Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma

The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: A 13-year study in a tertiary hospital

Fatal abusive head trauma is a major cause of death in children and toddlers who suffer from cruel physical abuse. Postmortem differentiation of fatal abusive head trauma from accidental head trauma can be a complicated process. This consecutive case series study aimed to determine the role of subdural optic nerve sheath hemorrhage (ONSH) in 70 autopsy cases of children ≤3 years old in making this differentiation. The study took place over a 13 year period (between August 1st 2003 and July 31st 2016) at a tertiary hospital in Thailand. Eleven cases were diagnosed with fatal abusive head trauma and 10 were identified as being accidental closed head trauma cases. Bilateral retinal hemorrhage was noted in antemortem medical records in every hospitalized abusive head trauma case (n=10). Upon autopsy, ONSH was observed in all 11 fatal cases of abusive head trauma (bilateral=10 and unilateral=1) but not in any cases of accidental head trauma (0/5). Subdural hemorrhage was found in 10 out of 11 abusive head trauma victims but not in any of the 10 with accidental head trauma. Other postmortem findings in abusive head trauma included subarachnoid hemorrhage (5/11), marked brain swelling (3/11), skull fracture (4/11) and brain contusion (1/11). This study suggests that ONSH, together with subdural hemorrhage, plays an essential role in an accurate postmortem diagnosis of fatal abusive head trauma. Therefore, an ocular investigation should be performed in all autopsy cases where child abuse is suspected and where there is no reliable history/witnesses, confession or antemortem ophthalmologic examination.

Post-mortem imaging of the infant and perinatal dura mater and superior sagittal sinus using optical coherence tomography

Infants and young children are likely to present with subdural haemorrhage (SDH) if they are the victims of abusive head trauma. In these cases, the most accepted theory for the source of bleeding is the bridging veins traversing from the surface of the brain to the dura mater. However, some have suggested that SDH may result from leakage of blood from a dural vascular plexus. As post-mortem examination of the bridging veins and dura is challenging, and imaging modalities such as magnetic resonance and computed tomography do not have the resolution capabilities to image small blood vessels, we have trialled the use of intravascular and benchtop optical coherence tomography (OCT) systems for imaging from within the superior sagittal sinus (SSS) and through the dura during five infant/perinatal autopsies. Numerous vessel-like structures were identified using both OCT systems. Measurements taken with the intravascular rotational system indicate that the approximate median diameters of blood vessels entering anterior and posterior segments of the SSS were 110 μm (range 70 to 670 μm, n = 21) and 125 μm (range 70 to 740 μm, n = 23), respectively. For blood vessels close to the wall of the SSS, the median diameters for anterior and posterior segments of the SSS were 80 μm (range 40 to 170 μm, n = 25) and 90 μm (range 30 to 150 μm), respectively. Detailed characterisation of the dural vasculature is important to aid understanding of the source of SDH. High resolution 3-dimensional reconstructions of the infant dural vasculature may be possible with further development of OCT systems.

Photographic assessment of retinal hemorrhages in infant head injury: the Childhood Hemorrhagic Retinopathy Study

BACKGROUND

Retinal hemorrhages (RH) in babies in the absence of severe trauma or a medical cause have been strongly associated with abusive head trauma (AHT). We examined the pattern of RH in accidental head injury and AHT objectively using widefield retinal imaging.

METHODS

A total of 118 infants and children 1-36 months of age admitted with head injuries at two centers were included in this prospective, consecutive, comparative cohort study. Dilated fundus examination was performed with indirect ophthalmoscopy and widefield imaging. Designation of AHT was made using predetermined criteria independent of retinal findings. Retinal images were graded by two independent observers.

RESULTS

There were 21 cases of AHT. RH were present in 14 cases (66%); macular retinoschisis or retinal folds, in 8 (38%). There were 86 cases of accidental head injuries, with RH present in 2 (2%); there were none with retinal folds or retinoschisis. In cases of head injury with intracranial hemorrhage, the positive likelihood ratio of AHT with RH was 5.7 (95% CI, 2.6-12.00) and negative likelihood ratio was 0.26 (95% CI, 0.11-0.62). A severe, panretinal pattern with multilayered hemorrhages was the most specific for AHT.

CONCLUSIONS

Our imaging study confirmed that RH in infants with head injury have a high positive likelihood ratio for AHT. A severe hemorrhagic retinopathy, particularly in association with perimacular folds or macular retinoschisis, has the highest positive predictive value for AHT.

Cyclic Head Rotations Produce Modest Brain Injury in Infant Piglets

Repetitive back-and-forth head rotation from vigorous shaking is purported to be a central mechanism responsible for diffuse white matter injury, subdural hemorrhage, and retinal hemorrhage in some cases of abusive head trauma (AHT) in young children. Although animal studies have identified mechanisms of traumatic brain injury (TBI) associated with single rapid head acceleration-decelerations at levels experienced in a motor vehicle crash, few experimental studies have investigated TBI from repetitive head rotations. The objective of this study was to systematically investigate the post-injury pathological time-course after cyclic, low-velocity head rotations in the piglet and compare them with single head rotations. Injury metrics were the occurrence and extent of axonal injury (AI), extra-axial hemorrhage (EAH), red cell neuronal/axonal change (RCNAC), and ocular injury (OI). Hyperflexion/extension of the neck were purposefully avoided in the study, resulting in unscaled angular accelerations at the lower end of reported infant surrogate shaking kinematics. All findings were at the mild end of the injury spectrum, with no significant findings at 6 h post-injury. Cyclic head rotations, however, produced modest AI that significantly increased with time post-injury (p < 0.035) and had significantly greater amounts of RCNAC and EAH than noncyclic head rotations after 24 h post-injury (p < 0.05). No OI was observed. Future studies should investigate the contributions of additional physiological and mechanical features associated with AHT (e.g., hyperflexion/extension, increased intracranial pressure from crying or thoracic compression, and more than two cyclic episodes) to enhance our understanding of the causality between proposed mechanistic factors and AHT in infants.

