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Lin K, Khan SS, Truong T, Parsikia A, Mbekeani JN. Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome. Childs Nerv Syst 2024:10.1007/s00381-024-06441-5. [PMID: 38709256 DOI: 10.1007/s00381-024-06441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. METHODS We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. RESULTS Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. CONCLUSIONS Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.
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Affiliation(s)
- Kira Lin
- Medical School Program, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabine S Khan
- Department of Surgery (Ophthalmology), Jacobi Medical Center,1400, 1400 Pelham Parkway, Bronx, NY, 10461, USA
- Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy Truong
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
| | - Afshin Parsikia
- Department of Research Services, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce N Mbekeani
- Department of Surgery (Ophthalmology), Jacobi Medical Center,1400, 1400 Pelham Parkway, Bronx, NY, 10461, USA.
- Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, NY, USA.
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Hutchinson K, van Zandwijk JP, Vester MEM, Seth A, Bilo RAC, van Rijn RR, Loeve AJ. Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Update to parts I&II: A systematic review of animal, mathematical and physical models. Forensic Sci Med Pathol 2024:10.1007/s12024-023-00765-5. [PMID: 38236351 DOI: 10.1007/s12024-023-00765-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/19/2024]
Abstract
Inflicted shaking trauma can cause injury in infants, but exact injury mechanisms remain unclear. Controversy exists, particularly in courts, whether additional causes such as impact are required to produce injuries found in cases of (suspected) shaking. Publication rates of studies on animal and biomechanical models of inflicted head injury by shaking trauma (IHI-ST) in infants continue rising. Dissention on the topic, combined with its legal relevance, makes maintaining an up-to-date, clear and accessible overview of the current knowledge-base on IHI-ST essential. The current work reviews recent (2017-2023) studies using models of IHI-ST, serving as an update to two previously published reviews. A systematic review was conducted in Scopus and PubMed for articles using animal, physical and mathematical models for IHI-ST. Using the PRISMA methodology, two researchers independently screened the publications. Two, five, and ten publications were included on animal, physical, and mathematical models of IHI-ST, respectively. Both animal model studies used rodents. It is unknown to what degree these can accurately represent IHI-ST. Physical models were used mostly to investigate gross head-kinematics during shaking. Most mathematical models were used to study local effects on the eye and the head's internal structures. All injury thresholds and material properties used were based on scaled adult or animal data. Shaking motions used as inputs for animal, physical and mathematical models were mostly greatly simplified. Future research should focus on using more accurate shaking inputs for models, and on developing or and validating accurate injury thresholds applicable for shaking.
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Affiliation(s)
- Kim Hutchinson
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands
| | - Jan Peter van Zandwijk
- Division of Digital and Biometric Traces, Netherlands Forensic Institute, Laan Van Ypenburg 6, 2497, The Hague, GB, Netherlands
| | - Marloes E M Vester
- Care Needs Assessment Centre CIZ, Orteliuslaan 1000, 3500 GR, Utrecht, Netherlands
| | - Ajay Seth
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands
| | - Rob A C Bilo
- Veilig Thuis Rotterdam Rijnmond (Center for the Reporting of Child Abuse, Domestic Violence and Elder Abuse), Paul Krugerstraat 181, 3072 GJ, Rotterdam, Netherlands
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Academic Medical Center Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, Netherlands
- Department of Forensic Medicine, Netherlands Forensic Institute, Laan Van Ypenburg 6, 2497, The Hague, GB, Netherlands
| | - Arjo J Loeve
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands.
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Knappstein J, Reed PW, Kelly P. ICD-10 codes for surveillance of non-fatal abusive head trauma in Aotearoa New Zealand: a retrospective cohort study. BMJ Open 2023; 13:e069199. [PMID: 37277218 DOI: 10.1136/bmjopen-2022-069199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
OBJECTIVES To assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New Zealand. DESIGN A retrospective cohort study of hospital inpatient records. SETTING A tertiary children's hospital in Auckland, New Zealand. PARTICIPANTS 1731 children less than 5 years of age who were discharged after a non-fatal head trauma event over a 10-year period from 1 January 2010 to 31 December 2019. OUTCOME MEASURES The outcome of assessment by the hospital's multidisciplinary child protection team (CPT) was compared with the outcome of ICD, Tenth Revision (ICD-10) discharge coding for non-fatal abusive head trauma (AHT). The ICD-10 code definition of AHT was derived from an ICD, Ninth Revision, Clinical Modification definition developed by the Centers for Disease Control, Atlanta, Georgia, which requires both a clinical diagnosis code and a cause-of-injury code. RESULTS There were 1755 head trauma events with 117 determined as AHT by the CPT. The ICD-10 code definition had a sensitivity of 66.7% (95% CI 57.4 to 75.1) and specificity of 99.8% (95% CI 99.5 to 100). There were only three false positives but 39 false negatives, with 18 of the false negatives coded with X59 (exposure to unspecified factor). CONCLUSIONS The ICD-10 code broad definition of AHT is a reasonable epidemiological tool for passive surveillance of AHT in New Zealand but it underestimates the incidence. Its performance could be improved by clear documentation of child protection conclusions in clinical notes, clarifying coding practice and removing the exclusion criteria from the definition.
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Affiliation(s)
- Joanne Knappstein
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Te Toka Tumai, Te Whatu Ora, Health New Zealand, Auckland, New Zealand
- Department of Paediatrics, Hauora a Toi Bay of Plenty, Te Whatu Ora, Health New Zealand, Tauranga, New Zealand
| | | | - Patrick Kelly
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Te Toka Tumai, Te Whatu Ora, Health New Zealand, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
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4
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Macorano E, Gentile M, Stellacci G, Manzionna M, Mele F, Calvano M, Leonardelli M, Duma S, De Gabriele G, Cristalli A, Minella R, Di Fazio A, Introna F. 'Compressed Baby Head': A New 'Abusive Head Trauma' Entity? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1003. [PMID: 37371236 DOI: 10.3390/children10061003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. DISCUSSION The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. CONCLUSIONS To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.
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Affiliation(s)
- Enrica Macorano
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mattia Gentile
- Medical Genetics, Maternal and Child Department, Hospital of Venus, 70012 Bari, Italy
| | | | - Mariano Manzionna
- Complex Operating Unit, Paediatric and Neonatology, San Paolo Hospital, ASL Bari, 70100 Bari, Italy
| | - Federica Mele
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mariagrazia Calvano
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mirko Leonardelli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Stefano Duma
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Giovanni De Gabriele
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Alessandro Cristalli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Raffaella Minella
- School of Biological and Environmental Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
| | - Aldo Di Fazio
- Regional Complex Intercompany Institute of Legal Medicine, 85100 Potenza, Italy
| | - Francesco Introna
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
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Simon CL, Ude I, Levin MR, Alexander JL. Retinal hemorrhages in abusive head trauma with atraumatic neuroimaging. J AAPOS 2023; 27:39-42. [PMID: 36516943 PMCID: PMC9975066 DOI: 10.1016/j.jaapos.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Abstract
We report 3 cases of suspected abusive head trauma with retinal hemorrhages on fundus examination and neuroimaging findings not necessarily suggestive of shaking injury. Previous studies have suggested that retinal hemorrhages are rare in patients without neuroimaging abnormalities. These cases demonstrate some common features (rib fractures, developmental delay, and history of abuse) that may increase suspicion for abusive head trauma. Our findings suggest a potential role for ophthalmic consultation in scenarios with high clinical suspicion for abusive head trauma without definitive neuroimaging evidence of head injury. The nonspecific neuroimaging features of these 3 cases highlight the importance of interpreting cases with global clinical context.
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Affiliation(s)
| | - Ifeoma Ude
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Moran R Levin
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet L Alexander
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland.
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6
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Traumatic head injury due to child maltreatment: epidemiology, cost analysis, and impact of prevention. Childs Nerv Syst 2022; 38:2281-2287. [PMID: 35680684 DOI: 10.1007/s00381-022-05560-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Traumatic head injury due to child maltreatment (THI-CM), also known as abusive head trauma (AHT), is a significant public health problem due to the wide array of consequences affecting multiple domains of a child's health and development. Several studies have evaluated its cost on healthcare systems, families, and societies. Many jurisdictions have implemented caregiver education programs to prevent THI-CM. OBJECTIVES This paper aims to provide a brief overview of the epidemiology and cost analysis of THI-CM and discuss its prevention and the intergenerational transmission of child maltreatment. METHODS Although not systematic, a literature search of original articles published from 2000 to 2022 in English and French was undertaken using the following databases: PubMed, EMBASE (Ovid), and PsycINFO (OVID). The search combined terms related to traumatic head injury and child maltreatment, with terms related to its cost and prevention. Studies of children aged 0-5 years old were included. The authors completed a screen of the titles and abstracts to determine relevance with respect to this article. RESULTS Globally, although THI-CM accounts for a small proportion of cases of child maltreatment, there is a high incidence of death and neurological sequelae compared to other causes of head trauma.The incidence of THI-CM is likely underestimated due to the lack of standardized definitions, differences in reporting, and challenges in identifying less severe cases. Cost analysis studies reveal the significant short- and long-term costs associated with THI-CM. Caregiver education programs have been studied and implemented in many centers and have shown varying but promising results. CONCLUSION A multi-pronged approach to prevention efforts should be considered to support families and help to prevent THI-CM and maltreatment throughout childhood.
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7
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Lãzãrescu AM, Benichi S, Blauwblomme T, Beccaria K, Bourgeois M, Roux CJ, Vergnaud E, Montmayeur J, Meyer P, Cohen JF, Chalumeau M, Blangis F, Orliaguet G. Abusive Head Trauma in Infants During the COVID-19 Pandemic in the Paris Metropolitan Area. JAMA Netw Open 2022; 5:e2226182. [PMID: 36040743 PMCID: PMC9428740 DOI: 10.1001/jamanetworkopen.2022.26182] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse. OBJECTIVE To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS In a time-series analysis of a longitudinal, population-based, cohort study, all consecutive cases of AHT in infants younger than 12 months old referred between January 2017 and December 2021 to Necker Hospital for Sick Children, the single regional pediatric neurosurgery center for the Paris metropolitan area, were included. AHT was defined as 1 or more subdural hemorrhage and a positive multidisciplinary evaluation after a social, clinical, biological, and radiological workup. Data were analyzed from January to March 2022. MAIN OUTCOMES AND MEASURES The primary outcome was the monthly incidence of AHT, which was analyzed using Poisson regression modeling. Secondary outcomes included mortality and severe morbidity and were studied with logistic and linear regressions. The monthly incidence of neurosurgical interventions for hydrocephalus was used as a control series. RESULTS Among the 99 included infants with AHT (median [IQR] age, 4 [3-6] months; 64 boys [65%]), 86 of 99 (87%) had bridging vein thrombosis, 74 of 99 (75%) had retinal hemorrhages, 23 of 72 (32%) had fractures, 26 of 99 (26%) had status epilepticus, 20 of 99 (20%) had skin injuries, 53 of 99 (54%) underwent neurosurgical interventions, and 13 of 99 (13%) died. Compared with the prepandemic period (2017-2019), AHT incidence was stable in 2020 (adjusted incidence rate ratio, 1.02; 95% CI, 0.59-1.77) and then significantly increased in 2021 (adjusted incidence rate ratio, 1.92; 95% CI, 1.23-2.99). The severity of AHT worsened in 2021 in terms of mortality (odds ratio 9.39; 95% CI, 1.88-47.00). Other secondary outcomes and the control series were not significantly modified. CONCLUSIONS AND RELEVANCE In this cohort study, a marked increase in AHT incidence and severity occurred during the COVID-19 pandemic in the Paris metropolitan area. These results suggest the need for clinical awareness and preventive actions.
