A profile of suspected child abuse as a subgroup of major trauma patients

Pediatric Trauma Recidivism: A Statewide Risk Factor Analysis of the Maryland Health Services Cost Review Commission (HSCRC)

BACKGROUND

National estimates suggest pediatric trauma recidivism is uncommon but are limited by short follow up and narrow ascertainment. We aimed to quantify the long-term frequency of trauma recidivism in a statewide pediatric population and identify risk factors for re-injury.

METHODS

The Maryland Health Services Cost Review Commission Dataset was queried for 0-19-year-old patients with emergency department or inpatient encounters for traumatic injuries between 2013 and 2019. We measured trauma recidivism by identifying patients with any subsequent presentation for a new traumatic injury. Univariate and multivariable regressions were used to estimate associations of patient and injury characteristics with any recidivism and inpatient recidivism.

RESULTS

Of 574,472 patients with at least one injury encounter, 29.6% experienced trauma recidivism. Age ≤2 years, public insurance, and self-inflicted injuries were associated with recidivism regardless of index treatment setting. Of those with index emergency department presentations 0.06% represented with an injury requiring inpatient admission; unique risk factors for ED-to-inpatient recidivism were age >10 years (aOR 1.61), cyclist (aOR 1.31) or burn (aOR 1.39) mechanisms, child abuse (aOR 1.27), and assault (aOR 1.43). Among patients with at least one inpatient encounter, 6.3% experienced another inpatient trauma admission, 3.4% of which were fatal. Unique risk factors for inpatient-to-inpatient recidivism were firearm (aOR 2.48) and motor vehicle/transportation (aOR 1.62) mechanisms of injury (all p < 0.05).

CONCLUSIONS

Pediatric trauma recidivism is more common and morbid than previously estimated, and risk factors for repeat injury differ by treatment setting. Demographic and injury characteristics may help develop and target setting-specific interventions.

LEVEL OF EVIDENCE

III (Retrospective Comparative Study).

Glimpsing the Iceberg: Parent-Child Physical Aggression and Abuse

Despite evidence that parents' physical aggression abuse has long-lasting negative consequences, information about the true population prevalence of aggression and physical abuse is limited. We have even less information about how parental aggression and abuse vary by child age, parent gender, and how that aggression and abuse might be clustered within families. To address these gaps, an anonymous, computer-based assessment was administered to nearly 40,000 parents of more than 60,000 children in the United States Air Force, which included a detailed assessment on up to four minor children of aggression and its impact. The survey was the largest of its type ever conducted in the United States, allowing for stable, crossvalidated estimation of rates of both corporal punishment and physical abuse. Approximately 39% of children experienced corporal punishment, peaking at three years of age, and 7% experienced physical abuse, peaking at age six. About 45% of parents reported perpetrating corporal punishment and 8% abuse; these rates were higher in multi-child families and most often involved more than one child. Parent gender was not associated with physical aggression or abuse.

A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma

INTRODUCTION

We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT.

METHODS

We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT.

RESULTS

47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT.

CONCLUSIONS

AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT.

TYPE OF STUDY

Observational cohort study.

LEVEL OF EVIDENCE

III.

Hospitalization for physical child abuse: Associated medical factors and medical history since birth

BACKGROUND

Physical abuse often begins at a very young age and sometimes results in serious or fatal injuries. It is crucial to diagnose physical abuse as early as possible to protect this vulnerable population.

OBJECTIVE

To study the factors associated with the first hospitalization for physical abuse from birth to the infant's first birthday in France.

PARTICIPANTS AND SETTING

We included all singleton children born in a hospital setting in France between 2009 and 2013, who were identified from the French national information system database (SNDS).

METHODS

To study factors associated with the first hospitalization for physical abuse during the first year after birth, we used the Fine and Gray regression model. Factors included in the multivariate model were the infant's sex, prematurity, neonatal conditions, the number of hospitalizations (at least two), medical consultations and complementary universal health insurance (proxy for family precariousness and socio-economic vulnerability).

RESULTS

Over the 2009-2013 period, among 3,432,921 newborn singletons, 903 (0.026 %) were hospitalized for physical abuse in the year following birth. Among the factors associated with physical abuse, such as prematurity (aHR = 2.2[1.8-2.7]), male sex (aHR = 1.3[1.2-1.5]), or having had at least two hospitalizations (aHR = 1.7[1.4-2.1]), we found that complementary universal health insurance coverage was the factor most associated (aHR = 4.1[3.5-4.7]) with being hospitalized for physical abuse.