Pediatric Ophthalmologists' Experiences With Abusive Head Trauma

PURPOSE

To estimate the number of cases of abusive head trauma seen by pediatric ophthalmologists and analyze factors associated with physician subpoenas and court testimonies.

METHODS

Pediatric ophthalmologists were surveyed about their experiences with abusive head trauma. The survey was sent to 875 active members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

RESULTS

The response rate was 15% (132 surveys). The median pediatric ophthalmologist is consulted 10.0 (interquartile range [IQR] = 4.0 to 19.0) times per year to evaluate patients for abusive head trauma and sees 2.5 (IQR = 1.0 to 6.0) patients with probable abusive head trauma each year. Pediatric ophthalmologists were equally likely to be subpoenaed (4.6% vs 4.8%, P = .84) or to testify (1.9% vs 1.7%, P = .79) whether they did or did not perform retinal photography. Physicians were equally likely to be subpoenaed (4.8% vs 7.1%, P = .92) or to testify (2.2% vs 0.0%, P = .17) whether a child abuse team was involved in patient care or not. Geographic location had no statistical significance on how frequently pediatric ophthalmologists were subpoenaed (P = .17) or testified in court (P = .12). When a pediatric ophthalmologist was subpoenaed to court, the median number of missed clinic days was 1.0 (IQR = 1.0 to 2.0), with an estimated cost of $3,000 (IQR = $1,750 to $4,750) in lost revenue.

CONCLUSIONS

Obtaining retinal imaging, having a child abuse team, and geographic location had no significant relationship with how often pediatric ophthalmologists were subpoenaed or testified in court.

Gray cases of child abuse: Investigating factors associated with uncertainty

Research in child abuse pediatrics has advanced clinicians' abilities to discriminate abusive from accidental injuries. Less attention, however, has been paid to cases with uncertain diagnoses. These uncertain cases - the "gray" cases between decisions of abuse and not abuse - represent a meaningful challenge in the practice of child abuse pediatricians. In this study, we describe a series of gray cases, representing 17% of 134 consecutive children who were hospitalized at a single pediatric hospital and referred to a child abuse pediatrician for concerns of possible abuse. Gray cases were defined by scores of 3, 4, or 5 on a 7-point clinical judgment scale of the likelihood of abuse. We evaluated details of the case presentation, including incident history, patient medical and developmental histories, family social histories, medical studies, and injuries from the medical record and sought to identify unique and shared characteristics compared with abuse and accidental cases. Overall, the gray cases had incident histories that were ambiguous, medical and social histories that were more similar to abuse cases, and injuries that were similar to accidental injuries. Thus, the lack of clarity in these cases was not attributable to any single element of the incident, history, or injury. Gray cases represent a clinical challenge in child abuse pediatrics and deserve continued attention in research.

Potential Impact of a Validated Screening Tool for Pediatric Abusive Head Trauma

OBJECTIVE

To conduct a retrospective, theoretical comparison of actual pediatric intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT screening guided by a previously validated 4-variable clinical prediction rule (CPR) in datasets used by the Pediatric Brain Injury Research Network to derive and validate the CPR.

STUDY DESIGN

We calculated CPR-based estimates of abuse probability for all 500 patients in the datasets. Next, we demonstrated a positive and very strong correlation between these estimates of abuse probability and the overall diagnostic yields of our patients' completed skeletal surveys and retinal examinations. Having demonstrated this correlation, we applied mean estimates of abuse probability to predict additional, positive abuse evaluations among patients lacking skeletal survey and/or retinal examination. Finally, we used these predictions of additional, positive abuse evaluations to extrapolate and compare AHT detection (and 2 other measures of AHT screening accuracy) in actual PICU screening for AHT vs AHT screening guided by the CPR.

RESULTS

Our results suggest that AHT screening guided by the CPR could theoretically increase AHT detection in PICU settings from 87%-96% (P < .001), and increase the overall diagnostic yield of completed abuse evaluations from 49%-56% (P = .058), while targeting slightly fewer, though not significantly less, children for abuse evaluation.

CONCLUSIONS

Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.

