Annual incidence of shaken impact syndrome in young children

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.

Predictive value of clinical and radiological findings in inflicted traumatic brain injury

AIMS

The aim of this study is to evaluate the value of early radiological investigations in predicting the long-term neurodevelopmental outcome of infants with inflicted traumatic brain injury (ITBI).

METHODS

Clinical and radiological investigations of 24 infants with ITBI were performed during the acute phase of injury (1-3 days), and during the early (4 days up to 3 months) and late (>9 months) postinjury phases. The clinical outcome in survivors (n = 22) was based on the Rankin Disability Scale and the Glasgow Outcome Score.

RESULTS

Five out of 24 infants (21%) had a poor neurodevelopmental outcome (death and severe disability), 17 infants (71%) had different developmental problems and 2 infants were normal at the mean age of 62 (54-70) (95% CI) months. A low initial Glasgow Coma Scale score of 8 or below [p < 0.05, OR 13.0 (1.3-133.3)], the development of brain oedema [p < 0.005, OR 13.0 (1.6-773)], focal changes in the basal ganglia during the acute phase [p < 0.01, OR 45 (2.1-937.3)], the development of new intracerebral focal changes early postinjury [p < 0.05, OR 24.1(1.0-559.1)], a decrease in white matter [p < 0.01, OR 33 (1.37-793.4)] and the development of severe atrophy before 3 months postinjury [p < 0.05, OR 24 (11.0-559.1)] were significantly correlated with a poor neurodevelopmental outcome.

CONCLUSIONS

Early clinical and radiological findings in ITBI are of prognostic value for neurodevelopmental outcome.

Shaken baby syndrome in Switzerland: results of a prospective follow-up study, 2002-2007

Since the incidence of shaken baby syndrome in Switzerland was not known, we conducted a nationwide prospective follow-up study for a 5-year period (from 2002 to 2007). The data were collected through the Swiss Pediatric Surveillance Unit. Inclusion criteria were the presence, in a child <or=6 years of age, of 1) more than or equal to two clinical symptoms (altered consciousness, convulsions, respiratory irregularities, and bulging fontanel), 2) one eye finding (retinal hemorrhages, vitreous hemorrhages), 3) one MRI/CT finding (subdural hematoma, subarachnoid hematoma, and parenchymatous lesions), or 4) history of shaking. Exclusion criteria were age >6 years or documented accident/disease explaining symptoms/findings. To describe outcome, we used the King's Outcome Scale for Childhood Head Injury (KOSCHI). 56 cases were reported from 13 of 26 Swiss cantons, representing 80% of the Swiss population; 49 cases met the inclusion criteria. Preponderance of male infants was high (31 male and 18 female); median age at admission was 4 months (1-58). Clinical symptoms were present in 42 infants, retinal/vitreous hemorrhages in 39 infants, and pathological brain/head imaging in 46 infants. In 13 cases, the caregivers admitted shaking the child. Outcomes (KOSCHI 1-5; n = 47 patients) were death (KOSCHI 1) 8 (17.7%), vegetative state (KOSCHI 2) 0, severe disability (KOSCHI 3) 11 (22.2%), moderate disability (KOSCHI 4) 14 (31.1%), and good recovery (KOSCHI 5) 14 (28.8%). Based on these data, the incidence of shaken baby syndrome in Switzerland is 14 per 100 000 live births, which corresponds to the incidence in other Western countries. Demographic characteristics and outcomes of Swiss patients were comparable to published studies.

Seasonality of child homicide

OBJECTIVE

To determine whether there is seasonal variation (by season and month of year) in homicides among young children.

STUDY DESIGN

Homicide deaths in children<or=5 years (n=797), as identified in death certificates from 5 states (Indiana, Ohio, Missouri, Oklahoma, and Washington), were analyzed for a seasonality effect in the years 1999-2006. Season and month of calendar year were used as categorical variables. A chi2 goodness of fit test was used to compare observed and expected proportions of homicides for the entire population. Stratified analyses of children dying before age 2 years and those dying between 2 and 5 years of age were also conducted.

RESULTS

The occurrence of homicide was proportional to the time interval in each category (P=.05). For the total population, there was no statistically significant variation between the expected and observed percentage of homicides by either season or month of calendar year (P=.46 and P=.74, respectively). For the stratified analyses, there was no statistically significant variation between expected and observed percentages of homicides by either season or month of calendar year for either population.

CONCLUSION

There is no seasonality to child homicides by month of year or season of year among young children in the examined population.

Yield of retinal examination in suspected physical abuse with normal neuroimaging

OBJECTIVE

In some centers, dedicated ophthalmologic examination is performed for all children who are evaluated for potential physical abuse. Although retinal hemorrhages have been reported in rare cases of abused children with normal neuroimaging results, the utility of ophthalmologic examination in this group is currently unknown. The objective of this study was to determine the prevalence of retinal hemorrhages in children younger than 2 years who were evaluated for physical abuse and who had no evidence of traumatic brain injury (TBI) on neuroimaging.

PATIENTS AND METHODS

We performed retrospective analysis of data obtained from 1676 children younger than 5 years who were evaluated for potential physical abuse as a part of the Using Liver Transaminases to Recognize Abuse research network. We reviewed results of dedicated ophthalmologic examination in all children younger than 2 years with no evidence of TBI on neuroimaging.

RESULTS

Among 282 children who met inclusion criteria, only 2 (0.7% [95% confidence interval: 0.1%-2.5%]) had retinal hemorrhages considered "characteristic" of abuse. Seven other children (2.5% [95% confidence interval: 1.0%-5.1%]) had a nonspecific pattern of retinal hemorrhages. Both children with characteristic retinal hemorrhages in the absence of TBI showed evidence of head or facial injury on physical examination and/or altered mental status.

CONCLUSIONS

In children younger than 2 years being evaluated for physical abuse without radiographic evidence of brain injury, retinal hemorrhages are rare. Dedicated ophthalmologic examination should not be considered mandatory in this population.

Child maltreatment fatalities in children under 5: Findings from the National Violence Death Reporting System

OBJECTIVE

To describe the distribution of child maltreatment fatalities of children under 5 by age, sex, race/ethnicity, type of maltreatment, and relationship to alleged perpetrator using data from the National Violent Death Reporting System (NVDRS).

