Trends in shaken baby syndrome diagnosis codes among young children hospitalized for abuse

Neural circuit plasticity transforms infant neglect into maternal care

Infants in distress evoke strong emotional responses in adults, which help to elicit caretaking behaviors from parents to ensure infant needs are met1-3. However, neonatal care can also be challenging, and interactions with infants can lead to stress and negative affect even in potential caregivers4-7. Child neglect and maltreatment rates in human populations make it important to understand the neural mechanisms of regulating negative emotions and stress in the parental brain8-10. Here we show how rapid plasticity in female mouse central amygdala (CeA) transforms infant aversion into attentiveness after initial pup experience. Projections from CeA to locus coeruleus (CeA→LC) were strongly activated upon initial pup contact leading to pup aversion. CeA→LC pup responses were reduced with parental experience and down-regulating CeA→LC activity led to less aversion. Oxytocin signaling in central amygdala was required to switch pup aversion to attention, inducing rapid long-term depression of excitatory inputs onto projection neurons. CeA→LC projectors released the stress hormone corticotropin-releasing factor onto LC neurons, modulating phasic firing to regulate attention. This circuit organization enables local CeA computations of pup valence to be broadcast throughout the brain by the LC central arousal system, leading to appropriate pup-directed behaviors depending on adult state.

Variability in Occult Injury Screening Among Siblings/Household Contacts of Physical Abuse Victims

OBJECTIVE

The objective of this study is to examine radiologic occult injury screening performance/yield among contacts presenting for precautionary medical assessments and assess factors associated with deferred screening.

METHODS

Data were collected retrospectively from charts of contacts younger than 8 years presenting for precautionary evaluation to a level 1 pediatric emergency department January 1, 2018 to March 31, 2023. Demographics, radiologic performance/yield, physical examination, social work-based psychosocial assessment, reasons for deferred imaging, and diagnostic codes were abstracted. Descriptive statistics and χ 2 analysis are reported.

RESULTS

Three hundred ninety contacts were identified; 364 (93.3%) were biological siblings. Most (276, 70.8%) were 2 to 8 years old. Statistically significant relationships were identified with age, insurance, and hospital social work assessment and screening. Thirty-four infants (54%) underwent neuroimaging; no studies were abnormal. Of 114 contacts, <2 years old, 97 (85%) underwent skeletal survey (SS); 9 (9%) SS were abnormal. Twenty-seven (24%) returned for follow-up SS; 4 (14.8%) were abnormal. For 2 contacts, an abnormal initial SS was refuted by follow-up imaging. Physical examinations were abnormal for 11% of contacts. Reasons for deferred imaging included contact well appearance, caregiver concerns, and clinician disagreement with indications. Encounter International Classification of Diseases codes varied, commonly reflecting nonspecific screening assessments.

CONCLUSIONS

Despite national clinical practice guidelines, studies of abusive injury prevalence and radiologic yield among at-risk contacts exposed to unsafe environments are few. Screening evaluations inclusive of physical examination and radiologic studies identify abuse concerns among at-risk contacts. Further study of factors impacting radiologic screening decisions is needed. Considerations to advance epidemiologic research include standardized diagnostic coding and prospective assessment of radiologic yield.

Increasing incidence of pediatric mild traumatic brain injury in Finland - a nationwide register study from 1998 to 2018

AIM

The purpose of this study is to document the annual incidence and incidence trends of pediatric traumatic brain injury (pTBI) in Finland over the course of 21 years.

METHODS

We conducted a retrospective nationwide register-based cohort study and used the Finnish Care Register and Population information statistics from 1998 to 2018. The patient group includes all patients aged <18 at the time of injury. We included all emergency department (ED) visits and subsequent inpatient admissions (meaning at least one night in the hospital) with International Classification of Diseases diagnostic code S06*. We calculated pTBI incidences per 100,000 person-years with 95% confidence intervals and the incidences were compared by incidence rate ratios (IRR), including age, diagnosis, and gender stratified analyses.

RESULTS

A total of 71,972 patients were included with 76,785 ED visits or hospitalizations for pTBI diagnoses. The annual incidence of diagnosed pTBI was 251 (CI: 241-260) per 100,000 in 1998 and 547 (CI: 533-561) per 100,000 in 2018, indicating a 118% increase in the incidence (IRR 2.18 CI: 2.09-2.28). Boys had 32% higher incidence (IRR 1.32 CI: 1.30-1.34) than girls. The highest cumulative incidence was observed among boys aged <1 years, 525 (CI: 507-543) per 100,000, and boys had higher incidences in all age groups. The most used diagnostic code was concussion, which included 92.1% of the diagnoses followed by diffuse brain injury, which included 2.3% of the diagnoses. The increase in the incidence of diagnosed pTBI was notably high after 2010. Concussion diagnoses and pTBI cases that were discharged directly from the ED had more than a two-fold increase from 2010 to 2018, whereas the incidence of inpatient admissions for pTBI increased by 53%.

CONCLUSIONS

The overall incidence of diagnosed pTBI has increased in Finland especially since 2010. Boys have higher incidence of diagnosed pTBI in all age groups. Most of the increase was due to increase in the concussion diagnoses, which may be due to the centralization of EDs into bigger units and increased diagnostic awareness of mild pTBI.

Neonatal Abusive Head Trauma without External Injuries: Suspicion Improves Diagnosis

The term “shaken baby syndrome” has been replaced by “abusive head trauma (AHT)” based on the mechanism of injury. The reported mortality rate of AHT ranges from 10% to 30%. Up to two-thirds of survivors suffer from serious long-term disabilities. Thus, an expeditious and accurate diagnosis is crucial to prevent further abuse that might result in death or serious disabilities. It remains a challenge for physicians to diagnose AHT when parents do not give a history of trauma in preverbal infants without any external signs. Here, we report a case of a 14-day-old boy who presented with a febrile convulsion without evident external injuries nor history of trauma according to his parents. He was diagnosed with AHT based on MRI findings of subacute subdural hemorrhage, multiple cortical hemorrhages, cerebral edema, and diffuse axonal injury. In conclusion, health care providers should keep in mind that the history of trauma provided by the parents or caregivers might not always be true and that reasonable suspicion of abuse is the most important in the diagnosis of AHT, although neuroimaging plays a pivotal role. Reasonable suspicion of AHT in combination with a thorough physical examination, neuroimaging, and skilled neuroradiologist can improve diagnosis and help victims in a timely manner.