Annual incidence of shaken impact syndrome in young children

Short term outcomes of children with abusive head trauma two years post injury: A retrospective study

PURPOSE

Abusive head trauma (AHT) can have debilitating sequelae for children who survive. A retrospective medical record review was used to describe short-term developmental outcomes of children with AHT and identify predictors of poorer outcomes.

METHOD

Children with AHT who received follow up by the hospital's rehabilitation department for 12 to 24 months post-injury were included in this review. Data for 85 children were collected on hearing, vision, gross motor, fine motor, speech and language, cognition, play, adaptive functioning, behaviour and personal-social skills.

RESULTS

Global assessment found 42% of children had a good recovery, 34% had a moderate disability and 24% had a severe disability. For whom there was data, more than half had abnormal cognition, behaviour and personal-social skills, whilst more than a third had abnormal speech and language, neurological signs on last assessment, vision, play skills, and gross and fine motor skills. Factors that predicted poorer prognosis across all developmental domains included paediatric intensive care unit admission, longer length of hospital stay, breathing difficulty and lower Glasgow Coma Scale on presentation.

CONCLUSION

This study highlights the substantial number of children who have abnormal development in the short-term post-AHT and assists in identifying those who require extensive long-term follow up.

The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada

BACKGROUND

Abusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported.

OBJECTIVE

This study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program.

PARTICIPANTS AND SETTING

Children aged 0-24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study.

METHODS

An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services' perspectives using decision tree models.

RESULTS

There were sixty-four AHT events between 2002-2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system.

CONCLUSIONS

This study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society.

Awareness of abusive head trauma in a German population-based sample: implications for prevention

BACKGROUND

Despite efforts to reduce the incidence of abusive head trauma (AHT), incidence rates remain high. One cause is that prevention programs mostly aim to educate mothers of newborns on AHT and infant crying. However, mothers commonly have already a high knowledge and constitute only a minority among identified AHT perpetrators. The hypothesis was that there are great differences in AHT awareness in different subgroups. To assess awareness of AHT, a population-based study was performed.

METHODS

A population-based representative sample of the German population aged >14 years (N = 2510) was assessed in a cross-sectional observational survey. The sample was selected in a random route approach between November 2017 and February 2018.

RESULTS

Overall knowledge of AHT was higher in women (67.9%) than in men (48.8%, p < 0.001). Female gender, having children, higher age, and level of education were predictors for the awareness of AHT. A majority of participants reported to have heard about AHT from the media.

CONCLUSIONS

Awareness of AHT differs significantly within the population. In groups at higher risk to perpetrate AHT, including men, young caregivers, and those with low educational level, awareness of AHT was low. These subgroups should be targeted by tailored education programs for prevention.

Pediatric Abusive Head Trauma: Return to Hospital System in the First Year Post Injury

BACKGROUND

Abusive head trauma (AHT) may result in costly, long-term sequelae.

OBJECTIVE

To describe the burden of AHT on the hospital system within the first year of injury.

METHODS

Single institution retrospective evaluation of AHT cases from January 2009 to August 2016. Demographic, clinical (including injury severity graded I-III), and charge data associated with both initial and return hospital visits within 1 yr of injury were extracted.

RESULTS

A total of 278 cases of AHT were identified: 60% male, 76% infant, and 54% African-American. Of these 278 cases, 162 (60%) returned to the hospital within the first year, resulting in 676 total visits (an average of 4.2 returns/patient). Grade I injuries were less likely to return than more serious injuries (II and III). The majority were outpatient services (n = 430, 64%); of the inpatient readmissions, neurosurgery was the most likely service to be involved (44%). Neurosurgical procedures accounted for the majority of surgeries performed during both initial admission and readmission (85% and 68%, respectively). Increasing injury severity positively correlated with charges for both the initial admission and returns (P < .001 for both). Total calculated charges, including initial admission and returns, were over $25 million USD.

CONCLUSION

AHT has a high potential for return to the hospital system within the first year. Inpatient charges dominate and account for the vast majority of hospital returns and overall charges. A more severe initial injury correlates with increased charges on initial admission and on subsequent hospital return.

Epidemiology of abusive head trauma in West Virginia children <24 months: 2000-2010

BACKGROUND

Few states have published statewide epidemiology of abusive head trauma (AHT).

OBJECTIVE

To examine the statewide epidemiology of AHT in West Virginia (WV), with the primary objective of establishing AHT incidence for comparison to national data, and to use as a baseline for comparison to incidence post-implementation of a statewide AHT prevention program.

PARTICIPANTS AND SETTING

AHT cases in children less than 2 years old were identified from the 3 tertiary pediatric centers in WV.

METHODS

Cases were identified by using ICD-9 codes for initially identifying those with injuries which might be consistent with AHT, followed by medical record review to determine which of these met the criteria for inclusion as a case. Medical examiner data was used to find additional cases of AHT. Using the number of cases identified along with relevant census data, incidence of AHT was calculated.

RESULTS

There were 120 cases of AHT treated in WV hospitals from 2000 to 2010, 100 of which were WV residents. The incidence was 36.1/100,000 children <1 year of age and was 21.9 cases per 100,000 children <2 years of age. Incidence in infants increased during the latter years (2006-2010) of the study to 51.8/100,000 compared to the incidence during 2000-2005, which was 24.0/100,000 (p < .01).

CONCLUSIONS

Compared to US national, state and regional figures, the WV incidence of AHT was among the highest. In addition, the incidence of AHT increased significantly over the study period. Possible factors contributing to the rise in incidence are discussed.

