluate the long-term impact of AHT.


      : Using administrative claims from 2000–2018, children <3 years old with documented AHT who had follow-up through ages 5 and 11 years were identified. The primary outcome was incidence of neurodevelopmental disability and the secondary outcome was the effect of age at time of AHT on long-term outcomes.


      :  1,165 children were identified with follow-up through age 5; 358 also had follow-up through age 11.  The incidence of neurodevelopmental disability was 68.0% (792/1165) at 5 years of age and 81.6% (292/358) at 11 years of age.  The incidence of disability significantly increased for the 358 children followed from 5 to 11 years old (+14.3 percentage points, p<0.0001).  Children <1 year old at the time of AHT were more likely to develop disabilities when compared to 2 year olds.


      : AHT is associated with significant long-term disability by age 5 and the incidence increased by age 11 years.  There is an association between age at time of AHT and long-term outcomes. Efforts to improve comprehensive follow-up as children continue to age is important.

      Level of Evidence

      : IV



      AHT (Abusive head trauma), COBRA (Consolidated Omnibus Budget Reconciliation Act), ICD (International Classification of Diseases), CM (Clinical Modification), CPT (Current Procedural Terminology), IRB (Internal Review Board), CDC (Centers for Disease Control and Prevention), ICISS (ICD-Based Injury Severity Score), ISS (Injury Severity Score), SRR (survival risk ratios), SD (standard deviation), IQR (interquartile range), CI (confidence interval), OR (odds ratio), GCS (Glasgow Coma Scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. National Center for Injury Prevention and Control DoVP. Preventing Abusive Head Trauma in Children.; 2020.

        • Shaahinfar A.
        • Whitelaw K.D.
        • Mansour K.M.
        Update on abusive head trauma.
        Curr Opin Pediatr. 2015; 27: 308-314
      2. StatPearls. 2020.

        • Peterson C.
        • Xu L.
        • Florence C.
        • Parks S.E.
        Annual Cost of U.S. Hospital Visits for Pediatric Abusive Head Trauma.
        Child Maltreat. 2015; 20: 162-169
        • Frasier L.D.
        • Kelly P.
        • Al-Eissa M.
        • Otterman G.J.
        International issues in abusive head trauma.
        Pediatr Radiol. 2014; 44 (Suppl): S647-S653
        • Barlow K.M.
        • Spowart J.J.
        • Minns R.A.
        Early posttraumatic seizures in non-accidental head injury: relation to outcome.
        Dev Med Child Neurol. 2000; 42: 591-594
        • Fanconi M.
        • Lips U.
        Shaken baby syndrome in Switzerland: results of a prospective follow-up study, 2002-2007.
        Eur J Pediatr. 2010; 169: 1023-1028
        • Nuño M.
        • Ugiliweneza B.
        • Zepeda V.
        • Anderson J.E.
        • Coulter K.
        • Magana J.N.
        • et al.
        Long-term impact of abusive head trauma in young children.
        Child Abuse Negl. 2018; 85: 39-46
        • Health IW.
        White paper: ibm marketscan research databases for health services researchers.
        2020 ( [accessed Accessed October 26, 2020])
        • Parks SE A.J.
        • Hill H.A.
        • Karch D.L
        Pediatric abusive head trauma: recommended definitions for public health surveillance and research.
        Centers for Disease Control and Prevention, Atlanta, GA2012
        • Osler T.
        • Rutledge R.
        • Deis J.
        • Bedrick E.
        ICISS: an international classification of disease-9 based injury severity score.
        J Trauma. 1996; 41 (discussion 6-8): 380-386
        • Meredith J.W.
        • Kilgo P.D.
        • Osler T.
        A fresh set of survival risk ratios derived from incidents in the National Trauma Data Bank from which the ICISS may be calculated.
        J Trauma. 2003; 55: 924-932
      3. CMS' ICD-9-CM to and from ICD-10-CM and ICD-10-PCS Crosswalk or General Equivalence Mappings. Cambridge, MA: National Bureau of Economic Research; 2020.