Outcomes and factors associated with infant abusive head trauma in the US

OBJECT Head trauma is the leading cause of death in abused children, particularly prior to the age of 2 years. An awareness of factors associated with this condition as well as with a higher risk of mortality is important to improve outcomes and prevent the occurrence of these events. The objective of this study was to evaluate outcomes and factors associated with poor outcomes in infants with diagnosed abusive head trauma (AHT). Patient characteristics, socioeconomic factors, and secondary conditions such as retinal bleeding, contusion, and fractures were considered. METHODS Data were obtained from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. From the Kids' Inpatient Database (KID) sample, the authors identified infants no older than 23 months who had been diagnosed with AHT in 2000, 2003, 2006, and 2009. All statistical analyses were conducted in SAS 9.2. Descriptive statistics were provided, and multivariate logistic regression models were applied to evaluate factors associated with mortality and nonroutine discharge. RESULTS A total of 5195 infants were analyzed in this study. Most infants (85.5%) had ages ranging between 0 and 11 months and were male (61.6%). Overall mortality was 10.8%, with a rate of 9.8% in the 0- to 11-month-old cohort and 16.5% in the 12- to 23-month-olds (p = 0.0003). The overall nonroutine discharge rate of 25.6% increased significantly from 23.3% to 39.0% with increasing age (0-11 vs 12-23 months of age, p < 0.0001). Assuming a multivariate model that adjusted for multiple confounders, the authors found that older infants (12-23 vs 0-11 months, OR 1.81, 95% CI 1.18-2.77) with a secondary diagnosis of retinal bleeding (OR 2.85, 95% CI 2.02-4.00) or shaken baby syndrome (OR 2.09, 95% CI 1.48-2.94) had an increased risk of mortality; these factors were similarly associated with an increased odds of a nonroutine discharge. A higher income ($30,001-$35,000 vs $1-$24,999) was associated with a reduction in the odds of mortality (OR 0.46, 95% CI 0.29-0.72). In the subset of cases (1695 [32.6%]) that specified the perpetrator involved in infant injury, the authors found that the father, stepfather, or boyfriend was most frequently reported (67.4%). A trend for a higher AHT incidence was documented in the early ages (peak at 2 months) compared with older ages. CONCLUSIONS Despite the higher incidence of AHT among infants during the earlier months of life, higher mortality was documented in the 12- to 23-month-olds. Retinal bleeding and shaken baby syndrome were secondary diagnoses associated with higher mortality and nonroutine discharge. Males (67.4%) were overwhelmingly documented as the perpetrators involved in the injury of these infants.

Adding Insult to Injury: Nonconvulsive Seizures in Abusive Head Trauma

The primary objectives of this study were to determine the prevalence of nonconvulsive seizures and nonconvulsive status epilepticus in patients with abusive head trauma who underwent electroencephalography (EEG) monitoring and to describe predictive factors for this population. Children with a diagnosis of abusive head trauma were studied retrospectively to determine the rate of EEG monitoring, the rate of nonconvulsive seizures and nonconvulsive status epilepticus, and the associated neuroimaging findings. Over 11 years, 73 of 199 (36.8%) children with abusive head trauma had electroencephalography monitoring performed. Of these, 20 (27.4%) had nonconvulsive seizures and 3 (4.1%) had nonconvulsive status epilepticus. The presence of subarachnoid hemorrhage and cortical T2 / fluid-attenuated inversion recovery signal abnormalities were both significantly associated with the presence of nonconvulsive seizures / nonconvulsive status epilepticus. Nonconvulsive seizures are relatively common in abusive head trauma and may go unrecognized. Specific neuroimaging characteristics increase the likelihood of nonconvulsive seizures on EEG.

Parenchymal Brain Laceration as a Predictor of Abusive Head Trauma

BACKGROUND AND PURPOSE

Accurate differentiation of abusive head trauma and accidental head injury in infants and young children is critical and impacts clinical care, patient prognosis, forensic investigations, and medicolegal proceedings. No specific finding seen on cross-sectional brain imaging has been reported to distinguish abusive head trauma from accidental injury. Our study investigated whether a specific imaging finding, parenchymal brain laceration, is unique to children diagnosed with abusive head trauma.

MATERIALS AND METHODS

We retrospectively identified 137 patients with abusive head trauma and 28 patients who incurred moderate to severe accidental brain injury. Brain MR imaging represented the imaging standard for characterizing intracranial injuries.

RESULTS

Among the abusive head trauma cohort, parenchymal brain lacerations were identified in 18 patients, while none were identified in any patients with accidental injury.

CONCLUSIONS

Our findings are in concurrence with the existing forensic, pathology, and imaging literature, which suggests that parenchymal brain lacerations may be related to abusive injury mechanisms.

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.

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.

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.

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.

Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience

Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children's Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children's Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children's Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT.

The yield of high-detail radiographic skeletal surveys in suspected infant abuse

BACKGROUND

Skeletal surveys are routinely performed in cases of suspected child abuse, but there are limited data regarding the yield of high-detail skeletal surveys in infants.

OBJECTIVE

To determine the diagnostic yield of high-detail radiographic skeletal surveys in suspected infant abuse.

MATERIAL AND METHODS

We reviewed the high-detail American College of Radiology standardized skeletal surveys performed for suspected abuse in 567 infants (median: 4.4 months, SD 3.47; range: 4 days-12 months) at a large urban children's hospital between 2005 and 2013. Skeletal survey images, radiology reports and medical records were reviewed. A skeletal survey was considered positive when it showed at least one unsuspected fracture.

RESULTS

In 313 of 567 infants (55%), 1,029 definite fractures were found. Twenty-one percent (119/567) of the patients had a positive skeletal survey with a total of 789 (77%) unsuspected fractures. Long-bone fractures were the most common injuries, present in 145 children (26%). The skull was the site of fracture in 138 infants (24%); rib cage in 77 (14%), clavicle in 24 (4.2%) and uncommon fractures (including spine, scapula, hands and feet and pelvis) were noted in 26 infants (4.6%). Of the 425 infants with neuroimaging, 154 (36%) had intracranial injury. No significant correlation between positive skeletal survey and associated intracranial injury was found. Scapular fractures and complex skull fractures showed a statistically significant correlation with intracranial injury (P = 0.029, P = 0.007, respectively).