STUDY DESIGN

Two independent coders reviewed information from death certificates, medical examiner and police reports corresponding to all deaths in children less than 5 years of age reported to NVDRS in 16 states.

RESULTS

Of the 1,374 deaths for children under 5 reported to NVDRS, 600 were considered attributable to child maltreatment. Over a half of the 600 victims of child maltreatment in this age group were under 1 year old, 59% were male, 42% non-Hispanic Whites, and 38% were non-Hispanic Blacks. Two thirds of child maltreatment fatalities in children under 5 were classified as being due to abusive head trauma (AHT), 27.5% as other types of physical abuse, and 10% as neglect. Based on these data, fathers or their substitutes were significantly more likely than mothers to be identified as alleged perpetrators for AHT and other types of physical abuse, while mothers were more likely to be assigned responsibility for neglect.

CONCLUSIONS

Among children under 5 years, children under 1 are the main age group contributing to child maltreatment fatalities in the NVDRS. AHT is the main cause of death in these data. These findings are limited by underascertainment of cases and fair inter-rater reliability of coding.

PRACTICE IMPLICATIONS

The findings suggest the need to develop and evaluate interventions targeting AHT to reduce the overall number of child maltreatment deaths in young children. These interventions should make special efforts to include fathers and their substitutes.

Nonaccidental head injury is the most common cause of subdural bleeding in infants <1 year of age

OBJECTIVE

Subdural bleeding (SDB) in infants is considered an essential symptom of nonaccidental head injury (NAHI). Recently, this view has been challenged by the "unified hypothesis," which claims that SDB in infants is related to hypoxia and brain swelling rather than to traumatic shearing of bridging veins. We analyzed a large series of infants' autopsies for the presence and causes of SDB, which should be a common event according to the unified hypothesis.

METHODS

Autopsy, clinical, and legal information for infants <1 year of age from a single institution over 50 years were analyzed regarding cause of death, presence, morphology, and cause of SDB, and brain weight.

RESULTS

From a total of 16 661 autopsies during the study period, 715 (4.3%) involved infants <1 year of age. Fifty (7.0%) of those had SDB. NAHI was identified in 17 patients. The most common cause of SDB was trauma (15 cases [30.0%]), with NAHI accounting for 14 cases. SDB was present in 82.4% of patients with NAHI but only 5.2% of infants with other causes of death. Four patients (8.0%) had unexplained SDB with no discernible cause of bleeding. Statistical analysis did not reveal any correlation between the presence of SDB and brain weight.

CONCLUSIONS

In the study population, unexplained SDB in infants was an extreme rarity. Moreover, a correlation between brain swelling and the presence of SDB could not be drawn. Our data argue strongly against the unified hypothesis and strengthen the association between SDB and NAHI in infancy.

Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes

OBJECT

Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions.

METHODS

A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores.

RESULTS

There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up.

CONCLUSIONS

Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.

[Clinical assessment of suspected child physical abuse]

Violence against children has many faces. Child physical abuse, neglect, sexual abuse and interparental violence can cause acute and permanent damage and affect children's development and their life plans in the long term. In industrialized nations almost 1 child in 10 is affected. Up to 10% of child physical abuse cases involve the central nervous system with 80% of these cases occurring during the first year of life. Worldwide more than 50,000 children die as a result of violence, abuse and neglect every year, according to the United Nations Children's Fund UNICEF. In Germany, there are about 120 cases of non-accidental head injury per year. In addition to the officially known cases there is a large grey area for all forms of violence. Recognition of these cases and the provision of help for the victims require an appropriate suspicion and understanding of the pertinent pathophysiology. Suspicion must be based on a well-documented medical history and multidisciplinary diagnostic assessment. Medical confidentiality prevents the disclosure of such information making early detection networks and guidelines for collaboration absolutely indispensable.

A review of social factors in the investigation and assessment of non-accidental head injury to children

Investigation and assessment work in non-accidental head injury cases is complex and challenging. This article discusses briefly the professional systems involved and the conditions necessary for effective practice. It then reviews briefly the literature on social factors in serious and fatal child abuse in order to provide a context for discussion of recent UK studies of non-accidental head injuries/shaken baby syndrome. The findings on social factors are compared and areas for further research are suggested. The article then considers how best to use the existing knowledge base about these cases within assessment frameworks currently in use and considers issues in presenting assessment conclusions to decision-makers.

Non-accidental head injury in New Zealand: the outcome of referral to statutory authorities

OBJECTIVES

To describe the outcome of referral to the statutory authorities for infants under 2 years with non-accidental head injury (NAHI), and to establish whether the authorities held sufficient information to develop a risk profile for these cases.

METHODS

Retrospective review of cases admitted to hospital in Auckland, New Zealand from 1988 to 1998. Records from the hospital admission, child protective services and Police were reviewed, up to 19 years from diagnosis.

RESULTS

Of 39 infants, 33 survived to leave hospital. Documentation of risk factors was erratic, and sometimes incongruent between agencies. Inter-agency case conferences took place in 17/39 (44%). The Department of Child, Youth and Family Services (CYF) used an informal family agreement to secure safety in 15/33 survivors (45%). Family Group Conferences occurred in 17/33 (52%). Nine of 33 were placed permanently outside the home (27%), two (6%) with unrelated caregivers. Charges were laid in 18/39 cases (46%). Fifteen cases came to trial, with 14 convictions (36%). Of the survivors, 44% were later renotified to CYF. There was no obvious relationship between type of intervention and re-notification.

CONCLUSIONS

Ensuring the safety of an infant with NAHI, and identifying and taking appropriate action with regard to the offender, are complex tasks. In New Zealand, data collection is often incomplete and inter-agency practice and collaboration is variable. Although the rate of prosecution was relatively high by international standards, many children were later notified again for further concerns of abuse or neglect, suggesting that our interventions have been only partially successful.

PRACTICE IMPLICATIONS

This paper suggests that all infants admitted to hospital with non-accidental head injury should become part of a prospective inter-agency research study, using a standardised data collection instrument. This should include the systematic collection of all data known or suspected to be associated with risk of child abuse, and incorporate long-term prospective follow-up, regardless of child protective or legal outcomes. Without large numbers followed prospectively and according to sound methodology, it is difficult to prove which forms of intervention are better than others at reducing the risk of further abuse.

