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

Developmental outcomes in abusive head trauma

Abusive head trauma (AHT) is associated with high mortality and poorer outcomes compared to accidental head injuries. The short and long-term developmental outcomes for AHT are not well identified. Variability in outcome measures, small sample sizes, difficulty in measuring domain-specific developmental skills, co-existence of comorbidities, genetic and environmental factors and high attrition rates all contribute to the challenges on providing data in this area. The objective of this article is to review the scientific literature on the developmental outcomes of AHT, highlighting factors that affect outcomes, the available assessment tools, and short and long-term developmental outcomes, recommended follow up, societal costs, and future opportunities for research. Authors searched OVID Medline and PubMed for articles published between 2013 and 2023 using the terms "abuse", "craniocerebral trauma" and "development". Fifty-five records were included for this review. The data shows that injuries sustained from AHT result in a spectrum of outcomes ranging from normal development to death. There are more than 100 outcome assessment tools limiting the ability to compare studies. More than half of patients are left with disabilities post discharge. Gross motor and cognition/academics are the 2 most common domains studied. Advancement in surgical and neurocritical care management has influenced AHT outcomes. Close long-term follow up is recommended to maximize each child's developmental potential, irrespective of the presence of disability at discharge. We suggest that future research should focus on adopting a consistent diagnostic and assessment approach and explore the social environmental factors that can affect recovery.

An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse

Abusive head trauma (AHT) is an extreme form of physical child abuse, a subset of which is shaken baby syndrome (SBS). While traumatic injury in children is most readily observed as marks of contusion on the body, AHT/SBS may result in internal injuries that can put the life of the child in danger. One pivotal sign associated with AHT/SBS that cannot be spotted with the naked eye is retinal injury (RI), an early sign of which is retinal hemorrhage (RH) in cases with rupture of the retinal vasculature. If not addressed, RI can lead to irreversible outcomes, such as visual loss. It is widely assumed that the major cause of RI is acceleration-deceleration forces that are repeatedly imposed on the patient during abusive shaking. Still, due to the controversial nature of this type of injury, few investigations have ever sought to delve into its biomechanical and/or biochemical features using realistic models. As such, our knowledge regarding AHT-/SBS-induced RI is significantly lacking. In this mini-review, we aim to provide an up-to-date account of the traumatology of AHT-/SBS-induced RI, as well as its biomechanical and biochemical features, while focusing on some of the experimental models that have been developed in recent years for studying retinal hemorrhage in the context of AHT/SBS.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Circumstances of injury in children with abusive versus non-abusive injuries

BACKGROUND

Although previous studies have examined differences in the characteristics of abusive versus non-abusive injuries, no study has focused on the differences in the circumstances surrounding these injuries, such as whether the event that caused the injury was witnessed or heard, or EMS was called.

OBJECTIVE

To determine predictors related to the circumstances of the injury (COI) for distinguishing abusive versus non-abusive injuries.

PARTICIPANTS/SETTING

Children younger than 3-years-old who were hospitalized with either a head injury or a fracture and evaluated by the child abuse consultation service between June 1, 2008 and June 30, 2017.

METHODS

In this case-control study, abusive (cases) and non-abusive (controls) injuries were determined by a consensus of two experts blinded to the COI. Multivariable logistic regression was used to identify COI predictors of abusive injuries.

RESULTS

We identified 302 children: 80 cases (26.5%) and 222 controls (73.5%). Abused children were less likely to have a clear event described (p < .001). Of the 251 with a clear event, we found that the significant variables for abuse were father's presence (adjusted odds ratio [aOR] 8.37; 95% CI 3.35-20.92), delay ≥24 h in seeking care (aOR 6.23; 95% CI 1.95-19.92) and calling EMS (aOR 3.21; 95% CI 1.10-9.36). In contrast, the event being heard (aOR 0.22; 95% CI 0.08-0.0.59) and the child being dropped (aOR 0.09; 95% CI 0.01-0.77) were less likely to be abusive.

CONCLUSION

We identified five COI predictors that may help clinicians in determining whether a child's injuries are due to abuse.

The Use of Experts to Evaluate a Child Abuse Guideline in Community Emergency Departments

OBJECTIVE

Guidelines and pathways exist to help frontline providers evaluate injured children for suspected child abuse. Little, however, is known about whether the decision-making resulting from these interventions is correct. Therefore, in the absence of an available gold-standard test, we used experts' judgments to examine the appropriateness of these clinical decisions. We evaluated community emergency department (ED) providers' adherence to a guideline recommending a child protection team (CPT) consultation for infants with injuries associated with abuse. We then compared providers' decision-making to experts' recommendations before and after guideline implementation.

METHODS

Two experts conducted a blinded, retrospective review of injured infants from 3 community EDs (N = 175). Experts rated the likelihood that an injury was abusive, indeterminate, or accidental, and made recommendations that were compared with skeletal survey (SS) testing and child protective services (CPS) reporting by providers before and after guideline implementation.

RESULTS

Postguideline implementation, there was a significant increase in CPT consultations in indeterminate cases (14.3% vs 72.2%, P < .001) and in SS testing when experts recommended SS (20.6% vs 56.8%, P = .002). In contrast, a higher percentage of cases for whom the experts did not recommend reporting were reported to CPS (1.8% vs 14.6%, P = .02).

CONCLUSIONS

Providers consulted the CPT most often for indeterminate cases. SS testing was in line with expert recommendations, but CPS reporting diverged from expert recommendations. Interventions linking community ED providers with a CPT may improve the evaluation of infants with injuries concerning for abuse.