Accuracy of the history of injury obtained from the caregiver in infantile head trauma

Early Childhood Concussion

The unconsolidated motor and cognitive skills that are typical of the early childhood period place infants, toddlers, and preschoolers at risk for a variety of traumatic injuries. Such injuries may include mild traumatic brain injury or concussion. Knowledge regarding the risk, diagnosis, outcomes, and management of early childhood concussion is limited, especially compared with what is known about concussion in school-age children, adolescents, and adults. This state-of-the-art review aims to provide current knowledge on the epidemiology, physical signs, behavior, and clinical outcomes associated with early childhood concussion. Research on this condition has been challenged by the need to adapt methods to the unique physical, behavioral, and developmental characteristics of young children. We provide information on observable symptoms associated with concussion, recommended approaches to care, and suggestions for overcoming barriers to research in this area. Developmentally appropriate efforts are needed to improve our ability to identify, evaluate, and treat early childhood concussion.

Nonfatal Emergency Department Visits Associated with Fall-Related Fractured Skulls of Infants Aged 0-4 Months

BACKGROUND

Children aged 0-4 years have the highest rate of emergency department (ED) visits for traumatic brain injury (TBI); falls are the leading cause. Infants younger than 2 years are more likely to sustain a fractured skull after a fall.

OBJECTIVE

This study examined caregiver actions and products associated with ED visits for fall-related fractured skulls in infants aged 0-4 months.

METHODS

Data were analyzed from the 2001-2017 National Electronic Injury Surveillance System-All Injury Program. Case narratives of infants aged 0-4 months who visited an ED for a fall-related skull fracture were examined to code caregiver actions preceding the fall. Product codes determined fall location and product type involved (e.g., flooring, bed, or stairs). All national estimates were weighted.

RESULTS

There were more than 27,000 ED visits (weighted estimate) of infants aged 0-4 months for a nonfatal fall-related fractured skull between 2001 and 2017. Most were younger than 2 months (46.7%) and male (54.4%). Falls occurred primarily in the home (69.9%) and required hospitalization (76.4%). Primary caregiver actions coded involved placing (58.6%), dropping (22.7%), and carrying an infant (16.6%). Floor surfaces were the most common product (mentioned in 24.0% of the cases).

CONCLUSIONS

Fall-related fractured skulls are a health and developmental concern for infants, highlighting the importance of a comprehensive assessment at the time of the injury to better understand adult actions. Findings indicated the need to develop prevention messages that include safe carrying and placement of infants.

Navigating the Challenges of Delayed Subdural Hemorrhage and COVID-19: A Case Report

The delayed onset of posttraumatic subdural hemorrhage (SDH) represents non-specific clinical features, complicating the diagnostic process, especially in individuals predisposed due to pre-existing risk factors and comorbidities. This case report delineates the medical trajectory of a 61-year-old female patient who sustained a traumatic fall, initially displaying neither clinical nor radiological signs indicative of hemorrhage. However, three weeks post-injury, she developed altered mental status, cephalgia, and emesis. Diagnostic imaging unveiled a significant bilateral acute-on-chronic subdural hemorrhage exerting pronounced mass effect and leading to obliteration of the basal cisterns. Complicating her clinical picture was a concurrent SARS-CoV-2 infection and a medical history of hypertension. Emergent neurosurgical intervention was undertaken, encompassing the creation of bilateral burr holes for drainage and the placement of subdural drains. The patient was managed with the requisite medical therapies. Post-operatively, the patient regained consciousness and exhibited significant neurological improvement. Follow-up imaging demonstrated complete resolution of the subdural hemorrhage, and the patient achieved a full recovery of cognitive function. This case underscores the critical necessity for vigilant surveillance for delayed SDH in patients lacking initial radiographic findings and advocates for individualized therapeutic approaches in patients with concurrent pathologies. Prompt recognition, timely neurosurgical management, and care are pivotal to optimizing outcomes in delayed posttraumatic SDH cases.

Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma

BACKGROUND

The purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT).

METHODS

We performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL).

RESULTS

Seventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the "average" range, 17% in the "below average" range, and 70% in the "very low" range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt.

CONCLUSIONS

For patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.

Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are Associated With Clinically Important Traumatic Brain Injury, Classification as Abuse, and Poor Prognosis?

BACKGROUND

Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED).

OBJECTIVE

The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge.

PARTICIPANTS AND SETTING

Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included.

METHODS

Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification.

RESULTS

On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge.

CONCLUSIONS

No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.

Mild abusive head injury: diagnosis and pitfalls

Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury. An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries. Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.

Occurrence of traumatic brain injury due to short falls with or without a witness by a nonrelative in children younger than 2 years

OBJECTIVE

There is disagreement about the occurrence of severe traumatic brain injury, especially subdural hematoma, caused by short falls in very young children. To verify intracranial injury due to these falls and examine its characteristics, the authors compared infants and toddlers with head trauma witnessed by a nonrelative with those whose injuries were not witnessed by a nonrelative.