CONCLUSION

These findings could help introduce preventative measures for infant protection in certain groups, such as parents of infants born prematurely, especially if they are in a precarious situation. This study also suggests that particular attention should be paid to infants who have been hospitalized at least two times in the first year of life, whatever the reason.

Integrating unsupervised and supervised learning techniques to predict traumatic brain injury: A population-based study

This work aimed to identify pre-existing health conditions of patients with traumatic brain injury (TBI) and develop predictive models for the first TBI event and its external causes by employing a combination of unsupervised and supervised learning algorithms. We acquired up to five years of pre-injury diagnoses for 488,107 patients with TBI and 488,107 matched control patients who entered the emergency department or acute care hospitals between April 1st, 2002, and March 31st, 2020. Diagnoses were obtained from the Ontario Health Insurance Plan (OHIP) database which contains province-wide claims data by physicians in Ontario, Canada for inpatient and outpatient services. A screening process was conducted on the OHIP diagnostic codes to limit the subsequent analysis to codes that were predictive of TBI, which concluded that 314 codes were significantly associated with TBI. The Latent Dirichlet Allocation (LDA) model was applied to the diagnostic codes and generated an optimal number of 19 topics that concur with published literature but also suggest other unexplored areas. Estimated word-topic probabilities from the LDA model helped us detect pre-morbid conditions among patients with TBI by uncovering the underlying patterns of diagnoses, meanwhile estimated document-topic probabilities were utilized in variable creation as form of a dimension reduction. We created 19 topic scores for each patient in the cohort which were utilized along with socio-demographic factors for Random Forest binary classifier models. Test set performances evaluated using area under the receiver operating characteristic curve (AUC) were: TBI event (AUC = 0.85), external cause of injury: falls (AUC = 0.85), struck by/against (AUC = 0.83), cyclist collision (AUC = 0.76), motor vehicle collision (AUC = 0.83). Our analysis successfully demonstrated the feasibility of using machine learning to predict TBI due to various external causes and identified the most important factors that contribute to this prediction.

International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse

Importance

Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse.

Objective

To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse.

Evidence Review

This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021.

Findings

Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child.

Conclusions and Relevance

This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.

Disparities in detection of suspected child abuse

BACKGROUND

Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.

METHODS

The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.

RESULTS

Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.

CONCLUSIONS

Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Prehospital vital sign monitoring in paediatric patients: an interregional study of educational interventions

BACKGROUND

Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives.

METHODS

Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region.

RESULTS

In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period.

CONCLUSIONS

Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.

How much paediatric major trauma is truly paediatric? Experience from a level 1 urban Major Trauma Centre

Background

At its inception, there was no formal provision for children within the English major trauma network. There are now combined and stand-alone centres, but the scarcity of paediatric trauma facilities in some regions can result in long patient transfers and impact patient outcomes. The objective of this study was to determine the proportion of paediatric trauma patients who may benefit from input by adult services or may be safely managed within the local adult MTC, either because of patient physiology or injury patterns.

Methods

All trauma presentations to our urban MTC aged ≤16 over a 3-year period were retrospectively identified and grouped, based on age and weight. ‘Young adult’ mechanisms of trauma and patient destinations (whether paediatric or adult wards) were determined.

Results

There were 847 paediatric trauma cases recorded with a mean age of 9 and a male preponderance. Based on age and weight, 10–45% of cases could be considered physiologically adult-like, and 22–28% pubertal. Almost all penetrating trauma occurred in males, increasing with age. 14% of all admissions were managed on adult wards, with frequency increasing with patient age and with mechanism of actions (MOIs) relating to interpersonal violence.

Conclusion

In this dataset, nearly half of paediatric trauma was ‘pubertal’ or ‘adult’ in their physiology and of these most presented with ‘young adult’ MOIs. These children likely benefit from combined paediatric and adult trauma services; where these do not exist, some older patients may be safely managed within local adult MTCs.

