Introduction

Abusive head trauma (AHT) is a one of the leading causes of fatal head injury in infants and children under 2 years of age [1, 2]. When a child with AHT was severely injured, the neurosurgical management and intensive care show high homogeneity among different institutes; however, the circuit of patients with AHT may vary widely. This study presents the efforts that have been made for this potentially preventable disease in Taiwan in the past decade.

Impact of pediatric abusive head trauma (AHT) in Taiwan

In a nationwide population-based study between 2006 and 2015, there were 538 cases of AHT and 67 fatal cases in Taiwan. The incidence in children is 20/1,000,000 person-years under 1 year of age and 1.7/1,000,000 person-years between 1 and 2 years of age, respectively. Over 40% of cases had severe sequelae, and the mortality was around 13% [3]. In the USA, over half of the AHT survivors need further medical care [4]. In Taiwan, the cost of healthcare utilization is 10 times greater than that of the non-AHT children of the same age [5]. Despite the significant impact of AHT, it is easily overlooked by the healthcare providers who are not familiar with child protection.

Efforts of the Ministry of Health and Welfare and Taiwan Pediatric Association

The Taiwan Pediatric Association (TPA) had long been concerning the underrecognition of AHT in Taiwan society. TPA issued its first recommendations for the prevention and management of AHT in 2013, which was updated in 2021 [6]. The recommendations highlight the importance of education and training of all healthcare providers to be familiar with the symptoms and signs of AHT (Table 1). To facilitate the education and training of pediatric healthcare providers on the recognition and management of child abuse and neglect, the TPA and the Ministry of Health and Welfare (MOHW) had published a child abuse and neglect manual for medical professionals [7]. The manual emphasizes the multiple mechanisms of AHT, which include not only shaking, but also blunt impact or other abusive ways. It also provides a checklist for children with suspected abuse or neglect and recommends laboratory and imaging studies for these children (Tables 2 and 3).

Table 1 Key recommendations of the Taiwan Pediatric Association on the management and prevention of abusive head trauma (AHT)[6] (translated from the original statements in Chinese)
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Table 2 Important observation of the clinical symptoms and history of the abusive head trauma (AHT) [7]
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Table 3 Recommended examinations for children with suspected abusive head trauma (AHT) by Ministry of Health and Welfare and Taiwan Pediatric Association [7]
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Challenges in the determination of abusive head trauma

Although the medical professionals in Taiwan are aware AHT more than before, the diagnosis and subsequent managements of the suspicious cases are still challenging. There is not a specific single sign, examination, or criteria that can differentiate AHT from the non-AHT with sufficient sensitivity and specificity. For example, retinal hemorrhage can be caused by many etiologies other than AHT. Most AHT patients had bilateral retinal hemorrhage; however, unilateral or no retinal hemorrhage cannot rule out AHT [8]. In many cases, a multidisciplinary expert committee is needed to cautiously review the results of medical examination and the history provided by the caregivers. The multidisciplinary expert committee of our Child Protection Medical Center consists of at least 6 physicians as the core team. The pediatricians need to be trained both in child abuse and neglect and critical care and emergency medicine. The other core members include radiologists, forensic pathologists, and so on. Related specialists such as neurologist, neurosurgeon, orthopedic physician, obstetrician, gynecologist, ophthalmologist, and others will be invited to meet the needs of specific cases.

In Taiwan, there are 23 medical centers and 5 children’s hospitals [9]. The MOHW had funded 10 regional centers for child protection medical service. Most of the regional centers are operated by Children’s Hospitals and the Pediatric Departments of Medical Centers with sufficient facilities and well-trained personnel in that region. The regional centers of child protection medical service are responsible to receive medical referral and provide instant medical consultation, medical, psychiatric and psychological support, and follow-up of the survivors of AHT. They also provide expert opinions of injury identification, the clinical and forensic evidence for the judicial system. Besides, each center arranges training and continuing education courses for the child protection network annually. These educational programs strongly facilitate the knowledge and sensitivity in the network.

In some cases, the cause of injury could not be determined after the cautious review by the multidisciplinary expert committee. Incomplete initial clinical assessment and workup, poor quality or incomplete medical images, lack of photography, and detailed description of the retinal examination are the possible obstacles that may hinder the team from determining the cause of injury in the review process. Children with special needs are also often overlooked when they are abused, because the presentation may be ascribed to their underlying clinical condition. Experts of medical genetics also need to be incorporated in the committee to review patients with rare genetic disorders.

The collaboration between the healthcare, social welfare administration, and the judicial system

To identify, recognize, and properly manage cases of AHT, a child protection network across the healthcare, social welfare administration, and judicial systems has to be established. The healthcare system is usually the first system to get involved in the case of AHT. The high level of alertness of the clinicians on the suspicion of AHT is crucial for early identification and management of AHT. With the assistance of government social workers, important information can be collected for a best decision of the care plan and disposition of these children.

In 2018, an Early Judicial Investigation Process was established in Taiwan for the majorly injured cases due to child abuse, which included the cases of AHT. This process led by the prosecutors may be initiated as early as within 24 h after the notification of the child protection service, which is composed of the medical professionals and police officers. With the collaboration of these teams, early investigation of the clinical, social, and legal issues can be undertaken and the important information can be shared across the child protection network aiming at making a care plan in the best interest of these children.

Conclusion

After the setting up of the child protection network and the continuing cross-system professional trainings, there is more consensus and improvement of the diagnosis and care management of AHT than before in Taiwan. However, there are always challenges in the diagnosis and management of AHT. There is no end to protecting children from AHT.