METHODS

The authors retrospectively reviewed clinical records of children younger than 2 years with head trauma due to a short fall who visited the emergency department of the National Center for Child Health and Development in Japan between April 2015 and March 2018. Patients were classified into two groups: falls that were witnessed by a nonrelative and falls not witnessed by a nonrelative. The authors compared the age in months, sex, mechanism of injury, fall height, prevalence rate of intracranial injury, skull fracture, type of traumatic brain injury, retinal hemorrhage, rib or long-bone fracture, and outcomes between patients whose fall was witnessed by a nonrelative and those whose fall was not witnessed by a nonrelative.

RESULTS

Among 1494 patients included in the present analysis, 392 patients were classified into the group of falls witnessed by a nonrelative, and 1102 patients were classified into the group of falls that were not witnessed by a nonrelative. The prevalence rates of intracranial injury, skull fracture, epidural hematoma, and subarachnoid hemorrhage were equal between the groups. The prevalence rate of subdural hematoma in the group whose falls were witnessed by a nonrelative was significantly lower than that of the other group (p = 0.027). There were no patients with subdural hematoma, retinal hemorrhage, or neurological sequelae in the group whose fall was witnessed by a nonrelative.

CONCLUSIONS

Subdural hematoma, retinal hemorrhage, and neurological sequelae due to short falls were not seen after witnessed falls in the present study.

Implications of Increased Weight Status for the Occurrence of Fall-Induced Intracranial Hemorrhage in Children Aged 4 Years or Younger

OBJECTIVES

The aim of this study was to investigate the association between increased weight status (IWS), a weight for age/sex at greater than the 95th percentile, and fall-induced intracranial hemorrhage (ICH) in children aged 4 years or younger.

METHODS

In 7072 children aged 4 years or younger with head injury who visited a tertiary care hospital emergency department in Korea from 2013 through 2015, the presence of fall-induced ICH was reviewed. The association between IWS and ICH was investigated by multivariable logistic regression. We retrospectively validated the Pediatric Emergency Care Applied Research Network rule alone and in combination with IWS for predicting ICH.

RESULTS

Of 7072 children, 547 (7.7%) underwent computed tomography, of whom 451 (6.4%) were enrolled. Of these, 41 (9.1%; estimated event rate, 0.6%) had ICHs, and 26 (5.8%) had IWS. Increased weight status was more common in the children with ICH (P = 0.023). The association between IWS and ICH remained significant after adjustment (odds ratio, 5.24; 95% confidence interval [CI], 1.49-18.46; P = 0.010). The validation of the rule in combination with IWS showed no significant increases in a sensitivity (92.7% [95% CI, 80.1%-98.5%] to 95.7% [95% CI, 83.5%-99.4%]) and negative predictive value (98.2% [95% CI, 94.7%-99.4%] to 98.8% [95% CI, 95.4%-99.8%]).

CONCLUSIONS

Increased weight status is associated with fall-induced ICH in children aged 4 years or younger. Information on weight status could be potentially helpful in predicting ICH in young children with fall-induced head injury.

Paediatric abusive head trauma in the emergency department: A multicentre prospective cohort study

AIM

Abusive head trauma (AHT) is associated with high morbidity and mortality. We aimed to describe characteristics of cases where clinicians suspected AHT and confirmed AHT cases and describe how they differed.

METHODS

This was a planned secondary analysis of a prospective multicentre cohort study of head injured children aged <18 years across five centres in Australia and New Zealand. We identified cases of suspected AHT when emergency department clinicians raised suspicion on a clinical report form or based on research assistant-assigned epidemiology codes. Cases were categorised as AHT positive, negative and indeterminate after multidisciplinary review. Suspected and confirmed AHT and non-AHT cases were compared using odds ratios with 95% confidence intervals.

RESULTS

AHT was suspected in 70 of 13 371 (0.5%) head-injured children. Of these, 23 (32.9%) were categorised AHT positive, 18 (25.7%) AHT indeterminate and 29 (27.1%) AHT negative. Median age was 0.8 years in suspected, 1.4 years in confirmed AHT and 4.1 years in non-AHT cases. Odds ratios (95% confidence interval) for presenting features and outcomes in confirmed AHT versus non-AHT were: loss of consciousness 2.8 (1.2-6.9), scalp haematoma 3.9 (1.7-9.0), seizures 12.0 (4.0-35.5), Glasgow coma scale ≤12 30.3 (11.8-78.0), abnormal neuroimaging 38.3 (16.8-87.5), intensive care admission 53.4 (21.6-132.5) and mortality 105.5 (22.2-500.4).

CONCLUSIONS

Emergency department presentations of children with suspected and confirmed AHT had higher rates of loss of consciousness, scalp haematomas, seizures and low Glasgow coma scale. These cases were at increased risk of abnormal computed tomography scans, need for intensive care and death.