The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen

Traumatic brain injury (TBI) represents a major public health concern. Although the majority of individuals that suffer mild-moderate TBI recover relatively quickly, a substantial subset of individuals experiences prolonged and debilitating symptoms. An exacerbated response to physiological and psychological stressors after TBI may mediate poor functional recovery. Individuals with TBI can suffer from poor stress tolerance, impairments in the ability to evaluate stressors, and poor initiation (and cessation) of neuroendocrine stress responses, all of which can exacerbate TBI-mediated dysfunction. Here, we pay tribute to the pioneering neuroendocrinologist Dr. Bruce McEwen by discussing the ways in which his work on stress physiology and allostatic loading impacts the TBI patient population both before and after their injuries. Specifically, we will discuss the modulatory role of hypothalamic-pituitary-adrenal axis responses immediately after TBI and later in recovery. We will also consider the impact of stressors and stress responses in promoting post-concussive syndrome and post-traumatic stress disorders, two common sequelae of TBI. Finally, we will explore the role of early life stressors, prior to brain injuries, as modulators of injury outcomes.

Domestic violence and injuries: prevalence and patterns-a pilot database study to identify suspected cases in a UK major trauma centre

BACKGROUND

Victim-survivors of domestic violence and abuse (DVA) present to secondary care with isolated injuries to the head, limb or face. In the UK, there are no published studies looking at the relationship of significant traumatic injuries in adults and the relationship to DVA.The primary objective was to assess the feasibility of using a tailored search method to identify cases of suspected DVA in the national audit database for trauma. The secondary objective was to assess the association of DVA with clinical characteristics.

METHODS

We undertook a single-centre retrospective observational cohort pilot study. Data were analysed from the local Trauma and Audit Research Network (TARN) database. The 'Scene Description' field in the database was searched using a tailored search strategy. Feasibility was evaluated with notes review and assessed by the PPV and prevalence. Secondary objectives used a logistic regression in Excel.

RESULTS

This method of identifying suspected cases of DVA from the TARN database is feasible. The PPV was 100%, and the prevalence of suspected DVA in the study period was 3.6 per 1000 trauma discharges. Of those who had experienced DVA, 52.7% were male, median age 43 (IQR: 33-52) and mortality 5.5%. Subgroup analysis of older people demonstrated longer hospital stay (p=0.17) and greater likelihood of admission to intensive care (OR 2.60, 95% CI 0.48 to 14.24).

CONCLUSION

We have created a feasible methodology to identify suspected DVA-related injuries within the TARN database. Future work is needed to further understand this relationship on a national level.

Maltreatment Related Hospitalizations Among Children Ages 17 Years and Younger: New York State, 2011-2013

BACKGROUND

Child maltreatment is an important societal and public health problem. However, there are limited data on the epidemiology of maltreatment related hospitalizations.

OBJECTIVE

The objective of this study was to describe maltreatment related hospitalizations among children ages 17 and younger in New York State (NYS).

METHODS

Using 2011-2013 statewide planning and research cooperative system (SPARCS) inpatient hospital discharge data, maltreatment related hospitalizations among children ages 17 years and younger were identified using international classification of diseases, ninth revision, clinical modification codes for diagnoses and external cause of injury. Distributions of demographic and inpatient care characteristics were compared between hospitalizations for maltreatment and those for other causes, and between different types of maltreatment, using chi-square tests (for categorical variables) and t-tests (for continuous variables).

RESULTS

During 2011-2013, a total of 853 maltreatment related hospitalizations among 836 children ages 17 years and younger were documented in NYS SPARCS. Infants (children < 1) had the highest rates of hospitalization. Overall, physical abuse was the most prevalent maltreatment type reported.

CONCLUSIONS

This is the first study in NYS to describe the epidemiology of child maltreatment hospitalizations; it establishes a statewide baseline for this public health and societal issue.

Physical abuse of young children during the COVID-19 pandemic: Alarming increase in the relative frequency of hospitalizations during the lockdown period

BACKGROUND

In France, the COVID-19 pandemic led to a general lockdown from mid-March to mid-May 2020, forcing families to remain confined. We hypothesized that children may have been victims of more physical abuse during the lockdown, involving an increase in the relative frequency of hospitalization.