        • Tepas J.J.
        • Leaphart C.L.
        • Celso B.G.
        • Tuten J.D.
        • Pieper P.
        • Ramenofsky M.L.
        Risk stratification simplified: the worst injury predicts mortality for the injured children.
        J Trauma. 2008; 65 (discussion 61-3): 1258-1261
        • Fischer H.
        • Allasio D.
        Permanently damaged: long-term follow-up of shaken babies.
        Clin Pediatr (Phila). 1994; 33: 696-698
        • Rhine T.
        • Wade S.L.
        • Makoroff K.L.
        • Cassedy A.
        • Michaud L.J.
        Clinical predictors of outcome following inflicted traumatic brain injury in children.
        J Trauma Acute Care Surg. 2012; 73 (Suppl 3): S248-S253
        • Bonnier C.
        • Nassogne M.C.
        • Saint-Martin C.
        • Mesples B.
        • Kadhim H.
        • Sébire G.
        Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome.
        Pediatrics. 2003; 112: 808-814
        • Ilves P.
        • Lintrop M.
        • Talvik I.
        • Sisko A.
        • Talvik T.
        Predictive value of clinical and radiological findings in inflicted traumatic brain injury.
        Acta Paediatr. 2010; 99: 1329-1336
        • Barlow K.M.
        • Minns R.A.
        Annual incidence of shaken impact syndrome in young children.
        Lancet. 2000; 356: 1571-1572
        • Lind K.
        • Toure H.
        • Brugel D.
        • Meyer P.
        • Laurent-Vannier A.
        • Chevignard M.
        Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma.
        Child Abuse Negl. 2016; 51: 358-367
        • Vinchon M.
        • Defoort-Dhellemmes S.
        • Nzeyimana C.
        • Vallée L.
        • Dhellemmes P.
        Infantile traumatic subdural hematomas: outcome after five years.
        Pediatr Neurosurg. 2003; 39: 122-128
        • Vinchon M.
        • Defoort-Dhellemmes S.
        • Desurmont M.
        • Dhellemmes P.
        Accidental and nonaccidental head injuries in infants: a prospective study.
        J Neurosurg. 2005; 102 (Suppl): 380-384
        • Zablotsky B.
        • Black L.I.
        • Maenner M.J.
        • Schieve L.A.
        • Danielson M.L.
        • Bitsko R.H.
        • et al.
        Prevalence and trends of developmental disabilities among children in the United States: 2009-2017.
        Pediatrics. 2019; 144
        • Boyle C.A.
        • Yeargin-Allsopp M.
        • Doernberg N.S.
        • Holmgreen P.
        • Murphy C.C.
        • Schendel D.E.
        Prevalence of selected developmental disabilities in children 3-10 years of age: the Metropolitan Atlanta Developmental Disabilities Surveillance Program.
        MMWR CDC Surveill Summ. 1991; 45 (1996): 1-14
        • Camp B.W.
        • Broman S.H.
        • Nichols P.L.
        • Leff M.
        Maternal and neonatal risk factors for mental retardation: defining the 'at-risk' child.
        Early Hum Dev. 1998; 50: 159-173
        • Varma R.
        • Tarczy-Hornoch K.
        • Jiang X.
        Visual Impairment in Preschool Children in the United States: demographic and Geographic Variations From 2015 to 2060.
        JAMA Ophthalmol. 2017; 135: 610-616
        • Keenan H.T.
        • Runyan D.K.
        • Marshall S.W.
        • Nocera M.A.
        • Merten D.F.
        A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury.
        Pediatrics. 2004; 114: 633-639
        • Duhaime A.C.
        • Christian C.
        • Moss E.
        • Seidl T.
        Long-term outcome in infants with the shaking-impact syndrome.
        Pediatr Neurosurg. 1996; 24: 292-298
        • Talvik I.
        • Männamaa M.
        • Jüri P.
        • Leito K.
        • Põder H.
        • Hämarik M.
        • et al.
        Outcome of infants with inflicted traumatic brain injury (shaken baby syndrome) in Estonia.
        Acta Paediatr. 2007; 96: 1164-1168
        • Shein S.L.
        • Bell M.J.
        • Kochanek P.M.
        • Tyler-Kabara E.C.
        • Wisniewski S.R.
        • Feldman K.
        • et al.
        Risk factors for mortality in children with abusive head trauma.
        J Pediatr. 2012; 161 (e1.): 716-722
        • Nuño M.
        • Pelissier L.
        • Varshneya K.
        • Adamo M.A.
        • Drazin D.
        Outcomes and factors associated with infant abusive head trauma in the US.
        J Neurosurg Pediatr. 2015; 16: 515-522
        • Anderson V.
        • Spencer-Smith M.
        • Leventer R.
        • Coleman L.
        • Anderson P.
        • Williams J.
        • et al.
        Childhood brain insult: can age at insult help us predict outcome?.
        Brain. 2009; 132 (Pt 1): 45-56
        • Anderson V.
        • Catroppa C.
        • Morse S.
        • Haritou F.
        • Rosenfeld J.
        Functional plasticity or vulnerability after early brain injury?.
        Pediatrics. 2005; 116: 1374-1382
        • Jayawant S.
        • Parr J.
        Outcome following subdural haemorrhages in infancy.
        Arch Dis Child. 2007; 92: 343-347
        • Ashton R.
        Practitioner review: beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury?.
        J Child Psychol Psychiatry. 2010; 51: 967-980
        • Andersen S.L.
        Trajectories of brain development: point of vulnerability or window of opportunity?.
        Neurosci Biobehav Rev. 2003; 27: 3-18