CONCLUSION

Previously unsuspected fractures are noted on skeletal surveys in 20% of cases of suspected infant abuse. These data may be helpful in the design and optimization of global skeletal imaging in this vulnerable population.

Alternate theories of causation in abusive head trauma: what the science tells us

When cases of suspected abusive head trauma are adjudicated in courts of law, several alternative theories of causation are frequently presented. This paper reviews common theories and examines their scientific basis.

Diagnosing abusive head trauma: the challenges faced by clinicians

This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.

Experimental analyses of the retinal and subretinal haemorrhages accompanied by shaken baby syndrome/abusive head trauma using a dummy doll

INTRODUCTION

We explored several modes of violent shaking using a dummy doll with an eyeball model to reproduce abusive events that lead to retinal haemorrhages (RH) seen in shaken baby syndrome or abusive head trauma (SBS/AHT).

MATERIALS AND METHODS

A dummy doll equipped with an eyeball model was prepared. The eyeball model was filled with a model of vitreous body, i.e. agar gel or water, and was with a pressure sensor to measure normal stress.

RESULTS

The modes of shaking were classified into three patterns, i.e. fast shaking with the fore arms, fast shaking with the whole arms and synchronized shaking with the whole arms. The frequency of the cyclic acceleration-deceleration history experienced by the head of the dummy doll was 5.0, 4.0 and 2.2 Hz, respectively, with the maximum acceleration of 20, 20 and 60 m/s(2), respectively. We considered the last of these three modes of shaking as possibly corresponding to the worst case of violent shaking. This mode of shaking could be instructed to volunteers who acted as imitate perpetrators, and resulted in both increased peak intensities of the acceleration experienced by the head of the dummy doll and increased stresses on the retina at the posterior pole of the eyeball model.

DISCUSSION

The time integral of the stress through a single cycle of shaking was 107 Pa·s, much larger than that of a single event of fall, which resulted in 60-73 Pa·s. Taking into account that abusive shaking is likely to include multiple cycles, the time integral of the stress due to abusive shaking can be even larger. This clear difference may explain why RH in SBS/AHT is frequent, while RH in accidental falls is rare.

[Birth-related retinal hemorrhages in the newborn: incidence and relationship with maternal, obstetric and neonatal factors. Prospective study of 2,031 cases]

PURPOSE

To assess the prevalence, morphology and distribution of retinal hemorrhages in healthy newborns and their relationship to neonatal, maternal and obstetrical factors, and to determine their natural history.

PATIENTS AND METHODS

The present study prospectively included 2,031 consecutive healthy newborns. Indirect ophthalmoscopy was performed within 24 hours after birth in all newborns. Infants with retinal hemorrhages were reexamined weekly until the hemorrhage resolved. Annual ophthalmologic follow-up was also scheduled in these children. Neonatal, maternal and obstetric parameters were analyzed in all newborns and compared between newborns with retinal hemorrhages and those without retinal hemorrhages.

RESULTS

31.8 % of newborns exhibited retinal hemorrhages. 72.6 % of hemorrhages were bilateral. They tended to be localized around the optic discs and in the posterior pole, but their distribution was variable. Retinal hemorrhages were of variable shapes. The prevalence of retinal hemorrhages was higher in newborns delivered with vacuum-assisted extraction (38 %, P<0.001), intermediate during normal vaginal delivery (32.6 %, P<0.001) and lower with cesarean section (20.8 %). Comparative analysis between elective cesarean section and emergency cesarean showed a higher incidence of retinal hemorrhages in the emergency cesarean group (P=0.006). On multivariate analysis, vacuum-assisted delivery was the only factor associated with a higher prevalence of retinal hemorrhages in newborns (P=0.045). Two thirds of hemorrhages had disappeared by one week after birth. Retinal hemorrhages had resolved in all newborns within four weeks.

CONCLUSION

Birth-related retinal hemorrhages are common (1/3 of our newborns). Vacuum-assisted delivery is the main risk factor in this study. All hemorrhages resolved by one month of age. These findings may help in differential diagnosis with shaken baby syndrome.

Nonconvulsive electrographic seizures are common in children with abusive head trauma*

OBJECTIVE

To determine the prevalence of nonconvulsive seizures in children with abusive head trauma.

DESIGN

Retrospective study of children with abusive head trauma undergoing clinically indicated continuous electroencephalographic monitoring.

SETTING

PICU of a tertiary care hospital.

SUBJECTS

Children less than or equal to 2 years old with evidence of abusive head trauma determined by neuroimaging, physical examination, and determination of abuse by the Child Protection Team.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-two children with abusive head trauma were identified with a median age of 4 months (interquartile range 3, 5.5 months). Twenty-one of 32 children (66%) underwent electroencephalographic monitoring. Those monitored were more likely to have a lower admission Glasgow Coma Scale (8 vs 15, p = 0.05) and be intubated (16 vs 2, p = 0.002). Electrographic seizures occurred in 12 of 21 children (57%) and constituted electrographic status epilepticus in 8 of 12 children (67%). Electrographic seizures were entirely nonconvulsive in 8 of 12 children (67%). Electroencephalographic background category (discontinuous and slow-disorganized) (p = 0.02) and neuroimaging evidence of ischemia were associated with the presence of electrographic seizures (p = 0.05). Subjects who had electrographic seizures were no more likely to have clinical seizures at admission (67% electrographic seizures vs 33% none, p = 0.6), parenchymal imaging abnormalities (61% electrographic seizures vs 39% none, p = 0.40), or extra-axial imaging abnormalities (56% electrographic seizures vs 44% none, p = 0.72). Four of 21 (19%) children died prior to discharge; none had electrographic seizures, but all had attenuated-featureless electroencephalographic backgrounds. Follow-up outcome data were available for 16 of 17 survivors at a median duration of 9.5 months following PICU admission, and the presence of electrographic seizures or electrographic status epilepticus was not associated with the Glasgow Outcome Scale score (p = 0.10).