METHODS

Using the national administrative database on all admissions to public and private hospitals (PMSI), we selected all children aged 0-5 years hospitalized and identified physically abused children based on ICD-10 codes. We included 844,227 children hospitalized in March-April 2017-2020, of whom 476 (0.056%) were admitted for physical abuse. Relative frequency of hospitalization for physical abuse observed in March to April 2020 were compared with those from the same months in the three previous years (2017-2019).

FINDINGS

Even if absolute number of children exposed to physical abuse did not fluctuate significantly, we found a significant increase in the relative frequency of young children hospitalized for physical abuse from 2017 (0.053%) to 2020 (0.073%). Compared with the 2017-2019 period, and considering the observed decrease in the number of overall hospital admissions during the first lockdown, the number of children exposed to physical violence was 40% superior to what would be expected.

INTERPRETATION

The sharp increase in the relative frequency of hospitalizations for physical abuse in children aged 0-5 years in France is alarming. As only the most severe cases were brought to the hospital for treatment during the lockdown, our figures probably only represent the tip of the iceberg of a general increase of violence against young children.

Recidivism following childhood maltreatment necessitating inpatient care in the United States

INTRODUCTION

Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population.

METHODS

The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries.

RESULTS

NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers.

CONCLUSION

Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children.

LEVEL OF EVIDENCE

III.

TYPE OF EVIDENCE

Case Control Study.

Palm Bruising in Infants: A Recognizable Pattern of Abuse

BACKGROUND

Bruising in an infant is an important sentinel injury that should raise concern for child physical abuse, and should prompt a medical evaluation for occult injury. Hyperflexion during forceful squeezing of an infant's hand results in a distinct pattern of bruising along the palmar and interdigital creases, as well as the palmar eminences. Self-inflicted injury by the infant or injury resulting from benign handling should not be accepted as plausible explanations for this injury. The presence of concurrent occult injuries is common, and further supports concerns for abuse. However, when this distinct pattern of palm bruising is identified in an infant, the absence of occult injuries should not prevent the recognition of child physical abuse.

CASE REPORT

We report 11 cases depicting this distinct pattern of palm bruising in infants. Additionally, we include a perpetrator's documented confession. To the best of our knowledge, this pattern of bruising has not been previously described in the medical literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians play a crucial role in recognizing and addressing child physical abuse. Prompt recognition of this finding can aid in the identification of child physical abuse, even in the absence of underlying occult injury. This, in turn, can potentially prevent further injury, and even death, of an infant.

At risk child: a contemporary analysis of injured children in London and the South East of England: a prospective, multicentre cohort study

BACKGROUND

Injury is a leading health burden in children yet relatively little is reported about the contemporary risks they face. Current national registry data may under-represent the true burden of injury to children. We aim to analyse contemporary patterns of paediatric trauma and identify current factors putting children at risk of injury.

METHODS

A 3-month prospective multicentre cohort evaluation of injured children across the London Major Trauma System was performed. All children receiving a trauma team activation; meeting National Institute for Health and Care Excellence CT head criteria; or admitted/transferred out due to trauma were included. Data were collected on demographics, mechanism and location of injury, and body region injured. The primary outcome was in-hospital mortality and secondary outcome was safeguarding concerns.

RESULTS

659 children were included. Young children were more likely to be injured at home (0-5 years old: 70.8%, n=167 vs adolescents: 15.6%, n=31). Adolescents were more likely to be injured in the street (42.7%, n=85). Head trauma caused over half of injuries in 0-5 years old (51.9%, n=121). Falls were common and increasingly prevalent in younger children, causing 56.6% (n=372) of injuries. In adolescents, penetrating violence caused more than one in five injuries (21.9%, n=50). Most injured children survived (99.8%, n=658), however, one in four (26.1%, n=172) had safeguarding concerns and a quarter of adolescents had police, third sector or external agency involvement (23.2%, n=53).

CONCLUSIONS

This study describes modern-day paediatric trauma and highlights the variance in injury patterns in young children and adolescents. Importantly, it highlights differences in actual rates of injuries compared with those reported from current national registry data. We must understand real risks facing 21st century children to effectively safeguard future generations. The results provide an opportunity to reassess the current approach to injury prevention, child and adolescent safeguarding, and public health campaigns for child safety.