Evaluation of documentation in potential abusive head injury of infants in a Paediatric Emergency Department

AIM

The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI.

METHODS

A database search was performed to find all medical records over a period of one year relating to those children who had one AHI-related primary complaint and who had had a CT head-scan performed in conjunction with admission. Each medical record was reviewed, in order to assess whether potential abuse had been investigated and documented. Each CT-scan image was re-evaluated for missed indications of potential injuries attributable to AHI.

RESULTS

Forty-seven such medical records were found. Of these, 87% showed the diagnosis to be head injuries. The largest group of children was in the age group 0-3 months (38%). Of the children admitted to the Paediatric ED due to a head injury, 54% had a history deemed to raise suspicions of abuse but only five of them had had a documented investigation of child abuse. The re-evaluation of the CT-scans showed no missed cases.

CONCLUSION

In this study we found that among children with known risk factors for AHI, only a few had documentation regarding potential child abuse. The use of a standardized protocol could be helpful in the important work to help staff discover potential AHI.

Abusive head trauma

Child physical abuse that results in injury to the head or brain has been described using many terms, including battered child syndrome, whiplash injuries, shaken infant or shaken impact syndrome, and nonmechanistic terms such as abusive head trauma or nonaccidental trauma. These injuries sustained by child abuse victims are discussed in detail in this article, including information about diagnosis, management and outcomes. The use of forensics, the use imaging studies, and associated injuries are also detailed.

Do educational materials change knowledge and behaviour about crying and shaken baby syndrome? A randomized controlled trial

BACKGROUND

Shaken baby syndrome often occurs after shaking in response to crying bouts. We questioned whether the use of the educational materials from the Period of PURPLE Crying program would change maternal knowledge and behaviour related to shaking.

METHODS

We performed a randomized controlled trial in which 1279 mothers received materials from the Period of PURPLE Crying program or control materials during a home visit by a nurse by 2 weeks after the birth of their child. At 5 weeks, the mothers completed a diary to record their behaviour and their infants' behaviour. Two months after giving birth, the mothers completed a telephone survey to assess their knowledge and behaviour.

RESULTS

The mean score (range 0-100 points) for knowledge about infant crying was greater among mothers who received the PURPLE materials (63.8 points) than among mothers who received the control materials (58.4 points) (difference 5.4 points, 95% confidence interval [CI] 4.1 to 6.5 points). The mean scores were similar for both groups for shaking knowledge and reported maternal responses to crying, inconsolable crying and self-talk responses. Compared with mothers who received control materials, mothers who received the PURPLE materials reported sharing information about walking away if frustrated more often (51.5% v. 38.5%, difference 13.0%, 95% CI 6.9% to 19.2%), the dangers of shaking (49.3% v. 36.4%, difference 12.9%, 95% CI 6.8% to 19.0%), and infant crying (67.6% v. 60.0%, difference 7.6%, 95% CI 1.7% to 13.5%). Walking away during inconsolable crying was significantly higher among mothers who received the PURPLE materials than among those who received control materials (0.067 v. 0.039 events per day, rate ratio 1.7, 95% CI 1.1 to 2.6).

INTERPRETATION

The receipt of the Period of PURPLE Crying materials led to higher maternal scores for knowledge about infant crying and for some behaviours considered to be important for the prevention of shaking.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

BACKGROUND

Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality.

METHODS

Selective literature review including an overview over national and international recommendations.

RESULTS

Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations.

CONCLUSIONS

The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial

BACKGROUND

Infant crying is an important precipitant for shaken-infant syndrome. OBJECTIVE. To determine if parent education materials (The Period of PURPLE Crying [PURPLE]) change maternal knowledge and behavior relevant to infant shaking.

METHODS

This study was a randomized, controlled trial conducted in prenatal classes, maternity wards, and pediatric practices. There were 1374 mothers of newborns randomly assigned to the PURPLE intervention and 1364 mothers to the control group. Primary outcomes were measured by telephone 2 months after delivery. These included 2 knowledge scales about crying and the dangers of shaking; 3 scales about behavioral responses to crying generally and to unsoothable crying, and caregiver self-talk in response to unsoothable crying; and 3 questions concerning the behaviors of sharing of information with others about crying, walking away if frustrated, and the dangers of shaking.

RESULTS

The mean infant crying knowledge score was greater in the intervention group (69.5) compared with controls (63.3). Mean shaking knowledge was greater for intervention subjects (84.8) compared with controls (83.5). For reported maternal behavioral responses to crying generally, responses to unsoothable crying, and for self-talk responses, mean scores for intervention mothers were similar to those for controls. For the behaviors of information sharing, more intervention mothers reported sharing information about walking away if frustrated and the dangers of shaking, but there was little difference in sharing information about infant crying. Intervention mothers also reported increased infant distress.

CONCLUSIONS

Use of the PURPLE education materials seem to lead to higher scores in knowledge about early infant crying and the dangers of shaking, and in sharing of information behaviors considered to be important for the prevention of shaking.

Recognising and responding to child maltreatment

Professionals in child health, primary care, mental health, schools, social services, and law-enforcement services all contribute to the recognition of and response to child maltreatment. In all sectors, children suspected of being maltreated are under-reported to child-protection agencies. Lack of awareness of the signs of child maltreatment and processes for reporting to child-protection agencies, and a perception that reporting might do more harm than good, are among the reasons for not reporting. Strategies to improve recognition, mainly used in paediatric practice, include training, use of questionnaires for asking children and parents about maltreatment, and evidence-based guidelines for who should be assessed by child-protection specialists. Internationally, studies suggest that policies emphasising substantiation of maltreatment without concomitant attention to welfare needs lead to less service provision for maltreated children than do those in systems for which child maltreatment is part of a broad child and family welfare response.

Abusive head trauma in infants and young children: a unique contributor to developmental disabilities

Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.

Secondary analysis of the "Love Me...Never Shake Me" SBS education program

OBJECTIVE

Shaken baby syndrome (SBS) is preventable; however, an estimated 21-74 per 100,000 children worldwide are victims annually. This study examined the effectiveness of an SBS prevention program in the US.