Compliance With Skeletal Surveys for Child Abuse in General Hospitals: A Statewide Quality Improvement Process

OBJECTIVE. The purpose of this study is to perform a statewide quality improvement process to improve compliance with the American College of Radiology (ACR) guidelines in performing skeletal surveys for suspected child abuse. SUBJECTS AND METHODS. We prospectively identified all outside hospital skeletal surveys for suspected child abuse in children younger than 3 years referred to our tertiary children's hospital in 2016-2017. We included a 3-month baseline and 21-month intervention period. The quality improvement process was based on sending educational material to all ACR member radiologists in the state and making telephone calls to radiology technologist team leaders whenever the surveys were not compliant, followed by e-mails with guidance on performing skeletal surveys. We documented the views obtained and compared them with the ACR guidelines. The percentage of compliance with each individual view was assessed with the chi-square test. The total number of compliant views per survey was evaluated with ANOVA. RESULTS. Two hundred twenty-seven patients (105 female) with a mean age of 0.8 year (SD, 0.67 year; range, 0.01-3 years) were evaluated. These 227 surveys (baseline, n = 27; postintervention, n = 200) were performed at 69 different outside hospitals. Compliance significantly (p = 0.006) improved from 25.9% (7/27) during baseline to 54.0% (108/200) after intervention. There was a nonsignificant trend of improved compliance between the first (51.9%; 41/79) and last 7-month (62.3%; 33/53) periods of intervention. Among individual views, only rib oblique views showed significantly (p = 0.02) improved compliance after the intervention, from 51.9% (14/27) to 73.5% (147/200). CONCLUSION. The compliance rate with ACR guidelines for skeletal surveys in suspected child abuse at outside general hospitals significantly increased after implementation of a quality improvement process.

Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

Background

The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria.

Methods

This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis.

Results

Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities.

Conclusions

Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.

Understanding Subdural Collections in Pediatric Abusive Head Trauma

Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects.

Incidence and Age Distribution of Hospitalized Presumptive and Possible Abusive Head Trauma of Children Under 12 Months Old in Japan

Background

Abusive head trauma (AHT) is the leading cause of fatal maltreatment among young children. The incidence of AHT in Japan, however, remains unknown. This study examined the incidence and distribution of age in months among young children under 12 months of age hospitalized with intracranial injury in Japan.

Methods

We conducted a multicenter cross-sectional study of children under 36 months old admitted with intracranial injury to hospitals that employed the Diagnostic Procedure Combination (DPC) payment system between 2010 and 2013. Presumptive and possible AHT were defined using the combination of ICD-10 codes modified from the coding system recommended by the United States Centers for Disease Control and Prevention.

Results

The average incidence was 7.2 (95% confidence interval [CI], 7.18–7.26) for presumptive and 41.7 (95% CI, 41.7–41.8) for possible AHT per 100,000 children less than 12 months old from 2010 to 2013. The distributions of age in months for both presumptive AHT and possible AHT had peaks at around 2 and 8 months.

Conclusions

This is the first study to report the incidence of hospitalized children with presumptive and possible AHT using population-based data. Further datasets are needed to evaluate the incidence and specific preventive strategies to prevent AHT in infants during the months of highest risk.

The added value of a second read by pediatric radiologists for outside skeletal surveys

BACKGROUND

Fractures are the second most common finding in non-accidental trauma after cutaneous signs. Interpreting skeletal surveys could be challenging as some fractures are subtle and due to anatomical variations that can mimic injuries.

OBJECTIVE

To determine the effect of a second read by a pediatric radiologist of skeletal surveys for suspected non-accidental trauma initially read at referring hospitals by general radiologists.

MATERIALS AND METHODS

In 2016 and 2017, we identified all patients referred to our children's hospital with previous surveys performed and read at a community hospital by an outside radiologist. We excluded patients older than 3 years and studies performed at a children's hospital. The surveys were reviewed by a pediatric radiologist with the printed outside report available. Surveys with disagreement between outside read and pediatric radiologist read were reviewed by a second pediatric radiologist. A disagreement in the second read included only definite discrepant findings agreed upon by both pediatric radiologists. The Fisher exact test was performed to compare the ratio of discrepancies between readers in normal and abnormal surveys.

RESULTS

Two hundred twenty-five surveys were performed (120 male) at 62 referring hospitals, with a mean patient age of 10.5 months (range: 5 days-3 years). The outside read identified fractures in 104/225 (46.2%) surveys. Thirty-seven of the 225 (16.4%) contained discrepancies in interpretation (n=111). Most of these disagreements (29/37, 78.4%) resulted in a significant change in the report. There was a significant (P<0.0001) difference between disagreement rate in outside read negative (4/111, 3.2%) and positive surveys (34/104, 31.7%). The second read identified additional fractures in 22/225 (9.8%) of the surveys and disagreed with first-read fractures in 17/256 (7.6%). Four of 19 (21.1%) classic metaphyseal lesions diagnosed by the outside read were normal variants; 18 classic metaphyseal lesions were missed by the outside read.

CONCLUSIONS

This study supports second reads by pediatric radiologists of skeletal surveys for non-accidental trauma.

Estimating the probability of abusive head trauma after abuse evaluation

BACKGROUND

Evidence-based, patient-specific estimates of abusive head trauma probability can inform physicians' decisions to evaluate, confirm, exclude, and/or report suspected child abuse.

OBJECTIVE

To derive a clinical prediction rule for pediatric abusive head trauma that incorporates the (positive or negative) predictive contributions of patients' completed skeletal surveys and retinal exams.

PARTICIPANTS AND SETTING

500 acutely head-injured children under three years of age hospitalized for intensive care at one of 18 sites between 2010 and 2013.

METHODS

Secondary analysis of an existing, cross-sectional, prospective dataset, including (1) multivariable logistic regression to impute the results of abuse evaluations never ordered or completed, (2) regularized logistic regression to derive a novel clinical prediction rule that incorporates the results of completed abuse evaluations, and (3) application of the new prediction rule to calculate patient-specific estimates of abusive head trauma probability for observed combinations of its predictor variables.

RESULTS

Applying a mean probability threshold of >0.5 to classify patients as abused, the 7-variable clinical prediction rule derived in this study demonstrated sensitivity 0.73 (95% CI: 0.66-0.79) and specificity 0.87 (95% CI: 0.82-0.90). The area under the receiver operating characteristics curve was 0.88 (95% CI: 0.85-0.92). Patient-specific estimates of abusive head trauma probability for 72 observed combinations of its seven predictor variables ranged from 0.04 (95% CI: 0.02-0.08) to 0.98 (95% CI: 0.96-0.99).

CONCLUSIONS

Seven variables facilitate patient-specific estimation of abusive head trauma probability after abuse evaluation in intensive care settings.

Ocular and Intracranial MR Imaging Findings in Abusive Head Trauma

Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.