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Affiliation(s)
- Alina-Marilena Lãzãrescu
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Sandro Benichi
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Kévin Beccaria
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Marie Bourgeois
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Charles-Joris Roux
- Department of Pediatric Radiology, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Estelle Vergnaud
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Juliette Montmayeur
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Philippe Meyer
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Gilles Orliaguet
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Unit EA7323 Evaluation of Therapeutics and Pharmacology in Perinatality and Pediatrics, Université Paris Cité, Paris, France
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Sayrs LW, Ortiz JB, Notrica DM, Kirsch L, Kelly C, Stottlemyre R, Cohen A, Misra S, Green TR, Adelson PD, Lifshitz J, Rowe RK. Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP6785-NP6812. [PMID: 33092447 DOI: 10.1177/0886260520967151] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(β) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.
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Affiliation(s)
- Lois W Sayrs
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - J Bryce Ortiz
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - David M Notrica
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Lisa Kirsch
- Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Cara Kelly
- Phoenix Children's Hospital, Phoenix, AZ, USA
- Arizona State University School of Social Work, Phoenix, AZ, USA
| | | | - Aaron Cohen
- Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Shivani Misra
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Tabitha R Green
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - P David Adelson
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Jonathan Lifshitz
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
- Phoenix Veteran Affairs Health Care System, Phoenix, AZ, USA
| | - Rachel K Rowe
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
- Phoenix Veteran Affairs Health Care System, Phoenix, AZ, USA
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Bailhache M, Lafagne A, Lagarde M, Richer O. Do Victims of Abusive Head Trauma Visit Emergency Departments More Often Than Children Hospitalized for Fever? A Case-Control Study. Pediatr Emerg Care 2022; 38:e310-e315. [PMID: 33105462 DOI: 10.1097/pec.0000000000002264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE During the first years of life, infant crying is a common trigger of abusive head trauma (AHT). Emergency department (ED) use by AHT victims before visits for child abuse symptoms is not well known, particularly for infant crying. Furthermore, diagnosis could be missed. In the same period, fever is a common reason for hospitalization unconnected with AHT. The main goal of our study was to compare the ED use by AHT victims before visits for child abuse symptoms and by children of the same age hospitalized for fever. METHODS We conducted a retrospective case-control study from 2011 to June 2018 in a French hospital. We compared cases of AHT selected using the International Classification of Diseases and control subjects hospitalized in the general pediatric unit for fever without immunodeficiency matched in age. Univariate and multivariate analyses were performed. RESULTS Among the 75 victims of AHT, 5 had at least 1 previous ED visit not linked with abuse. None had visited for infant crying. Among the control subjects, 34 had at least 1 previous ED visit, including 6 for infant crying. Among the 57 dyads of controls and cases living in the hospital's area, the controls had significantly more previous ED visits than the cases (P < 0.001). There were more male infants among the cases (72% vs. 55%, P = 0.033). CONCLUSIONS Our study suggests that AHT victims had no more ED visits before visits for child abuse symptoms, particularly not for infant crying.
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Affiliation(s)
| | - Ambre Lafagne
- From the Department of Pediatrics, Centre Hospitalo-Universitaire de Bordeaux, Place Amélie Raba Léon
| | - Marie Lagarde
- From the Department of Pediatrics, Centre Hospitalo-Universitaire de Bordeaux, Place Amélie Raba Léon
| | - Olivier Richer
- From the Department of Pediatrics, Centre Hospitalo-Universitaire de Bordeaux, Place Amélie Raba Léon
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Feld K, Ricken T, Feld D, Helmus J, Hahnemann M, Schenkl S, Muggenthaler H, Pfeiffer H, Banaschak S, Karger B, Wittschieber D. Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study. Int J Legal Med 2021; 136:591-601. [PMID: 34862583 PMCID: PMC8847172 DOI: 10.1007/s00414-021-02751-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Tim Ricken
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | | | - Sebastian Schenkl
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Holger Muggenthaler
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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11
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Bechtel K, Derbyshire M, Gaither JR, Leventhal JM. Characteristics That Distinguish Abusive From Nonabusive Causes of Sudden Unexpected Infant Deaths. Pediatr Emerg Care 2021; 37:e780-e783. [PMID: 30829845 DOI: 10.1097/pec.0000000000001787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department. METHODS Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes. RESULTS We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30). CONCLUSIONS Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.
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Affiliation(s)
- Kirsten Bechtel
- From the Department of Pediatrics, Yale School of Medicine, New Haven
| | | | - Julie R Gaither
- From the Department of Pediatrics, Yale School of Medicine, New Haven
| | - John M Leventhal
- From the Department of Pediatrics, Yale School of Medicine, New Haven
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12
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Wilson TA, Gospodarev V, Hendrix S, Minasian T. Pediatric abusive head trauma: ThinkFirst national injury prevention foundation. Surg Neurol Int 2021; 12:526. [PMID: 34754576 PMCID: PMC8571401 DOI: 10.25259/sni_194_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/27/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Pediatric abusive head trauma (AHT) represents 80% of nonaccidental trauma deaths, remaining a lead cause of death among infants and young children. Furthermore, neurosurgical intervention can ameliorate damage from secondary injury, but we are currently unable to alter the impact of the primary injury. Thus, prevention through increased public awareness is imperative. This study identifies injuries and predictors of outcomes in pediatric AHT and highlights the importance of partnering with our community through ThinkFirst, a national injury prevention foundation, to educate parents and caregivers about prevention. Methods: This single-institution retrospective review identifies injuries and predictors of outcomes in pediatric AHT and highlights the importance of partnering with our community to raise awareness and educate parents and caregivers about prevention. Results: The number of pediatric AHT cases continues to steadily increase over time (P < 0.001), and over 70% of these patients are <1 year of age (P < 0.001). Patients suffering AHT have a mortality rate of nearly 10%. In addition to morbidity and mortality, the economic burden of caring for abused children is high as they often require high levels of care, long hospital stays, and extensive rehabilitation. Furthermore, Medicaid pays for nearly 80% of these patients. Conclusion: The population of patients with AHT is unique, and one that will benefit from continued efforts at increased multidisciplinary and public awareness. Prevention of AHT through awareness is critical. Through partnering with ThinkFirst, a national injury prevention foundation, we aim to educate parents and caregivers about prevention.
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Affiliation(s)
- Taylor Anne Wilson
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Vadim Gospodarev
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Sean Hendrix
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Tanya Minasian
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
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13
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Sidpra J, Chhabda S, Oates AJ, Bhatia A, Blaser SI, Mankad K. Abusive head trauma: neuroimaging mimics and diagnostic complexities. Pediatr Radiol 2021; 51:947-965. [PMID: 33999237 DOI: 10.1007/s00247-020-04940-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/13/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.
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Affiliation(s)
- Jai Sidpra
- University College London Medical School, London, UK
| | - Sahil Chhabda
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, UK
| | - Aashim Bhatia
- Department of Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susan I Blaser
- Department of Radiology, Hospital for Sick Children, Toronto, ON, Canada
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
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14
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Harper NS, Eddleman S, Shukla K, Narcise MV, Padhye LJ, Peterson LJ, Murati MA, George CLS. Radiologic Assessment of Skull Fracture Healing in Young Children. Pediatr Emerg Care 2021; 37:213-217. [PMID: 32868623 PMCID: PMC8016511 DOI: 10.1097/pec.0000000000002215] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Skull fractures are commonly seen after both accidental and nonaccidental head injuries in young children. A history of recent trauma may be lacking in either an accidental or nonaccidental head injury event. Furthermore, skull fractures do not offer an indication of the stage of healing on radiologic studies because they do not heal with callus formation as seen with long bone fractures. Thus, a better understanding on the timing of skull fracture resolution may provide guidance on the medical evaluation for accidental or nonaccidental head injury. OBJECTIVE The aim of the study was to determine the time required for radiographic skull fracture resolution in children younger than 24 months. METHODS This was a retrospective observational analysis of children younger than 24 months referred with skull fractures between January 2008 and December 2012. Analysis included children with accidental head injuries with a known time interval since injury and a negative skeletal survey who underwent serial radiographic studies. Complete healing of a skull fracture was defined as resolution of fracture lucency by radiograph. RESULTS Of the 26 children who met inclusion criteria, 11 (42.3%) demonstrated resolution of skull fracture(s) on follow-up imaging. Fracture resolution on radiologic studies ranged from 2 to 18 weeks. Twelve fractures in 10 children demonstrated fracture resolution at 10 or more weeks after injury. CONCLUSIONS Healing or resolution of a skull fracture can take months in children younger than 24 months. With the high variability in skull fracture presentation and large window to fracture resolution, unexplained or multiple skull fractures in children younger than 24 months may be the result of a single or multiple events of head trauma.
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Affiliation(s)
- Nancy S. Harper
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | | | | | | | - Laura J. Padhye
- Department of Family Medicine and Community Health, University of Minnesota, M Health Fairview St. Joseph's Hospital
| | - Loralie J. Peterson
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Michael A. Murati
- Department of Radiology, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Caroline L. S. George
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
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15
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Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history. J Pediatr Surg 2021; 56:390-396. [PMID: 33220974 DOI: 10.1016/j.jpedsurg.2020.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. METHODS A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. RESULTS Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity. CONCLUSIONS To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. STUDY TYPE/LEVEL OF EVIDENCE Prognostic, Level III.