Estimating the Relevance of Historical Red Flags in the Diagnosis of Abusive Head Trauma

OBJECTIVE

To replicate the previously published finding that the absence of a history of trauma in a child with obvious traumatic head injuries demonstrates high specificity and high positive predictive value (PPV) for abusive head trauma.

STUDY DESIGN

This was a secondary analysis of a deidentified, cross-sectional dataset containing prospective data on 346 young children with acute head injury hospitalized for intensive care across 18 sites between 2010 and 2013, to estimate the diagnostic relevance of a caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma inconsistent with the child's gross motor skills. Cases were categorized as definite or not definite abusive head trauma based solely on patients' clinical and radiologic findings. For each presumptive historical "red flag," we calculated sensitivity, specificity, predictive values, and likelihood ratio (LR) with 95% CI for definite abusive head trauma in all patients and also in cohorts with normal, abnormal, or persistent abnormal neurologic status.

RESULTS

A caregiver's specific denial of any trauma demonstrated a specificity of 0.90 (95% CI, 0.84-0.94), PPV of 0.81 (95% CI, 0.71-0.88), and a positive LR (LR+) of 4.83 (95% CI, 3.07-7.61) for definite abusive head trauma in all patients. Specificity and LR+ were lowest-not highest-in patients with persistent neurologic abnormalities. The 2 other historical red flags showed similar trends.

CONCLUSIONS

A caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma that is developmentally inconsistent are each highly specific (>0.90) but may provide weaker support than previously reported for a diagnosis of abusive head trauma in patients with persistent neurologic abnormalities.

SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations

Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.

Prognostic factors of acute neurological outcomes in infants with traumatic brain injury

PURPOSE

The purpose of this study is to clarify risk factors for poor neurological outcomes and distinctive characteristics in infants with traumatic brain injury.

METHODS

The study retrospectively reviewed data of 166 infants with traumatic intracranial hemorrhage from three tertiary institutions in Japan between 2002 and 2013. Univariate and multivariate analyses were used to identify clinical symptoms, vital signs, physical findings, and computed tomography findings associated with poor neurological outcomes at discharge from the intensive care unit.

RESULTS

In univariate analysis, bradypnea, tachycardia, hypotension, dyscoria, retinal hemorrhage, subdural hematoma, cerebral edema, and a Glasgow Coma Scale (GCS) score of ≤ 12 were significantly associated with poor neurological outcomes (P < 0.05). In multivariate analysis, a GCS score of ≤ 12 (OR = 130.7; 95% CI, 7.3-2323.2; P < 0.001), cerebral edema (OR = 109.1; 95% CI, 7.2-1664.1; P < 0.001), retinal hemorrhage (OR = 7.2; 95% CI, 1.2-42.1; P = 0.027), and Pediatric Index of Mortality 2 score (OR = 1.6; 95% CI, 1.1-2.3; P = 0.018) were independently associated with poor neurological outcomes. Incidence of bradypnea in infants with a GCS score of ≤ 12 (25/42) was significantly higher than that in infants with GCS score of > 12 (27/90) (P = 0.001).

CONCLUSIONS

Infants with a GCS score of ≤ 12 are likely to have respiratory disorders associated with traumatic brain injury. Physiological disorders may easily lead to secondary brain injury, resulting in poor neurological outcomes. Secondary brain injury should be prevented through early interventions based on vital signs and the GCS score.

Consistent screening of admitted infants with head injuries reveals high rate of nonaccidental trauma

PURPOSE

Implementation of a nonaccidental trauma (NAT) screening guideline for the evaluation of infants admitted with an unwitnessed head injury has eliminated screening disparities. This study sought to determine the overall NAT rate and key predictive factors using this guideline.

METHODS

All infants screened via the guideline from 2008 to 2015 were retrospectively reviewed. The overall rate of NAT as determined by our child abuse team was determined. In addition, a logistic regression model was developed to evaluate potential predictors of increased risk of NAT.

RESULTS

A total of 563 infants were screened with an overall rate of NAT of 25.6% (n=144). NAT screening was consistent across race and insurance status. By univariate analysis, patients with government insurance or no insurance had a significantly higher rate of NAT, but race was not a factor. Also NAT victims had significantly higher ISS. Skeletal survey showed high positive predictive value of 94%. When regression modeling was performed, ISS, abnormal skeletal survey and having public or no insurance were significantly correlated with NAT, while race showed no correlation.

CONCLUSION

One quarter of infants admitted with a head injury not witnessed in a public situation were identified as the victims of NAT. The high rate of abuse among this population supports routine screening in order to avoid missing intentional injuries and preventing future injuries. Race is not a predictor of NAT, but insurance status, as a proxy for socioeconomic status, is correlated, and further investigation is needed.

LEVEL OF EVIDENCE

III.