CONCLUSIONS

Electrographic seizures and electrographic status epilepticus are common in children with abusive head trauma. Most seizures have no clinical correlate. Further study is needed to determine whether seizure identification and management improves outcome.

Descriptive factors of abusive head trauma in young children--United States, 2000-2009

OBJECTIVE

Abusive head trauma (AHT) is a leading cause of severe injury in maltreated children in the United States. There is little research from nationally representative datasets available to characterize young children who had AHT compared to non-abusive head trauma (NAHT).

METHODS

Using the recent CDC AHT case definition, we performed a retrospective analysis of 2000, 2003, 2006 and 2009 hospitalization data using the Kids' Inpatient Database (KID) from the Healthcare Cost and Utilization Project. Logistic regression was used to compare AHT to NAHT patients <2 years of age. Socio-demographic data and indicators of socioeconomic status (i.e., insurance status and household income), presence of chronic conditions, injury severity (i.e., length of hospital stay and vital status), hospital specialization (i.e., hospital type), hospital region, and season of admission were used as independent variables.

RESULTS

A weighted sample of 7,603 AHT and 25,339 NAHT patients was identified. National rates for AHT were 39.8 per 100,000 population for children <1 year and 6.8 per 100,000 population for children 1 year old. Compared to NAHT, children with AHT were more often <1 year of age (adjusted odds ratio [aOR]=2.66; 95% confidence interval [CI]: 2.35-3.01), male (aOR=1.10; 95% CI: 1.01-1.20), enrolled in Medicaid (aOR=2.78; 95% CI: 2.49-3.11), hospitalized longer (aOR=8.26; 95% CI: 7.24-9.43), died during hospitalization (aOR=5.12; 95% CI: 4.01-6.53), and seen at children's hospitals (aOR=1.97; 95% CI: 1.63-2.38) and hospitals outside the Northeast [aOR=2.65 (95% CI: 2.10-3.33) for the Midwest, 1.90 (95% CI: 1.52-2.38) for the South and 1.93 (95% CI: 1.45-2.57) for the West, respectively].

CONCLUSIONS

The results confirm that injuries from AHT are more severe and more often lethal than other head injuries. Socioeconomically disadvantaged families with children <1 year are an important focus for primary prevention. The associations of AHT, compared to NAHT with hospital type and hospital region warrant further investigation. Referral or reporting patterns, or true differences in the incidence may contribute to the identified associations.

Evaluating for suspected child abuse: conditions that predispose to bleeding

Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding/bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, the pediatrician must consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising/bleeding and should be considered when evaluating for abusive injury.

Derivation of a clinical prediction rule for pediatric abusive head trauma

OBJECTIVES

Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that-if validated-can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse.

DESIGN

Prospective, multicenter, cross-sectional, observational.

SETTING

Fourteen PICUs.

PATIENTS

Acutely head-injured children less than 3 years old admitted for intensive care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity-to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%.

CONCLUSIONS

A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform-not dictate-their early decisions to launch (or forego) an evaluation for abuse.

The effect of pediatric traumatic brain injury on behavioral outcomes: a systematic review

AIM

To review systematically the empirical evidence on traumatic brain injury (TBI) during childhood and subsequent behavioral problems.

METHOD

An initial literature search with keywords 'brain injury,''children,' and 'behavior' was conducted using Web of Knowledge and PubMed databases. Ancestry was also used. Original research studies published between 1990 and February 2012 focusing on behavioral outcomes of children sustaining TBI from ages 0 to 18 years were included.

RESULTS

Fifty studies, varying considerably in methodologies, were included in the review. Findings showed that up to 50% of brain-injured children are at risk for presenting with specific behavioral problems and disorders. These problems may emerge shortly or several years after injury and often persist and even worsen with time. These behavioral impairments appear to be moderated by the family environment.

INTERPRETATION

Survivors of childhood TBI are at risk for developing and sustaining behavioral impairments. Stronger research is needed to identify cognitive and environmental factors that contribute to the onset and maintenance of these problems. Healthcare providers should ensure adequate follow-up and assessment of a child's behavioral, social, and neurocognitive domains. Caregivers should be encouraged to provide positive environments and parenting styles, which may help reduce chronic behavioral problems after brain injury.

Clinical clues for head injuries amongst Malaysian infants: accidental or non-accidental?

Identifying the differences between infants with non-accidental head injuries (NAHI) and accidental head injuries (AHI) may help alert clinicians to recognize markers of abuse. A retrospective review of infants <1 year of age admitted to a tertiary referral centre in Malaysia over a two year period with a diagnosis of head injury or abnormal computed tomography head scans was conducted to identify the clinical features pointing towards a diagnosis of NAHI by comparing the socio-demographics, presenting complaints, clinical features and the extent of hospital investigations carried out. NAHI infants were more likely to be symptomatic, under a non-related caregiver's supervision, and presented with inconsistent or no known mechanism of injury. Subdural haemorrhages were more common in NAHI infants. The history, mechanism of injury, presenting signs and symptoms as well as the nature of the injuries sustained are all valuable clues as to whether a head injury sustained during infancy is likely to be accidental or not.

