Non-accidental injury: a two-year study in central Liverpool

Abusive head injury in the very young: outcomes from a Singapore children's hospital

PURPOSE

Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature.

METHODS

This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model.

RESULTS

From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds.

CONCLUSION

This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.

Neurosurgical aspects of abusive head trauma management in children: a review for the training neurosurgeon

The management of head trauma in children from suspected abuse is multidisciplinary. The primary role of neurosurgeons is to manage the acute clinical situation. They also have a secondary role in assisting others to determine the cause of the injury and prevent recurrences. This article aims to guide the trainee neurosurgeon on management of this patient group according to current literature.

Acute Subdural Hematoma in Infants with Abusive Head Trauma: A Literature Review

The number of cases with child abuse is increasing in Japan, and abusive head trauma (AHT) is a major cause of death in abused children. Child abuse has been recognized by the late 19th century, and widely accepted as battered child syndrome in the middle of the 20th century. As terms, there had been considerable mechanistic controversies between shaken-baby and -impact syndrome until the beginning of the 21st century. In recent years, AHT has been utilized as a less mechanistic term. Most of the characteristics of AHT in Japan have been similar to those in the United States as follows: infant is the most common victim, acute subdural hematoma (SDH) is the most common intracranial lesion, and retinal hemorrhage is often complicated. On the other hand, several characteristics have been different as follows: mother is the most common perpetrators, impact is a more common mechanism of trauma than shaking, and external trauma is more common reflecting the existence of impact. Since AHT as well as child abuse is a social pathological phenomenon influenced by victims, perpetrators, socioeconomic circumstances, and so on, various aspects of AHT as well as child abuse can be changed with times. Actually, a recent paper suggests such changes in infants with acute SDH due to AHT. In this review article, AHT, abusive infantile acute SDH in particular, are reviewed from the aspect of neurosurgical perspectives, including its mechanisms of trauma, biomechanics, clinical features, management, and prognosis, to update the trend in Japan.

Clinical predictors of outcome following inflicted traumatic brain injury in children

BACKGROUND

The study aimed to determine which acute injury variables were predictors of long-term functional outcome following inflicted traumatic brain injury (iTBI).

METHODS

A retrospective case review of 35 children with iTBI was performed. After controlling for age at injury and time since injury, the generalized estimation equations method was used to identify acute injury variables that were significantly related to the Glasgow Outcome Scale scores at the initial follow-up assessments. When available, functional sequelae at these and longer-term follow-ups were also examined.

RESULTS

In bivariate generalized estimation equations analyses, a low Glasgow Coma Scale (GCS) eye component score, a low GCS motor component score, a low GCS verbal component score, need for neurosurgical intervention, seizures in the first week after injury, need for mechanical ventilation for more than 10 days, length of intensive care unit stay of more than 10 days, initial hyperglycemia, and neuroimaging findings of cerebral edema or loss of gray-white matter differentiation were significantly (p ≤ 0.05) related to having a poor outcome, as defined by their Glasgow Outcome Scale score at the initial follow-up. In multivariable analyses, considering the significant predictors while controlling for age at injury and time since injury, the presence of cerebral edema on neuroimaging (odds ratio, 27.21; 95% confidence interval, 4.40-168.22), and length of intensive care unit stay of more than 10 days (odds ratio, 21.57; 95% confidence interval, 3.09-150.48) were significantly related to having a poor outcome.

CONCLUSION

Early clinical data following iTBI help predict long-term functional outcome. Further research to support these findings may help delineate acutely after injury which children with iTBI are at risk for a poor prognosis and should be more closely followed up over time.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Abusive head trauma

Abusive head trauma is a leading cause of morbidity and mortality in infants and young children. These patients will often first present to the emergency department. They may present with dramatic or subtle findings. It is important that pediatric emergency physicians be aware of the possible presentations of abusive head trauma. This article will review the epidemiology, the clinical findings, the diagnosis, the differential diagnosis, and the management of abusive head trauma.