Child Abuse and Conditions That Mimic It

One percent to 2% of children in the United States are confirmed victims of child abuse, with many more likely affected. It can be difficult to diagnose, with often misleading medical histories, but acute care providers should be aware of its presenting warning signs and how to evaluate and document suspicious physical findings. Young children who cannot disclose are most vulnerable to forms of abuse with high morbidity and mortality, so it is important to keep it in the differential diagnosis and to be aware of and know how to rule out medical conditions that mimic abuse.

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.

Epidemiology of subdural haemorrhage during infancy: A population-based register study

Objectives

To analyse subdural haemorrhage (SDH) during infancy in Sweden by incidence, SDH category, diagnostic distribution, age, co-morbidity, mortality, and maternal and perinatal risk factors; and its association with accidents and diagnosis of abuse.

Methods

A Swedish population-based register study comprising infants born between 1997 and 2014, 0–1 years of age, diagnosed with SDH-diagnoses according to the (International Classification of Diseases, 10^th version (ICD10), retrieved from the National Patient Register and linked to the Medical Birth Register and the Death Cause Register. Outcome measures were: 1) Incidence and distribution, 2) co-morbidity, 3) fall accidents by SDH category, 4) risk factors for all SDHs in the two age groups, 0–6 and 7–365 days, and for ICD10 SDH subgroups: S06.5 (traumatic SDH), I62.0 (acute nontraumatic), SDH and abuse diagnosis.

Results

Incidence of SDH was 16·5 per 100 000 infants (n = 306). Median age was 2·5 months. For infants older than one week, the median age was 3·5 months. Case fatality was 6·5%. Male sex was overrepresented for all SDH subgroups. Accidental falls were reported in 1/3 of the cases. One-fourth occurred within 0–6 days, having a perinatal risk profile. For infants aged 7–365 days, acute nontraumatic SDH was associated with multiple birth, preterm birth, and small-for-gestational age. Fourteen percent also had an abuse diagnosis, having increased odds of being born preterm, and being small-for-gestational age.

Conclusions

The incidence was in the range previously reported. SDH among newborns was associated with difficult birth and neonatal morbidity. Acute nontraumatic SDH and SDH with abuse diagnosis had similar perinatal risk profiles. The increased odds for acute nontraumatic SDH in twins, preterm births, neonatal convulsions or small-for-gestational age indicate a perinatal vulnerability for SDH beyond 1st week of life. The association between prematurity/small-for-gestational age and abuse diagnosis is intriguing and not easily understood.

Eight-year outcome of implementation of abusive head trauma prevention

Low incidence rates and economic recession have hampered interpretation of educational prevention efforts to reduce abusive head trauma (AHT). Our objective was to determine whether the British Columbia experience implementing a province-wide prevention program reduced AHT hospitalization rates. A 3-dose primary, universal education program (the Period of PURPLE Crying) was implemented through maternal and public health units and assessed by retrospective-prospective surveillance. With parents of all newborn infants born between January 2009 and December 2016 (n = 354,477), nurses discussed crying and shaking while delivering a booklet and DVD during maternity admission (dose 1). Public health nurses reinforced Talking Points by telephone and/or home visits post-discharge (dose 2) and community education was instituted annually (dose 3). During admission, program delivery occurred for 90% of mothers. Fathers were present 74.4% of the time. By 2-4 months, 70.9% of mothers and 50.5% of fathers watched the DVD and/or read the booklet. AHT admissions decreased for <12-month-olds from 10.6 (95% CI: 8.3-13.5) to 7.1 (95% CI: 4.8-10.5) or, for <24-month-olds, from 6.7 (95% CI: 5.4-8.3) to 4.4 (95% CI: 3.1-6.2) cases per 100,000 person-years. Relative risk of admission was 0.67 (95% CI: 0.42-1.07, P = 0.090) and 0.65 (95% CI: 0.43-0.99, P = 0.048) respectively. We conclude that the intervention was associated with a 35% reduction in infant AHT admissions that was significant for <24-month-olds. The results are encouraging that, despite a low initial incidence and economic recession, reductions in AHT may be achievable with a system-wide implementation of a comprehensive parental education prevention program.

Management of Subdural Hematomas: Part I. Medical Management of Subdural Hematomas

PURPOSE OF REVIEW

Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation.

RECENT FINDINGS

Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO₂ > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.

National study shows that abusive head trauma mortality in Sweden was at least 10 times lower than in other Western countries

AIM

The validity of the diagnostic criteria for abusive head trauma (AHT) and its attributes has been widely debated. This national study investigated the possibility of false-positive and false-negative cases of fatal AHT in Sweden.

METHOD

This was a retrospective evaluation of the records of 733 deceased infants up to the age of 365 days who were examined during 1994-2013 at the six forensic medicine departments. All the records were scrutinised for possible cases of AHT.

RESULTS

We included 12 cases, of which eight had been diagnosed as AHT. Of these 12 infants, eight had a concomitant disease or perinatal illness, five were born prematurely and three were twins. Figures from other Western countries would suggest 6-7 deaths per 100,000 per year in Sweden, but in reality, there was a maximum possible incidence of 0.6 per 100,000 infants per year.

CONCLUSION

The risk of unreported fatal AHT in Sweden was low, and there may have been cases misdiagnosed as AHT. The at least 10 times lower incidence than has been reported from other Western countries, raises the question if previously reported higher incidences of fatal AHT have been exaggerated.

Pathophysiological and behavioral deficits in developing mice following rotational acceleration-deceleration traumatic brain injury

Abusive head trauma (AHT) is the leading cause of death from trauma in infants and young children. An AHT animal model was developed on 12-day-old mice subjected to 90° head extension-flexion sagittal shaking repeated 30, 60, 80 and 100 times. The mortality and time until return of consciousness were dependent on the number of repeats and severity of the injury. Following 60 episodes of repeated head shakings, the pups demonstrated apnea and/or bradycardia immediately after injury. Acute oxygen desaturation was observed by pulse oximetry during respiratory and cardiac suppression. The cerebral blood perfusion was assessed by laser speckle contrast analysis (LASCA) using a PeriCam PSI system. There was a severe reduction in cerebral blood perfusion immediately after the trauma that did not significantly improve within 24 h. The injured mice began to experience reversible sensorimotor function at 9 days postinjury (dpi), which had completely recovered at 28 dpi. However, cognitive deficits and anxiety-like behavior remained. Subdural/subarachnoid hemorrhage, damage to the brain-blood barrier and parenchymal edema were found in all pups subjected to 60 insults. Proinflammatory response and reactive gliosis were upregulated at 3 dpi. Degenerated neurons were found in the cerebral cortex and olfactory tubercles at 30 dpi. This mouse model of repetitive brain injury by rotational head acceleration-deceleration partially mimics the major pathophysiological and behavioral events that occur in children with AHT. The resultant hypoxia/ischemia suggests a potential mechanism underlying the secondary rotational acceleration-deceleration-induced brain injury in developing mice.