National Risk Factors for Child Maltreatment after Trauma: Failure to Prevent

The purpose of this study was to identify the risk factors for hospital readmission for child maltreatment after trauma, including admissions across different hospitals nationwide. The Nationwide Readmissions Database for 2010–2014 was queried for all patients younger than 18 years admitted for trauma. The primary outcome was readmission for child maltreatment. The secondary outcome was readmission for maltreatment presenting to a hospital different than the index admission hospital. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. There were 608,744 admissions identified and 44,569 (7.32%) involved maltreatment at the index admission. Readmission for maltreatment was found in 1,948 (0.32%) patients and 368 (18.89%) presented to a different hospital. The highest risk for readmission for maltreatment was found in patients with maltreatment identified at the index admission (odds ratios (OR) 9.48 [8.35–10.76]). The strongest risk factor for presentation to a different hospital was found with the lowest median household income quartile (OR 3.50 [2.63–4.67]). The subgroup analysis identified 647 (0.11%) children with readmission for maltreatment that was missed during the index admission. The strongest risk factor for this outcome was Injury Severity Score > 15 (OR 3.29 [2.68–4.03]). This study demonstrates that a significant portion of admissions for trauma in children and teenagers could be misrepresented as not involving maltreatment. These index admissions could be the only chance for intervention for child maltreatment. Identifying these at-risk individuals is critical to prevention efforts.

Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study

AIM

To characterise the causes, clinical characteristics and short-term outcomes of neonates who presented to paediatric emergency departments with a head injury.

METHODS

Secondary analysis of a prospective data set of paediatric head injuries at 10 emergency departments in Australia and New Zealand. Patients without neuroimaging were followed up by telephone call. We extracted epidemiological information, clinical findings and outcomes in neonates (≤28 days).

RESULTS

Of 20 137 children with head injuries, 93 (0.5%) occurred in neonates. These were mostly fall-related (75.2%), commonly from a care giver's arms, or due to being accidentally struck by a person/object (20.4%). There were three cases of non-accidental head injuries (3.2%). Most neonates were asymptomatic (67.7%) and many had no findings on examination (47.3%). Most neonates had a Glasgow Coma Scale 15 (89.2%) or 14 (7.5%). A total of 15.1% presented with vomiting and 5.4% were abnormally drowsy. None had experienced a loss of consciousness. The most common findings on examination were scalp haematoma (28.0%) and possible palpable skull fracture (6.5%); 8.6% underwent computed tomography brain scan and 4.3% received an ultrasound. Five of eight computed tomography scan (5.4% of neonates overall) showed traumatic brain injury and two of four (2.2% overall) had traumatic brain injury on ultrasound. Thirty-seven percent were admitted, one patient was intubated and none had neurosurgery or died.

CONCLUSIONS

Neonatal head injuries are rare with a mostly benign short-term outcome and are appropriate for observation. However, non-accidental injuries need to be considered.

Fifteen-minute consultation: How to be the paediatrician at a trauma call

The management of paediatric trauma patients can be complex, involving a coordinated multidisciplinary approach. Paediatricians form an integral part of the trauma team and are often tasked with managing circulation. In this article, we will discuss the assessment of catastrophic haemorrhage and 'circulation' through the viewpoint of a paediatrician via a case discussion. This will include initial investigations and management, noting the time critical nature in identifying and stopping catastrophic haemorrhage. The discussion will comment on how to address hypovolaemic shock and touch on the role of imaging.

Patterns of moderate and severe injury in children after the introduction of major trauma networks

OBJECTIVE

To describe the demographics, mechanisms, presentation, injury patterns and outcomes for children with traumatic injuries.

SETTING

Data collected from the UK's Trauma and Audit Research Network.

DESIGN AND PATIENTS

The demographics, mechanisms of injury and outcomes were described for children with moderate and severe injuries admitted to the Major Trauma Network in England between 2012 and 2017.

RESULTS

Data regarding 9851 children were collected. Most (69%) were male. The median age was 6.4 (SD 5.2) years, but infants aged 0.1 year (36.5 days) were the most frequently injured of all ages (0-15 years); 447 (36.0%) of injuries in infants aged <1 year were from suspected child abuse. Most injuries occurred in the home, from falls <2 m, after school hours, at weekends and during the summer. The majority of injuries were of moderate severity (median Injury Severity Score 9.0, SD 8.7). The limbs and pelvis, followed by the head, were the most frequently and most severely injured body parts. Ninety-two per cent were discharged home and 72.8% made a 'good recovery' according to the Glasgow Outcome Scale. 3.1% of children died, their median age was 7.0 years (SD 5.8), but infants were the most commonly fatally injured group.