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16
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Ayton D, Pritchard E, Tsindos T. Acquired Brain Injury in the Context of Family Violence: A Systematic Scoping Review of Incidence, Prevalence, and Contributing Factors. TRAUMA, VIOLENCE & ABUSE 2021; 22:3-17. [PMID: 30651050 DOI: 10.1177/1524838018821951] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Brain injury is often a precursor to, or result of, family violence. Yet there is little research identifying the connection of these two phenomena. The health cost (personal or societal) of brain injury within the family violence context is difficult to ascertain. Family violence can lead to lifelong psychological or physical scars and even death. A systematic review was conducted over three databases using Medical Subject Heading terms to investigate incidence, prevalence, and contributing factors of brain injury within a family violence context. Inclusion criteria were primary studies, any person who experienced traumatic brain injury in a familial context. Seven hundred and seven studies of varied designs were initially identified with 43 meeting inclusion criteria. Data were extracted and a deductive narrative synthesis was performed. The accuracy and generalizability of incidence and prevalence statistics was hindered by underreporting of family violence and the specificity of some of the population groups (e.g., female inmates). The factors contributing to brain injury within the family violence context had multifactorial causation and varied greatly across the populations studied. Five social determinants of health were identified: biological, behavioral, structural, social, and environmental. These factors included age and gender of parent/baby, crying as an antecedent of family violence, previous exposure to abuse as a child, hostile living environments, previous trauma, financial pressures, employment status, housing availability, and exposure to natural disasters. Future investigation into the nexus between brain injury and family violence is required; however, this is complicated due to global inconsistency of definitions, assessment tools, and research methods used.
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Affiliation(s)
- Darshini Ayton
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Elizabeth Pritchard
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tess Tsindos
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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17
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Rebbe R, Martinson ML, Mienko JA. The Incidence of Child Maltreatment Resulting in Hospitalizations for Children Under Age 3 Years. J Pediatr 2021; 228:228-234. [PMID: 32822739 PMCID: PMC7752851 DOI: 10.1016/j.jpeds.2020.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess the incidence of child maltreatment-related hospitalizations for children under 3 years for the population of Washington State. STUDY DESIGN A population-based study using retrospective linked administrative data for all children born in Washington State from 2000 through 2013 (n = 1 191 802). The dataset was composed of linked birth and hospitalization records for the entire state. Child maltreatment-related hospitalizations were identified using diagnostic codes, both specifically attributed to and suggestive of maltreatment. Incidence were calculated for the population, by birth year, by sex, and by maltreatment subtype. RESULTS A total of 3885 hospitalizations related to child maltreatment were identified for an incidence of 10.87 per 10 000 person-years. Hospitalizations related to child maltreatment accounted for 2.1% of all hospitalizations for children under the age of 3 years. This percentage doubled over time, reaching a high in 2012 (3.6%). More than one-half of all hospitalizations were related to neglect. Maltreatment-related hospitalizations occurred most frequently in the first year of life for all subtypes except for neglect, which occurred the most between 1 and 2 years of age. Male children had higher incidence than female children in general (11.97 vs 9.70 per 10 000 person-years) and across all subtypes. CONCLUSIONS Hospitalizations can be a useful source of population-based child maltreatment surveillance. The identification of neglect-related hospitalizations, likely the result of supervisory neglect, because the most common subtype is an important finding for the development of prevention programming.
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Affiliation(s)
- Rebecca Rebbe
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA.
| | | | - Joseph A Mienko
- Center for Social Sector Analytics & Technology, School of Social Work, University of Washington
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18
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Feld K, Feld D, Karger B, Helmus J, Schwimmer-Okike N, Pfeiffer H, Banaschak S, Wittschieber D. Abusive head trauma in court: a multi-center study on criminal proceedings in Germany. Int J Legal Med 2020; 135:235-244. [PMID: 33030617 PMCID: PMC7782463 DOI: 10.1007/s00414-020-02435-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/30/2020] [Indexed: 12/03/2022]
Abstract
The shaken baby syndrome (SBS) is a common variant of abusive head trauma (AHT) in infants and toddlers. Data on the legal outcome of such cases are still sparse. By means of a retrospective multi-center analysis, 72 cases of living children diagnosed with SBS/AHT from three German university institutes of legal medicine were identified. Forty-six of these cases with 68 accused individuals were available and could be evaluated with regard to basic data on the course of the criminal proceedings as well as the profile of the defendants (sub-divided into suspects, convicts, and confessed perpetrators). Criminal proceedings predominantly commenced with a complaint by the treating hospital (62%) and were found to be closed (without judgment) in 50% of the cases, mostly due to a “lack of sufficient suspicion.” Of the 23 cases with judgment, the court decided on acquittal in 4 cases (17%). Imprisonment was the most frequent sentence (16 out of 19 cases with conviction, 84%), whereby the sentence has been suspended on probation in 63% of the cases. Suspects and perpetrators were mostly male and derived from the close family environment of the injured children. All confessed perpetrators stated an “excessive demand” as the reason for the violent shaking of the child. The results of the present study are in line with data from other studies with other legal systems. As many criminal proceedings were closed and the 4 acquittals occurred because the perpetration could not be ascribed to a specific perpetrator, improving the forensic methods for such an unequivocal assignment would be desirable.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | - Nneka Schwimmer-Okike
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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19
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Cala Cala LF, Kelly CL, Ramos E, VanVleet M, High P. Which Mothers Know That All Babies Cry? A Randomized Controlled Trial of a Child Abuse Prevention Program for Low-Income New Mothers. Clin Pediatr (Phila) 2020; 59:865-873. [PMID: 32432487 DOI: 10.1177/0009922820922532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study evaluated an intervention for low-income new mothers, half from Spanish-speaking homes, that provides education around infant crying and abusive head trauma (AHT). At enrollment, non-US-born mothers were less likely than US-born mothers to have heard of shaken baby syndrome (60% vs 89%, P ≤ .0001) or to know shaking babies could lead to brain damage or death (48% vs 80%, P < .0001). At follow-up, non-US-born intervention mothers had improved knowledge of the peak of crying (31% vs 4%, P = .009), improved knowledge that shaking a baby could lead to brain damage or death (36% vs 12%, P = .035), and identified more calming strategies for parenting stress compared with non-US-born control mothers (+0.8 [SD = 1.1] vs -0.4 [SD = 1.4]). This study identifies a gap in AHT knowledge at baseline of non-US-born mothers. These mothers had improved knowledge with intervention and are an important population for similar prevention efforts.
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Affiliation(s)
- Luisa F Cala Cala
- Brown University, Providence, RI, USA.,Hasbro Children's/Rhode Island Hospital, Providence, RI, USA.,Women and Infants' Hospital, Providence, RI, USA
| | - Carrie Leah Kelly
- Brown University, Providence, RI, USA.,Hasbro Children's/Rhode Island Hospital, Providence, RI, USA
| | - Elaina Ramos
- Brown University, Providence, RI, USA.,Hasbro Children's/Rhode Island Hospital, Providence, RI, USA
| | - Marcia VanVleet
- Brown University, Providence, RI, USA.,Women and Infants' Hospital, Providence, RI, USA.,Baystate Medical Center, Springfield, MA, USA
| | - Pamela High
- Brown University, Providence, RI, USA.,Hasbro Children's/Rhode Island Hospital, Providence, RI, USA.,Women and Infants' Hospital, Providence, RI, USA
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20
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Chang YT, Chang HY, Chen LW, Lu TH, Tsai HJ, Chen YW, Chang YC, Feng JY. Incidence and characteristics of paediatric abusive head trauma in Taiwan, 2006-2015: a nationwide population-based study. Inj Prev 2020; 27:356-362. [PMID: 32788223 DOI: 10.1136/injuryprev-2020-043805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/13/2020] [Accepted: 07/18/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To examine the incidence rate and characteristics of paediatric abusive head trauma (PAHT) among children under age 5 years in Taiwan. METHODS The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) was used to identify broad and narrow definitions of children aged under 5 years with PAHT from 2006 to 2015 in Taiwan using a representative national insurance research database. Medical resource utilisation was also analysed. Incidence rates per 100 000 person-years were calculated and presented with 95% CI. Joinpoint regression analysis was used to detect the changes in trends and calculate the annual percentage change in PAHT incidence over time. RESULTS From 2006 to 2015, 479 (narrow definition) and 538 (broad definition) PAHT cases were identified. Incidence rates of PAHT by narrow and broad definitions among children under 1 year of age (18.7/100 000 and 20.0/100 000) were nearly 10-fold or 20-fold higher than for children aged 1-2 (1.7/100 000 and 2.1/100 000) and 3-5 (0.9/100 000 and 1.2/100 000) years. The PAHT incidence significantly increased since 2012, with trends varying by age and gender. Our results suggest that over 40% of the children with PAHT experienced serious injury and nearly 13% were fatal cases. For 87% (n=57) of fatal cases, this was their first ever hospitalisation. The number of fatal cases among infants was fourfold higher than that of children aged 1-5 years. CONCLUSIONS This study provides a robust national estimate of PAHT and identifies infants as the most vulnerable group for PAHT in Taiwan. Education to enhance healthcare profession's sensitivity and competence for the early identification and diagnosis of PAHT is critical.
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Affiliation(s)
- Yi-Ting Chang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsin-Yi Chang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Li-Wen Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Hsueh Lu
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Ju Tsai
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Yi-Wen Chen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chun Chang
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jui-Ying Feng
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan .,Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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21
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Nuño M, Shelley CD, Ugiliweneza B, Schmidt AJ, Magaña JN. Differences in Incidence and Case Fatality of Abusive Head Trauma. CHILD ABUSE & NEGLECT 2020; 104:104488. [PMID: 32334138 DOI: 10.1016/j.chiabu.2020.104488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/25/2020] [Accepted: 03/30/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) in children older than 1 and younger than 5 years old is thought uncommon and rarely studied. OBJECTIVE This study estimates national incidence and case fatality rate of abusive head trauma (AHT), and evaluates differences by age, sex, race, and region, with a focus on children of 2-4 years. PARTICIPANTS AND SETTING Hospital discharges were extracted from The Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000, 2003, 2006, 2009, and 2012 using the CDC's narrow definition of AHT. METHODS Survey-weighted chi-square tests were used to assess differences in incidence and case fatality rates. RESULTS The average annual incidence per 100,000 children was highest in <1 year-olds (27), followed by age 1 (4), age 2 (3), and age 3-4 (1). Average annual incidence varied significantly by sex (p = 0.0001), race (p < 0.0001), and region (p = 0.0002) within each age category. The average annual case fatality rate increased significantly with age, with a rate of 0.10 among children age <1 year, 0.15 for age 1, 0.23 for age 2, and 0.20 for age 3-4 years. The average annual case fatality rate was higher in the South (0.12) than West (0.10), Midwest (0.09), and Northeast (0.08) among children <1 year of age. CONCLUSIONS Black and Hispanic children and hospitals in the Midwest experienced higher incidence of AHT than White children and Northeast hospitals, respectively, especially in cases <1 year of age. Case fatality rates increased significantly with age, and the South experienced the highest rates for infants <1 year.