Assessment of Maternal Knowledge and Confidence About Abusive Head Trauma and Coping With Infant Crying Before and After Infant Safety Education in the Neonatal Intensive Care Unit

Infants with a history of perinatal illness are at higher risk for abusive head trauma (AHT). Crying is a common trigger for physical abuse, and education on coping with infant crying is an important component of AHT prevention. This study assesses the effects of education in the neonatal intensive care unit (NICU) on mothers' knowledge about AHT and infant crying, self-efficacy in applying the education to infant cares and providing the education to others, and the quality of AHT and infant crying education after discharge. Mothers received a standardized education program about AHT and infant crying and completed a preeducation survey, posteducation survey, and 4- to 5-month follow-up survey. Overall, there was a sustained increase in knowledge (P < .001) and confidence (P < .001). Mothers who received verbal education reported a higher increase in confidence (P = .03). Few received information from healthcare providers about crying (35%) and AHT (20%) after discharge. At follow-up survey, most felt highly confident in their ability to share information about AHT (97%) and calm their infant (95%). Most had shared the education with others (77%). Education on AHT and crying in the NICU can produce sustained increases in mothers' knowledge and confidence, but the effectiveness may be improved by addressing unique barriers to education in this population.

Predictors of long-term neurological outcomes in non-accidental head injury

BackgroundNon-accidental head injury (NAI) is an inflicted injury usually on a child, often resulting in long-term neurological impairment and occasionally death. This study aimed to investigate the predictive values of acute findings, especially ocular, for long-term neurological outcomes.MethodsMedical records including retinal images of all children who attended the local Children's hospital with a diagnosis of NAI from over a period of 5 years were reviewed and data collected via the electronic patient record system. Patient demographics, injuries sustained, wide-field digital retinal images, visual acuity and sequalae, neurological function, and global function was noted. IBM SPSS software program was used for statistical analysis.ResultsOf the 38 patients (24 males, 14 females), 12 children died acutely from the head injury with the remaining 26 children available for long-term follow-up. A younger age of injury (P=0.004) was the only statistically significant predictor of good neurological outcome as compared with absence of macular retinoschisis, unilateral retinal haemorrhage, and unilateral subdural haemorrhage. Of the 38 children, 17 children had retinoschisis; 9 children with macular retinoschisis died acutely while 4 suffered a degree of developmental delay and only 4 were developmentally normal at the last follow-up. Long-term visual acuity data was available for 18 of the 26 survivors (range: NPL to Snellen 6/5). A statistical significance was noted between retinoschisis and worsened visual acuity (P<0.05).ConclusionsBilateral macular retinoschisis on acute presentation of NAI is associated with a seven-fold and unilateral with a four-fold increase in the development of a poor neurological outcome and eventual death. Conflicting to other studies, younger children presented better neurological outcomes.

Pituitary insufficiency following traumatic thoracic injury in an adolescent male patient: A case report and literature review

RATIONALE

Traumatic thoracic injuries in adolescents are rare but could be connected with traumatic brain injuries (TBI) and development of chronic hypopituitarism. Early recognition of these endocrine problems is a significant challenge to clinicians. We present difficulties in diagnosis of hypothalamic-pituitary insufficiency following traumatic thoracic injury in adolescence. We also review the literature of similar cases.

PATIENT CONCERNS

We present a case of a 24-years-old male. In 2007, at the age of 15 he underwent a severe traffic accident followed by thoracic injury with concussion, hemothorax and dissection of the aorta requiring aortic stent-graft implantation.

DIAGNOSES

During the post-traumatic period, transient polydipsia and polyuria symptoms were observed. The patient had no medical history of any serious disease before the accident, his growth and pubertal development was normal. After the accident the patient did not undergo any routine medical check-ups. In 2013 gonadal axis deficiency was diagnosed during investigation of libido problems. Following the diagnosis testosterone replacement therapy was initiated.

INTERVENTIONS

Further endocrinological investigation was carried out in 2016. The patient's main complaints were decreased mood and poor physical fitness. BMI was 27.34 kg/m, with a tendency to abdominal fat distribution. The patient's height is 160 cm, while Mid Parental Height (MPH) is 173.5 cm. Decreased bone density was found in DEXA examination. Serum growth hormone level (GH) was normal while insulin-like growth factor-1 (IGF-1) level was below normal. Insulin tolerance test (ITT) and low levels of IGF-1 confirmed somatotropic axis deficiency. Nuclear magnetic resonance (NMR) of the hypothalamo-pituitary region showed no abnormalities. PROP 1 and other common genetic mutations associated with GH deficits were excluded. Testosterone treatment was continued. The patient increased physical activity and implemented diet.

OUTCOMES

The patient has lost weight, improved physical activity performance and is feeling better. The procedure to start GH supplementation is now in process.

LESSONS

Based on our case and available literature we suggest that adolescent patients after traumatic brain injuries may require precise investigation and strict monitoring due to the possibility of unrecognized hypopituitarism.

Prevention and recognition of abusive head trauma: training for healthcare professionals in Vietnam

AIM

This study presents results from an intervention designed to improve identification and response to abusive head trauma in a tertiary paediatric hospital in Vietnam.

METHODS

One hundred and sixteen healthcare professionals (paediatric medical and nursing staff) completed a clinical training programme and participated in its evaluation. A pre-post-test and follow-up design was used to evaluate the outcomes. Questionnaires were used to collect data prior to training, at six weeks and at six months. Generalised linear modelling was used to examine changes in diagnostic skills and knowledge of the consequences of shaken baby syndrome (SBS) (a form of abusive head trauma), its prevention and treatment.

RESULTS

At baseline, awareness and knowledge reflected no former abusive head trauma training. Following the intervention, participants had an increased awareness of shaken baby syndrome and the potential consequences of shaking infants and had acquired techniques to inform parents how to manage the crying infant.