A case of shaken baby syndrome after discharge from the newborn intensive care unit

Preterm infants may be at higher risk of physical abuse after hospital discharge. Nonaccidental or inflicted head neurotrauma is the most common cause of mortality and morbidity in physical-abuse cases, and shaken baby syndrome (SBS) is the most common form of abuse. In the majority of the cases, parents who shake their infant do not intend to harm the infant. This article presents a report of a former preterm infant who presented to the pediatrician's office with a maternal report of an accidental fall. Shaken baby syndrome was suspected based on bilateral subdural hemorrhages of varying ages, which were inconsistent with the history provided. The differential diagnosis and systematic clinical evaluation for SBS are provided, and medical and nursing management is discussed. Patient care, advocacy, and mandatory reporting are reviewed. The newborn intensive care unit caregivers' role in preventing SBS in this high-risk population, including specific parent teaching and anticipatory guidance, is reviewed with an emphasis on teaching all caregivers about the dangers of shaking an infant.

Pediatric trauma: postinjury care in the pediatric intensive care unit

Traumatic injuries occur in > 20 million children each year and are the leading source of death in children over the age of 1 yr. Mechanisms of injury and subsequent therapies for critically injured children are diverse. This review will focus on resources and management strategies for caring for the severely injured child in the pediatric intensive care unit.

Pediatric minor head trauma

Head trauma is one of the most common childhood injuries, annually accounting for more than 500,000 emergency department visits, 95,000 hospital admissions, 7,000 deaths, and 29,000 permanent disabilities; hospital care costs alone exceed $1 billion annually. The majority of patients have minor head trauma, and, although most of these injuries are insignificant, minor head trauma causes a large number of intracranial injuries. The largest reduction in head trauma mortality rates results from preventing deterioration and secondary brain injury in patients with minor or moderate head injuries who initially appear to be at low risk. The goal of the clinician, therefore, is to identify those at risk for intracranial injury and subsequent deterioration, while limiting unnecessary imaging procedures. This article reviews the current data and practice in assessing and treating minor head trauma in children.

The behaviour of 3-year-old children who were born preterm

The behaviour of 3-year-old children born preterm was compared with that of full-term children of the same age. The preterm group were born between 32 and 37 weeks gestation, and weighed between 1500 g and 2500 g at birth, and thus (in comparison to even earlier, lower birthweight babies) comprised a 'low risk' group. The children and their mothers were interviewed at home and information obtained about the following: behaviour, the number of accidents requiring medical attention, language development, maternal mental health and demographic data. The preterm group did not show an excess of behaviour problems overall but they did show significantly more problems when certain individual behaviours were considered, namely sleep related problems, tempers and dependence. The preterm group had also had significantly more accidents. The nature of the behavioural differences suggested they represented styles of parental management rather than neurological impairment in the preterm group. There was no evidence of language delay in either group and no significant association between child behaviour and maternal mental health. This study showed that consideration of socioeconomic factors is important. Children from manual socioeconomic groups showed significantly more behaviour problems than children from non-manual groups, and mothers from manual groups had significantly poorer mental health.

Illegitimate birth and deprivation: recent findings from an exploratory study

The association between illegitimate birth and deprivation documented in studies from the 1950s is re-examined using data from an exploratory investigation of three cohorts of illegitimate children born in the 1970s. Because the link between illegitimate birth and disadvantage has been complicated by the complex set of interrelationships between illegitimacy, specific demographic characteristics of the illegitimate childbearing population, familial organization preceding and succeeding illegitimate birth and consequences for the illegitimate child and his mother, recent changes in the incidence, demographic patterning and familial configurations of illegitimacy are outlined before living conditions are described. In addition, control factors have been introduced in the study from which findings are reported to allow separation of the influences of illegitimacy from the impact of correlated demographic and familial variables. An examination of past and current living conditions in terms of housing, income, use of social services and child health reveals a continued association between illegitimate birth and relative deprivation. The persistence of disadvantage is related to the high incidence of single parenthood among illegitimate childbearers and the predominance of illegitimate childbearing among young, single, primiparous, poor women.