METHODS

A descriptive, secondary analysis of the Prevent Child Abuse Ohio (PCAO) "Love Me...Never Shake Me" SBS education program database included 7,051 women who completed a commitment statement, pre and post-test, and follow-up survey.

RESULTS

Participants were mostly White (76%), had at least some college education (62%), were privately insured (62%), and lived with the father and infant (63%). Mothers knew of the dangers of shaking (96%) and recommended SBS education for all parents (98%) because they found it helpful (97%). Scores on the pre and post-tests were significantly different, but there was no difference based on education site or demographics. There was a significant increase in a pre/post-test item pertaining to infant crying. At follow-up, participants remembered postpartum SBS education (98%), but post-discharge did not receive SBS education from their primary care provider (62%). Most mothers practiced infant soothing techniques (79%) provided in the education; however, few women practiced self-coping techniques (36%) and accessed community support services (9%).

CONCLUSIONS

Postpartum SBS prevention education should continue. Development of SBS programs should result from these study findings focusing on education content and program evaluation.

PRACTICE IMPLICATIONS

Mothers report that shaken baby syndrome education is important for all parents and memorable at follow-up. Postpartum SBS education should continue because the hospital is the primary place they receive education. Mothers' report they less frequently receive education from healthcare sources post-discharge. Diligence of primary care providers to incorporate SBS prevention education in well child visits will increase parental exposure to this information. Education may need to place greater emphasis on infant crying and soothing, as well as parent support and self-coping techniques versus the dangers of shaking.

Characteristics that distinguish abusive from nonabusive head trauma among young children who underwent head computed tomography in Japan

OBJECTIVE

Distinguishing abusive head trauma in young children from other diseases by symptoms is difficult in practice. Comparisons between abusive and nonabusive head trauma in young children in Japan, where computed tomography is widely and easily available, might contribute to identifying markers of abusive head trauma that differ from that in Western countries. The objective of this study was to compare the characteristics of abusive and nonabusive head trauma in young children in Japan.

METHODS

A comparative case series study involving a retrospective medical chart and social work record review of children who were aged 0 to 2 years, visited the National Center for Child Health and Development (Tokyo, Japan) from March 1, 2002, to December 31, 2005, and underwent computed tomography scanning because of suspected intracranial injury was performed. Patients (N = 260) were identified and classified as having either abusive or nonabusive head trauma on the basis of the published definition. Demographic and perinatal characteristics, injury history, clinical presentation, and outcomes were compared by using chi2 and Fisher's exact tests.

RESULTS

Patients with abusive head trauma were significantly younger than patients with nonabusive head trauma and had a peak at approximately 2 to 4 and 7 to 9 months. Patients with abusive head trauma more likely presented no injury history by the caregiver, neurologic symptoms (unconsciousness, seizure, paralysis), subdural hemorrhage, and retinal hemorrhages. Although patients with abusive head trauma had severe clinical outcomes, only 32% of them were separated from the caregiver by social welfare services.

CONCLUSIONS

This study highlights the several clinical markers to detect abusive head trauma at a medical visit, including an absence of injury history, neurologic symptoms, subdural hemorrhage, and retinal hemorrhage. These markers can be used to detect abusive head trauma cases by physicians and social welfare workers to protect children from additional abuse.

Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database

OBJECTIVE

The goal was to assess the proportion of children with fractures attributable to abuse and the incidence of fractures caused by abuse among children <36 months of age who were hospitalized in the United States.

METHODS

We used the Kids' Inpatient Database, which has discharge data on 80% of acute pediatric hospitalizations in the United States, for 3 time periods (1997, 2000, and 2003). Fractures attributable to abuse in children <36 months of age were identified by both an International Classification of Diseases, Ninth Revision, Clinical Modification code for fracture and a diagnosis external-cause-of-injury code for abuse. Weighted estimates of the incidence were calculated.

RESULTS

Among children <36 months of age who were hospitalized with fractures, the proportions of cases attributable to abuse were 11.9% in 1997, 11.9% in 2000, and 12.1% in 2003. The proportions of cases attributable to abuse decreased with increasing age; for example, in 2003, the proportions attributable to abuse were 24.9% for children <12 months of age, 7.2% for children 12 to 23 months of age, and 2.9% for children 24 to 35 months of age. In 2003, the incidence of fractures caused by abuse was 15.3 cases per 100000 children <36 months of age. The incidence was 36.1 cases per 100000 among children <12 months of age; this decreased to 4.8 cases per 100000 among 12- to 23-month-old children and 4.8 cases per 100000 among 24- to 35-month-old children.

CONCLUSIONS

The Kids' Inpatient Database can be used to provide reasonable estimates of the incidence of hospitalization with fractures attributable to child abuse. For children <12 months of age, the incidence was 36.1 cases per 100000, a rate similar to that of inflicted traumatic brain injury (25-32 cases per 100000).

Retinal haemorrhages in- head trauma resulting from falls: differential diagnosis with non-accidental trauma in patients younger than 2 years of age

INTRODUCTION

Falls are a common chief complaint among children seeking medical attention in emergency departments and are the leading cause of injuries requiring hospitalisation. Falls are also a frequent excuse to conceal cases of maltreatment in small children. Retinal haemorrhages could be a useful marker for their differential diagnosis.

OBJECTIVE

This study aims to determine the prevalence and characteristics of retinal haemorrhages in children with head trauma resulting from a vertical fall.

MATERIALS AND METHODS

This was a prospective study of children younger than 2 years of age admitted to the hospital with head trauma from a vertical fall. The circumstances of the falls and injuries were analysed. All children were evaluated by an ophthalmologist for retinal haemorrhage.

RESULTS

One hundred fifty-four patients were included. Eighty-three percent of the falls were from a height equal to or less than 120 cm. The most common mechanism of injury was fall from a stroller followed by rolling off the bed. Sixteen children had evidence of intracranial injuries. Three patients had retinal haemorrhages (prevalence 1.9%; 95%CI, 0.4-5.6%), all unilateral, in association with severe epidural haematoma with a midline shift. The detection of retinal haemorrhages could be related to the presence of intracranial injury but not with the circumstances of the fall.

