Nonaccidental Trauma in Pediatric Surgery

Can Hemorrhagic Stroke Genetics Help Forensic Diagnosis in Pediatric Age (<5 Years Old)?

When stroke occurs in pediatric age, it might be mistakenly interpreted as non-accidental head injury (NAHI). In these situations, a multidisciplinary approach is fundamental, including a thorough personal and familial history, along with accurate physical examination and additional investigations. Especially when the clinical picture is uncertain, it is important to remember that certain genetic conditions can cause bleeding inside the brain, which may resemble NAHI. Pediatric strokes occurring around the time of birth can also be an initial sign of undiagnosed genetic disorders. Hence, it is crucial to conduct a thorough evaluation, including genetic testing, when there is a suspicion of NAHI but the symptoms are unclear. In these cases, a characteristic set of symptoms is often observed. This study aims to summarize some of the genetic causes of hemorrhagic stroke in the pediatric population, thus mimicking non-accidental head injury, considering elements that can be useful in characterizing pathologies. A systematic review of genetic disorders that may cause ICH in children was carried out according to the Preferred Reporting Item for Systematic Review (PRISMA) standards. We selected 10 articles regarding the main genetic diseases in stroke; we additionally selected 11 papers concerning patients with pediatric stroke and genetic diseases, or studies outlining the characteristics of stroke in these patients. The disorders we identified were Moyamoya disease (MMD), COL4A1, COL4A2 pathogenic variant, Ehlers-Danlos syndrome (E-D), neurofibromatosis type 1 (Nf1), sickle cell disease (SCD), cerebral cavernous malformations (CCM), hereditary hemorrhagic telangiectasia (HHT) and Marfan syndrome. In conclusion, this paper provides a comprehensive overview of the genetic disorders that could be tested in children when there is a suspicion of NAHI but an unclear picture.

Structural evaluation of child physical abuse in trauma: Social determinants of health at the population level

PURPOSE

Child physical abuse (CPA) is closely linked to social factors like insurance status with limited evaluation at a structural population-level. This study evaluates the role of social determinants of health within the built environment on CPA.

METHODS

A single-institution retrospective review of pediatric trauma patients was conducted between January 2016 and December 2020. Patient address was geocoded to the census-tract level. Socioeconomic metrics, including poverty rate, supermarket access and Social Vulnerability Index (SVI) were estimated from the Food Access Research Atlas. Univariate and multivariable regression analyses were conducted to compare demographics and outcomes.

RESULTS

Of 3,540 patients, 317 (9.0%) had concern for physical abuse reported in the registry. CPA patients were younger (7.5 vs 9.6 years, p<0.0001) and more often Black (37.0%, N = 117 vs 23.5%, N = 753; p<0.0001). CPA had higher injury severity scores (ISS) (7.9 vs 5.8, p<0.0001) and longer length of stay (5.3 vs 2.9 days, p<0.0001). CPA had higher Medicaid (73.0%, N = 232 vs 53.8%, N = 1748, p<0.0001) and SVI (0.65 vs 0.59, p<0.0001) with lower median income ($52,100 vs $56,100, p<0.0001) and more low-food access tracts (59.6% vs 53.6%, p = 0.06). Combined low-income and low-food access populations showed widened disparities (40.0% vs 28.9%, p = 0.0002). On multivariate analysis, CPA was associated with poverty (OR 2.3, 95% CI [0.979, 3.60], p = 0.0006), low-access Black share (OR 3.3, 95% CI [1.18, 5.47], p = 0.002) and urban designation (OR 1.5, 95% CI [1.13, 1.87], p = 0.004).

CONCLUSION

The built-environment and population-level social determinants of health are related to child physical abuse and should influence advocacy and prevention.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective.

The true cost of child abuse at a level 1 pediatric trauma center

BACKGROUND

Child physical abuse (CPA) is a significant cause of morbidity and mortality. Children who sustain CPA consume significant healthcare resources. We hypothesized that the costs to care for children who sustain for children with CPA-type injuries are greater than the costs to care for children who sustain accidental injuries.

METHODS

All confirmed CPA patients between the ages of 0 and 19 years old, who were admitted to a level 1 pediatric trauma center between January 2010 and September 2018, were retrospectively reviewed. We compared outcomes, including mortality, length of stay (LOS), diagnostic work-up, and overall cost using propensity matching between CPA and accidentally injured trauma patients. Patients were matched based on injury severity score (ISS).

RESULTS

The CPA cohort (n = 595) was younger (1.31 +/- 1.96 years, p < 0.0001) than the accidental trauma patients (8.6 +/-5.54 years). The majority of the CPA patients had Medicaid coverage (75.1%), when compared to accidental trauma patients (37.5%; p < 0.0001). CPA patients had longer ICU LOS (2.43 days; p < 0.0001), increased ventilation days (2.57 days; p < 0.0001), and longer hospital LOS (6.56 days; p = 0.0004). The overall mortality rate for CPA patients was higher than accidental trauma patients (9.9% vs. 1.2%; p < 0.0001). The median hospital cost was significantly higher for those with CPA ($18,000) than accidental trauma ($10,100; p < 0.0001).

CONCLUSION

The costs to care for children who sustain CPA-type injuries are significantly greater than the costs to care for children who sustain accidental trauma. Better screening tools, more provider education and broader community outreach efforts are needed to reduce the societal and economic costs associated with child physical abuse.

STUDY TYPE

Treatment.

LEVEL OF EVIDENCE

Level III.

Non-accidental trauma increases length of stay and mortality in pediatric trauma

PURPOSE

More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT).

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16 years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis.

RESULTS

From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9 years, p < 0.001) and higher median injury severity score (10 vs. 5, p  < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2 days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001).

CONCLUSION

Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.