Bleeding disorders and non-accidental injury

Fifty children with suspected non-accidental injury, most of whom had bruising, were investigated to exclude a bleeding disorder. The following investigations were undertaken in each child: full blood count; platelet count, size, and shape; prothrombin time; partial thromboplastin time including mix with normal plasma; fibrinogen; and a bleeding time. The results of these initial investigations were abnormal in eight children (16%). One child had a severe coagulopathy secondary to spontaneously acquired inhibitory activity to coagulation factors which led to spontaneous bruising and noticeable signs of injury after a minor accident. The remaining children had several features supporting a diagnosis of non-accidental injury. Two had associated bleeding disorders in the form of von Willebrand's disease and a platelet aggregation abnormality and a baby had an acquired platelet disorder secondary to salicylates, provoking severe haemorrhage from a minor injury. The remaining four children initially had an abnormal laboratory finding--a prolonged partial thromboplastin time--which resulted in lengthy discussions during subsequent legal proceedings. Evidence of a bleeding disorder is not uncommon in non-accidental injury and the two conditions are not mutually exclusive.

Parents who physically abuse their children

Increased knowledge of child abuse has mad what was once an infrequently diagnosed condition become recognised as a major pediatric and social problem. While there is no typical profile of an abusive parent, characteristics that have been found more frequently include a history of having been deprived and possible abused in the parent's own childhood, low self-esteem in the mother and increased ill-health in the immediate family members. Personality testing shows that the parents relate poorly to their children and to other people and that they have immature and impetuous personalities. Predictive studies show that abuse is commoner in families where the above characteristics are found, where family supports are minimal and where there are complications in the pregnancy, birth and in the neonatal period. However it should be recognised that the majority of families with these characteristics do not abuse their children. There is evidence that supportive measures provided to families who have known risk factors for abuse can reduce the incidence of this problem.

Persisting characteristics of parents of battered children

To study the personality of mothers whose children had suffered from child abuse in the past, a group of 36 such mothers was compared with a control group of mothers matched for social class. There was no difference between the two groups in pregnancy experience, in general health or in the number of family problems they had. The mothers from the study group had higher expectations for their children and perceived their children as having more personality problems than did the control mothers. The study-group mothers were less likely to have been brought up by their own parents, had more negative feelings towards their fathers, and were more likely to have received help for an emotional disorder than the control mothers. On formal testing, they were more likely to have suspicious, assertive, and demanding personality characteristics. As the majority of abused children remain in their natural families, these maternal factors are likely to influence the emotional development of their children. The children, as well as the parents, from families where child abuse has occurred should receive long-term supportive treatment to try to ameliorate some of the effects of these parental characteristics.

Intervention in child abuse: experience in Liverpool

The subsequent life events and development of 50 abused Liverpool children who had been removed from their parents and taken into the care of the Local Authority have been determined. Information was obtained by interviewing the district social worker responsible for each child's supervision. Medical progress and school performance was assessed in each case. Following their period in care, 26 children have had an unsatisfactory outcome indicated by the presence, either alone or in combination, of abnormal physical development, emotional disturbance, poor educational progress and occurrence of further abuse. Rehabilitation at home after varying periods of time was attempted for 25 children, five of whom suffered further abuse. The prognosis was worse the older the child on reception into care and the more placements while in care. The children who best survived their experiences after being taken into care were those for whom an early decision was made to sever parental contact and to place the child permanently with a substitute family.

The effects of premature birth on parents and their relationship

This study examined the effects of a relatively low-risk premature birth on the parents and their relationship. The results indicate that the birth caused a crisis in the immediate postpartum period, but that distress decreased once the babies were at home. At one month and seven months after discharge, parents of both preterm and fullterm infants described their feelings in similar ways--the only difference at one month was that mothers of fullterm infants were more upset than those in the preterm group. Parents of preterm babies became more attuned to each other with time than did parents of fullterm infants, and only preterm mothers became pregnant within the 26 months following their first baby's birth. Mothers in both groups rated themselves as more distressed than fathers throughout the study period, which suggests that within the low-risk preterm sample, becoming a mother for the first time had more impact than did giving birth prematurely.

