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To our members, As the American Academy of Pediatrics (AAP) releases their new technical report on abusive head trauma (AHT), the American Society of Pediatric Neurosurgeons (ASPN) and the American Association of Neurological Surgeons (AANS) / Congress of Neurological Surgeons (CNS) Joint Section on Pediatric Neurological Surgery would like to take an opportunity to comment on this important and charged topic. Our membership cares for infants and children with head injuries on a daily basis. Sadly, some of these children are victims of abuse. The existence of both child abuse and abusive head trauma is well established with epidemiology that is not subject to debate. There are, based on CDC data, more than 1300 cases of abusive head injury reported annually in the United States. Unfortunately, establishing a diagnosis of AHT in an individual patient is not straightforward. Perpetrators of abuse are rarely forthcoming with information regarding how or when a child was injured; pre-verbal children are obviously unable to provide additional history. Depending on the timing, mechanism (striking/contact injuries, shaking or other) and force applied (ranging from mild to severe), a child may present with a wide range of both signs/symptoms as well as physical/radiologic/laboratory findings. Pediatric neurosurgeons are important members of the healthcare team; however, we do not evaluate these children alone. Child abuse pediatricians (CAP), pediatric surgeons, ophthalmologists, pediatric radiologists, and other subspecialists contribute to the evaluation of a child with suspected abuse. The team assembles a differential diagnosis, obtains appropriate diagnostic testing and directs treatment. At centers with child abuse pediatricians, consultants may also assist with interpretation of diagnostic testing to support the CAP in his/her interface with social services and law enforcement. In contrast, pediatric neurosurgeons are typically not a component of the social service or law enforcement teams who are decision makers from the perspective of either removing custody from or filing charges against an alleged perpetrator. We recognize the challenges faced by our colleagues in social services, law enforcement and the judicial system. We also appreciate the right of children to safety, and when required, the right of individuals and families to receive fair consideration/adjudication of safety concerns. We have been disappointed in representations of pediatricians and pediatric subspecialists in the media as purveyors of ‘junk science’ on the ‘disproven theory’ of ‘shaken baby syndrome’. As a society, we endorse this technical report and the previous 2019 AAP Policy Statement on Abusive Head Trauma, and have confidence in the methodology outlined regarding the evaluation of the child with suspected AHT. As evidenced by this technical report, there is a substantial volume of multidisciplinary literature on the epidemiology, history, biomechanics, clinical exam, diagnostic evaluation, differential diagnosis, treatment, outcomes and even prevention of abusive head trauma. Critically, this literature has been subject to rigorous peer review. There remains much about AHT that is not known- to that end, researchers will continue to ask questions and pursue answers through careful design, observation and data collection/analysis with subsequent peer review. The lack of certainty inherent to both clinical medicine and scientific inquiry will always provide opportunities for mischaracterization by those with an alternative agenda. The blueprint for sewing distrust in the scientific community was drafted by the tobacco industry in the mid-20th century, and continues to be applied to new circumstances - current attacks in the lay press on the validity of the diagnosis of abusive head trauma are simply the latest application of this old saw. In closing, the ASPN and the AANS/CNS Section on Pediatric Neurological Surgery commend the work of the team that assembled this technical report on abusive head trauma. The document highlights the tremendous volume of work that has been accomplished to date allowing physicians (including pediatric neurosurgeons) to evaluate and care for the children and families that we serve. |