CONCLUSION

The intervention was effective in raising awareness of shaken baby syndrome and its consequences amongst the participating healthcare professionals in Vietnam. Training can improve detection and prevention of abusive head trauma, and the intervention has the potential to be adapted for similar settings internationally.

[Shaken baby syndrome]

The shaken baby syndrome (SBS) or shaking trauma describes the occurrence of subdural hematoma, retinal hemorrhage and diffuse injury to the brain by vigorous shaking of an infant that has a poor prognosis. Rapid cranial acceleration and deceleration leads to tearing of bridging veins, retinal hemorrhages and diffuse brain injuries. In addition to clinical symptoms, such as irritability, feeding difficulties, somnolence, apathy, seizures, apnea and temperature regulation disorders, vomiting also occurs due to increased intracranial pressure. Milder forms of SBS often go undiagnosed and the number of unreported cases (grey area) is probably much higher. Up to 20 % of patients die within days or weeks due to SBS and survivors often show cognitive deficits and clinical symptoms, such as physical disabilities, impaired hearing, impaired vision up to blindness, epilepsy and mental retardation as well as a combination of these conditions; therefore, prevention is very important.

[Child abuse from a pediatric perspective]

CLINICAL ISSUE

Child abuse is the physical, sexual or emotional maltreatment, or neglect of a child or children. Child maltreatment is defined as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Child abuse can occur in a child's home, or in the organizations, schools or communities the child interacts with. There are four major categories of child abuse: neglect, physical abuse, psychological or emotional abuse, and sexual abuse.

DIAGNOSTIC WORK-UP

In child abuse, establishing an early diagnosis is essential. Apart from taking a detailed history and performing a meticulous physical examination, including forensic evaluation as indicated, further diagnostic steps (imaging studies, ophthalmic examination/funduscopy, laboratory studies, etc.) may be warranted.

PRACTICAL RECOMMENDATIONS

In addition to providing acute medical help, longer-term, multidisciplinary interventions have to be put in place in cases of child abuse. This article summarizes the most important facts pertinent to this subject.

In Vivo Demonstration of Traumatic Rupture of the Bridging Veins in Abusive Head Trauma

OBJECTIVE

In victims of abusive head trauma, bridging vein thrombosis is a common finding on magnetic resonance imaging. We aimed to evaluate the utility of high-resolution coronal susceptibility-weighted imaging (SWI) in depicting bridging vein thrombosis as well as to verify the morphology of the bridging vein thrombosis on axial SWI. We additionally analyzed the correlations between bridging vein thrombosis or bridging vein deformation and other magnetic resonance imaging findings that often occur in association with abusive head trauma.

METHODS

Seventeen patients with abusive head trauma were retrospectively evaluated for the presence of thrombosis on axial SWI. The affected veins were localized on coronal SWI, and the strength of association between the presence of bridging vein thrombosis on axial versus high-resolution coronal SWI was determined.

RESULTS

Of 11 patients identified with thrombosis on axial SWI, high-resolution coronal SWI verified bridging vein thrombosis in four individuals (36%). The previously reported "tadpole sign" on axial images did not predict bridging vein thrombosis on coronal SWI (odds ratio = 0.3 [0.02, 5.01], P = 0.538). Volumetric coronal SWI disclosed additional irregularities of the bridging vein walls which was associated with the presence of subdural hematoma on magnetic resonance imaging (P = 0.03), suggesting traumatic injury.

CONCLUSION

Coronal SWI confirmed thrombosis of the bridging veins only in a minority of cases. Diffusely irregular contours of the veins observed on high-resolution coronal SWI was a major finding in our study. Disruption of the normal anatomy of the bridging veins in abusive head trauma further supports the traumatic nature of the disease.

Association of a Postnatal Parent Education Program for Abusive Head Trauma With Subsequent Pediatric Abusive Head Trauma Hospitalization Rates

IMPORTANCE

Studies suggest that a postnatal parental intervention may reduce the incidence of abusive head trauma (AHT) of infants and young children.

OBJECTIVE

To assess the effect of statewide universal AHT education for parents on AHT hospitalization rates in Pennsylvania and on parents' self-reported knowledge gains and parenting behaviors.

DESIGN, SETTING, AND PARTICIPANTS

Changes in AHT hospitalization rates in Pennsylvania before and during the intervention were compared with those in 5 other states lacking universal parental AHT education during the same period. Data were collected from maternity units and birthing centers throughout Pennsylvania from the parents of 1 593 834 infants born on these units from January 1, 2003, to December 31, 2013. Parental behavior and knowledge were assessed through immediate (n = 16 111) and 7-month postintervention (n = 146) parent surveys in a per protocol analysis of evaluable parents.

INTERVENTIONS

Parents read a brochure, viewed an 8-minute video about infant crying and AHT, asked questions of the nurse, and signed a commitment statement affirming their participation. Educational posters were displayed on each unit.

MAIN OUTCOMES AND MEASURES

Changes in AHT hospitalization rates before and during the intervention in Pennsylvania and 5 other states. Secondary outcomes included self-reported knowledge gains and changes in parenting practices.

RESULTS

A total of 1 180 291 parents (74.1%) of children ranging in age from 0 to 23 months signed a commitment statement. Incidence rate ratios for hospitalization for AHT increased in Pennsylvania from 24.1 (95% CI, 22.1-26.3) to 26.6 (95% CI, 24.9-28.4) per 100 000 children aged 0 to 23 months during the intervention period; changes in Pennsylvania were not significantly different from aggregate changes in the 5 other states, from 22.4 (95% CI, 21.2-23.6) to 22.0 (95% CI, 21.2-22.8) per 100 000 children aged 0 to 23 months. A total of 16 111 parents (21.5% men, 78.5% women) completed the postnatal survey. Despite an overall 74.1% adherence with the intervention, only 20.6% of parents saw the brochure and video and only 5.7% were exposed to the entire intervention. Among the respondents answering individual questions on the postnatal surveys, 10 958 mothers (91.0%) and 2950 fathers (88.6%) reported learning a lot about understanding infant crying as normal; 11 023 mothers (92.2%) and 2923 fathers (88.9%), calming their infant, 11 396 mothers (94.6%) and 3035 fathers (91.9%), calming themselves; 10 060 mothers (85.1%) and 2688 fathers (83.4%), selecting other infant caregivers; and 11 435 mothers (94.8%) and 3201 fathers (95.8%), that the information would decrease the likelihood of shaking an infant. Among the 143 respondents completing the 7-month survey, 109 (76.2%) reported remembering the information while their child was crying.