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Affiliation(s)
- Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA.
| | - Courtney D Shelley
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA
| | | | - Alec J Schmidt
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA
| | - Julia N Magaña
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, USA
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Abstract
BACKGROUND Abusive head trauma (AHT) peaks during early infancy and decreases in toddler years. Infants and toddlers experience different injuries, possibly impacting the risk of mortality. We aimed to evaluate the association of age with mortality. METHODS We conducted a retrospective study of AHT hospitalizations in 2000, 2003, 2006, 2009, and 2012 from the Kid's Inpatient Claims Database. An accidental head trauma cohort was included to hypothesize that the association between age and mortality is unique to abuse. A nested multivariable logistic regression was used to perform the analysis. RESULTS Children aged 2 years to 4 years experienced higher mortality than those younger than 2 years (22% vs. 10%, p < 0.0001; adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2). The presence of subarachnoid hemorrhage (OR, 1.9; 95% CI, 1.3-2.9), cerebral edema (OR, 4.0; 95% CI, 2.9-5.4), and retinal hemorrhage (OR, 1.9; 95% CI, 1.5-2.5) were associated with an increase risk in mortality. Children younger than 2 years experienced more fractures and hemorrhage (subdural, subarachnoid, retinal) while children aged 2 years to 4 years encountered more internal injuries and cerebral edema.In children with accidental head trauma, those aged 2 years to 4 years have a lower mortality compared with those younger than 2 years (OR, 0.4; 95% CI, 0.3-0.6). Among children younger than 2 years, AHT and accidental trauma had comparable risk of mortality (OR, 0.9; 95% CI, 0.6-1.3). However, among those aged 22 years to 4 years, AHT had a higher risk of mortality than accidental trauma (OR, 3.3; 95% CI, 2.1-5.1). CONCLUSION There is a considerable risk of mortality associated with age at diagnosis in children with AHT.Children younger than 2 years and those aged 2 years to 4 years present with different types of injuries. The high risk of mortality in the children aged 2 years to 4 years is unique to AHT. Efforts should be made to increase awareness about the risk of mortality and identify factors that can aide in a timely accurate diagnosis. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
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23
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Rebbe R, Mienko JA, Martinson ML. Incidence and Risk Factors for Abusive Head Trauma: A Population-Based Study. CHILD ABUSE REVIEW (CHICHESTER, ENGLAND : 1992) 2020; 29:195-207. [PMID: 33071539 PMCID: PMC7567009 DOI: 10.1002/car.2630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/25/2020] [Indexed: 06/11/2023]
Abstract
Previous studies on Abusive Head Trauma (AHT) suggest incidence may vary by geographic location and there is limited information regarding population-based risk factors on this form of child maltreatment. This study provides new knowledge regarding these two aspects using the population of the US state of Washington born between 1999 and 2013. We used a linked administrative dataset comprised of birth, hospital discharge, child protective services (CPS) and death records to identify the scale and risk factors for AHT for the state population using quantitative survival methods. We identified AHT using diagnostic codes in hospital discharge records defined by the US Centers for Disease Control. A total of 354 AHT hospitalisations were identified and the incidence for the state was 22.8 per 100 000 children under the age of one. Over 11 per cent of these children died. Risk factors included a teenaged mother at the time of birth, births paid for using public insurance, child's low birth weight, and maternal Native American race. The strongest risk factor was a prior CPS allegation, a similar finding to a California study on injury mortality. The practice and policy implications of these findings are discussed.
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Affiliation(s)
- Rebecca Rebbe
- University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA
| | - Joseph A Mienko
- Center for Social Sector Analytics & Technology, University of Washington School of Social Work, Seattle, WA, USA
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24
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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25
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Diaz-Chávez A, Lajud N, Roque A, Cheng JP, Meléndez-Herrera E, Valdéz-Alarcón JJ, Bondi CO, Kline AE. Early life stress increases vulnerability to the sequelae of pediatric mild traumatic brain injury. Exp Neurol 2020; 329:113318. [PMID: 32305419 DOI: 10.1016/j.expneurol.2020.113318] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/09/2020] [Accepted: 04/14/2020] [Indexed: 12/13/2022]
Abstract
Early life stress (ELS) is a risk factor for many psychopathologies that happen later in life. Although stress can occur in cases of child abuse, studies on non-accidental brain injuries in pediatric populations do not consider the possible increase in vulnerability caused by ELS. Hence, we sought to determine whether ELS increases the effects of pediatric mild traumatic brain injury (mTBI) on cognition, hippocampal inflammation, and plasticity. Male rats were subjected to maternal separation for 180 min per day (MS180) or used as controls (CONT) during the first 21 post-natal (P) days. At P21 the rats were anesthetized with isoflurane and subjected to a mild controlled cortical impact or sham injury. At P32 the rats were injected with the cell proliferation marker bromodeoxyuridine (BrdU, 500 mg/kg), then evaluated for spatial learning and memory in a water maze (P35-40) and sacrificed for quantification of Ki67+, BrdU+ and Iba1+ (P42). Neither MS180 nor mTBI impacted cognitive outcome when provided alone but their combination (MS180 + mTBI) decreased spatial learning and memory relative to Sham controls (p < .01). mTBI increased microglial activation and affected BrdU+ cell survival in the ipsilateral hippocampus without affecting proliferation rates. However, only MS180 + mTBI increased microglial activation in the area adjacent to the injury and the contralateral CA1 hippocampal subfield, and decreased cell proliferation in the ipsilateral neurogenic niche. Overall, the data show that ELS increases the vulnerability to the sequelae of pediatric mTBI and may be mediated by increased neuroinflammation.
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Affiliation(s)
- Arturo Diaz-Chávez
- División de Neurociencias, Centro de Investigación Biomédica de Michoacán, Instituto Mexicano del Seguro Social, Morelia, Michoacán, Mexico; Instituto de Investigaciones sobre los Recursos Naturales - Benemérita y Centenaria Universidad Michoacana de San Nicolás de Hidalgo, Morelia, Michoacán, Mexico
| | - Naima Lajud
- División de Neurociencias, Centro de Investigación Biomédica de Michoacán, Instituto Mexicano del Seguro Social, Morelia, Michoacán, Mexico
| | - Angélica Roque
- División de Neurociencias, Centro de Investigación Biomédica de Michoacán, Instituto Mexicano del Seguro Social, Morelia, Michoacán, Mexico
| | - Jeffrey P Cheng
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Esperanza Meléndez-Herrera
- Instituto de Investigaciones sobre los Recursos Naturales - Benemérita y Centenaria Universidad Michoacana de San Nicolás de Hidalgo, Morelia, Michoacán, Mexico
| | - Juan José Valdéz-Alarcón
- Centro Multidisciplinario de Estudios en Biotecnología, Benemérita y Centenaria Universidad Michoacana de San Nicolás de Hidalgo, Morelia, Michoacán, Mexico
| | - Corina O Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America; Neurobiology, University of Pittsburgh, Pittsburgh, PA, United States of America; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Anthony E Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States of America; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States of America; Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, United States of America; Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America; Psychology, University of Pittsburgh, Pittsburgh, PA, United States of America.
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26
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Babl FE, Pfeiffer H, Kelly P, Dalziel SR, Oakley E, Borland ML, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Lyttle MD, Bressan S, Donath S, Hearps SJC, Smith A, Crowe L. Paediatric abusive head trauma in the emergency department: A multicentre prospective cohort study. J Paediatr Child Health 2020; 56:615-621. [PMID: 31821681 DOI: 10.1111/jpc.14700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/10/2019] [Accepted: 10/27/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Franz E Babl
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Helena Pfeiffer
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Patrick Kelly
- Emergency department, Starship Children's Health, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Stuart R Dalziel
- Emergency department, Starship Children's Health, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Amit Kochar
- Emergency department, Women's & Children's Hospital, Adelaide, South Australia, Australia
| | - Sarah Dalton
- Emergency department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - John A Cheek
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Yuri Gilhotra
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Mark D Lyttle
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom.,Academic Department of Emergency Care, University of the West of England, Bristol, United Kingdom
| | - Silvia Bressan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Susan Donath
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen J C Hearps
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Anne Smith
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Victorian Forensic Paediatric Medical Service, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Louise Crowe
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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27
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Avoiding skull radiographs in infants with suspected inflicted injury who also undergo head CT: "a no-brainer?". Eur Radiol 2019; 30:1480-1487. [PMID: 31797078 PMCID: PMC7033062 DOI: 10.1007/s00330-019-06579-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/08/2019] [Accepted: 11/07/2019] [Indexed: 11/13/2022]
Abstract
Objectives To assess whether head CT with 3D reconstruction can replace skull radiographs (SXR) in the imaging investigation of suspected physical abuse (SPA)/abusive head trauma (AHT). Methods PACS was interrogated for antemortem skeletal surveys performed for SPA, patients younger than 2 years, SXR and CT performed within 4 days of each other. Paired SXR and CT were independently reviewed. One reviewer analysed CT without and (3 months later) with 3D reconstructions. SXR and CT expert consensus review formed the gold standard. Observer reliability was calculated. Results A total of 104 SXR/CT examination pairs were identified, mean age 6.75 months (range 4 days to 2 years); 21 (20%) had skull fractures; two fractures on CT were missed on SXR. There were no fractures on SXR that were not seen on CT. For SXR and CT, respectively: PPV reviewer 1, 95% confidence interval (CI) 48–82% and 85–100%; reviewer 2, 67–98% and 82–100%; and NPV reviewer 1, 95%, CI 88–98% and 96–100%; reviewer 2, 88–97% and 88–98%. Inter- and intra-observer reliability were respectively the following: SXR, excellent (kappa = 0.831) and good (kappa = 0.694); CT, excellent (kappa = 0.831) and perfect (kappa = 1). All results were statistically significant (p < 0.001). Conclusions CT has greater diagnostic accuracy than SXR in detecting skull fractures which is increased on concurrent review of 3D reconstructions and should be performed in every case of SPA/AHT. SXR does not add further diagnostic information and can be omitted from the skeletal survey when CT with 3D reconstruction is going to be, or has been, performed. Key Points • Head CT with 3D reconstruction is more sensitive and specific for the diagnosis of skull fractures. • Skull radiographs can be safely omitted from the initial skeletal survey performed for suspected physical abuse when head CT with 3D reconstruction is going to be, or has been, performed.
