Long-term outcome of abusive head trauma

The neuroimaging mimics of abusive head trauma

Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the paediatric population, typically in children under the age of two years. Neuroimaging plays a key role in the diagnostic work up of these patients as information regarding the mechanism of injury is often lacking and the findings on examination can be nonspecific. A number of conditions, both traumatic and atraumatic can mimic AHT based on neuroimaging features alone. The repercussions associated with a diagnosis or misdiagnosis of AHT can be severe and radiologists therefore need to be aware of and familiar with the imaging differentials of AHT. In this paper we review the imaging findings of the radiological mimics of AHT and focus on features that can help differentiate these entities from AHT.

The medical and social outcome in 2016 of infants who were victims of shaken baby syndrome between 2005 and 2013

INTRODUCTION

There are few studies that have investigated the long-term outcome of children who have been victims of shaken baby syndrome (SBS). However, the consequences appear to be significant and the data available from a social point of view are scarce. The main objective of this study was to define the medical and social outcome in 2016 of the infants who were victims of SBS and admitted to one of the Marseille university hospitals. The number of patients followed by a specialized team was evaluated along with their clinical state, living conditions, and whether a social support system such as the Child welfare system had been put into place.

METHOD

The study was retrospective and descriptive. Patients under 1 year of age who were hospitalized between January 2005 and December 2013 and manifested clinical and paraclinical characteristics enabling the diagnosis of SBS were included in the study. The diagnosis was certain, probable, or possible according to the definitions given by the consensus of the 2011 shaken baby health authority conference (HAS).

RESULTS

Eighty babies qualified for the study, three of whom died in intensive care. Only ten of these patients (12.9%) had regular (annual) neuropediatric check-up during the whole study period. Thirty-seven patients (48%) had an annual neuropediatric check-up during the first 2 years only following the diagnosis. Only 12 of the children (15.6%) were still being followed after the age of 6. The children were followed up on average for 2.5 years (29.6 months). In 24 cases (31%), the last medical visit revealed an abnormal neurological examination including multiple disabilities due to spastic quadriplegia and severe intellectual deficit, which led to total dependency in half of these cases. Forty-four patients (57%) had a normal neurological examination. Concerning the babies' social outcome, 50 patients (64.9%) had returned home, 12 (15.6%) benefited, from educational assistance at the patient's home (AEMO) following the ruling of a children's judge, and 19 (24.7%) were still placed in foster care (ASE). The average foster care placement lasted 34.7 months.

DISCUSSION AND CONCLUSION

Long-term medical follow-up for children having sustained serious head injury as a result of abuse is inadequate. Sequelae such as multiple disabilities are less frequent than described in the literature. According to this study, a longer-term follow-up is necessary for children suffering from sequelae such as learning disabilities than what is actually possible in our center.

Long-term impact of abusive head trauma in young children

OBJECTIVE

Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs).

METHODS

We used the Truven Health MarketScan Research Claims Database (2000-2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes.

RESULTS

The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance.

CONCLUSION

AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.

Consensus statement on abusive head trauma in infants and young children

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

Effectiveness of a Pediatric Abusive Head Trauma Prevention Program Among Spanish-Speaking Mothers

INTRODUCTION

This study aimed to evaluate participants' knowledge of and intent to share key messages of the Period of PURPLE Crying abusive head trauma prevention program among a majority Spanish-speaking population.

METHODS

This study was a retrospective review of a postintervention survey administered in the perinatal unit of a community birthing hospital. Surveys were administered to mothers of newborns by perinatal nurses as part of routine process evaluation prior to hospital discharge between May 30, 2014, and May 15, 2015.

RESULTS

A majority of participants (86.4%) answered all six knowledge questions correctly. Among participants who reported that the father or significant other was not present during the PURPLE education (44.1%), all (100%) reported intending to share the PURPLE information with their partners. The majority of participants (88.1%) intended to share the information with others who take care of their infants.

CONCLUSION

The PURPLE abusive head trauma prevention program demonstrated positive preliminary results in knowledge and intended behavior among a population of majority Spanish-speaking participants. These findings offer an important first step toward provision of effective universal abusive head trauma prevention among growing Spanish-speaking populations. Further evaluation is needed of acceptability, retention of messages, and postintervention behavior change among Spanish-speaking participants and nurses.

Radiologic head CT interpretation errors in pediatric abusive and non-abusive head trauma patients

BACKGROUND

Pediatric head trauma, including abusive head trauma, is a significant cause of morbidity and mortality.