DISCUSSION AND CONCLUSIONS

Any cranial injury from a vertical fall that produces severe epidural bleeding can also cause retinal haemorrhages, mainly unilateral. The finding of diffuse and bilateral retinal haemorrhages or their presence in the absence of this type of intracranial haemorrhage must continue to point out another cause different from the fall as origin of the traumatism, being necessary to exclude non-accidental trauma.

Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event

OBJECTIVES

Apparent life-threatening events in infants constitute a significant challenge for health care providers. Apparent life-threatening event evaluation and management are poorly defined, and outcomes have not been clearly determined. Our objectives were to characterize short- and long-term risks for death, child abuse, and abnormal neurological outcomes of infants after an apparent life-threatening event and to identify clinical features that are predictive of these outcomes.

METHODS

We collected data from infants ages birth to 12 months of age who were hospitalized after an apparent life-threatening event during a 5-year time period. Patients were evaluated for subsequent death, child abuse, or adverse neurological outcome (chronic epilepsy or developmental delay).

RESULTS

A total of 471 patients met inclusion criteria and were followed an average of 5.1 years. Two patients died after developing chronic epilepsy and severe developmental delay. Fifty-four (11%) patients were diagnosed as being a victim of child abuse, but only 2 were identified at initial presentation. There were 23 (4.9%) patients with adverse neurological outcomes, including 17 (3.6%) with chronic epilepsy and 14 (3.0%) with developmental delay. Of those who developed chronic epilepsy, 71% returned within 1 month of the initial apparent life-threatening event with a second event. Neurological evaluation at the time of the apparent life-threatening event had low yield for predicting those who would develop chronic epilepsy.

CONCLUSIONS

Infants who suffer an apparent life-threatening event are at risk for subsequent child abuse and adverse neurological outcomes. Deaths were uncommon and only occurred in the setting of severe developmental delay and seizure disorders. Neurological evaluation during hospitalization for a first apparent life-threatening event is of low yield, but close follow-up is essential.

Shaken baby syndrome and a baby's cry

The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact. During the period between January 1, 1997 and December 31, 2003, 26 cases of shaken baby syndrome (SBS) were identified in Estonia. The incidence of SBS was 28.7 per 100,000 children under 1 year of age during the whole study period. In this group there were four children from twin pairs: two twin boys and a girl from a twin pair and a boy from another twin pair. This represents 15.4% of the 26 cases. Twins in Estonia represent 2.12% of infant births. The mean age on admission was 3.9 months. According to outpatient records almost all parents (88.5%) in the study group (23/26) had contacted their family physicians and other specialists because of excessive crying or irritability of the baby prior to the admission to the hospital with SBS or death. We found that the time curve of crying was similar to the curve of highest incidence of cases of SBS except the crying curve began earlier. CONCLUSION. Our data confirm that the families with twins are at additional risk for SBS and parent's complaints of excessive crying of their infants should be taken as signal that parents need to be carefully counselled.

Demographics of abusive head trauma in the Commonwealth of Pennsylvania

OBJECT

The aim of this study was to characterize the prevalence and demographic features of abusive head trauma (AHT) among infants and children < 36 months of age in Pennsylvania.

METHODS

The authors included all cases of substantiated AHT involving children < 36 months of age in Pennsylvania between 1996 and 2002 that had been reported to a statewide registry. Demographic information was derived from child abuse reports and birth certificates; the study cohort was contrasted with all infants born in Pennsylvania during the same period.

RESULTS

The study identified 327 cases. The incidence was 14.7 cases (95% confidence interval 13.1-16.5) per 100,000 person-years for the first 2 years of life with a higher incidence during the 1st year (26.0 cases per 100,000 person-years) than the 2nd year (3.4 cases per 100,000 person-years). The incidence was similar among metropolitan, non-metropolitan, and rural counties. Significantly more cases occurred during the holiday months (October-December). The median age of victims was 4.1 months. Both victims and perpetrators were more commonly male (58.4% of victims, and 70% of identified perpetrators). Compared with the entire population of Pennsylvania parents, the parents of the study cohort were more likely to be younger, less educated, and unmarried. Both mothers and fathers were more often African-American and fathers more often Hispanic. Finally, mothers more often smoked during pregnancy, sought prenatal care later in the pregnancy, and delivered low birth weight infants.

CONCLUSIONS

This population-based study of abusive head injuries throughout an entire state adds significantly to the growing knowledge about this condition. The results suggests that families of infants with abusive head injuries have significantly different demographic features compared with the general population, although which of these variables is independently significant cannot be ascertained from this study and require further investigation.

Practical aspects of conducting a prospective statewide incidence study: the incidence of serious inflicted traumatic brain injury in North Carolina

The article describes practical problems encountered in setting up and maintaining an active statewide surveillance system for a low-frequency but high-impact injury, inflicted traumatic brain injury (inflicted TBI). A system was designed to identify prospectively all children aged <2 years with a traumatic brain injury (TBI) admitted to any of the nine pediatric intensive care units (ICUs) in North Carolina in 2000 and 2001. Children who died prior to admission to hospital were identified from the records of the Office of the Chief Medical Examiner. The study design had strengths and weaknesses for ongoing surveillance. Strengths included a clear definition of a case, mechanisms to jury undecided cases, and a high level of quality control. Difficulties included appropriately addressing investigators' ethical and legal obligations in the study of child abuse, differing requirements of multiple institutional review boards (IRBs), and the time-intensive nature of the system. The described surveillance system produced high-quality data, but may not be practical for ongoing multi-year injury surveillance. Incorporation of inflicted TBI into an existing surveillance system, such as a trauma database, may be a feasible solution to many of the problems encountered.

Passive surveillance of shaken baby syndrome using hospital inpatient data

BACKGROUND

The conference from which these articles came addressed the question of public health surveillance for shaken baby syndrome (SBS) and explores one component of a comprehensive SBS surveillance system that would be relatively easy to implement and maintain: passive surveillance based on hospital inpatient data. Provisional exclusion and inclusion criteria are proposed for a two-level case definition of diagnosed SBS (strict definition) and cases presumed to be SBS (broad definition). The strict SBS definition is based on the single SBS code in the ICD-9-CM (995.55). The broader presumptive SBS definition is based on research studies that have identified a pattern of diagnostic codes often considered part of the clinical diagnosis of SBS.

