We will begin and end this course with a simple message:
Never, ever shake a baby!
Pediatric abusive head trauma (PAHT) is a preventable tragedy. It is a severe form of child abuse that causes brain injury, long-term developmental delays, lifelong severe health problems, and even death. The American Academy of Pediatrics estimates that in the United States about 1,300 children per year suffer from this form of abuse, and that 25% of them die from it. Upwards of 80% of the children who survive this form of assault suffer permanent harm, including blindness and neurological disability.
According to Dr. Dipesh Navsaria, on behalf of Head Start, a national childcare association,
“It is never OK to shake, throw, hit, slam, or jerk any child. The consequences can be deadly (Navsaria, 2024).”
1.1 Terminology: Shaken Baby, or Abusive Head Trauma
Although the term shaken baby syndrome is still in wide use, the American Academy of Pediatrics adopted the term abusive head trauma in 2009 to recognize the complex biomechanical forces (including shaking) that are involved in children’s head injuries (Narang et al., 2020). In addition to shaking, injury mechanisms include blunt trauma, rotational forces, and direct cranial impact (Krishnaprasadh et al., 2025).
The Centers for Disease Control and Prevention (CDC) launched an effort in 2012 to develop uniform case definitions of child maltreatment and abusive head trauma. The CDC defines pediatric abusive head trauma (PAHT) as
“. . . a severe form of child abuse that results in a brain injury. It often happens when a parent or caregiver becomes angry or frustrated because of a child's crying. It is caused by violent shaking and/or with blunt impact. The resulting injury can cause bleeding around the brain or behind the eyes.”
The medical, legal, and law enforcement communities often use different terms to describe traumatic brain injuries in infants, among them: shaken infant syndrome, shaking impact syndrome, non-accidental injury, non-accidental trauma, non-accidental head injury, and shaken baby syndrome/abusive head trauma (SBS/AHT). This course will use a variety of terms throughout.
1.2 Distinguishing PAHT from Unintentional Injury
Abusive head trauma can be difficult to diagnose because there is so much variability in the way symptoms present. Often, victims do not have visible injuries, and some of their injuries resemble accidental trauma. The diagnosis often starts with a medical professional or childcare provider’s suspicions, based on behavioral and other circumstantial clues.
No centralized reporting system exists for AHT, though it is the leading cause of abusive traumatic brain injury and fatal physical abuse in children (Krishnaprasadh et al., 2025). Children under 1 year, particularly those who are 2 to 4 months old, are particularly vulnerable. Children with special needs and those who suffer from health problems are at even greater risk.
Pediatricians acknowledge the difficulty of diagnosing AHT, because it has such a wide range of symptoms that are common with other diagnoses. Sometimes patients present with subtle indications like vomiting, lethargy, or fussiness. Injuries to the mouth, such as tears in the oral connective tissues, are often a tipoff that abuse has occurred. Damage to the eyes is commonly associated with AHT. TEN-4* bruising of the torso, ears, and neck in children under 4 years of age should alert medical personnel of the possibility of abuse (Narang et al., 2025).
*TEN-4-FACESp is a clinical screening tool used to identify potential child abuse by highlighting concerning bruises on children under 4 years old. It focuses on bruising to the Torso, Ears, Neck, any bruising on infants 4 months or younger, and specific facial areas (FACESp: Frenulum, Angle of jaw, Cheek, Eyelid, Subconjunctivae, and patterned bruising) (Mass General Brigham Hospital, 2025).
Pediatricians recommend a comprehensive medical evaluation, including head imaging (plus cranial and spinal MRI and cranial CT if intercranial injury is suspected), skeletal survey, ophthalmology consultation, and a thorough examination of the skin. This needs to be a team effort, involving specialists in child abuse pediatrics, radiology, ophthalmology, neurosurgery, and others, to make sure that nothing is missed (Narang, 2025).