CONCLUSIONS

A common age of injury and mortality was infants aged <1 year. Accident prevention strategies need to focus on the prevention of non-accidental injuries in infants. Trauma services need to be organised to accommodate peak presentation times, which are after school, weekends and the summer.

A review of children with severe trauma admitted to pediatric intensive care in Queensland, Australia

Background

The aim of this study is to review patient characteristics, injury patterns, and outcomes of trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Brisbane, Queensland, Australia.

Methods

Routinely recorded data collected prospectively from the Children’s Health Queensland Trauma Service registry from November 2008 to October 2015 were reviewed. Demographic and clinical characteristics of trauma cases in children under 16 years of age are described, and their association with age and mortality analyzed.

Results

There were 542 cases of pediatric trauma identified and 66.4% were male. The overall mortality since January 2012 was 11.1%. The median injury severity score (ISS) was 11 (IQR = 9–22), 48.2% (n = 261) had an ISS > 12 and 41.7% (n = 226) patients had an ISS > 15. The most common injury patterns were isolated head injury (29.7%; n = 161) and multiple trauma (31.2%; n = 169). In 28.4% of cases (n = 154) surgery was required. The home was reported to be the most common place of injury (37.6%; n = 204). Children aged 0–4 years were least likely to survive their injury (15.3% mortality) compared with the 5–9 (5.6% mortality) and 10–15 (9.0% mortality) age groups. Higher mortality was associated with more severe injuries, abdomen/spine/thorax injuries, inflicted injuries, drowning and hanging.

Conclusion

This description of major pediatric trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Australia, will inform future pediatric major trauma service requirements as it identifies injury patterns and profiles, injury severity, management and mortality across different age groups.

Rural versus urban pediatric non-accidental trauma: different patients, similar outcomes

Objective

Our aim was to compare urban and rural non-accidental trauma for trends and characterize where injury prevention efforts can be focused. Pediatric trauma patients (age 0–14 years) at two level I adult and pediatric trauma centers, one rural and one urban, were included and data from the trauma registries at each center was abstracted.

Results

Of 857 pediatric admissions, 10% of injuries were considered non-accidental. The mean age for all non-accidental trauma patients was significantly lower than the overall pediatric trauma population (2.6 vs. 7.7 years, P < 0.001). Significantly more fatalities occurred in the non-accidental trauma cohort (5.7% vs. 1% P = 0.007). In nearly half of all non-accidental trauma patients, the primary insurance was government programs (49%) and 46% were commercial insurance. The proportion of government insurance in non-accidental trauma was higher in both urban and rural cohorts. There were similar rates of urban and rural patients sustaining non-accidental trauma who were uninsured (6.5 vs. 5.3%). Patients that were younger, in a rural location, and receiving government insurance were at higher risk of non-accidental trauma on univariable analysis. However, only age remained an independent predictor on multivariable analysis.

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

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

Simulation-based research to improve infant health outcomes: Using the infant simulator to prevent infant shaking

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.

Age and Mortality in Pediatric Severe Traumatic Brain Injury: Results from an International Study

BACKGROUND

Although small series have suggested that younger age is associated with less favorable outcome after severe traumatic brain injury (TBI), confounders and biases have limited our understanding of this relationship. We hypothesized that there would be an association between age and mortality in children within an ongoing observational, cohort study.

METHODS

The first 200 subjects from the Approaches and Decisions for Acute Pediatric TBI trial were eligible for this analysis (inclusion criteria: severe TBI (Glasgow Coma Scale [GCS] score ≤ 8], age 18 years, and intracranial pressure (ICP) monitor placed; exclusion: pregnancy). Children with suspected abusive head trauma (AHT) were excluded to avoid bias related to the association between AHT and mortality. Demographics, and prehospital and resuscitation events were collected/analyzed, and children were stratified based on age at time of injury (< 5, 5-< 11, 11-18 years) and presented as mean ± standard error of the mean (SEM). Analyses of variance were used to test the equality of the means across the group for continuous variable, and Chi-square tests were used to compare percentages for discrete variables (post hoc comparisons were made using t test and Bonferroni corrections, as needed). Kaplan-Meier curves were generated for each age subgroup describing the time of death, and log-rank was used to compare the curves. Cox proportional hazards regression models were used to assess the effect of age on time to death while controlling for covariates.