RESULTS

Based on 2006 analyses, California inpatient data are presented for 1998-2004. The strict SBS definition identified 366 cases over the 7 years, whereas the broader definition captured nearly 1000 cases. Annual rates show little fluctuation from the overall rate of 5.1 for strict SBS and 14.0 for broad SBS (per 100,000 children aged <2 years). Selected demographic and outcome characteristics are presented for each definition. The broad definition produces rates that are roughly comparable to those produced in careful clinical and population-based studies that also included children who died without being hospitalized.

CONCLUSIONS

Despite the limitations of inpatient data, a passive surveillance system like the one proposed here can provide a critical component for a comprehensive SBS surveillance system and may be adequate for some purposes, including identifying high-risk areas or groups for intervention and monitoring trends over time.

Using hospital discharge data to track inflicted traumatic brain injury

BACKGROUND

Inflicted traumatic brain injury (inflicted TBI) in infants has been the subject of recent preventive interventions, yet the burden of this problem is poorly defined. This article estimates the national incidence of hospitalizations due to inflicted TBI in infants aged <1 year using hospital discharge databases (HDDs) over 3 years, compares findings to previous infant inflicted TBI studies, and assesses differences in case composition and coding over time.

METHODS

The Kids' Inpatient Databases (KIDs) for 1997, 2000, and 2003 were used to estimate the incidence of inflicted TBI hospitalizations in infants. Cases were identified by the presence of ICD-9-CM codes indicating both TBI and abuse. Incidence estimates were generated by dividing the weighted number of inflicted TBI cases identified by the year-specific infant population. Changes over time were evaluated using Cochran-Armitage and ANOVA statistical tests.

RESULTS

The 1997, 2000, and 2003 KIDs yielded infant inflicted TBI incidence estimates of 27.5 (95% CI=20.8-34.0), 27.5 (95% CI=22.6-32.3), and 32.2 (95% CI=26.9-37.4) cases per 100,000 infants per year, respectively. KIDs estimates were within the range of previous inflicted TBI incidence studies that used active surveillance. Over time, the proportion of cases covered by Medicaid increased (p<0.0001).

CONCLUSIONS

The KIDs can be used to generate incidence estimates of infant inflicted TBI hospitalizations that are consistent with previously published active surveillance estimates. HDDs can be used to assess the scope of infant inflicted TBI as well as trends in case composition and coding practices. Such assessments may be useful for the evaluation of prevention programs.

Incidence and demography of non-accidental head injury in southeast Scotland from a national database

BACKGROUND

This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland.

METHODS

This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period.

RESULTS

The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services.

CONCLUSIONS

The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.

Comparative study of the cognitive sequelae of school-aged victims of Shaken Baby Syndrome

OBJECTIVE

Shaken Baby Syndrome (SBS) is now recognized as being the main cause of severe traumatic brain injury in infancy. However, our understanding of the impact of this type of abuse on child development remains sketchy. The main objective of the current study was therefore to shed light on the cognitive dysfunctions that are particular to SBS victims once they are school-aged.

METHOD

A clinical group was formed of 11 children diagnosed with SBS who had been admitted between 1988 and 1999 to a tertiary pediatric hospital in Quebec, Canada. The children were matched for age, gender, socio-economic status, and family composition to 11 healthy Quebec children, who made up the control group. A battery of composite tests was developed to assess the children's main cognitive functions and was administered individually to the 22 children. A univariate t-test was used to compare the performances of the two groups.

RESULTS

The mean age of the children in the clinical and control groups at the time of the assessment was 87.64 months and 90.18 months, respectively. Pairing and birth data were equivalent for both groups. Significant weaknesses were noted in the clinical group for intelligence quotient (IQ), working memory, mental organization, alternation, and inhibition. These deficits seemed to have a greater impact on the verbal sphere of the children's mental functioning.

CONCLUSION

Primary results point to the anterior cerebral regions of the brain as the principal site of dysfunctions that persist years post-trauma. It is important to consider these results longitudinally, even in children apparently less extensively affected, since the frontal regions only reach maturity at the end of adolescence.

Shaken baby syndrome in New Zealand, 2000-2002

AIM

To describe the epidemiology of subdural haemorrhage (SDH) in New Zealand infants.

METHODS

Prospective enrollment of all cases of infantile SDH from 2000 to 2002. Retrospective analysis of national discharge and death data for the same period.

RESULTS

Seventy-seven cases of infantile SDH were identified prospectively, and a further 49 cases retrospectively. Of these 126 cases, 92 resulted from non-birth-related trauma. Forty-eight of these were attributed to abuse and 28 to accidental injury. Sixteen cases were undetermined. The 'minimum' annual incidence of inflicted infantile SDH in New Zealand is 14.7 per 100,000 (95% confidence interval(CI) 10.8-19.4), and the 'maximum' 19.6 per 100,000 (95% CI 15.1-25.0). Among Maori, the 'minimum' is 32.5 per 100,000 (95% CI 21.4-47.3), and the 'maximum' 38.5 per 100,000 (95% CI 26.3-54.4).

CONCLUSIONS

The epidemiology of infantile subdural haemorrhage in New Zealand is similar to that described elsewhere. Non-accidental head injury is a significant child health issue in New Zealand, and the incidence is particularly high among Maori.

Age-related incidence of publicly reported shaken baby syndrome cases: is crying a trigger for shaking?

OBJECTIVE

: This study aims to determine whether the age-specific incidences (1) of publicly reported cases of shaken baby syndrome (SBS) and (2) of publicly reported cases of SBS with crying as the stimulus have similar properties to the previously reported normal crying curve.

METHODS

: The study reports cases of SBS by age of the child at the time of the inflicted trauma from the data set of the National Center on Shaken Baby Syndrome using cases entered between January 1, 2003 and August 31, 2004.

RESULTS

: There were 591 cases of infants up to 1.5 years of age who had been reported to have been shaken or shaken and physically abused. Of these, crying was reported as the stimulus in 166 cases. In both samples, the curves of age-specific incidence started at 2-3 weeks, reached a clear peak at about 9-12 weeks of age, and declined to lower more stable levels by about 29-32 weeks of age, similar to the normal crying curve. These curves have similar onsets and shapes and a slightly later peak compared to the normal crying curve.