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28
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Zins ZP, Wheeler KK, Brink F, Armstrong M, Shi J, Groner JI, Xiang H. Trends in US physician diagnosis of child physical abuse and neglect injuries, 2006-2014. CHILD ABUSE & NEGLECT 2019; 98:104179. [PMID: 31704543 DOI: 10.1016/j.chiabu.2019.104179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/30/2019] [Accepted: 09/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if US child physical abuse and neglect injury rates changed from 2006 to 2014, whether definitive diagnoses of physical abuse and neglect were used more often over time, and what patient factors influenced definitive physical maltreatment diagnoses. METHODS Nationally estimated rates of definitive and suggestive physical abuse and neglect injuries for children <10 years were generated using the Nationwide Emergency Department Sample, the National Inpatient Sample, and census estimates. Trends over time were evaluated, including the trend in the proportion of definitive diagnoses to all diagnoses (definitive plus suggestive). Logistic regression was used to evaluate whether patient characteristics and hospital patient volumes were associated with definitive versus suggestive diagnoses. RESULTS The population rates of child physical maltreatment medically treated injuries were unchanged from 2006 to 2014; the trends were not statistically significant for ED or hospitalized patients. Over time, physician definitive diagnoses as a proportion of all physical maltreatment diagnoses (definitive plus suggestive) increased in admitted children from 17.6% in 2006 to 22.0% in 2014 (p = 0.02). Older age, white race, lower income by zip code, and public insurance as well as larger patient volumes increased the odds of definitive rather than suggestive diagnoses of physical abuse and neglect injuries. CONCLUSIONS Definitive diagnoses of physical abuse and neglect increased over the study period and were associated with hospital volume and patient characteristics which may reflect provider experience and possible bias. The use of electronic medical records may have influenced the coding of definitive diagnoses.
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Affiliation(s)
- Zachary P Zins
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Krista K Wheeler
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Farah Brink
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA; The Center for Family Safety and Healing, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Megan Armstrong
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Junxin Shi
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Jonathan I Groner
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA; Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Trauma Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Henry Xiang
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA; Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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29
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Thompson LW, Bass KD, Agyei JO, Naseem HUR, Borngraber E, Wang J, Reynolds RM. Incidence of nonaccidental head trauma in infants: a call to revisit prevention strategies. J Neurosurg Pediatr 2019; 24:689-696. [PMID: 31629317 DOI: 10.3171/2019.7.peds195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury is a major sequela of nonaccidental trauma (NAT) that disproportionately affects young children and can have lasting sequelae. Considering the potentially devastating effects, many hospitals develop parent education programs to prevent NAT. Despite these efforts, NAT is still common in Western New York. The authors studied the incidence of NAT following the implementation of the Western New York Shaken Baby Syndrome Education Program in 1998. METHODS The authors performed a retrospective chart review of children admitted to our pediatric hospital between 1999 and 2016 with ICD-9-CM and ICD-10-CM codes for types of child abuse and intracranial hemorrhage. Data were also provided by the Safe Babies New York program, which tracks NAT in Western New York. Children with a diagnosis of abuse at 0-24 months old were included in the study. Children who suffered a genuine accidental trauma or those with insufficient corroborating evidence to support the NAT diagnosis were excluded. RESULTS A total of 107 children were included in the study. There was a statistically significant rise in both the incidence of NAT (p = 0.0086) and the incidence rate of NAT (p = 0.0235) during the study period. There was no significant difference in trendlines for annual NAT incidence between sexes (y-intercept p = 0.5270, slope p = 0.5263). When stratified by age and sex, each age group had a distinct and statistically significant incidence of NAT (y-intercept p = 0.0069, slope p = 0.0374). CONCLUSIONS Despite educational interventions targeted at preventing NAT, there is a significant rise in the trend of newly reported cases of NAT, indicating a great need for better injury prevention programming.
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Affiliation(s)
- LaVerne W Thompson
- 1Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo; and
| | | | | | | | | | - Jiefei Wang
- 4Biostatistics, University at Buffalo, New York
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30
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Pritchard E, Tsindos T, Ayton D. Practitioner perspectives on the nexus between acquired brain injury and family violence. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:1283-1294. [PMID: 31140672 DOI: 10.1111/hsc.12770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 06/09/2023]
Abstract
Family violence has been highlighted by the World Health Organization as a major public health concern. Although family violence occurs to all genders, a higher prevalence of victims are female. Estimates report around 30% of all women experience intimate partner violence worldwide. Experiencing assault in the family violence context can lead to an acquired brain injury (ABI); however, the connection between these two phenomena has not been well established. The aim of this qualitative study was to explore the extent of, and factors contributing to, ABI and family violence. We conducted 22 semi-structured interviews and one focus group (n = 4) with practitioners working with family violence victims and/or perpetrators. Thematic data analysis utilised inductive and deductive coding approaches. The Social Determinants of Health Framework was used to guide analysis. Practitioners estimated 30%-40% of the clients on their caseloads had a suspected or diagnosed ABI. They identified that contributing factors were extremely complex. These included acquiring an ABI through assault (past family violence or other criminal act), and transport crashes. Complicating factors of ABI were identified as mental health conditions, alcohol and drug use, and post-traumatic stress disorder. Additional factors contributing to family violence were recognised as biological (age of parent, twin births, pregnancy, premature births, and children with congenital abnormalities), relationships (intimate partner, father, boyfriend, mother and siblings), previous trauma (family violence), and life stressors (unemployment, financial, and lack of housing). Social determinants of health included cultural (ethnicity, societal attitudes, values, and beliefs) and organisational (legislation and policy) factors which influenced behaviours and outcomes across all sectors. A model of Brain injury Family violence Nexus (BFN) was created to understand the interaction between these phenomena. Utilising the BFN model to understand the interaction can enhance the methods used within health and social services for a more efficacious approach.
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Affiliation(s)
- Elizabeth Pritchard
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tess Tsindos
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Darshini Ayton
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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31
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Gibbs KA, Dickinson A, Rasmussen S. Caring for Children with Non-Accidental Head Injuries: A Case for a Child-Centered Approach. Compr Child Adolesc Nurs 2019; 43:274-285. [PMID: 31424959 DOI: 10.1080/24694193.2019.1654039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Child abuse remains a significant issue. Non-accidental head injury (NAHI) is a major cause of mortality in young children with survivors often having to live a life with severe developmental and neurological dysfunction. The aim of this hermeneutic phenomenological research study was to examine the lived experiences of nurses who care for children and their families admitted to hospital with a non-accidental head injury. Semi-structured interviews were conducted with six nurses who had at least five years' experience of nursing children with NAHI. Following the interpretive approach described by van Manen data was analyzed and two essential themes identified. Firstly, nursing children with NAHI is different from the care of children admitted with a similar neurological injury related to accidental injuries or medical conditions. Secondly, when nursing these children nurses adopt protective qualities, conceptualized in this study as a shield of protection. The findings of this study support the findings of other studies in regard to the emotional labor required of nurses caring for children who have been subject to child abuse and the importance for nurses of maintaining a professional demeanor. The study highlighted the tensions of sustaining a family-centered care approach when caring for a child with NAHI. It is argued that greater acknowledgment and emotional support for nurses is needed and that a child-centered approach offers a more compatible model of care than Family-Centered Care in the acute phase of caring for children with a NAHI.
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Affiliation(s)
- Kristy-Anne Gibbs
- School of Clinical Sciences/Nursing, Auckland University of Technology , Auckland, New Zealand
| | - Annette Dickinson
- School of Clinical Sciences/Nursing, Auckland University of Technology , Auckland, New Zealand
| | - Shayne Rasmussen
- School of Clinical Sciences/Nursing, Auckland University of Technology , Auckland, New Zealand
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Fraser BD, Lingo PR, Khan NR, Vaughn BN, Klimo P. Pediatric Abusive Head Trauma: Return to Hospital System in the First Year Post Injury. Neurosurgery 2019; 85:E66-E74. [PMID: 30476266 DOI: 10.1093/neuros/nyy456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Abusive head trauma (AHT) may result in costly, long-term sequelae. OBJECTIVE To describe the burden of AHT on the hospital system within the first year of injury. METHODS Single institution retrospective evaluation of AHT cases from January 2009 to August 2016. Demographic, clinical (including injury severity graded I-III), and charge data associated with both initial and return hospital visits within 1 yr of injury were extracted. RESULTS A total of 278 cases of AHT were identified: 60% male, 76% infant, and 54% African-American. Of these 278 cases, 162 (60%) returned to the hospital within the first year, resulting in 676 total visits (an average of 4.2 returns/patient). Grade I injuries were less likely to return than more serious injuries (II and III). The majority were outpatient services (n = 430, 64%); of the inpatient readmissions, neurosurgery was the most likely service to be involved (44%). Neurosurgical procedures accounted for the majority of surgeries performed during both initial admission and readmission (85% and 68%, respectively). Increasing injury severity positively correlated with charges for both the initial admission and returns (P < .001 for both). Total calculated charges, including initial admission and returns, were over $25 million USD. CONCLUSION AHT has a high potential for return to the hospital system within the first year. Inpatient charges dominate and account for the vast majority of hospital returns and overall charges. A more severe initial injury correlates with increased charges on initial admission and on subsequent hospital return.
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Affiliation(s)
- Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - P Ryan Lingo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey, Memphis, Tennessee
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Smith EB, Lee JK, Vavilala MS, Lee SA. Pediatric Traumatic Brain Injury and Associated Topics: An Overview of Abusive Head Trauma, Nonaccidental Trauma, and Sports Concussions. Anesthesiol Clin 2019; 37:119-134. [PMID: 30711225 DOI: 10.1016/j.anclin.2018.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pediatric traumatic brain injury (TBI) uniquely affects the pediatric population. Abusive head trauma (AHT) is a subset of severe pediatric TBI usually affecting children in the first year of life. AHT is a form of nonaccidental trauma. Sports-related TBI resulting in concussion is a milder form of TBI affecting older children. Current recommended perioperative management of AHT and sports concussions relies on general pediatric TBI guidelines. Research into more specific pediatric TBI screening and management goals is ongoing. This article reviews the epidemiology, mechanisms, clinical signs, and management of AHT and sports-related concussions.
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Affiliation(s)
- Erik B Smith
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA.
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Monica S Vavilala
- Department of Anesthesiology, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Sarah A Lee
- Department of Anesthesiology, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA
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Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Part I: A systematic review of animal models. Forensic Sci Med Pathol 2019; 15:408-422. [PMID: 30828765 PMCID: PMC6687679 DOI: 10.1007/s12024-019-0082-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2019] [Indexed: 10/27/2022]
Abstract
Inflicted blunt force trauma and/or repetitive acceleration-deceleration trauma in infants can cause brain injury. Yet, the exact pathophysiologic mechanism with its associated thresholds remains unclear. In this systematic review an overview of animal models for shaking trauma and their findings on tissue damage will be provided. A systematic review was performed in MEDLINE and Scopus for articles on the simulation of inflicted head injury in animals. After collection, the studies were independently screened by two researchers for title, abstract, and finally full text and on methodological quality. A total of 12 articles were included after full-text screening. Three articles were based on a single study population of 13 lambs, by one research group. The other 9 articles were separate studies in piglets, all by a single second research group. The lamb articles give some information on tissue damage after inflicted head injury. The piglet studies only provide information on consequences of a single plane rotational movement. Generally, with increasing age and weight, there was a decrease of axonal injury and death. Future studies should focus on every single step in the process of a free movement in all directions, resembling human infant shaking. In part II of this systematic review biomechanical models will be evaluated.