CONCLUSIONS AND RELEVANCE

This intervention was not associated with a reduction in pediatric AHT hospitalization rates but was associated with self-reported gains in parental knowledge that were retained for 7 months.

Depression and anger in fathers of unsettled infants: A community cohort study

AIM

To examine the relationship between unsettled infant behaviour and fathers' depressive symptoms, cognitions surrounding infant sleep (anger, doubt), and personal sleep, in a community cohort.

METHODS

Data were collected from 102 fathers of healthy infants at 4 weeks, 4 months and 6 months of age. Measures included father report of infant sleep and crying problems, depressive symptoms, cognitions about infant sleep and own sleep quality and quantity. Data were analysed using adjusted regression models.

RESULTS

Sleep problems at 4 months of age were associated with increased depressive symptoms (adjusted mean difference 2.64 (1.27-4.00)), doubt (adjusted mean difference 1.82 (0.40-3.25)), anger (adjusted mean difference 1.86 (0.51-3.20)), poor personal sleep quantity (adjusted odds ratio (OR) 0.21; 95% confidence interval (CI) 0.09-0.51) and quality (adjusted OR 0.20; 95% CI 0.08-0.51); and at 6 months of age, with increased depressive symptoms (adjusted mean difference 2.56 (1.28-3.84)), anger (adjusted mean difference 1.63 (0.40-2.87)), poor personal sleep quantity (adjusted OR 0.14; 95% CI 0.05-0.38) and quality (adjusted OR 0.28; 95% CI 0.11-0.72). Infant cry problems at 4 months were associated with increased anger (adjusted mean difference 1.98 (0.60-3.36)) and doubt (adjusted mean difference 1.55 (0.05-3.05)); and at 6 months, with increased depressive symptoms (adjusted mean difference 3.04 (1.59-4.69)), anger (adjusted mean difference 2.73 (1.29-4.17)) and less personal sleep (adjusted OR 0.22; 95% CI 0.07-0.71).

CONCLUSION

Fathers of unsettled infants reported greater anger towards their infant and increased depressive symptoms by 4 months infant age, with these symptoms persisting 2 months later. Evidence-based interventions are needed for these fathers.

Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma

BACKGROUND

Abusive head trauma is the leading cause of death from physical abuse. Misdiagnosis of abusive head trauma as well as other types of brain abnormalities in infants is common and contributes to increased morbidity and mortality. We previously derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction rule to assist physicians deciding which high-risk infants should undergo computed tomography of the head.

METHODS

Well-appearing infants 30 to 364 days of age with temperature <38.3°C, no history of trauma, and a symptom associated with an increased risk of having a brain abnormality were eligible for enrollment in this prospective, multicenter clinical prediction rule validation. By using a predefined neuroimaging paradigm, subjects were classified as cases or controls. The sensitivity, specificity, and negative and positive predictive values of the rule for prediction of brain injury were calculated.

RESULTS

A total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0 months (1 point), head circumference >85th percentile (1 point), and serum hemoglobin <11.2g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%-96.3%) and 53% (95% confidence interval 49.3%-57.1%), respectively.

CONCLUSIONS

Our data suggest that the PIBIS accurately identifies infants who would benefit from neuroimaging to evaluate for brain injury. An implementation analysis is needed before the PIBIS can be integrated into clinical practice.

Inadequate sociomedical evaluation of possible abusive head trauma in Yokohama

BACKGROUND

There have been no previous studies on the adequacy of combined evaluation of possible abusive head trauma cases by frontline medical personnel, hospital-based child protection teams, and child protective services in local districts of Japan.

METHODS

We conducted a questionnaire survey of hospitalized patients under 24 months old with a diagnosis of intracranial hemorrhage (ICH) from January 2011 to December 2013. Eleven large-scale general hospitals in Yokohama, Japan were surveyed, which provide centralized inpatient care to moderately-severely ill children.

RESULTS

A total of 51 ICH patients were listed from eight hospitals. Median patient age was 7 months, and 84% were younger than 12 months. The most common diagnosis on computed tomography was subdural hematoma (n = 26; 51%). Of a total of 51 cases, 31 (61%) occurred inside the home; the injury scene was unknown in six cases (12%). We reviewed these 37 cases from the viewpoint of evaluation with concern for suspected child abuse. Three out of 37 patients (8%) were not examined for inflicted skin lesions, and skeletal surveys and funduscopy were not conducted in 14 (38%) and 15 (41%), respectively. Thirteen out of 37 cases (35%) were not reported to hospital-based child protection teams and 22 (59%) were not reported to regional child protective services.

CONCLUSION

The sociomedical evaluation of possible child abuse appears to be systematically inadequate in Yokohama.

Association of Pediatric Abusive Head Trauma Rates With Macroeconomic Indicators

OBJECTIVE

We aimed to examine abusive head trauma (AHT) incidence before, during and after the recession of 2007-2009 in 3 US regions and assess the association of economic measures with AHT incidence.

METHODS

Data for children <5 years old diagnosed with AHT between January 1, 2004, and December 31, 2012, in 3 regions were linked to county-level economic data using an ecologic time series analysis. Associations between county-level AHT rates and recession period as well as employment growth, mortgage delinquency, and foreclosure rates were examined using zero-inflated Poisson regression models.

RESULTS

During the 9-year period, 712 children were diagnosed with AHT. The mean rate of AHT per 100,000 child-years increased from 9.8 before the recession to 15.6 during the recession before decreasing to 12.8 after the recession. The AHT rates after the recession were higher than the rates before the recession (incidence rate ratio 1.31, P = .004) but lower than rates during the recession (incidence rate ratio 0.78, P = .005). There was no association between the AHT rate and employment growth, mortgage delinquency rates, or foreclosure rates.

CONCLUSIONS

In the period after the recession, AHT rate was lower than during the recession period yet higher than the level before the recession, suggesting a lingering effect of the economic stress of the recession on maltreatment risk.

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

IMPORTANCE

Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life.