CONCLUSIONS

: The findings provide convergent indirect evidence that crying, especially in the first 4 months of age, is an important stimulus for SBS.

Outcome of infants with inflicted traumatic brain injury (shaken baby syndrome) in Estonia

This is a population-based prospective study to identify the long-term outcome of children with inflicted traumatic brain injury (ITBI). Twenty-two survivors were identified and followed up. Only 2 of 22 had no developmental problems at follow-up, 20 of 22 children were having different developmental problems, among them 3 of 22 were severely handicapped. Psychological tests passed 17 of 22, 5 did not pass due to severe handicap (3 children) or were too young (2 patients). Epilepsy was found in 7 of 22, being intractable in 3 cases. Serious motor problems were identified in 5 of 22. Ophthalmologic problems were found in 4 of 22. The most important predictor of adverse outcome was young age at the time of the insult.

CONCLUSION

the outcome of these potentially healthy children is poor. The key question is prevention. Health care professionals should be more concerned about these problems.

Traumatic head injury in infants and toddlers

AIM

To describe the presenting characteristics, type of injury and hospital course in young children with traumatic head injury, and to identify characteristics indicating that the trauma was inflicted.

METHODS

A retrospective medical record review of 91 children less than 3 years of age who were admitted to a tertiary teaching hospital in Norway from 1995 through 2005 with a traumatic head injury. Patients were identified by diagnostic codes, and categorized by type of injury as skull fractures (n = 39), epidural haemorrhage (EDH) (n = 12), subdural haemorrhage (n = 27) and parenchymal brain injury (n = 13). Further the cases were classified as inflicted injury (n = 17), accident (n = 35) or indeterminate (n = 39).

RESULTS

The mechanism of injury was similar for EDHs and isolated skull fractures, and none were classified as inflicted. Sixty-three percent of the cases with subdural haematoma were classified as inflicted. When compared to the accident group, children in the inflicted group more frequently had subdural haemorrhage without a skull fracture (OR = 6.9, CI = 1.7-28.2), and seizures (OR = 9.5, CI = 2.1-43.3).

CONCLUSIONS

Inflicted and accidental head injuries differed in presenting characteristics and injury type. Nearly two-third of the subdural haemorrhages were classified as inflicted, but none of the epidural EDHs or skull fractures. Inflicted injuries tended to present with seizures.

Cost-effectiveness of head computed tomography in infants with possible inflicted traumatic brain injury

OBJECTIVE

Early diagnosis of inflicted traumatic brain injury may reduce morbidity and mortality associated with repeated inflicted traumatic brain injuries. We undertook this study to estimate the cost-effectiveness of a policy of head computed tomography (CT) for inflicted traumatic brain injury in selected infants seen in an emergency department.

METHODS

We constructed Markov models to compare a policy of CT to no CT in an asymptomatic 5-week-old infant with either (1) unexplained scalp bruising or (2) a history of an apparent life-threatening event. Health states modeled were no inflicted traumatic brain injury, misdiagnosed inflicted traumatic brain injury, mild inflicted traumatic brain injury (diagnosed or undiagnosed), and severe and fatal inflicted traumatic brain injury. Infants with undiagnosed inflicted traumatic brain injury were at increased risk of repeat inflicted traumatic brain injury. We used available literature to estimate probabilities, costs, and outcomes. The models terminated at death or at 52 weeks of age. Outcomes considered were severe and fatal inflicted traumatic brain injury cases averted through early detection of mild inflicted traumatic brain injury.

DATA SOURCES

We conducted a literature review for estimates of inflicted traumatic brain injury incidence, outcome probabilities, and medical and societal costs. Wide ranges were set for sensitivity and Monte Carlo analyses.

RESULTS

From a medical payer perspective, head CT for inflicted traumatic brain injury in infants with unexplained scalp bruising saved money. Sensitivity analysis demonstrated costs less than $50,000 per severe or fatal inflicted traumatic brain injury averted in scenarios in which initial inflicted traumatic brain injury prevalence was >3%. From a societal perspective, costs of child protection made head CT for inflicted traumatic brain injury more expensive.

CONCLUSIONS

From a medical payer perspective, our models demonstrate that CT for inflicted traumatic brain injury can be cost-effective and improve outcomes. The finding of higher societal cost reflects the substantial short-term costs of child protection. Our study supports a low medical threshold for CT screening and highlights the need for improved understanding of long-term costs and outcomes of child abuse.

Outcome following subdural haemorrhages in infancy

Subdural haemorrhages (SDH) are associated with significant neurodisability in affected individuals. The incidence of SDH in infants is between 12 and 25 cases per 100,000 children and most detected SDH are due to physical abuse. In the infant brain, SDH are caused by tearing of the bridging veins in the subdural space and may result in significant brain injury. The challenge of assessing outcome in infants with SDH is evaluating whether SDH or other accompanying brain insults are instrumental in the neurodevelopmental outcome.

Late intellectual and academic outcomes following traumatic brain injury sustained during early childhood

OBJECT

Although long-term neurological outcomes after traumatic brain injury (TBI) sustained early in life are generally unfavorable, the effect of TBI on the development of academic competencies is unknown. The present study characterizes intelligence quotient (IQ) and academic outcomes an average of 5.7 years after injury in children who sustained moderate to severe TBI prior to 6 years of age.

METHODS

Twenty-three children who suffered inflicted or noninflicted TBI between the ages of 4 and 71 months were enrolled in a prospective, longitudinal cohort study. Their mean age at injury was 21 months; their mean age at assessment was 89 months. The authors used general linear modeling approaches to compare IQ and standardized academic achievement test scores from the TBI group and a community comparison group (21 children). Children who sustained early TBI scored significantly lower than children in the comparison group on intelligence tests and in the reading, mathematical, and language domains of achievement tests. Forty-eight percent of the TBI group had IQs below the 10th percentile. During the approximately 5-year follow-up period, longitudinal IQ testing revealed continuing deficits and no recovery of function. Both IQ and academic achievement test scores were significantly related to the number of intracranial lesions and the lowest postresuscitation Glasgow Coma Scale score but not to age at the time of injury. Nearly 50% of the TBI group failed a school grade and/or required placement in self-contained special education classrooms; the odds of unfavorable academic performance were 18 times higher for the TBI group than the comparison group.