Primary prevention of pediatric abusive head trauma: a cost audit and cost-utility analysis

OBJECTIVES

To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program.

METHODS

A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs.

RESULTS

There were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes.

CONCLUSIONS

Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention.

Prediction of inflicted brain injury in infants and children using retinal imaging

BACKGROUND

Retinal hemorrhages (RHs) occur in inflicted traumatic brain injury (ITBI), accidental traumatic brain injury (ATBI), and some medical conditions, although the reported number, distribution, type, and frequency vary greatly between these different etiologies. We hypothesize that these RH characteristics reliably help to distinguish ITBI from ATBI and nontraumatic etiologies.

METHODS

A 6-year prospective observational study using wide-field retinal imaging (RetCam) was conducted within 24 hours of admission to PICU, on serially recruited children with traumatic and nontraumatic encephalopathies. "Definite" and "probable" ITBI cases were confirmed by multiagency child protection case conferences. Image analysis used digital color and grayscale images for retinal "zoning" and "layering" of hemorrhages.

RESULTS

Significant differences were found between the mean numbers of hemorrhages in ATBI/ITBI, and ITBI/nontraumatic etiologies for the 3 retinal zones (range, P = .003-.009) and for the dot-blot hemorrhages (range P = .001-.002). The mean numbers of RHs per ITBI patient in the peripapillary, macula, and peripheral zones were 14, 28, and 31 respectively. RHs in ATBI were near the optic disc and more superficial than in ITBI, where hemorrhages involved deeper layers (range, P = .003-.039) and were more peripheral (P = .03). The positive predictive value for ITBI in children <3 years with >25 dot-blot (intraretinal) hemorrhages was 93%.

CONCLUSIONS

This prospective study, which included all potential causes of RHs, with objective retinal methodology, has confirmed that a young age and a high dot-blot count are strong predictors of ITBI. This high predictive value may support medicolegal deliberations.

Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review

AIM

To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT).

METHODS

A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT.

RESULTS

Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined.

CONCLUSIONS

Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.

Cortisol response to synacthen stimulation is attenuated following abusive head trauma

BACKGROUND

Child abuse and other early-life environmental stressors are known to affect the hypothalamic-pituitary-adrenal axis. We sought to compare synacthen-stimulated cortisol responses in children who suffered inflicted or accidental traumatic brain injury (TBI).

METHODS

Children with a history of early-childhood TBI were recruited from the Starship Children's Hospital database (Auckland, New Zealand, 1992-2010). All underwent a low-dose ACTH(1-24) (synacthen 1 μg IV) test, and serum cortisol response was compared between inflicted (TBI(I) ) and accidental (TBI(A) ) groups.

RESULTS

We assessed 64 children with TBI(I) and 134 with TBI(A) . Boys were more likely than girls to suffer accidental (P < 0·001), but not inflicted TBI. TBI(I) children displayed a 14% reduction in peak stimulated cortisol in comparison with the TBI(A) group (P < 0·001), as well as reduced cortisol responses at + 30 (P < 0·01) and + 60 min (P < 0·001). Importantly, these differences were not associated with severity of injury. The odds ratio of TBI(I) children having a mother who suffered domestic violence during pregnancy was 6·2 times that of the TBI(A) group (P < 0·001). However, reported domestic violence during pregnancy or placement of child in foster care did not appear to affect cortisol responses.

CONCLUSION

Synacthen-stimulated cortisol response is attenuated following inflicted TBI in early childhood. This may reflect chronic exposure to environmental stress as opposed to pituitary injury or early-life programming.

Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review

BACKGROUND AND OBJECTIVE

To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in children.

METHODS

We searched MEDLINE, EMBASE, PubMed, conference proceedings, and reference lists to identify relevant studies. Two reviewers independently selected studies that compared clinical and/or radiographic characteristics including historical features, physical exam and imaging findings, and presenting signs or symptoms in hospitalized children ≤ 6 years old with AHT and nAHT.

RESULTS

Twenty-four studies were included. Meta-analysis was complicated by inconsistencies in the reporting of characteristics and high statistical heterogeneity. Notwithstanding these limitations, there were 19 clinical and radiographic variables that could be meta-analyzed and odds ratios were determined for each variable. In examining only studies deemed to be high quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no adequate history given were significantly associated with AHT. Epidural hemorrhage(s), scalp swelling, and isolated skull fracture(s) were significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal injury, cerebral edema, head and neck bruising, any bruising, and vomiting were not significantly associated with either type of trauma.

CONCLUSIONS

Clinical and radiographic characteristics associated with AHT and nAHT were identified, despite limitations in the literature. This systematic review also highlights the need for consistent criteria in identifying and reporting clinical and radiographic characteristics associated with AHT and nAHT.

Educational paper : retinal haemorrhages in abusive head trauma in children

Retinal haemorrhages are an important component of the clinical effects of non-accidental head injuries which have significant visual morbidity. Their importance extends into the legal investigations of carers of children with subdural haemorrhages and encephalopathy who are suspected of having been non-accidentally injured. The vital precision in diagnosis relies not just on the presence of retinal haemorrhages but on the severity, extent, bilaterality and their location in the retina. Inadequate documentation of ophthalmological clinical findings and too short a follow-up to allow proper assessment of severity each give rise to difficulties for both expert witnesses and the courts.