Characteristics of child battering in Hong Kong: a controlled study

The characteristics in Hong Kong of 37 cases of child battering and their families compared to a control group matched for age of child and social class of family revealed that the families of battered children had significantly more problems, with a higher prevalence of psychiatric disorder among the parents. The victims were usually the product of unwanted pregnancy and had been separated from their parents in the first year of life. In Hong Kong older children rather than infants were at risk of being battered. The cultural factors in operation are discussed.

Unusual injury? Recent injury in normal children and children with suspected non-accidental injury

Four hundred normal children aged between 2 weeks and 11 years were examined to determine the prevalence and site of recent injury of any type. There was evidence of injury in 37% with a steady increase in prevalence to 60% by the end of the third year of life. Bruising of the hands and feet and of the lower legs was the most frequent type of injury. Head and facial injuries were most common between 18 months and 3 years (17% of children) but were rare at other ages. Injury to the lumbar region was unusual before 5 years but was present in 14% of children of school age. In 84 children of similar age where non-accidental injury was proved or suspected a different pattern of injury was present. Sixty per cent had injuries to the head and face; this increase in prevalence was seen at all ages. These children also had more frequent injuries in the lumbar region, particularly before the age of 5 years.

Household composition and the risk of child abuse and neglect

The incidence of child abuse and neglect resulting in validated case reports to the American Humane Association in 1976 was determined in relation to household composition, family income and age of the victim. Abuse and neglect were both maximal in father-only homes and minimal in two-natural-parent homes. Mother-only households exceed those with one natural and one step-parent in neglect incidence, but the reverse is true for abuse incidence. Poverty is more strongly associated with neglect risk than with abuse risk, and probably cannot account for the high risks of abuse and neglect in father-only and step-parent families. Evidence that the presence of an unrelated adult filling a parental role exacerbates the risk of physical abuse is presented and discussed.

Teenage parenting and child abuse: are they related?

The relationship between teenage parenting and child abuse is examined in terms of three methodological problems that must be considered in assessing this relationship. Four data sets illustrative of the methodological difficulties are described. Results suggest that the hypothesized association between teenage pregnancy and child abuse may be confounded by the association of each variable with social class.

Separation and other stress in child abuse

80 children who had been abused by their parents or caretakers were examined for separation experience early in life and for other stress factors within their families. Although early separation of parent and infant was common in abusing families, combinations of other stresses and conflicts were also present. These were considered to have predisposed towards the battering.

Relationship between abortion and child abuse

Although permissive abortion has been advocated on the grounds it will reduce the prevalence of child abuse and infanticide, there is no evidence to prove it has. There is a growing concern that it may have contributed to the problem. This article outlines eight possible methods whereby an increasing rate of abortion will lead to an increasing rate of abuse. There is evidence that an abortion results in depression which hinders mother-infant bonding in a subsequent pregnancy. An abortion of the first pregnancy may interrupt the developing bonding mechanism and interfere with the ability to bond to the next infant. If the hypothesis is correct, medicine by endorsing abortion on request may be jeopardizing the safety and care of a large number of children.

Disturbance in parent-child relationship following preterm delivery

Increasing concern is expressed that the psychosocial development of preterm infants may be hindered by a disturbance of parental attitudes following the initial period of specialised care. Attitudes of parents of 17 preterm infants were compared with those of parents of 17 full-term infants at a single semi-structured interview six to 20 months after the birth. The groups of parents were matched for parity and did not differ in their social, ethnic and educational backgrounds. There was evidence of some disturbance in parent-child relationships in the preterm group, consisting of delays in maternal attachment to the child, negative maternal perception of the child compared with expectation of an 'average' baby, and persistent parental anxiety about leaving the child with a baby-sitter. In addition, two preterm children had been abused or neglected. Parental reaction to a preterm birth is discussed and the need for adequate support to be given to parents in the early period following the birth is stressed.