CONCLUSIONS

Traumatic brain injury sustained early in life has significant and persistent consequences for the development of intellectual and academic functions and deleterious effects on academic performance.

Traumatic brain injury induced hypothalamic-pituitary dysfunction: a paediatric perspective

In survivors of traumatic brain injury (TBI), impairment in anterior pituitary hormone function may be an important cause of long-term morbidity. Histopathological evidence from post-mortem studies suggests that the hypothalamic-pituitary structures are vulnerable to damage following head injury. Pituitary dysfunction, present months or years after injury, is now well recognised in adults, however, little evidence is known about this potential complication in children and adolescents. This article reviews the available paediatric data, which shows that hypopituitarism may occur after both mild and severe TBI, with growth hormone and gonadotrophin deficiencies appearing to be most common abnormalities. Central precocious puberty has also been documented. There are, however, few published data within a population of children with TBI on the incidence or prevalence of hypopituitarism, nor on its natural history or response to hormone replacement, and prospective studies are needed. Given the critical role of anterior pituitary hormones in the regulation of growth, pubertal and neurocognitive development in childhood, early detection of hormone abnormalities following TBI is important. We propose that a multidisciplinary approach to follow-up and endocrine assessment is required for the long-term management and rehabilitation of children and adolescents who survive moderate to severe head injury.

Nonfatal Traumatic Brain Injury–Related Hospitalization in Very Young Children—15 States, 1999

OBJECTIVE

To document age-related patterns of nonfatal hospitalization associated with traumatic brain injury (TBI) among children younger than 2 years of age, by intent/cause and diagnosis.

METHODS

Data describing 2536 nonfatal TBI-related hospitalizations in 15 states for the year 1999 were obtained from the Centers for Disease Control and Prevention Central Nervous System Injury surveillance system for children younger than 2 years of age (0-23 months) at the time of injury.

MAIN OUTCOME MEASURES

Incidence rates (overall, by intent/cause, and by diagnosis) were calculated by combining TBI surveillance data with population data from the US Census Bureau and the National Center for Health Statistics.

RESULTS

Overall rates of nonfatal TBI-related hospitalization peaked at 1 month of age (178.0 cases per 100,000 person-years) followed by a secondary peak at 8 months of age (127.9 cases per 100,000 person-years). Rates for fall-related (unintentional) cases and assault-related cases were significantly higher for infants (0-11 months) than for 1-year-olds (12-23 months), with rates for both types of cases peaking in the earliest months of life. Rates for cases with diagnoses of skull fracture and/or intracranial injury were also significantly higher for the younger group. Assault-related cases frequently coincided with a diagnosis of intracranial injury regardless of age.

CONCLUSIONS

Prevention efforts should focus on falls and assaults, which account for the majority of TBI-related hospitalizations in early childhood. Such efforts may also need to emphasize the unusually high risk during the first few months of life.

Epidemiology and outcomes of pediatric traumatic brain injury

Traumatic brain injury is a leading cause of death and disability in the pediatric age group. Causes of injury vary with child developmental age, with more inflicted injuries in infants, fall-related injuries among toddlers, sports-related injuries among middle-school-aged children and motor vehicle crashes in older children. Prevention strategies exist for some pediatric traumatic brain injury; however, all suffer from lack of compliance and enforcement. Neuropsychological and behavioral outcomes for injured children vary with the severity of injury, child age at injury, premorbid child characteristics, family factors and the families' socioeconomic status. Each of these factors needs to be taken into account when designing rehabilitation strategies and assessing factors related to outcome.

Nonaccidental head trauma as a cause of childhood death

OBJECT

The authors present the demographic and clinical information in 36 children who died as a result of abusive head trauma at a Level 1 pediatric trauma center between January 1, 1997, and January 1, 2004.

METHODS

Abusive head trauma was defined as radiographic evidence of intracranial injury and documentation from a multidisciplinary child protection team that the injury was nonaccidental. There was no sex bias for the children in the 1st year of life (nine girls, nine boys). In children older than 1 year of age, boys were much more likely to be victims (14 boys, four girls). At the time of admission, every child exhibited a seriously impaired level of consciousness and 81% had retinal hemorrhages. Injuries to other organ systems were rare (17%). The most common abnormality found on neuroimaging studies was subdural hematoma. Six children underwent craniotomy for extraaxial hematomas. Death occurred within 24 hours after hospital admission in one half of the cases.

CONCLUSIONS

Abusive head trauma was the cause of death in 36 (86%) of the 42 children whose deaths were classified as nonaccidental at the Children's Hospital in Denver between 1997 and 2003. The authors were unable to identify anything that could have been done from a medical or neurosurgical viewpoint to prevent the deaths of these children after they came to medical attention.

Delayed white matter injury in a murine model of shaken baby syndrome

Shaken baby syndrome, a rotational acceleration injury, is most common between 3 and 6 months of age and causes death in about 10 to 40% of cases and permanent neurological abnormalities in survivors. We developed a mouse model of shaken baby syndrome to investigate the pathophysiological mechanisms underlying the brain damage. Eight-day-old mouse pups were shaken for 15 seconds on a rotating shaker. Animals were sacrificed at different ages after shaking and brains were processed for histology. In 31-day-old pups, mortality was 27%, and 75% of survivors had focal brain lesions consisting of hemorrhagic or cystic lesions of the periventricular white matter, corpus callosum, and brainstem and cerebellar white matter. Hemorrhagic lesions were evident from postnatal day 13, and cysts developed gradually between days 15 and 31. All shaken animals, with or without focal lesions, had thinning of the hemispheric white matter, which was significant on day 31 but not earlier. Fragmented DNA labeling revealed a significant increase in cell death in the periventricular white matter, on days 9 and 13. White matter damage was reduced by pre-treatment with the NMDA receptor antagonist MK-801. This study showed that shaking immature mice produced white matter injury mimicking several aspects of human shaken baby syndrome and provided evidence that excess release of glutamate plays a role in the pathophysiology of the lesions.

Clinical response to child abuse

This article focuses on current practice in the diagnosis and management of the pediatric patient who is a potential victim of abuse. We will review diagnostic and management issues in the major manifestations of physical and sexual abuse are reviewed. This article serves as an aide to practitioners in the recognition of and response to child maltreatment.