RESULTS

In the final cohort (n = 155, 45 excluded for AHT), overall age was 9.2 years ± 0.4 and GCS was 5.3 ± 0.1. Mortality was similar between strata (14.0, 20.0, 20.9%, respectively, p = 0.58). Motor vehicle accidents were the most common mechanism across all strata, while falls tended to be more common in the youngest stratum (p = 0.08). The youngest stratum demonstrated increased incidence of spontaneous hypothermia at presentation and decreased hemoglobin concentrations and coagulopathies, while the oldest demonstrated lower platelet counts.

CONCLUSIONS

In contrast to previous reports, we failed to detect mortality differences across age strata in children with severe TBI. We have discerned novel associations between age and various markers of injury-unrelated to AHT-that may lead to testable hypotheses in the future.

Modelo para mejorar la anemia y el cuidado infantil en un ámbito rural del Perú

Objetivo.

Determinar la efectividad de la Estrategia para el Crecimiento y Desarrollo Integral (ECDI) de World Vision Perú sobre la anemia, desnutrición, desarrollo psicomotor y cuidado y protección infantil en niños menores de tres años de edad que residían en tres comunidades rurales de la Región Ayacucho del Perú.

Métodos.

Se realizó un estudio cuasiexperimental en tres distritos rurales de la región Ayacucho, Perú. La medición de anemia se realizó con sangre capilar y el analizador HemoCue®, con ajuste de los valores de hemoglobina según a la altitud. La desnutrición se midió a través de los indicadores antropométricos de talla y peso; para ello se utilizó la herramienta Anthro de la Organización Mundial de la Salud. El desarrollo psicomotor se midió mediante el Test Abreviado del Ministerio de Salud del Perú. El cuidado y protección de los niños se midió a través de una ficha especialmente elaborada para este fin. Se realizaron tres mediciones, la línea basal en mayo del 2013, la medición intermedia en noviembre del mismo año y la final en mayo del 2014. En total, 283 niños tuvieron dos o más mediciones incluida la medición final y 205 tuvieron las tres mediciones.

Resultados.

El análisis multivariado para medidas repetidas mostró una efectividad estimada de la ECDI para reducir la anemia de 33,1% (intervalo de confianza del 95%: 1,0%-54,7%) ajustada para la edad, sexo, consumo de alimentos ricos en hierro, consumo de alimentos potenciadores de la absorción de hierro, consumo de alimento inhibidores de la absorción de hierro, haber recibido suplementación de hierro en los últimos seis meses y haber participado del Programa Cuna Más.

Conclusiones.

La ECDI fue efectiva para mejorar la nutrición de los menores de 36 meses de edad a través de la reducción de la anemia y el incremento del consumo de potenciadores de la absorción de hierro. Las intervenciones que incluyen componentes educativos y de seguimiento comunitarios podrían ser de gran ayuda para combatir la anemia en los niños menores de 36 meses de edad en comunidades rurales.

A retrospective review of paediatric head injuries in Asia - a Pan Asian Trauma Outcomes Study (PATOS) collaboration

OBJECTIVE

We aim to examine the mechanisms of head-injured children presenting to participating centres in the Pan Asian Trauma Outcomes Study (PATOS) and to evaluate the association between mechanism of injury and severe outcomes.

DESIGN AND SETTING

We performed a retrospective review of medical records among emergency departments (EDs) of eight PATOS centres, from September 2014 - August 2015.

PARTICIPANTS

We included children <16 years old who presented within 24 hours of head injury and were admitted for observation or required a computed tomography (CT) of the brain from the ED. We excluded children with known coagulopathies, neurological co-morbidities or prior neurosurgery. We reviewed the mechanism, intent, location and object involved in each injury, and the patients' physical findings on presentation.

OUTCOMES

Primary outcomes were death, endotracheal intubation or neurosurgical intervention. Secondary outcomes included hospital and ED length of stay.