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Mankad K, Chhabda S, Lim W, Oztekin O, Reddy N, Chong WK, Shroff M. The neuroimaging mimics of abusive head trauma. Eur J Paediatr Neurol 2019; 23:19-30. [PMID: 30527893 DOI: 10.1016/j.ejpn.2018.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the paediatric population, typically in children under the age of two years. Neuroimaging plays a key role in the diagnostic work up of these patients as information regarding the mechanism of injury is often lacking and the findings on examination can be nonspecific. A number of conditions, both traumatic and atraumatic can mimic AHT based on neuroimaging features alone. The repercussions associated with a diagnosis or misdiagnosis of AHT can be severe and radiologists therefore need to be aware of and familiar with the imaging differentials of AHT. In this paper we review the imaging findings of the radiological mimics of AHT and focus on features that can help differentiate these entities from AHT.
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Affiliation(s)
- Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, United Kingdom.
| | - Sahil Chhabda
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Wanyin Lim
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Ozgur Oztekin
- Department of Neuroradiology, Tepecik Education and Research Hospital, Izmir, 35180, Turkey
| | - Nihaal Reddy
- Department of Radiology, The Royal Children's Hospital, Melbourne, Australia
| | - Wui Kean Chong
- Department of Neuroradiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Manohar Shroff
- Department of Neuroradiology, SickKids, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
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Amanullah S, Schlichting LE, Linakis SW, Steele DW, Linakis JG. Emergency Department Visits Owing to Intentional and Unintentional Traumatic Brain Injury among Infants in the United States: A Population-Based Assessment. J Pediatr 2018; 203:259-265.e1. [PMID: 30266505 DOI: 10.1016/j.jpeds.2018.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/24/2018] [Accepted: 08/09/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine national trends of emergency department (ED) visits owing to traumatic brain injury (TBI) among infants (age <12 months), specifically in the context of intentional and unintentional mechanisms. STUDY DESIGN National Electronic Injury Surveillance System-All Injury Program data documenting nonfatal ED visits from 2003 to 2012 were analyzed. TBI was defined as ED visits resulting in a diagnosis of concussion, or fracture, or internal injury of the head. Intentional and unintentional injury mechanisms were compared using multivariable models. Joinpoint regression was used to identify significant time trends. RESULTS TBI-related ED visits (estimated n = 713 124) accounted for 28% of all injury-related ED visits by infants in the US, yielding an average annual rate of 1722 TBI-related ED visits per 100 000 infants. Trend analysis showed an annual increase of 9.48% in the rate of TBI-related ED visits over 10 years (P < .05). For these visits, an estimated 701 757 (98.4%) were attributed to unintentional mechanisms and 11 367 (1.6%) to intentional mechanisms. Unintentional TBI-related ED visit rates increased by 9.52% annually (P < .05) and the rates of intentional TBI were relatively stable from 2003 to 2012. Infants with intentional TBI were more likely to be admitted (aOR, 11.44; 95% CI, 3.02-21.75) compared with those with unintentional TBI. CONCLUSIONS The rate of TBI-related ED visits in infants increased primarily owing to unintentional mechanisms and intentional TBI-related ED visits remained stable over the decade. Improved strategies to reduce both intentional and unintentional injuries in infants are required.
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Affiliation(s)
- Siraj Amanullah
- Department of Emergency Medicine; Department of Pediatrics, Alpert Medical School of Brown University; Department of Health Services, Policy and Practice; Hassenfeld Child Health Innovation Institute, Brown School of Public Health; Injury Prevention Center, Rhode Island Hospital, Providence, RI.
| | | | - Seth W Linakis
- Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Dale W Steele
- Department of Emergency Medicine; Department of Pediatrics, Alpert Medical School of Brown University; Department of Health Services, Policy and Practice; Center for Evidence Synthesis in Health, Brown School of Public Health, Providence, RI
| | - James G Linakis
- Department of Emergency Medicine; Department of Pediatrics, Alpert Medical School of Brown University; Hassenfeld Child Health Innovation Institute, Brown School of Public Health; Injury Prevention Center, Rhode Island Hospital, Providence, RI
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Kralik SF, Supakul N, Wu IC, Delso G, Radhakrishnan R, Ho CY, Eley KA. Black bone MRI with 3D reconstruction for the detection of skull fractures in children with suspected abusive head trauma. Neuroradiology 2018; 61:81-87. [DOI: 10.1007/s00234-018-2127-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
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Miller TR, Steinbeigle R, Lawrence BA, Peterson C, Florence C, Barr M, Barr RG. Lifetime Cost of Abusive Head Trauma at Ages 0-4, USA. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2018; 19:695-704. [PMID: 28685210 PMCID: PMC5756522 DOI: 10.1007/s11121-017-0815-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids' Inpatient Database, and previous studies. Unit costs were derived from published sources. From society's perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2-9.2 million) for a death. It averages $2.6 million (95% CI $1.0-2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5-16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.
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Affiliation(s)
- Ted R Miller
- Pacific Institute for Research and Evaluation, 11720 Beltsville Drive, Suite 900, Calverton, MD, 20705, USA.
- Centre for Population Health Research, Curtin University, Perth, Australia.
| | | | - Bruce A Lawrence
- Pacific Institute for Research and Evaluation, 11720 Beltsville Drive, Suite 900, Calverton, MD, 20705, USA
| | - Cora Peterson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Curtis Florence
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Marilyn Barr
- National Center on Shaken Baby Syndrome, Farmington, UT, USA
| | - Ronald G Barr
- Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
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Bechtel K, Bhatnagar A, Auerbach M. Simulation-based research to improve infant health outcomes: Using the infant simulator to prevent infant shaking. Infant Behav Dev 2018; 56:101263. [PMID: 29903429 DOI: 10.1016/j.infbeh.2018.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
Abstract
Simulation is a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions. We will first provide an introduction to simulation in healthcare and describe the two types of simulation-based research (SBR) in the pediatric population. We will then provide an overview of the use of SBR to improve health outcomes for infants in health care settings and to improve parent-child interactions using the infant simulator. Finally, we will discuss previous and future research using simulation to reduce morbidity and mortality from abusive head trauma, the most common cause of traumatic death in infancy.
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Affiliation(s)
- Kirsten Bechtel
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States.
| | - Ambika Bhatnagar
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States
| | - Marc Auerbach
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States
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Kim SY, Morgan LA, Baldwin AJ, Suh DW. Comparison of the characteristics of retinal hemorrhages in abusive head trauma versus normal vaginal delivery. J AAPOS 2018; 22:139-144. [PMID: 29548839 DOI: 10.1016/j.jaapos.2017.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 12/06/2017] [Accepted: 12/19/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Retinal hemorrhage (RH) is one of the hallmarks of abusive head trauma (AHT); however, RH is also encountered with normal vaginal deliveries (NVD) and thus presents the clinician with a diagnostic dilemma. The purpose of this study was to compare RHs in AHT with those of NVD. METHODS Records of with AHT and NVD infants with RH evaluated from 2013 to 2015 were reviewed retrospectively. Pattern, size, extent, and severity were compared using RetCam images. Severities were calculated using the RH grading scale. RESULTS A total of 20 patients with AHT and 200 NVD infants were included. RH size was significantly larger in AHT patients compared to the NVD group (3.1 ± 0.512 vs 0.96 ± 0.046 disk diameters, resp.). The AHT group also demonstrated a higher RH incidence involving all three retinal layers compared to the NVD group (60% vs 0.6%, resp. [P < 0.001]). Vitreous hemorrhages were more common in the AHT group compared to the NVD group (54.3% vs 1.5% [P < 0.001]). Also, the grading scale demonstrated higher scores in the AHT group than the NVD group (7.15 ± 0.948 vs 3.59 ± 0.274, resp.). CONCLUSIONS AHT and NVD share similar retinal findings, but they also have unique differentiators. In our subjects, AHT presented with more severe retinal findings than NVD, including larger RH size, a higher percentage involving all three retinal layers, a higher percentage of vitreous hemorrhages, and higher RH grading scale scores. Also, NVD retinal hemorrhages resolved quickly, within 4 weeks of birth in 95% of the patients.
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Affiliation(s)
- So Young Kim
- Children's Hospital and Medical Center, Omaha, Nebraska
| | - Linda A Morgan
- Children's Hospital and Medical Center, Omaha, Nebraska.
| | | | - Donny W Suh
- Children's Hospital and Medical Center, Omaha, Nebraska; University of Nebraska Medical Center, Omaha, Nebraska
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Does Payer Type Influence Pediatric Burn Outcomes? A National Study Using the Healthcare Cost and Utilization Project Kids' Inpatient Database. J Burn Care Res 2018; 37:314-20. [PMID: 26284632 DOI: 10.1097/bcr.0000000000000290] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric burns are a considerable source of injury in the United States. Socioeconomic status has been demonstrated to influence other disease outcomes. The goal of this study was to analyze national pediatric burn outcomes based on payer type. A retrospective study was designed using the Kids' Inpatient Database (KID), years 2000 to 2009. Patients 18 years of age and under with Major Diagnostic code number 22 for burn were included. A total of 22,965 patients were identified, estimating 37,856 discharges. Descriptive and bivariate statistics were performed. Multiple regression analysis was used to assess correlation of payer type with complications and length of stay (LOS). The majority of patients were Medicaid (52.3%). Medicaid patients were younger (4.25, P < .05), had a higher rate of being in the first quartile of their zipcode's income (46.26%, P < .05), and contained a higher proportion of African-Americans (30.01%, P < .05). Overall complication rate was higher among Medicaid patients than private insurance and self-pay patients (6.64 vs 5.51 and 4.35%, respectively, P = .11). Logistic regression analysis of complications showed that Medicaid coverage (P < .001) was associated with complications. The geometric mean LOS among Medicaid patients was 3.7 days compared with private insurance (3.5 days) and self-pay patients (3.1 days). Medicaid patients had longer LOS and more complications. Regression analysis revealed that payer type was a factor in LOS and overall complication rate. Identifying dissimilar outcomes based on patient and injury characteristics is critical in providing information on how to improve those outcomes.
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Khan NR, Fraser BD, Nguyen V, Moore K, Boop S, Vaughn BN, Klimo P. Pediatric abusive head trauma and stroke. J Neurosurg Pediatr 2017; 20:183-190. [PMID: 28574318 DOI: 10.3171/2017.4.peds16650] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite established risk factors, abusive head trauma (AHT) continues to plague our communities. Cerebrovascular accident (CVA), depicted as areas of hypodensity on CT scans or diffusion restriction on MR images, is a well-known consequence of AHT, but its etiology remains elusive. The authors hypothesize that a CVA, in isolation or in conjunction with other intracranial injuries, compounds the severity of a child's injury, which in turn leads to greater health care utilization, including surgical services, and an increased risk of death. METHODS The authors conducted a retrospective observational study to evaluate data obtained in all children with AHT who presented to Le Bonheur Children's Hospital (LBCH) from January 2009 through August 2016. Demographic, hospital course, radiological, cost, and readmission information was collected. Children with one or more CVA were compared with those without a CVA. RESULTS The authors identified 282 children with AHT, of whom 79 (28%) had one or more CVA. Compared with individuals without a CVA, children with a stroke were of similar overall age (6 months), sex (61% male), and race (56% African-American) and had similar insurance status (81% public). Just under half of all children with a stroke (38/79, 48%) were between 1-6 months of age. Thirty-five stroke patients (44%) had a Grade II injury, and 44 (56%) had a Grade III injury. The majority of stroke cases were bilateral (78%), multifocal (85%), associated with an overlying subdural hematoma (86%), and were watershed/hypoperfusion in morphology (73%). Thirty-six children (46%) had a hemispheric stroke. There were a total of 48 neurosurgical procedures performed on 28 stroke patients. Overall median hospital length of stay (11 vs 3 days), total hospital charges ($13.8 vs $6.6 million), and mean charges per patient ($174,700 vs $32,500) were significantly higher in the stroke cohort as a whole, as well as by injury grade (II and III). Twenty children in the stroke cohort (25%) died as a direct result of their AHT, whereas only 2 children in the nonstroke cohort died (1%). There was a 30% readmission rate within the first 180-day postinjury period for patients in the stroke cohort, and of these, approximately 50% required additional neurosurgical intervention(s). CONCLUSIONS One or more strokes in a child with AHT indicate a particularly severe injury. These children have longer hospital stays, greater hospital charges, and a greater likelihood of needing a neurosurgical intervention (i.e., bedside procedure or surgery). Stroke is such an important predictor of health care utilization and outcome that it warrants a subcategory for both Grade II and Grade III injuries. It should be noted that the word "stroke" or "CVA" should not automatically imply arterial compromise in this population.
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Affiliation(s)
| | - Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | - Scott Boop
- University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Brandy N Vaughn
- Department of Neurosurgery, Le Bonheur Children's Hospital; and
| | - Paul Klimo
- Department of Neurosurgery and.,Department of Neurosurgery, Le Bonheur Children's Hospital; and.,Semmes Murphey Clinic, Memphis, Tennessee
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Kelly P, Thompson JMD, Koh J, Ameratunga S, Jelleyman T, Percival TM, Elder H, Mitchell EA. Perinatal Risk and Protective Factors for Pediatric Abusive Head Trauma: A Multicenter Case-Control Study. J Pediatr 2017; 187:240-246.e4. [PMID: 28550953 DOI: 10.1016/j.jpeds.2017.04.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/29/2017] [Accepted: 04/26/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To estimate associations between factors recorded in pregnancy and the first week of life and subsequent abusive head trauma. STUDY DESIGN Multicenter, retrospective case-control study of perinatal records from 142 cases of abusive head trauma and 550 controls, matched by date and hospital of birth from 1991 to 2010. Multiple logistic regression assessed the relationship between perinatal exposures and abusive head trauma. RESULTS The risk of abusive head trauma decreased with increasing maternal age (OR, 0.91 per year; 95% CI 0.85-0.97) and increasing gestational age at birth (OR 0.79 per week; 95% CI 0.69-0.91). Mothers of cases were more likely to be Māori (OR 4.61; 95% CI 1.98-10.78), to be single (OR 5.10; 95% CI 1.83-14.23), have recorded social concerns (OR 4.29; 95% CI 1.32-13.91), and have missing data for antenatal care, partner status, social concerns, and substance abuse (OR 13.53; 95% CI 2.39-76.47). Case mothers were more likely not to take supplements in pregnancy (OR 3.53; 95% CI 1.30-9.54), to have membrane rupture longer than 48 hours before delivery (OR 13.01; 95% CI 2.84-59.68), and to formula feed (OR for mixed breast and formula feeding 6.06; 95% CI 2.39-15.36) before postnatal discharge (median 3 days). CONCLUSIONS Factors associated with subsequent abusive head trauma can be identified from routine perinatal records. Targeted interventions initiated perinatally could possibly prevent some cases of abusive head trauma. However, any plans for targeted prevention strategies should consider not only those with identified risk factors but also those for which data are missing.
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Affiliation(s)
- Patrick Kelly
- Departments of Pediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand; Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - John M D Thompson
- Departments of Pediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand; Obstetrics and Gynecology, University of Auckland, Auckland, New Zealand
| | - Jean Koh
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Shanthi Ameratunga
- Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Timothy Jelleyman
- Pediatrics and Newborn Services, Waitemata District Health Board, Auckland, New Zealand
| | - Teuila M Percival
- Departments of Pediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand; Kidz First Children's Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Hinemoa Elder
- Te Whare Wānanga o Awanuiārangi, Auckland, New Zealand
| | - Edwin A Mitchell
- Departments of Pediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Kralik SF, Finke W, Wu IC, Hibbard RA, Hicks RA, Ho CY. Radiologic head CT interpretation errors in pediatric abusive and non-abusive head trauma patients. Pediatr Radiol 2017; 47:942-951. [PMID: 28497263 DOI: 10.1007/s00247-017-3872-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/20/2017] [Accepted: 04/19/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric head trauma, including abusive head trauma, is a significant cause of morbidity and mortality. OBJECTIVE The purpose of this research was to identify and evaluate radiologic interpretation errors of head CTs performed on abusive and non-abusive pediatric head trauma patients from a community setting referred for a secondary interpretation at a tertiary pediatric hospital. MATERIALS AND METHODS A retrospective search identified 184 patients <5 years of age with head CT for known or potential head trauma who had a primary interpretation performed at a referring community hospital by a board-certified radiologist. Two board-certified fellowship-trained neuroradiologists at an academic pediatric hospital independently interpreted the head CTs, compared their interpretations to determine inter-reader discrepancy rates, and resolved discrepancies to establish a consensus second interpretation. The primary interpretation was compared to the consensus second interpretation using the RADPEER™ scoring system to determine the primary interpretation-second interpretation overall and major discrepancy rates. MRI and/or surgical findings were used to validate the primary interpretation or second interpretation when possible. The diagnosis of abusive head trauma was made using clinical and imaging data by a child abuse specialist to separate patients into abusive head trauma and non-abusive head trauma groups. Discrepancy rates were compared for both groups. Lastly, primary interpretations and second interpretations were evaluated for discussion of imaging findings concerning for abusive head trauma. RESULTS There were statistically significant differences between primary interpretation-second interpretation versus inter-reader overall and major discrepancy rates (28% vs. 6%, P=0.0001; 16% vs. 1%, P=0.0001). There were significant differences in the primary interpretation-second interpretation overall and major discrepancy rates for abusive head trauma patients compared to non-abusive head trauma patients (41% vs 23%, P=0.02; 26% vs. 12%, P=0.03). The most common findings resulting in major radiologic interpretation errors were fractures and subdural hemorrhage. Differences in the age of the patient and the percentage of patients with hemorrhage were statistically significant between the abusive head trauma versus non-abusive head trauma groups, while no statistical difference was identified for skull fractures, ischemia, head CT radiation dose, or presence of multiplanar or 3-D reformatted images. The second interpretation more frequently indicated potential for abusive head trauma compared to the primary interpretation (P=0.0001). MRI and/or surgical findings were in agreement with the second interpretation in 29/29 (100%) of patients with discrepancies. CONCLUSION A high incidence of radiologic interpretation errors may occur in pediatric trauma patients at risk for abusive head trauma who are referred from a community hospital. This suggests value for second interpretations of head CTs at a tertiary pediatric hospital for this patient population.
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Affiliation(s)
- Stephen F Kralik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 714 N. Senate Ave., Indianapolis, IN, 46202, USA.
| | - Whitney Finke
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 714 N. Senate Ave., Indianapolis, IN, 46202, USA
| | - Isaac C Wu
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 714 N. Senate Ave., Indianapolis, IN, 46202, USA
| | - Roberta A Hibbard
- Department of Pediatrics, Section of Child Protection Programs, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ralph A Hicks
- Department of Pediatrics, Section of Child Protection Programs, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chang Y Ho
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 714 N. Senate Ave., Indianapolis, IN, 46202, USA
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Lee EP, Hsia SH, Huang JL, Lin JJ, Chan OW, Lin CY, Lin KL, Chang YC, Chou IJ, Lo FS, Lee J, Hsin YC, Chan PC, Hu MH, Chiu CH, Wu HP. Epidemiology and clinical analysis of critical patients with child maltreatment admitted to the intensive care units. Medicine (Baltimore) 2017; 96:e7107. [PMID: 28591056 PMCID: PMC5466234 DOI: 10.1097/md.0000000000007107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Children with abuse who are admitted to the intensive care unit (ICU) may have high mortality and morbidity and commonly require critical care immediately. It is important to understand the epidemiology and clinical characteristics of these critical cases of child maltreatment.We retrospectively evaluated the data for 355 children with maltreatments admitted to the ICU between 2001 and 2015. Clinical factors were analyzed and compared between the abuse and the neglect groups, including age, gender, season of admission, identifying settings, injury severity score (ISS), etiologies, length of stay (LOS) in the ICU, clinical outcomes, and mortality. In addition, neurologic assessments were conducted with the Pediatric Cerebral Performance Category (PCPC) scale.The most common type of child maltreatments was neglect (n = 259), followed by physical abuse (n = 96). The mean age of the abuse group was less than that of the neglect group (P < .05). Infants accounted for the majority of the abuse group, and the most common etiology of abuse was injury of the central nervous system (CNS). In the neglect group, most were of the preschool age and the most common etiologies of abuse were injury of the CNS and musculoskeletal system (P < .001). The mortality rate in the ICU was 9.86%. The ISS was significantly associated with mortality in both the 2 groups (both P < .05), whereas the LOS in the ICU and injuries of the CNS, musculoskeletal system, and respiratory system were all associated with mortality in the neglect group (all P < .05). The PCPC scale showed poor prognosis in the abuse group as compared to the neglect group (P < .01).In the ICU, children in the abuse group had younger age, higher ISS, and worse neurologic outcome than those in the neglect group. The ISS was a predictor for mortality in the abuse and neglect groups but the LOS in the ICUs, injuries of the CNS, musculoskeletal system, and respiratory system were indicators for mortality in the neglect group. Most importantly, identifying the epidemiological information may provide further strategies to reduce the harm, lower the medical costs, and improve clinical care quality and outcomes in children with abuse.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine
- College of Medicine, Chang Gung University
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine
- College of Medicine, Chang Gung University
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Jing-Long Huang
- College of Medicine, Chang Gung University
- Division of Pediatric Allery, Asthma, and Rheumatology1
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine
- College of Medicine, Chang Gung University
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine
- College of Medicine, Chang Gung University
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Chia-Ying Lin
- Division of Pediatric Critical Care Medicine
- College of Medicine, Chang Gung University
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- College of Medicine, Chang Gung University
- Division of Pediatric Neurology
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Yu-Ching Chang
- Division of Pediatric General Medicine
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - I-Jun Chou
- College of Medicine, Chang Gung University
- Division of Pediatric Neurology
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Fu-Song Lo
- Division of Pediatric Endocrinology
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Jung Lee
- College of Medicine, Chang Gung University
- Division of Pediatric General Medicine
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Yi-Chen Hsin
- College of Medicine, Chang Gung University
- Division of Pediatric General Medicine
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Pei-Chun Chan
- College of Medicine, Chang Gung University
- Division of Pediatric General Medicine
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Mei-Hua Hu
- College of Medicine, Chang Gung University
- Division of Pediatric General Medicine
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- College of Medicine, Chang Gung University
- Division of Pediatric Infectious Diseases
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
| | - Han-Ping Wu
- College of Medicine, Chang Gung University
- Division of Pediatric General Medicine
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan
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Kralik SF, Yasrebi M, Supakul N, Lin C, Netter LG, Hicks RA, Hibbard RA, Ackerman LL, Harris ML, Ho CY. Diagnostic Performance of Ultrafast Brain MRI for Evaluation of Abusive Head Trauma. AJNR Am J Neuroradiol 2017; 38:807-813. [PMID: 28183837 DOI: 10.3174/ajnr.a5093] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/05/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MR imaging with sedation is commonly used to detect intracranial traumatic pathology in the pediatric population. Our purpose was to compare nonsedated ultrafast MR imaging, noncontrast head CT, and standard MR imaging for the detection of intracranial trauma in patients with potential abusive head trauma. MATERIALS AND METHODS A prospective study was performed in 24 pediatric patients who were evaluated for potential abusive head trauma. All patients received noncontrast head CT, ultrafast brain MR imaging without sedation, and standard MR imaging with general anesthesia or an immobilizer, sequentially. Two pediatric neuroradiologists independently reviewed each technique blinded to other modalities for intracranial trauma. We performed interreader agreement and consensus interpretation for standard MR imaging as the criterion standard. Diagnostic accuracy was calculated for ultrafast MR imaging, noncontrast head CT, and combined ultrafast MR imaging and noncontrast head CT. RESULTS Interreader agreement was moderate for ultrafast MR imaging (κ = 0.42), substantial for noncontrast head CT (κ = 0.63), and nearly perfect for standard MR imaging (κ = 0.86). Forty-two percent of patients had discrepancies between ultrafast MR imaging and standard MR imaging, which included detection of subarachnoid hemorrhage and subdural hemorrhage. Sensitivity, specificity, and positive and negative predictive values were obtained for any traumatic pathology for each examination: ultrafast MR imaging (50%, 100%, 100%, 31%), noncontrast head CT (25%, 100%, 100%, 21%), and a combination of ultrafast MR imaging and noncontrast head CT (60%, 100%, 100%, 33%). Ultrafast MR imaging was more sensitive than noncontrast head CT for the detection of intraparenchymal hemorrhage (P = .03), and the combination of ultrafast MR imaging and noncontrast head CT was more sensitive than noncontrast head CT alone for intracranial trauma (P = .02). CONCLUSIONS In abusive head trauma, ultrafast MR imaging, even combined with noncontrast head CT, demonstrated low sensitivity compared with standard MR imaging for intracranial traumatic pathology, which may limit its utility in this patient population.
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Affiliation(s)
- S F Kralik
- From the Department of Radiology and Imaging Sciences (S.F.K., M.Y., N.S., C.L., L.G.N., C.Y.H.)
| | - M Yasrebi
- From the Department of Radiology and Imaging Sciences (S.F.K., M.Y., N.S., C.L., L.G.N., C.Y.H.)
| | - N Supakul
- From the Department of Radiology and Imaging Sciences (S.F.K., M.Y., N.S., C.L., L.G.N., C.Y.H.)
| | - C Lin
- From the Department of Radiology and Imaging Sciences (S.F.K., M.Y., N.S., C.L., L.G.N., C.Y.H.)
| | - L G Netter
- From the Department of Radiology and Imaging Sciences (S.F.K., M.Y., N.S., C.L., L.G.N., C.Y.H.)
| | - R A Hicks
- Child Protective Program (R.A. Hicks, R.A. Hibbard)
| | - R A Hibbard
- Child Protective Program (R.A. Hicks, R.A. Hibbard)
| | | | - M L Harris
- Neurology (M.L.H.), Indiana University School of Medicine, Indianapolis, Indiana
| | - C Y Ho
- From the Department of Radiology and Imaging Sciences (S.F.K., M.Y., N.S., C.L., L.G.N., C.Y.H.)
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47
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Abstract
OBJECTIVE Research on pediatric abusive head trauma (AHT) has largely focused on clinical presentation and management. The authors sought to review a single-institution experience from a public health perspective to gain a better understanding of the local population affected, determine overall incidence and seasonal trends, and provide details on the initial hospitalization, including extent of injuries, neurosurgical interventions, and hospital charges. METHODS All cases of AHT involving patients who presented to Le Bonheur Children's Hospital (LBCH) from 2009 through 2014 were identified. AHT was defined as skull fracture or intracranial hemorrhage in a child under the age of 5 years with a suspicious mechanism or evidence of other intentional injuries, such as retinal hemorrhages, old or new fractures, or soft-tissue bruising. Injuries were categorized as Grade I (skull fracture only), Grade II (intracranial hemorrhage or edema not requiring surgical intervention), or Grade III (intracranial hemorrhage requiring intervention or death due to brain injury). RESULTS Two hundred thirteen AHT cases were identified. The demographics of the study population are similar to those reported in the literature: the majority of the patients involved were 6 months of age or younger (55%), male (61%), African American (47%), and publicly insured (82%). One hundred one neurosurgical procedures were performed in 58 children, with the most common being bur hole placement for treatment of subdural collections (25%) and decompressive hemicraniectomy (22%). The annual incidence rate rose from 2009 (19.6 cases per 100,000 in the population under 5 years of age) to 2014 (47.4 cases per 100,000) and showed seasonal peaks in January, July, and October (6-year average single-month incidence, respectively, 24.7, 21.7, and 24.7 per 100,000). The total hospital charges were $13,014,584, with a median cost of $27,939. Treatment costs for children who required surgical intervention (i.e., those with Grade III) were up to 10 times those of children with less severe injuries. CONCLUSIONS In the authors' local population, victims of AHT are overwhelmingly infants, are more often male than female, and are disproportionately from lower socioeconomic ranks. The incidence is increasing and initial hospitalization charges are substantial and variable. The authors introduce a simple 3-tiered injury classification scheme that adequately stratifies length of hospital stay and cost.
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Affiliation(s)
- Scott Boop
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mary Axente
- Neuroscience Institute, Le Bonheur Children's Hospital
| | | | - Paul Klimo
- Neuroscience Institute, Le Bonheur Children's Hospital.,Department of Neurosurgery, University of Tennessee Health Science Center; and.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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Sato A, Kikuchi N, Yokota S. Inadequate sociomedical evaluation of possible abusive head trauma in Yokohama. Pediatr Int 2016; 58:445-9. [PMID: 26513132 DOI: 10.1111/ped.12840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 09/11/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND There have been no previous studies on the adequacy of combined evaluation of possible abusive head trauma cases by frontline medical personnel, hospital-based child protection teams, and child protective services in local districts of Japan. METHODS We conducted a questionnaire survey of hospitalized patients under 24 months old with a diagnosis of intracranial hemorrhage (ICH) from January 2011 to December 2013. Eleven large-scale general hospitals in Yokohama, Japan were surveyed, which provide centralized inpatient care to moderately-severely ill children. RESULTS A total of 51 ICH patients were listed from eight hospitals. Median patient age was 7 months, and 84% were younger than 12 months. The most common diagnosis on computed tomography was subdural hematoma (n = 26; 51%). Of a total of 51 cases, 31 (61%) occurred inside the home; the injury scene was unknown in six cases (12%). We reviewed these 37 cases from the viewpoint of evaluation with concern for suspected child abuse. Three out of 37 patients (8%) were not examined for inflicted skin lesions, and skeletal surveys and funduscopy were not conducted in 14 (38%) and 15 (41%), respectively. Thirteen out of 37 cases (35%) were not reported to hospital-based child protection teams and 22 (59%) were not reported to regional child protective services. CONCLUSION The sociomedical evaluation of possible child abuse appears to be systematically inadequate in Yokohama.
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Affiliation(s)
- Atsuo Sato
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Kanagawa, Japan.,Department of Pediatrics, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Nobuyuki Kikuchi
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Kanagawa, Japan.,Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Shumpei Yokota
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Kanagawa, Japan.,Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma. J Trauma Acute Care Surg 2016; 80:711-6. [DOI: 10.1097/ta.0000000000000954] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Bailhache M, Bénard A, Salmi LR. Simulation of the Impact of Programs for Prevention and Screening of Pediatric Abusive Head Trauma. J Neurotrauma 2016; 33:1397-403. [PMID: 26566679 DOI: 10.1089/neu.2015.4014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Primary prevention programs of pediatric abusive head trauma (PAHT) exist and early screening is proposed, but negative effects of mislabeling parents as abusers, an important issue, are not well documented. The aim of our study was to simulate the possible impact of programs for the primary prevention and screening of PAHT. We developed Markov models that simulate the life histories of PAHT with no intervention, with primary prevention program only, with screening program, and with both programs in a hypothetical cohort of 800,000 newborns in a high-income country. Screening program would be addressed to all families until children are 2 years old, during repeated consultations. Potential side effects for parents being mislabeled as abusers were supposed to increase the probability of PAHT and decrease participation in screening. Time horizon was 2 years with cycles of 15 days. Outcomes were number of deaths and abused children avoided. Uncertainty was specified with probability distributions. After 2 years, the median number of deaths avoided through primary prevention would vary from 6 (95% confidence interval [CI] 2-11) to 28 (95% CI 6-51) per 100,000 newborns. Screening could prevent up to 6 (95% CI 0-29) or cause up to 66 (95% CI 0-361) deaths per 100,000 children born alive. The impact of both programs was uncertain. Our model confirmed the potential benefits of primary prevention and documented the uncertainty associated with screening of PAHT.
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Affiliation(s)
- Marion Bailhache
- 1 CHU de Bordeaux, Pole de pediatrie, Service d'information medicale , Bordeaux, France .,2 Univ. Bordeaux , ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France
| | - Antoine Bénard
- 2 Univ. Bordeaux , ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France .,3 Pole de sante publique, Service d'information medicale , Bordeaux, France .,4 Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique , Bordeaux, France
| | - Louis-Rachid Salmi
- 2 Univ. Bordeaux , ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France .,3 Pole de sante publique, Service d'information medicale , Bordeaux, France
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