Pediatric nonaccidental abdominal trauma: what the radiologist should know

Pediatric Stomach and Duodenal Imaging

Pediatric stomach and duodenum abnormalities constitute a unique spectrum of conditions unlike adults which are categorized broadly into congenital, inflammatory, neoplastic and miscellaneous conditions. The aim of this article is to describe the role of imaging modalities in gastric and duodenal pathology in children. Some of the entities are unique to this age group and their imaging findings are also highlighted.

Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center

Introduction

Pediatric nonaccidental trauma (NAT) is difficult to diagnose. Several isolated injuries in NAT could happen in the setting of accidental trauma (AT), and having a high index of suspicion is important to correctly identify abuse. NAT has a significant mortality rate if the sentinel event is not adequately diagnosed, and the infant is not separated from the perpetrator. Level 1 pediatric trauma centers (PTC) see a significant number of NAT. We evaluated the injury patterns of NAT admissions at our level 1 PTC.

Methods

Retrospective analysis of all cases of NAT for children under the age of two admitted at an ACS level 1 pediatric trauma center between the years of 2016 and 2018. Charts were queried for demographic data, injury patterns, mortality, and disposition. Correlation between disposition status and injury patterns was performed. The Fisher Exact test and student t-test were used to study the significance of differences in categorical and continuous data, respectively.

Results

32/91 (35%) trauma patients under the age of two years were diagnosed as NAT in the three-year study period. 21/32 (39%) male and 11/26 (42%) female admissions were confirmed NAT (p = NS). 20 were under 1 year of age, and 12 were aged between 1 and 2 years (p = NS). 13 (41%) were Caucasian, 6 (19%) were Hispanic/Latino, 11 (34%) were Black, and 2(6%) were of unknown ethnicity (p = NS). Facial, torso, lower extremity, retinal, and internal organ injury were significantly more common with NAT. Medicaid coverage was noted in 31/32 (97%) NAT patients. 20/32 (62.5%) patients were legally displaced as a result of the NAT.

Conclusion

1/3^rd of all admissions at a pediatric level 1 trauma center were identified as NAT. A high index of suspicion is necessary to not miss NAT, as injury patterns are variable. Nearly 1/3^rd of all victims go back to the same environment where they sustained NAT increasing their susceptibility to future NAT.

Physical child abuse demands increased awareness during health and socioeconomic crises like COVID-19

Background and purpose - Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation.Methods - We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities.Results - Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016.Interpretation - The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.

Unusual presentations of child abuse: A report of two cases and the role of imaging

Insufficient attention has been paid to child abuse in Nigeria, where corporal punishment is still acceptable both at home and in the wider public including schools. This is notlimited to the parents; these punitive measures can also be undertaken by the extended family, caregivers, and neighbors. Mild to extreme force is allowed particularly when the crime involves tarnishing the family image. We hereby report two cases of extreme discipline that can be termed as a form of child abuse to draw the attention of clinicians and radiologists to other possible findings aside from those already reported in literature.

Imaging of Abusive Trauma

"Shaken baby syndrome" is a term often used by the physicians and public to describe abusive trauma inflicted on infants and young children. Advances in the understanding of the mechanisms and the associated clinical spectrum of injury has lead us to modify our terminology and address it as "abusive trauma" (AT). Pediatric abusive head trauma is defined as an injury to the skull or intracranial contents of an infant or a young child (< 5 y age) due to inflicted blunt impact and/or violent shaking. This chapter focuses on the imaging aspects of childhood abusive trauma along with a brief description of the mechanism and pathophysiology of abusive injury. The diagnosis of AT is not always obvious, and abusive injuries in many infants may remain unrecognized. Pediatricians should be cognizant of AT since pediatricians play a crucial role in the diagnosis, management and prevention of AT.

Ultrasound follow-up in a patient with intestinal obstruction due to post-traumatic intramural duodenal hematoma

We report the case of a 7-year-old girl with intestinal obstruction due to post-traumatic intramural duodenal hematoma. She had fallen from the monkey bars the day before presenting to our hospital, and was admitted with signs of abdominal pain, vomiting, and nausea. Abdominal ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) demonstrated a heterogeneous solid mass located within the duodenal wall, compressing the descending part of the duodenum. The inferior vena cava was also compressed by the mass lesion, although no associated symptoms were evident. Based on these findings, the mass lesion was considered to represent intramural hematoma causing intestinal obstruction. She was managed conservatively with total parenteral nutrition. Although CT and MRI are useful for differentiating hematoma from other intestinal tumors, ultrasonography is minimally invasive and easier to perform repeatedly. In case of duodenal hematoma, ultrasonography may be quite helpful for diagnosis and follow-up by monitoring tumor size and characteristics, and the degree of duodenal compression during conservative treatment.

The radiologist's role in child abuse: imaging protocol and differential diagnosis

Child abuse or nonaccidental trauma is a major problem worldwide; in Spain, there are about 12,000 victims per year. The detection of specific lesions or findings that are incongruent with the reported mechanism of trauma mean that radiologists are often the physician responsible for sounding the alarm in cases of abuse. The triad consisting of subdural hematoma, metaphyseal fracture, and posterior rib fractures is very characteristic of the battered child syndrome. The finding of acute and chronic lesions in the same patient is highly specific for nonaccidental trauma. Fractures of long bones in patients who have yet begun to walk should also alert to possible child abuse. Lesions that are highly specific for abuse, such as classic metaphyseal fractures or posterior rib fractures, can be difficult to demonstrate radiographically and are usually clinically occult. The American College of Radiology (ACR) protocols recommend obtaining three separate X-rays of each upper and lower limb. It is important to use X-ray systems that give high resolution images with low kilovoltage (50-70 kvp) and appropriate milliamperage. A skeletal survey consisting of a series of images collimated to each body region is recommended for all children under the age of two years in whom abuse is suspected. A follow-up skeletal survey about two weeks after the initial survey is useful for detecting new fractures and for assessing the consolidation of others, which helps in dating the lesions. Head injuries are the leading cause of death in abused children. Although computed tomography is the first neuroimaging technique in nonaccidental trauma, magnetic resonance imaging of the head can better characterize the lesions seen on computed tomography and can help to estimate the age of the lesions.