RESULTS

1438 children were analysed. 953 children (66.3%) were male and the median age was 5.0 years (IQR 1.0-10.0). Falls predominated especially among children younger than 2 years (82.9%), while road traffic injuries were more likely to occur among children 2 years and above compared with younger children (25.8% vs 11.1%). Centres from upper and lower middle-income countries were more likely to receive head injured children from road traffic collisions compared with those from high-income countries (51.4% and 40.9%, vs 10.9%, p<0.0001) and attended to a greater proportion of children with severe outcomes (58.2% and 28.4%, vs 3.6%, p<0.0001). After adjusting for age, gender, intent of injury and gross national income, traffic injuries (adjusted OR 2.183, 95% CI 1.448 to 3.293) were associated with severe outcomes, as compared with falls.

CONCLUSIONS

Among children with head injuries, traffic injuries are independently associated with death, endotracheal intubation and neurosurgery. This collaboration among Asian centres holds potential for future prospective childhood injury surveillance.

Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury

OBJECTIVES

Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms.

DESIGN

First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial-a comparative effectiveness study using an observational, cohort study design.

SETTING

PICUs in tertiary children's hospitals in United States and abroad.

PATIENTS

Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%).

CONCLUSIONS

In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

Assault in children admitted to trauma centers: Injury patterns and outcomes from a 5-year review of the national trauma data bank

IMPORTANCE

While assault is commonly reported or suspected in children with traumatic wounds, a recent overview of these injuries, especially those requiring trauma surgery consultation is lacking in the literature.

OBJECTIVES

Explore the incidence, demographics and injury patterns of children presenting to trauma centers following an assault.

DESIGN

Retrospective review of the National Trauma Data Bank 2007 to 2011.

SETTING AND PARTICIPANTS

Subjects up to 18 years old with "assault" reported as the intent of injury. Patients were divided into infants (<2 years), young children (2-5 years), children (6-11 years), and adolescents (12-18 years).

MAIN OUTCOMES AND MEASURES

Mechanism of injury, injury severity and mortality based on age groups and race.

RESULTS

Of 609,207 children, 58,299 (9.6%) were victims of an assault. The median age was 16 years and 81% were male, with a median injury severity score (ISS) of 8. The majority of patients were adolescents (76%), followed by infants (17%) and young children (4%). There was a stepwise increase in the proportion of assaulted Black children with increasing age (23.2% for infants and up to 46.7% for adolescents, trend p < 0.01, effect size: 0.175) while the opposite applied for White children (46.0% for infants and down to 19.5% for adolescents, trend p < 0.01, effect size: -0.230). With increasing age, White subjects had the highest trend of being assaulted during an unarmed fight or brawl (p < 0.01, effect size: 0.393), while for Black victims the highest trend was noted for assault with a firearm (p < 0.01, effect size: 0.323). Almost 2 out of 3 infants sustained severe head trauma (59%). The overall mortality was 8%, highest among young children, where it reached 16% (p < 0.01).

CONCLUSIONS

Up to 10% of children admitted following trauma are victims of assault with traumatic brain injuries predominant in infants and firearm injuries predominant in adolescents. Injury patterns largely correlate to age and race. Assault in children is associated with a high mortality risk. These data highlight the magnitude of the problem and calls for further involvement of trauma surgeons to improve outcomes, bring awareness and promote preventative strategies to eliminate assault in children.

Validação de conteúdo de um instrumento para identificação de violência contra criança

Resumo Objetivo Elaborar e validar o conteúdo de um instrumento para identificação de violência contra criança. Métodos Estudo metodológico composto por duas etapas: a primeira foi a elaboração do instrumento, a partir de revisão da literatura; a segunda, de validação de conteúdo, mediante a avaliação do instrumento por 25 especialistas. Para análise, adotaram-se coeficiente Kappa ≥0,61 e índice de validade de conteúdo ≥0,75. Resultados Na primeira rodada, dos 62 itens, observou-se necessidade de reformulação do conteúdo de 23. Após as alterações sugeridas pelos especialistas, na segunda rodada, o instrumentou passou a possuir 50 itens. Destes, apenas um apresentou Kappa >0,61 (Kappa = 0,50). A insuficiência de concordância entre os especialistas ocasionou na exclusão dele, em uma terceira rodada. Conclusão O instrumento apresentou índice de validade de conteúdo satisfatório e pode ser utilizado para identificar os sinais de suspeita de violência e auxiliar os profissionais de saúde na assistência à criança.