OBJECTIVE

The purpose of this research was to identify and evaluate radiologic interpretation errors of head CTs performed on abusive and non-abusive pediatric head trauma patients from a community setting referred for a secondary interpretation at a tertiary pediatric hospital.

MATERIALS AND METHODS

A retrospective search identified 184 patients <5 years of age with head CT for known or potential head trauma who had a primary interpretation performed at a referring community hospital by a board-certified radiologist. Two board-certified fellowship-trained neuroradiologists at an academic pediatric hospital independently interpreted the head CTs, compared their interpretations to determine inter-reader discrepancy rates, and resolved discrepancies to establish a consensus second interpretation. The primary interpretation was compared to the consensus second interpretation using the RADPEER™ scoring system to determine the primary interpretation-second interpretation overall and major discrepancy rates. MRI and/or surgical findings were used to validate the primary interpretation or second interpretation when possible. The diagnosis of abusive head trauma was made using clinical and imaging data by a child abuse specialist to separate patients into abusive head trauma and non-abusive head trauma groups. Discrepancy rates were compared for both groups. Lastly, primary interpretations and second interpretations were evaluated for discussion of imaging findings concerning for abusive head trauma.

RESULTS

There were statistically significant differences between primary interpretation-second interpretation versus inter-reader overall and major discrepancy rates (28% vs. 6%, P=0.0001; 16% vs. 1%, P=0.0001). There were significant differences in the primary interpretation-second interpretation overall and major discrepancy rates for abusive head trauma patients compared to non-abusive head trauma patients (41% vs 23%, P=0.02; 26% vs. 12%, P=0.03). The most common findings resulting in major radiologic interpretation errors were fractures and subdural hemorrhage. Differences in the age of the patient and the percentage of patients with hemorrhage were statistically significant between the abusive head trauma versus non-abusive head trauma groups, while no statistical difference was identified for skull fractures, ischemia, head CT radiation dose, or presence of multiplanar or 3-D reformatted images. The second interpretation more frequently indicated potential for abusive head trauma compared to the primary interpretation (P=0.0001). MRI and/or surgical findings were in agreement with the second interpretation in 29/29 (100%) of patients with discrepancies.

CONCLUSION

A high incidence of radiologic interpretation errors may occur in pediatric trauma patients at risk for abusive head trauma who are referred from a community hospital. This suggests value for second interpretations of head CTs at a tertiary pediatric hospital for this patient population.

Diagnostic Performance of Ultrafast Brain MRI for Evaluation of Abusive Head Trauma

BACKGROUND AND PURPOSE

MR imaging with sedation is commonly used to detect intracranial traumatic pathology in the pediatric population. Our purpose was to compare nonsedated ultrafast MR imaging, noncontrast head CT, and standard MR imaging for the detection of intracranial trauma in patients with potential abusive head trauma.

MATERIALS AND METHODS

A prospective study was performed in 24 pediatric patients who were evaluated for potential abusive head trauma. All patients received noncontrast head CT, ultrafast brain MR imaging without sedation, and standard MR imaging with general anesthesia or an immobilizer, sequentially. Two pediatric neuroradiologists independently reviewed each technique blinded to other modalities for intracranial trauma. We performed interreader agreement and consensus interpretation for standard MR imaging as the criterion standard. Diagnostic accuracy was calculated for ultrafast MR imaging, noncontrast head CT, and combined ultrafast MR imaging and noncontrast head CT.

RESULTS

Interreader agreement was moderate for ultrafast MR imaging (κ = 0.42), substantial for noncontrast head CT (κ = 0.63), and nearly perfect for standard MR imaging (κ = 0.86). Forty-two percent of patients had discrepancies between ultrafast MR imaging and standard MR imaging, which included detection of subarachnoid hemorrhage and subdural hemorrhage. Sensitivity, specificity, and positive and negative predictive values were obtained for any traumatic pathology for each examination: ultrafast MR imaging (50%, 100%, 100%, 31%), noncontrast head CT (25%, 100%, 100%, 21%), and a combination of ultrafast MR imaging and noncontrast head CT (60%, 100%, 100%, 33%). Ultrafast MR imaging was more sensitive than noncontrast head CT for the detection of intraparenchymal hemorrhage (P = .03), and the combination of ultrafast MR imaging and noncontrast head CT was more sensitive than noncontrast head CT alone for intracranial trauma (P = .02).

CONCLUSIONS

In abusive head trauma, ultrafast MR imaging, even combined with noncontrast head CT, demonstrated low sensitivity compared with standard MR imaging for intracranial traumatic pathology, which may limit its utility in this patient population.

Maltreatment in Infancy: A Developmental Perspective on Prevention and Intervention

Burgeoning research has documented high rates of maltreatment during the first 3 years of life. Early exposure to maltreatment is related to a host of negative physical, developmental, and mental health outcomes in childhood and adulthood. Scientists have documented the "biological embedding" of maltreatment, including alterations in the structures and processes of the young brain. Maltreatment is a complex phenomenon, which manifests in contexts of family poverty, inadequate parental knowledge and skill regarding child development and caregiving, social isolation of parents, disruptions in parent-child relationships, compromised parental psychological functioning, and concrete issues that affect parenting. Capitalizing on research on young child maltreatment, interventions have been designed to ameliorate infant/toddler maltreatment, buffer young children against the effects of maltreatment, and promote the well-being of maltreated young children. There is a growing empirical base on interventions to address early maltreatment within the context of a public health prevention framework. Primary prevention programs aim to reduce the incidence of maltreatment and related outcomes for infants, toddlers, and their families through the implementation of population-based programs, such as home visiting and early care and education programs. Secondary prevention models target families with specific risk factors associated with maltreatment, such as maternal depression. Tertiary programs generally entail involuntary services, designed to prevent maltreatment recurrence and to improve parenting skills through therapeutic approaches targeting the parent-child dyad. Empirical knowledge about maltreated young children and their families and interventions to support them can inform the design and delivery of child welfare services.

Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma

Studies about long-term outcome following abusive head trauma (AHT) are scarce. The aims of this study were to report long-term neurological, cognitive, behavioral and academic outcomes, ongoing treatments and/or rehabilitation, several years after AHT diagnosis, and factors associated with outcome. In this retrospective study, all patients admitted to a single rehabilitation unit following AHT between 1996 and 2005, with subsequent follow-up exceeding 3 years, were included. Medical files were reviewed and a medical interview was performed with parents on the phone when possible. The primary outcome measure was the Glasgow Outcome Scale (GOS). Forty-seven children (out of 66) met the inclusion criteria (mean age at injury 5.7 months; SD=3.2). After a median length of follow-up of 8 years (range 3.7-12), only seven children (15%) had "good outcome" (normal life - GOS I) and 19 children (40%) presented with severe neurological impairment (GOS III and IV). Children sustained epilepsy (38%), motor deficits (45%), visual deficit (45%), sleep disorders (17%), language abnormalities (49%), attention deficits (79%) and behavioral disorders (53%). Most children (83%) had ongoing rehabilitation. Only 30% followed a normal curriculum, whereas 30% required special education services. Children with better overall outcome (GOS I and II) had significantly higher educated mothers than those with worse outcomes (GOS III and IV): graduation from high school 59% and 21% respectively (p=0.006). This study highlights the high rate of severe sequelae and health care needs several years post-AHT, and emphasizes the need for extended follow-up of medical, cognitive and academic outcomes.

Parents' behavior in response to infant crying: abusive head trauma education

Abusive head trauma (AHT) is still too common, and probably underestimated. It is the leading cause of death from child abuse. Crying is thought to contribute to the act of shaking. Objectives of this study were to (a) assess parents' knowledge about infant crying, their ability to manage crying, and their knowledge about AHT; and (b) assess the feasibility and the impact of a simple educational intervention about crying and AHT with parents shortly after their child's birth. A short questionnaire was completed orally by the parents of 190 consecutive newborns in a maternity hospital at day 2 of life. Then, during the routine examination of the child, the pediatrician gave parents a short talk about infant crying and AHT, and a pamphlet. Finally, parents were contacted by phone at 6 weeks for the post-intervention questionnaire assessing their knowledge about crying and AHT. Among 202 consecutive births, parents of 190 children were included (266 parents; 70% mothers) over a 1-month period and answered the pre-intervention questionnaire. The intervention was feasible and easy to provide. Twenty-seven percent of mothers and 36% of fathers had never heard of AHT. At 6 weeks, 183 parents (68% of the sample; 80% mothers) answered the post-intervention questionnaire. Parents' knowledge improved significantly post-intervention. Parents found the intervention acceptable and useful. Health care professionals such as pediatricians or nurses could easily provide this brief talk to all parents during systematic newborn examination.