OBJECTIVE

To assess the effectiveness of a statewide universal AHT prevention program.

DESIGN, SETTING, AND PARTICIPANTS

In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011).

INTERVENTION

The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign.

MAIN OUTCOMES AND MEASURES

Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011.

RESULTS

In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P < .001) and by 12% for children 3 to 12 months old (rate ratio, 0.88; 95% CI, 0.78-0.99; P = .03). No reduction in state-level AHT rates was observed, with mean rates of 34.01 person-years before the intervention and 36.04 person-years after the intervention. A difference-in-difference analysis from January 1, 2000, to December 31, 2011, controlling for economic indicators, indicated that the intervention did not have a statistically significant effect on AHT rates (β coefficient, -1.42; 95% CI, -13.31 to 10.45).

CONCLUSIONS AND RELEVANCE

The Period of PURPLE Crying intervention was associated with a reduction in telephone calls to a nurse advice line. The study found no reduction in AHT rates over time in North Carolina relative to other states. Consequently, while this observational study was feasible and supported the program effectiveness in part, further programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

Abusive head trauma: two case reports

Abusive head trauma is a serious form of child abuse and mostly seen in infants below the age of two years as a result of a strong shaking by the caregiver who aims to stop the infant's crying. Characteristic symptoms include subdural hematomas, encephalopathy, retinal hemorrhages and fractures of the long bones. When physically examined, there are generally no externally visible signs. For this reason, it can be underdiagnosed, if it is not considered in the differential diagnosis. When the information provided from the parents is inconsistent and contradictory with the clinical picture of the patient, this form of abuse must be suspected and retinal hemorrhages should be searched. In this article, two patients who were admitted to our emergency department and diagnosed with physical child abuse are reported. One of these patients had a history of minor head trauma after falling down from the sofa and the other one had a history of breathlessness and loss of consciousness as a result of excessive crying.

Differences between abusive head trauma and physical abuse in Japan

BACKGROUND

We examined differences in characteristics between abusive head trauma (AHT) and physical abuse (PA).

METHODS

We examined 45 AHT patients and 119 PA patients during the period 1 April 2000-31 March 2014, at Kanagawa Children's Medical Center (Kanagawa, Japan). We compared patient age, young maternal or parental age, being the first child, child factors (chronic illness, developmental disabilities and preterm birth), parental factors (substance abuse/alcohol abuse and depression or other mental illness), environmental factors (single-parent home, non-biologically related man living in the home and family or intimate partner violence). Logistic regression was used to examine predictors of differences between AHT and PA for children <1 year of age.

RESULTS

There were differences in characteristics between AHT and PA in those <1 year old in child factors (OR, 3.47; 95%CI: 1.01-11.9) and environmental factors (OR, 14.2; 95%CI: 1.45-139).

CONCLUSIONS

The risk factors for AHT differ from those of PA. We speculate that AHT is not merely physical abuse of young infants; the characteristics of AHT differ significantly from those of PA. These observations are important for understanding and thereby preventing child abuse.

Development of a computational biomechanical infant model for the investigation of infant head injury by shaking

The inertial loading thresholds for infant head injury are of profound medico-legal and safety-engineering significance. Injurious experimentation with infants is impossible, and physical and computational biomechanical modelling has been frustrated by a paucity of paediatric biomechanical data. This study describes the development of a computational infant model (MD Adams®) by combining radiological, kinematic, mechanical modelling and literature-based data. Previous studies have suggested the neck as critical in determining inertial head loading. The biomechanical effects of varying neck stiffness parameters during simulated shakes were investigated, measuring peak translational and rotational accelerations and rotational velocities at the vertex. A neck quasi-static stiffness of 0.6 Nm/deg and lowest rate-dependent stiffness predisposed the model infant head to the highest accelerations. Plotted against scaled infant injury tolerance curves, simulations produced head accelerations commensurate with those produced during simulated physical model shaking reported in the literature. The model provides a computational platform for the exploitation of improvements in head biofidelity for investigating a wider range of injurious scenarios.

Assessment of parental awareness of the shaken baby syndrome in Ireland

Shaken baby syndrome (SBS) results in cerebral trauma. Creating awareness through education may improve parental response to a distressed infant. We aim to assess current parental understanding of SBS and identify knowledge gaps. A prospective assessment was carried out in two independent maternity hospitals (National Maternity Hospital (NMH) and Midland Regional Hospital (MRH)) over a 4-month period. Multi-dimensional questionnaires were distributed to parents (n = 233) and results were assessed anonymously. Statistical analysis was performed using SPSS21 software. Two hundred thirty-three participants were included: n = 114 (NMH), n = 119 (MRH). Fifty-four percent (n = 62, NMH) and 50 % (n = 60, MRH) had never heard of SBS. Of those who had, media was the commonest source: 94 % (47/50) NMH; 86 % (47/59) MRH. Less than 1 % of participants obtained information through a health care provider. Nearly all respondents wanted further information, regardless of whether they had prior knowledge (100 % (NMH); 99.2 % (MRH)). Participants wanted information delivered via a midwife (51 % (58/114) NMH; 45 % (54/119) MRH), with reading material (61 % (69/114) NMH; 59 % (70/119) MRH), during pre-natal period (50 % (57/114) NMH; 65 % (77/119) MRH). Importantly, parents of Irish origin were more likely to have heard of SBS compared to those of non-Irish origin (p = 0.026 (NMH), p = 0.020 (MRH)).

CONCLUSION

Half of all participants had no prior knowledge of SBS, with majority expressing interest in learning more. Therefore, a national "Don't Shake" campaign is evolving.

WHAT IS KNOWN

• Studies have shown that educating parents regarding shaken baby syndrome (SBS) may result in a more safe and appropriate response to infant crying [ 3 ]. • In Ireland, there is no such education provided to parents in maternity hospitals. What is New: • Just over half of our participants had not heard of SBS, and we have identified parental perceptions of SBS, and parents preferred method of anti-SBS education delivery. • This research will act as a launching platform for an anti-SBS campaign in Ireland.

Validation of a Prediction Tool for Abusive Head Trauma

BACKGROUND AND OBJECTIVES

Abusive head trauma (AHT) may be missed in the clinical setting. Clinical prediction tools are used to reduce variability in practice and inform decision-making. From a systematic review and individual patient data analysis we derived the Predicting Abusive Head Trauma (PredAHT) tool, using multilevel logistic regression to predict likelihood of AHT. This study aims to externally validate the PredAHT tool.