The role of prothrombotic factors in the ocular manifestations of abusive and non-abusive head trauma: a feasibility study

OBJECTIVES

Retinal hemorrhage is a cardinal manifestation of abusive head injury. Thrombophilia is relatively common in the general population and in adults can be associated with retinal hemorrhage. The specificity of retinal hemorrhage for abusive head trauma in the presence of prothrombotic factors, in particular following non-abusive head trauma, has not been investigated. Our objective was to determine whether the hypothesis that prothrombotic factors affect specificity of retinal hemorrhage to AHT can be tested. This may have important ramifications both for diagnosis and expert witness testimony.

METHODS

To investigate the feasibility of studying this issue, we conducted a prospective cohort study of children with abusive and non-abusive head trauma. Thrombophilia screening and ophthalmic examinations were performed.

RESULTS

Six of 30 admitted children were fully enrolled. Enrollment obstacles included caregiver stress, animosity towards allegations of abuse, child protection services involvement, and research phlebotomy coordination. Prevalence of thrombophilia was high in children with retinal hemorrhage and in 1 case the question of hemorrhage adjudicated as abuse was considered in light of a history of a fall.

CONCLUSION

We estimate that to answer the critical question of retinal hemorrhage specificity for abuse in the presence of thrombophilia will require 53 centers for a 1 year study or 18 centers for a 3-year study. We identify potential obstacles and interventions.

Challenges in the evaluation for possible abuse: presentations of congenital bleeding disorders in childhood

OBJECTIVES

To describe children with congenital bleeding disorders that present in a manner that may be concerning for non-accidental trauma (NAT), and to evaluate associations with disease and demographic characteristics.

METHODS

Ten year retrospective chart review of subjects at a Hemophilia Treatment Center. Demographic, historical, and disease characteristics were collected. Findings were compared to a priori criteria for bleeding/bruising that is concerning for abuse.

RESULTS

Twenty-nine (15.3%) of the 189 children in the study had an initial presentation that was concerning for NAT. Of those 29, 75.9% were <5 years of age, 44.8% had von Willebrand disease (vWD), 51.8% had hemophilia, and 48.3% had a family history of a named bleeding disorder. Children from 9 months through 5 years of age were more likely than older children to present with findings concerning for abuse (OR 3.32, 1.21-9.10). No association was detected between presentation concerning for abuse and gender (OR 1.51, 0.6-3.77). Hemophilia was no more likely than vWD to present in a manner that was concerning for abuse (OR 0.7, 0.31-1.58). No children presented with patterned bruising.

CONCLUSIONS

Children with bleeding disorders may present with bruising/bleeding that is clinically highly suggestive of NAT.

PRACTICE IMPLICATIONS

Infants and young mobile children who have non-patterned bruising or bleeding as the only symptom concerning for abuse require an evaluation that includes testing for hemophilia and vWD. Children who have laboratory testing that indicates the presence of a bleeding disorder, but have clinical findings concerning for abuse, may benefit from a collaborative evaluation including a pediatric hematologist and a child abuse pediatrician.

Abnormal neuroimaging is associated with early in-hospital seizures in pediatric abusive head trauma

BACKGROUND

Abusive head trauma (AHT) is a common condition in children. Little is known in this condition regarding the frequency of seizures, the factors associated with increased risk of seizures, or the association of seizures with outcome. We sought to determine frequency and risks for in-hospital seizures after AHT.

METHODS

This was a single-center, retrospective chart review study at a 270 bed tertiary care referral pediatric hospital.

RESULTS

A total of 54 cases of AHT were identified during the study period. During the first week following hospital admission, 33% of patients were observed to have clinical seizures. The occurrence of clinical seizures after admission was associated with findings on initial CT including midline shift, cerebral edema, and loss of gray white differentiation. MRI findings associated with clinical seizures after admission included midline shift, cerebral edema, infarction, and restricted diffusion. The presenting complaint of seizures or acute mental status changes well as a variety of abnormal imaging findings including gray white blurring, infarction, and edema were associated with short-term outcomes.

CONCLUSIONS

Specific neuroradiologic findings identify children at greater risk for seizures, both clinical and subclinical, following AHT. Clinical and subclinical seizures are common in the initial hospitalization for AHT.

Child abuse consultations initiated by child protective services: the role of expert opinions

OBJECTIVE

To describe consultations provided by child abuse pediatricians for cases referred by child protective services (CPS); compare the opinions of the likelihood of child maltreatment of the initial physician, CPS, and the child abuse pediatrician; and examine predictors of the experts' opinions.

METHODS

Cases were referred by CPS for consultations between March 1, 1998, and June 30, 2005, to 2 child abuse pediatricians at Yale-New Haven Children's Hospital. We abstracted demographic and clinical information and the opinions of the initial physician, CPS, and the child abuse expert, each coded using a 5-point scale from definite maltreatment to definite benign cause (eg, accident).

RESULTS

Of 187 cases, 50.3% occurred in children younger than 1 year of age. Children's most serious injuries were fractures (50.8%), burns (16.6%), and bruises/abrasions (15.0%). The child abuse experts' opinions were 47.6% definite or probable maltreatment, 8.6% uncertain, and 43.9% definite or probable benign. Of the 119 cases with opinions from all 3 assessors, the expert agreed with the physician in 57.1% of cases (κ = 0.34) and with CPS in 64.7% (κ = 0.42). The best predictor of the expert's opinion that the injury was due to maltreatment was agreement between the physician and CPS that maltreatment had occurred.

CONCLUSIONS

Levels of agreement were fair to poor between the child abuse expert and either the physician or CPS. Child abuse experts' opinions have important value in selected cases to confirm previous assessments by the physician and/or CPS, or to change the opinion of the case.

Parent education by maternity nurses and prevention of abusive head trauma

OBJECTIVE

A consortium of the 19 community hospitals and 1 tertiary care children's hospital that provide maternity care in the New York State Hudson Valley region implemented a program to teach parents about the dangers of shaking infants and how to cope safely with an infant's crying. This study evaluated the effectiveness of the program in reducing the frequency of shaking injuries.

METHODS

The educational program, which was delivered by maternity nurses, included a leaflet explaining abusive head trauma ("shaken baby syndrome") and how to prevent it, an 8-minute video on the subject, and a statement signed by parents acknowledging receipt of the information and agreeing to share it with others who will care for the infant. Poisson regression analysis was used to compare the frequency of shaking injuries during the 3 years after program implementation with the frequency during a 5-year historical control period.

RESULTS

Sixteen infants who were born in the region during the 8-year study period were treated at the children's hospital for shaking injuries sustained during their first year of life. Of those infants, 14 were born during the 5-year control period and 2 during the 3-year postimplementation period. The decrease from 2.8 injuries per year (14 cases in 5 years) to 0.7 injuries per year (2 cases in 3 years) represents a 75.0% reduction (P = .03).

CONCLUSIONS

Parent education delivered in the hospital by maternity nurses reduces newborns' risks of sustaining an abusive head injury resulting from shaking during the first year of life.

Estimating the probability of abusive head trauma: a pooled analysis

CONTEXT AND OBJECTIVE

To determine which combinations of clinical features assist in distinguishing abusive head trauma (AHT) from nonabusive head trauma.

METHODS

Individual patient data from 6 comparative studies of children younger than 3 years with intracranial injury were analyzed to determine the association between AHT and combinations of apnea; retinal hemorrhage; rib, skull, and long-bone fractures; seizures; and head and/or neck bruising. An aggregate analysis of data from these studies used multiple imputation of combined clinical features using a bespoke hotdeck imputation strategy, which accounted for uncertainty arising from missing information.

RESULTS

Analyzing 1053 children (348 had AHT), excluding nonsignificant variables (gender, age, skull fractures), for a child with an intracranial injury and 1 or 2 of the 6 features, the positive predictive value (PPV) of AHT varies from 4% to 97% according to the different combinations. Although rarely recorded, apnea is significantly associated with AHT (odds ratio [OR]: 6.89 [confidence interval: 2.08-22.86]). When rib fracture or retinal hemorrhage was present with any 1 of the other features, the OR for AHT is >100 (PPV > 85%). Any combination of 3 or more of the 6 significant features yielded an OR of >100 (PPV for AHT > 85%).

CONCLUSIONS

Probabilities of AHT can be estimated on the basis of different combinations of clinical features. The model could be further developed in a prospective large-scale study, with an expanded clinical data set, to contribute to a more refined tool to inform clinical decisions about the likelihood of AHT.

Unilateral retinal hemorrhages with subarachnoid hemorrhage in a 5-week-old infant: is this nonaccidental injury?

PURPOSE

Retinal hemorrhages are an important sign in the setting of nonaccidental injury (NAI) (abusive head injury) in young infants and form a very important part of the evidence in support of the diagnosis. The diagnosis of NAI has serious social and legal implications. Other causes of retinal hemorrhages in an infant, such as birth trauma, accidental head injury, subarachnoid hemorrhage, other less common disorders of clotting, leukemia, and infections such as endocarditis, need to be considered and ruled out in making a diagnosis of NAI.

METHODS

Descriptive case report.

RESULTS

A 5-week-old child presented with rapid onset of symptoms of drowsiness and hypotonia, unilateral retinal hemorrhages, and an intracranial hemorrhage in the posterior fossa. NAI was high on the list of differential diagnosis, which caused considerable anxiety in the parents. The cause of the intracranial hemorrhage only became apparent at repeat neuroimaging several weeks later.

CONCLUSIONS

The case is presented to point out arteriovenous malformation as a possible cause of retinal hemorrhages in this age group where an early diagnosis of the etiology is often not possible. A diagnosis of NAI, commonly associated with a similar clinical presentation, can have serious social and legal implications.

Manifestations of ocular fundus in children with febrile seizures

PURPOSE

To study the potential incidence of retinopathy in children with febrile seizures.

METHODS

Thirty-four children with febrile seizures, aged 3 months to 9 years and admitted from January 2000 to June 2008, were retrospectively analyzed. All cases received fundus examination within 24 hours after admission and the incidence of retinopathy was calculated.

RESULTS

None of the subjects was found to have retinal hemorrhages. Therefore, using Hanley's Rule of Three, the upper limit of 95% confidence interval of retinal hemorrhages following febrile seizures in children is less than 10%.

CONCLUSION

The incidence of retinal hemorrhages in children with febrile seizures is lower than 10%. If retinal hemorrhages are found in children with febrile seizures, other causes need to be considered.

Abusive head trauma

Abusive head trauma is a leading cause of morbidity and mortality in infants and young children. These patients will often first present to the emergency department. They may present with dramatic or subtle findings. It is important that pediatric emergency physicians be aware of the possible presentations of abusive head trauma. This article will review the epidemiology, the clinical findings, the diagnosis, the differential diagnosis, and the management of abusive head trauma.