METHODS

Consecutive children aged <36 months admitted with an intracranial injury, confirmed as abusive or nonabusive, to 2 sites used in the original model were ascertained. Details of 6 influential features were recorded (retinal hemorrhage, rib and long -bone fractures, apnea, seizures, and head or neck bruising). We estimated the likelihood of an unrecorded feature being present with multiple imputation; analysis included sensitivity, specificity, and area under the curve, with 95% confidence intervals (CIs).

RESULTS

Data included 133 non-AHT cases and 65 AHT cases, 97% of children were <24 months old. Consistent with original predictions, when ≥3 features were present in a child <36 months old with intracranial injury, the estimated probability of AHT was >81.5% (95% CI, 63.3-91.8). The sensitivity of the tool was 72.3% (95% CI, 60.4-81.7), the specificity was 85.7% (95% CI, 78.8-90.7), area under the curve 0.88 (95% CI, 0.823-0.926).

CONCLUSIONS

When tested on novel data, the PredAHT tool performed well. This tool has the potential to contribute to decision-making in these challenging cases. An implementation study is needed to explore its performance and utility within the child protection process.

Severe Acute Subdural Hemorrhage in a Patient With Glutaric Aciduria Type I After Minor Head Trauma: A Case Report

Glutaric aciduria type I is a rare metabolic disorder caused by deficiency of glutaryl-coenzyme A dehydrogenase. Chronic subdural hematomas have been reported in glutaric aciduria type I and are considered as important differential diagnosis of nonaccidental head trauma. However, chronic subdural hematomas are usually thought to remain clinically silent in these patients. Here we report on a hitherto asymptomatic glutaric aciduria type I patient who developed severe, acute subdural hemorrhage after minor accidental head injury at age 23 months. Computed tomography confirmed significant mass effect on the brain necessitating decompressive hemicraniectomy. Subdural hemorrhage caused large hypoxic lesions of the cerebral cortex and subcortical regions resulting in spastic tetraplegia, dystonia, and loss of developmental milestones. This report emphasizes that acute subdural hemorrhage may be a life-threatening complication in glutaric aciduria type I patients after minor head trauma and should be considered in those patients presenting with neurologic deterioration after accidental head injury.

Abusive head trauma: a review of the evidence base

OBJECTIVE

The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma.

CONCLUSION

The evidence base for abusive head trauma encompasses diverse disciplines, including diagnostic imaging, pathology, pediatrics, biomechanics, ophthalmology, epidemiology, and orthopedics. When the varied sources of evidence are pieced together and taken in toto, abusive head trauma is often readily differentiated from alternative explanations of an infant's injuries.

Revisiting neuroimaging of abusive head trauma in infants and young children

OBJECTIVE

The purpose of this article is to use a mechanism-based approach to review the neuroimaging findings of abusive head trauma to infants. Advanced neuroimaging provides insights into not only the underlying mechanisms of craniocerebral injuries but also the long-term prognosis of brain injury for children on whom these injuries have been inflicted.

CONCLUSION

Knowledge of the traumatic mechanisms, the key neuroimaging findings, and the implications of functional imaging findings should help radiologists characterize the underlying causes of the injuries inflicted, thereby facilitating effective treatment.

Long-term outcomes of the shaken baby syndrome prevention program: Turkey's experience

AIM

Shaken baby syndrome (SBS) is a condition which may cause to serious health problems in the baby. SBS may be prevented by increasing awareness with giving education to parents especially in the early postnatal period. In shaken baby prevention programs, education is recommended to be given before the 2-4(th) month during which the frequency of crying is increased. It is important that education given in the early period is permanent until the period during which the frequency of crying is increased. The aim of this study was to evaluate the persistency of the benefit of the SBS prevention program until the 2-4(th) month during which crying is intensified.

MATERIAL AND METHODS

This study is an interventional study. When the babies became 2-4 months old, a questionnaire which questioned the usefulness of education and the experiences with babies was applied to a group selected randomly among the mothers who received SBS prevention education during pregnancy or in the first 7 postnatal days (group A). The same questionnaire was applied to 143 mothers whose babies completed their first 2 months, who presented to the hospital for vaccination and who did not receive education about SBS as the control group (group B). The data were evaluated using the Statistical Program for Social Sciences (SPSS) 15.0 statistical analysis package program. Ethical approval was obtained from the local ethics committee (30.12.2009, 2785).

RESULTS

The rate of the mothers who stated "yes" to the sentence "babies occasionally cry" which was one of the main messages of the education was statistically significantly higher in group A compared to group B (p=0.001). The rate of the mothers who stated "I agree" to the sentence "battering is harmful for babies" was statistically significantly higher in group A compared to group B (p=0.001).

CONCLUSIONS

Conclusively, it was found that SBS prevention program education was permanent until the 2-4(th) month.

Risk factors associated with retinal hemorrhage in suspected abusive head trauma

PURPOSE

To determine risk factors associated with retinal hemorrhage (RH) in pediatric abusive head trauma (AHT) suspects.

METHODS

Records of children aged 0-3 years hospitalized for suspected AHT from January 2007 to November 2011 were retrospectively reviewed in this case-control study. Children were classified into case and control groups based on RH presence. Medical history, presenting symptoms, reasons, and characteristics of injury were recorded. Logistic regression analysis was performed to identify risk factors.

RESULTS

A total of 168 children (104 males) were included. Of these, 103 were classified as cases and 65 as controls. The mean age (with standard deviation) was 9.3 ± 8.3 months (range, 1 day-36 months). Of the 103 cases, 22 (21%) had subretinal hemorrhage, 9 (9%) had retinoschisis, and 1 (1%) had vitreous hemorrhage. Children presenting with lethargy or altered mental status (P < 0.0001), subdural hemorrhage (P < 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P = 0.01546) were likely to have RH. All 23 children with skull or nonskull fracture without intracranial hemorrhage did not have RH (P < 0.0001 both categories).

CONCLUSIONS

Retinal hemorrhages were almost never found in the absence of intracranial hemorrhage and not found in the setting of fracture without intracranial hemorrhage.

Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications

Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan.