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Shahraki K, Suh DW. An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse. CHILDREN (BASEL, SWITZERLAND) 2024; 11:586. [PMID: 38790581 PMCID: PMC11119297 DOI: 10.3390/children11050586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
Abusive head trauma (AHT) is an extreme form of physical child abuse, a subset of which is shaken baby syndrome (SBS). While traumatic injury in children is most readily observed as marks of contusion on the body, AHT/SBS may result in internal injuries that can put the life of the child in danger. One pivotal sign associated with AHT/SBS that cannot be spotted with the naked eye is retinal injury (RI), an early sign of which is retinal hemorrhage (RH) in cases with rupture of the retinal vasculature. If not addressed, RI can lead to irreversible outcomes, such as visual loss. It is widely assumed that the major cause of RI is acceleration-deceleration forces that are repeatedly imposed on the patient during abusive shaking. Still, due to the controversial nature of this type of injury, few investigations have ever sought to delve into its biomechanical and/or biochemical features using realistic models. As such, our knowledge regarding AHT-/SBS-induced RI is significantly lacking. In this mini-review, we aim to provide an up-to-date account of the traumatology of AHT-/SBS-induced RI, as well as its biomechanical and biochemical features, while focusing on some of the experimental models that have been developed in recent years for studying retinal hemorrhage in the context of AHT/SBS.
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Affiliation(s)
| | - Donny W. Suh
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine School of Medicine, Irvine, CA 92697, USA;
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2
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Leahy KE, Lo-Cao E, Jamieson RV, Grigg JR. Managing the apparently blind child presenting in the first year of life: A review. Clin Exp Ophthalmol 2024; 52:452-463. [PMID: 38240137 DOI: 10.1111/ceo.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/21/2023] [Accepted: 12/15/2023] [Indexed: 06/14/2024]
Abstract
Severe vision impairment and blindness in childhood have a significant health burden on the child, family and society. This review article seeks to provide a structured framework for managing the apparently blind child presenting in the first year of life, starting from a comprehensive history and examination. Different investigation modalities and the increasingly important role of genetics will also be described, in addition to common causes of severe vision impairment. Crucially, a systematic approach to the blind infant is key to correct diagnoses and timely management. Incorrect diagnoses can be costly to all involved, however it is important to note that diagnoses can change with ongoing follow-up and investigations. Furthermore, the modern age of ophthalmology requires a multi-disciplinary approach and close collaboration with specialists including paediatricians, neurologists and geneticists, in addition to rehabilitation and low vision services, to ensure the best care for these vulnerable infants.
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Affiliation(s)
- Kate E Leahy
- Save Sight Institute, Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney and Sydney Eye Hospital, Sydney, New South Wales, Australia
- Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Edward Lo-Cao
- Save Sight Institute, Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney and Sydney Eye Hospital, Sydney, New South Wales, Australia
- Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Robyn V Jamieson
- Save Sight Institute, Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney and Sydney Eye Hospital, Sydney, New South Wales, Australia
- Eye Genetics Research Unit, Children's Medical Research Institute, Save Sight Institute, The University of Sydney and Sydney Eye Hospital, Sydney, New South Wales, Australia
- Discipline of Genetic Medicine, Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - John R Grigg
- Save Sight Institute, Discipline of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney and Sydney Eye Hospital, Sydney, New South Wales, Australia
- Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Eye Genetics Research Unit, Children's Medical Research Institute, Save Sight Institute, The University of Sydney and Sydney Eye Hospital, Sydney, New South Wales, Australia
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3
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Kelly JP, Feldman KW, Weiss A. OPTICAL COHERENCE TOMOGRAPHY AND VISUAL OUTCOMES IN PEDIATRIC ABUSIVE HEAD TRAUMA. Retin Cases Brief Rep 2024; 18:225-229. [PMID: 36121805 DOI: 10.1097/icb.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Compare follow-up optical coherence tomography with visual function in children with abusive head trauma (shaken baby syndrome). METHODS Retrospective follow-up studies of three children who were victims of abusive head trauma within the first year of life. RESULTS Optical coherence tomography showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in three of four eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual-evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage. CONCLUSION Significant abnormalities of retinal anatomy can be detected on optical coherence tomography years after abusive head trauma. Optical coherence tomographies and assessment of visual pathways help to elucidate causes of visual dysfunction in children with abusive head trauma.
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Affiliation(s)
- John P Kelly
- Roger H. Johnson Vision Clinic, Seattle Children's Hospital, Division of Ophthalmology, Seattle, Washington
- Department of Ophthalmology, University of Washington
| | - Kenneth W Feldman
- Seattle Children's Hospital, Safe Child and Adolescent Network, Seattle, Washington; and
- University of Washington, Division of General Pediatrics, Seattle, Washington
| | - Avery Weiss
- Roger H. Johnson Vision Clinic, Seattle Children's Hospital, Division of Ophthalmology, Seattle, Washington
- Department of Ophthalmology, University of Washington
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Liu YC, Chen IC, Yin HL, Wu YH, Lo SH, Liang WC, Jaw TS, Dai ZK, Hsu JH. Comparisons of characteristics and outcome between abusive head trauma and non-abusive head trauma in a pediatric intensive care unit. J Formos Med Assoc 2023; 122:1183-1188. [PMID: 37268475 DOI: 10.1016/j.jfma.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/27/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Abusive head trauma (AHT) is the leading cause of death in infants with traumatic brain injury (TBI). Early recognition of AHT is important for improving outcomes, but it can be challenging due to its similar presentations with non-abusive head trauma (nAHT). This study aims to compare clinical presentations and outcomes between infants with AHT and nAHT, and to identify the risk factors for poor outcomes of AHT. METHODS We retrospectively analyzed infants of TBI in our pediatric intensive care unit from January 2014 to December 2020. Clinical manifestations and outcomes were compared between patients with AHT and nAHT. Risk factors for poor outcomes in AHT patients were also analyzed. RESULTS 60 patients were enrolled for this analysis, including 18 of AHT (30%) and 42 of nAHT (70%). Compared with those with nAHT, patients with AHT were more likely to have conscious change, seizures, limb weakness, and respiratory failure, but with a fewer incidence of skull fractures. Additionally, clinical outcomes of AHT patients were worse, with more cases undergoing neurosurgery, higher Pediatric Overall Performance Category score at discharge, and more anti-epileptic drug (AED) use after discharge. For AHT patients, conscious change is an independent risk factor for a composite poor outcome of mortality, ventilator dependence, or AED use (OR = 21.9, P = 0.04) CONCLUSION: AHT has a worse outcome than nAHT. Conscious change, seizures and limb weaknesses but not skull fractures are more common in AHT. Conscious change is both an early reminder of AHT and a risk factor for its poor outcomes.
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Affiliation(s)
- Yi-Ching Liu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Chen Chen
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Ling Yin
- Department of Clinical Forensic Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Hsien Wu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Hsing Lo
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Twei-Shiun Jaw
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Zen-Kong Dai
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jong-Hau Hsu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Khosravi P, Huck NA, Shahraki K, Hunter SC, Danza CN, Kim SY, Forbes BJ, Dai S, Levin AV, Binenbaum G, Chang PD, Suh DW. Deep Learning Approach for Differentiating Etiologies of Pediatric Retinal Hemorrhages: A Multicenter Study. Int J Mol Sci 2023; 24:15105. [PMID: 37894785 PMCID: PMC10606803 DOI: 10.3390/ijms242015105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Retinal hemorrhages in pediatric patients can be a diagnostic challenge for ophthalmologists. These hemorrhages can occur due to various underlying etiologies, including abusive head trauma, accidental trauma, and medical conditions. Accurate identification of the etiology is crucial for appropriate management and legal considerations. In recent years, deep learning techniques have shown promise in assisting healthcare professionals in making more accurate and timely diagnosis of a variety of disorders. We explore the potential of deep learning approaches for differentiating etiologies of pediatric retinal hemorrhages. Our study, which spanned multiple centers, analyzed 898 images, resulting in a final dataset of 597 retinal hemorrhage fundus photos categorized into medical (49.9%) and trauma (50.1%) etiologies. Deep learning models, specifically those based on ResNet and transformer architectures, were applied; FastViT-SA12, a hybrid transformer model, achieved the highest accuracy (90.55%) and area under the receiver operating characteristic curve (AUC) of 90.55%, while ResNet18 secured the highest sensitivity value (96.77%) on an independent test dataset. The study highlighted areas for optimization in artificial intelligence (AI) models specifically for pediatric retinal hemorrhages. While AI proves valuable in diagnosing these hemorrhages, the expertise of medical professionals remains irreplaceable. Collaborative efforts between AI specialists and pediatric ophthalmologists are crucial to fully harness AI's potential in diagnosing etiologies of pediatric retinal hemorrhages.
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Affiliation(s)
- Pooya Khosravi
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA 92697, USA;
| | - Nolan A. Huck
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
| | - Kourosh Shahraki
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
| | - Stephen C. Hunter
- School of Medicine, University of California, 900 University Ave, Riverside, CA 92521, USA;
| | - Clifford Neil Danza
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
| | - So Young Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan 31151, Chungcheongnam-do, Republic of Korea;
| | - Brian J. Forbes
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (B.J.F.); (G.B.)
| | - Shuan Dai
- Department of Ophthalmology, Queensland Children’s Hospital, South Brisbane, QLD 4101, Australia;
| | - Alex V. Levin
- Department of Ophthalmology, Flaum Eye Institute, Golisano Children’s Hospital, Rochester, NY 14642, USA;
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (B.J.F.); (G.B.)
| | - Peter D. Chang
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA 92697, USA;
- Department of Radiological Sciences, School of Medicine, University of California, Irvine, CA 92697, USA
| | - Donny W. Suh
- Department of Ophthalmology, School of Medicine, University of California, Irvine, CA 92697, USA; (P.K.); (N.A.H.); (K.S.); (C.N.D.)
- Gavin Herbert Eye Institute, University of California, Irvine, CA 92697, USA
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Di Fazio N, Delogu G, Morena D, Cipolloni L, Scopetti M, Mazzilli S, Frati P, Fineschi V. New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2023; 13:1722. [PMID: 37238204 PMCID: PMC10217069 DOI: 10.3390/diagnostics13101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, 71100 Foggia, Italy;
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Sara Mazzilli
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
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Pediatric abusive head trauma: visual outcomes, evoked potentials, diffusion tensor imaging, and relationships to retinal hemorrhages. Doc Ophthalmol 2023:10.1007/s10633-023-09927-w. [PMID: 36881212 DOI: 10.1007/s10633-023-09927-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/06/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures. METHODS Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR). RESULTS Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping. DISCUSSION Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics.
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Even KM, Hymel KP, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Liang M, Wang M. The association of subcortical brain injury and abusive head trauma. CHILD ABUSE & NEGLECT 2022; 134:105917. [PMID: 36308893 DOI: 10.1016/j.chiabu.2022.105917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) remains a major pediatric problem with diagnostic challenges. A small pilot study previously associated subcortical brain injury with AHT. OBJECTIVES To investigate the association of subcortical injury on neuroimaging with the diagnosis of AHT. PARTICIPANTS AND SETTING Children <3 years with acute TBI admitted to 18 PICUs between 2011 and 2021. METHODS Secondary analysis of existing, combined, de-identified, cross-sectional dataset. RESULTS Deepest location of visible injury was characterized as scalp/skull/epidural (n = 170), subarachnoid/subdural (n = 386), cortical brain (n = 170), or subcortical brain (n = 247) (total n = 973). Subcortical injury was significantly associated with AHT using both physicians' diagnostic impression (OR: 8.41 [95 % CI: 5.82-12.44]) and a priori definitional criteria (OR: 5.99 [95 % CI: 4.31-8.43]). Caregiver reports consistent with the child's gross motor skills and historically consistent with repetition decreased as deepest location of injury increased, p < 0.001. Patients with subcortical injuries were significantly more likely to have traumatic extracranial injuries such as rib fractures (OR 3.36, 95 % CI 2.30-4.92) or retinal hemorrhages (OR 5.97, 95 % CI 4.35-8.24), respiratory compromise (OR 12.12, 95 % CI 8.49-17.62), circulatory compromise (OR 6.71, 95 % CI 4.87-9.29), seizures (OR 3.18, 95 % CI 2.35-4.29), and acute encephalopathy (OR 12.44, 95 % CI 8.16-19.68). CONCLUSIONS Subcortical injury is associated with a diagnosis of AHT, historical inaccuracies concerning for abuse, traumatic extracranial injuries, and increased severity of illness including respiratory and circulatory compromise, seizures, and prolonged loss of consciousness. Presence of subcortical injury should be considered as one component of the complex AHT diagnostic process.
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Affiliation(s)
- Katelyn M Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Menglu Liang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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Ferguson NM, Rebsamen S, Field AS, Guerrero JM, Rosario BL, Broman AT, Rathouz PJ, Bell MJ, Alexander AL, Ferrazzano PA. Magnetic Resonance Imaging Findings in Infants with Severe Traumatic Brain Injury and Associations with Abusive Head Trauma. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9071092. [PMID: 35884076 PMCID: PMC9322188 DOI: 10.3390/children9071092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Young children with severe traumatic brain injury (TBI) have frequently been excluded from studies due to age and/or mechanism of injury. Magnetic resonance imaging (MRI) is now frequently being utilized to detect parenchymal injuries and early cerebral edema. We sought to assess MRI findings in infants with severe TBI, and to determine the association between specific MRI findings and mechanisms of injury, including abusive head trauma (AHT). MRI scans performed within the first 30 days after injury were collected and coded according to NIH/NINDS Common Data Elements (CDEs) for Neuroimaging in subjects age < 2 years old with severe TBI enrolled in the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial. Demographics and injury characteristics were analyzed. A total of 81 children were included from ADAPT sites with MRI scans. Median age was 0.77 years and 57% were male. Most common MRI finding was ischemia, present in 57/81 subjects (70%), in a median of 7 brain regions per subject. Contusion 46/81 (57%) and diffuse axonal injury (DAI) 36/81 (44.4%) subjects followed. Children were dichotomized based on likelihood of AHT with 43/81 subjects classified as AHT. Ischemia was found to be significantly associated with AHT (p = 0.001) and “inflicted” injury mechanism (p = 0.0003). In conclusion, the most common intracerebral injury seen on MRI of infants with severe TBI was ischemia, followed by contusion and DAI. Ischemia was associated with AHT, and ischemia affecting > 4 brain regions was predictive of AHT.
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Affiliation(s)
- Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Susan Rebsamen
- Department of Radiology, University of Wisconsin, Madison, WI 53792, USA; (S.R.); (A.S.F.)
| | - Aaron S. Field
- Department of Radiology, University of Wisconsin, Madison, WI 53792, USA; (S.R.); (A.S.F.)
| | - Jose M. Guerrero
- Waisman Center, University of Wisconsin, Madison, WI 53705, USA; (J.M.G.); (A.L.A.)
- Department of Medical Physics, University of Wisconsin, Madison, WI 53705, USA
- Waisman Brain Imaging Laboratory, University of Wisconsin, Madison, WI 53705, USA
| | - Bedda L. Rosario
- Department of Epidemiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Aimee T. Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI 53705, USA;
| | - Paul J. Rathouz
- Department of Population Health, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA;
| | - Michael J. Bell
- Department of Pediatrics, Children’s National Medical Center, Washington, DC 20010, USA;
| | - Andrew L. Alexander
- Waisman Center, University of Wisconsin, Madison, WI 53705, USA; (J.M.G.); (A.L.A.)
- Department of Medical Physics, University of Wisconsin, Madison, WI 53705, USA
- Waisman Brain Imaging Laboratory, University of Wisconsin, Madison, WI 53705, USA
- Department of Psychiatry, University of Wisconsin, Madison, WI 53705, USA
| | - Peter A. Ferrazzano
- Waisman Center, University of Wisconsin, Madison, WI 53705, USA; (J.M.G.); (A.L.A.)
- Department of Pediatrics, University of Wisconsin, Madison, WI 53705, USA
- Correspondence: ; Tel.: +1-608-265-4839
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10
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Hymel KP, Boos SC, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Even K, Wang M. An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma. CHILD ABUSE & NEGLECT 2022; 129:105666. [PMID: 35567958 PMCID: PMC10724711 DOI: 10.1016/j.chiabu.2022.105666] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms. OBJECTIVES To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT. PARTICIPANTS AND SETTING Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021. METHODS Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values. RESULTS Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96. CONCLUSIONS The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Stephen C Boos
- Department of Pediatrics, UMass Chan Medical School-Baystate Health, 759 Chestnut Street, Springfield, MA 01199, USA.
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Katelyn Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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11
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Lupariello F, Capello F, Grossi V, Bonci C, Di Vella G. Child abuse and neglect: Are future medical doctors prepared? Leg Med (Tokyo) 2022; 58:102100. [PMID: 35749869 DOI: 10.1016/j.legalmed.2022.102100] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/05/2022] [Accepted: 06/18/2022] [Indexed: 11/27/2022]
Abstract
Diagnosis of child abuse and neglect is a challenging matter: in case of misdiagnosis, the child cannot benefit from an early treatment; erroneous interpretation may generate legal issues. Some studies reported physicians' lack of knowledge in child abuse and neglect. However, it is not clear if the reasons of this lack relay on an insufficient preparation of students during medical school and/or a deficiency in continuing medical education during/after fellowships. For these reasons, the authors of the present manuscript administered a questionnaire to last year medical students to: evaluate the degree of knowledge on this thematic in a medical student sample; understand if the abovementioned lack may be due to insufficient preparation of students during medical school. Study population included 179 students. The 77.7% demonstrated a low knowledge of this thematic, but they showed a high insight of their lack. The authors pointed out that medical school education can represent a weak point in future medical doctor knowledge on child abuse and neglect. It also allowed to identify as study sample's medical students had high awareness of their lacks in this field. In addition, comparison of medical schools from different geographical areas suggested common issues independent of which accreditation system is implemented. Thus - independent of which corrective strategy will be planned - the study highlighted necessity for each medical school to define: its current ability to properly train students in child abuse and neglect; students' awareness of their level of expertise. This can help schools to identify the most suitable correctives.
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Affiliation(s)
- Francesco Lupariello
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino", USA.
| | - Francesca Capello
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino", USA
| | - Valeria Grossi
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino", USA
| | - Camilla Bonci
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino", USA
| | - Giancarlo Di Vella
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino Dipartimento di Scienze della Sanità Pubblica e Pediatriche - Sezione di Medicina Legale - "Università degli Studi di Torino", USA
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12
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Eysenbach L, Leventhal JM, Gaither JR, Bechtel K. Circumstances of injury in children with abusive versus non-abusive injuries. CHILD ABUSE & NEGLECT 2022; 128:105604. [PMID: 35339797 DOI: 10.1016/j.chiabu.2022.105604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Although previous studies have examined differences in the characteristics of abusive versus non-abusive injuries, no study has focused on the differences in the circumstances surrounding these injuries, such as whether the event that caused the injury was witnessed or heard, or EMS was called. OBJECTIVE To determine predictors related to the circumstances of the injury (COI) for distinguishing abusive versus non-abusive injuries. PARTICIPANTS/SETTING Children younger than 3-years-old who were hospitalized with either a head injury or a fracture and evaluated by the child abuse consultation service between June 1, 2008 and June 30, 2017. METHODS In this case-control study, abusive (cases) and non-abusive (controls) injuries were determined by a consensus of two experts blinded to the COI. Multivariable logistic regression was used to identify COI predictors of abusive injuries. RESULTS We identified 302 children: 80 cases (26.5%) and 222 controls (73.5%). Abused children were less likely to have a clear event described (p < .001). Of the 251 with a clear event, we found that the significant variables for abuse were father's presence (adjusted odds ratio [aOR] 8.37; 95% CI 3.35-20.92), delay ≥24 h in seeking care (aOR 6.23; 95% CI 1.95-19.92) and calling EMS (aOR 3.21; 95% CI 1.10-9.36). In contrast, the event being heard (aOR 0.22; 95% CI 0.08-0.0.59) and the child being dropped (aOR 0.09; 95% CI 0.01-0.77) were less likely to be abusive. CONCLUSION We identified five COI predictors that may help clinicians in determining whether a child's injuries are due to abuse.
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Affiliation(s)
- Lindsay Eysenbach
- University of Washington Affiliated Hospitals, United States of America
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13
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Cheon JE, Kim JH. Imaging of Abusive Head Trauma : A Radiologists' Perspective. J Korean Neurosurg Soc 2022; 65:397-407. [PMID: 35483021 PMCID: PMC9082130 DOI: 10.3340/jkns.2021.0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/16/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most common and serious form of child abuse and a leading cause of traumatic death in infants and young children. The biomechanics of head injuries include violent shaking, blunt impact, or a combination of both. Neuroimaging plays an important role in recognizing and distinguishing abusive injuries from lesions from accidental trauma or other causes, because clinical presentation and medical history are often nonspecific and ambiguous in this age group. Understanding common imaging features of AHT can increase recognition with high specificity for AHT. In this review, we discuss the biomechanics of AHT, imaging features of AHT, and other conditions that mimic AHT.
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Affiliation(s)
- Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Chung CW, Levin AV, Forbes BJ, Binenbaum G. Retinal hemorrhage after pediatric neurosurgical procedures. J AAPOS 2022; 26:74.e1-74.e5. [PMID: 35304320 DOI: 10.1016/j.jaapos.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neurosurgical procedures may occur prior to eye examination in children with suspected abusive head trauma and raise questions by child abuse physicians and ophthalmologists regarding the contribution of neurosurgery to retinal hemorrhage found postoperatively. The purpose of this study was to determine the prevalence and patterns of retinal hemorrhage attributable to neurosurgical intervention in children. METHODS We conducted a retrospective cohort study of children undergoing neurosurgery who had postoperative ophthalmoscopy. Some children were also examined preoperatively. Primary outcome measures were the prevalence and patterns of retinal hemorrhage attributable to neurosurgical intervention. Medical records were reviewed to identify confounding coexistent diseases. RESULTS Among 267 children undergoing 289 neurosurgical procedures, there were no cases in which children had post-procedural retinal hemorrhage that could be attributed to neurosurgery. Retinal hemorrhage was seen in 32 (12%) cases, but in every case they were either already present on preoperative examination (13 cases) or matched the pattern of a coexistent known cause of retinal hemorrhage, including head trauma with unambiguous history and/or nonocular signs (13), hydrocephalus-related increased intracranial pressure with papilledema-associated peripapillary retinal hemorrhage (5), and retinopathy of prematurity ridge-associated retinal hemorrhage (1). No retinal hemorrhage could be attributed only to neurosurgery. CONCLUSIONS Although children undergoing child abuse evaluations may have intracranial hemorrhage requiring neurosurgery that occurs before a dilated retinal examination can be performed, our data suggest that neurosurgery independently is unlikely to produce retinal hemorrhage and therefore is not a significant confounding factor in the interpretation of retinal hemorrhage patterns in child abuse evaluations.
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Affiliation(s)
- Caroline W Chung
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V Levin
- Flaum Eye Institute and Golisano Children's Hospital, Rochester, New York
| | - Brian J Forbes
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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15
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Weiss R, He CH, Khan S, Parsikia A, Mbekeani JN. Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma. Pediatr Neurol 2022; 127:11-18. [PMID: 34922138 DOI: 10.1016/j.pediatrneurol.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.
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Affiliation(s)
- Rebecca Weiss
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | | | - Sabine Khan
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; Research Services, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce N Mbekeani
- Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York.
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16
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Burns J, Rohl S, Marth D, Proctor D, Amin R, Sekhon C. Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are Associated With Clinically Important Traumatic Brain Injury, Classification as Abuse, and Poor Prognosis? Pediatr Emerg Care 2022; 38:e254-e258. [PMID: 32925700 DOI: 10.1097/pec.0000000000002239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED). OBJECTIVE The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge. PARTICIPANTS AND SETTING Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included. METHODS Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification. RESULTS On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge. CONCLUSIONS No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.
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Affiliation(s)
- James Burns
- From the Pediatric Trauma Research Team, Studer Family Children's Hospital at Ascension Sacred Heart
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17
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Boos SC, Wang M, Karst WA, Hymel KP. Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis. Pediatrics 2022; 149:183816. [PMID: 34890450 PMCID: PMC9645685 DOI: 10.1542/peds.2021-051742] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Data guiding abusive head trauma (AHT) diagnosis rest on case-control studies that have been criticized for circularity. We wished to sort children with neurologic injury using mathematical algorithms, without reference to physicians' diagnoses or predetermined diagnostic criteria, and to compare the results to existing AHT data, physicians' diagnoses, and a proposed triad of findings. METHODS Unsupervised cluster analysis of an existing data set regarding 500 young patients with acute head injury hospitalized for intensive care. Three cluster algorithms were used to sort (partition) patients into subpopulations (clusters) on the basis of 32 reliable (κ > 0.6) clinical and radiologic variables. P values and odds ratios (ORs) identified variables most predictive of partitioning. RESULTS The full cohort partitioned into 2 clusters. Variables substantially (P < .001 and OR > 10 in all 3 cluster algorithms) more prevalent in cluster 1 were imaging indications of brain hypoxemia, ischemia, and/or swelling; acute encephalopathy, particularly when lasting >24 hours; respiratory compromise; subdural hemorrhage or fluid collection; and ophthalmologist-confirmed retinoschisis. Variables substantially (P < .001 and OR < 0.10 in any cluster algorithm) more prevalent in cluster 2 were linear parietal skull fracture and epidural hematoma. Postpartitioning analysis revealed that cluster 1 had a high prevalence of physician-diagnosed abuse. CONCLUSIONS Three cluster algorithms partitioned the population into 2 clusters without reference to predetermined diagnostic criteria or clinical opinion about the nature of AHT. Clinical difference between clusters replicated differences previously described in comparisons of AHT with non-AHT. Algorithmic partition was predictive of physician diagnosis and of the triad of findings heavily discussed in AHT literature.
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Affiliation(s)
- Stephen C. Boos
- Department of Pediatrics, University of Massachusetts Chan Medical School—Baystate, Baystate Medical Center, Springfield, Massachusetts,Address correspondence to Stephen C. Boos, MD, Baystate Medical Center, Family Advocacy Center, 300 Carew St, Springfield, MA 01199. E-mail:
| | - Ming Wang
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Wouter A. Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, Netherlands
| | - Kent P. Hymel
- Department of Pediatrics, College of Medicine, Pennsylvania State University and Penn State Health Children’s Hospital, Hershey, Pennsylvania
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18
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Feld K, Ricken T, Feld D, Helmus J, Hahnemann M, Schenkl S, Muggenthaler H, Pfeiffer H, Banaschak S, Karger B, Wittschieber D. Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study. Int J Legal Med 2021; 136:591-601. [PMID: 34862583 PMCID: PMC8847172 DOI: 10.1007/s00414-021-02751-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Tim Ricken
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | | | - Sebastian Schenkl
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Holger Muggenthaler
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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19
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Bechtel K, Derbyshire M, Gaither JR, Leventhal JM. Characteristics That Distinguish Abusive From Nonabusive Causes of Sudden Unexpected Infant Deaths. Pediatr Emerg Care 2021; 37:e780-e783. [PMID: 30829845 DOI: 10.1097/pec.0000000000001787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department. METHODS Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes. RESULTS We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30). CONCLUSIONS Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.
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Affiliation(s)
- Kirsten Bechtel
- From the Department of Pediatrics, Yale School of Medicine, New Haven
| | | | - Julie R Gaither
- From the Department of Pediatrics, Yale School of Medicine, New Haven
| | - John M Leventhal
- From the Department of Pediatrics, Yale School of Medicine, New Haven
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20
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Franchina M, Blaszkowska M, Lewis J, Johnson A, Clark A, Lam G, Mackey DA. Paediatric eye injuries during a COVID-19 pandemic lockdown. Clin Exp Optom 2021; 105:637-641. [PMID: 34402757 DOI: 10.1080/08164622.2021.1964921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
CLINICAL RELEVANCE Eye injuries, both accidental and non-accidental, are a significant cause of long-term visual impairment in children. An understanding of when and how such injuries occur is key to development of adequate prevention strategies. BACKGROUND To evaluate accidental and non-accidental eye injuries in children presenting to the major tertiary emergency department and outpatient ophthalmology clinic in Western Australia during the nationwide COVID-19 lockdown and to determine whether the frequency or nature of these injuries differed from pre-pandemic presentations. METHODS Retrospective review of the medical records of paediatric patients presenting to the emergency department and specialist ophthalmology clinic with an ocular injury and those presenting to the hospital Child Protection Unit with physical injuries during March-August 2020 and the same period in 2019. RESULTS There was no significant difference in the total number of accidental eye injury presentations during the lockdown period despite a significant decrease in emergency department attendance overall. Closed-globe injuries were the most common accidental eye injury presentation during lockdown (70/110, 64%), followed by adnexal injuries (39/110, 35%) and open-globe injuries (1/110, 1%). In contrast, referrals to the hospital Child Protection Unit for suspicious injuries declined during lockdown. Although eye injury presentations have changed in other parts of the world since the start of the pandemic, during COVID-19 lockdown in Western Australia, accidental paediatric ocular and adnexal trauma sustained at home continues to be a significant cause for hospital attendance. Public education regarding in-home eye injury prevention must be ongoing.
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Affiliation(s)
- Maria Franchina
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
| | - Magda Blaszkowska
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
| | - Joel Lewis
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Alice Johnson
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Antony Clark
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Geoffrey Lam
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - David A Mackey
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
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21
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[Nonaccidental traumatic brain injury in infants and children]. Radiologe 2021; 61:742-747. [PMID: 34251479 DOI: 10.1007/s00117-021-00885-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Violent traumatic brain injury (TBI) can cause brain dysfunction and injury. Accidental and nonaccidental trauma are still the leading cause of childhood death worldwide. It is assumed that about 20% of TBI in children under 2 years of age are nonaccidentally caused. In all cases, nonaccidental TBI is caused by the violent impact on the brain and spinal cord by the massive shaking of the child held by the upper arms or body. This can lead to a rupture of blood vessels, especially bridge veins, as well as axonal shear injuries to the nerve connections and brain swelling. Involvement of the brain stem can lead to initial short-term respiratory arrest. The resulting clinical symptoms include poor drinking, drowsiness, apathy, cerebral seizures, breathing disorders, temperature disorders, and vomiting as a result of increased intracranial pressure. Long-term disorders can include neurological and neuropsychological disorders, hearing disorders, visual disorders up to blindness, and poor school performance. In addition, there are metaphyseal fractures and rib fractures of various forms, also of different ages. Since shaking trauma has a poor prognosis, preventive measures are useful: education!
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Traumatic brain injury biomarkers in pediatric patients: a systematic review. Neurosurg Rev 2021; 45:167-197. [PMID: 34170424 DOI: 10.1007/s10143-021-01588-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/23/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
Traumatic brain injury (TBI) is the main cause of pediatric trauma death and disability worldwide. Recent studies have sought to identify biomarkers of TBI for the purpose of assessing functional outcomes. The aim of this systematic review was to evaluate the utility of TBI biomarkers in the pediatric population by summarizing recent findings in the medical literature. A total of 303 articles were retrieved from our search. An initial screening to remove duplicate studies yielded 162 articles. After excluding all articles that did not meet the inclusion criteria, 56 studies were gathered. Among the 56 studies, 36 analyzed serum biomarkers; 11, neuroimaging biomarkers; and 9, cerebrospinal fluid (CSF) biomarkers. Most studies assessed biomarkers in the serum, reflecting the feasibility of obtaining blood samples compared to obtaining CSF or performing neuroimaging. S100B was the most studied serum biomarker in TBI, followed by SNE and UCH-L1, whereas in CSF analysis, there was no unanimity. Among the different neuroimaging techniques employed, diffusion tensor imaging (DTI) was the most common, seemingly holding diagnostic power in the pediatric TBI clinical setting. The number of cross-sectional studies was similar to the number of longitudinal studies. Our data suggest that S100B measurement has high sensitivity and great promise in diagnosing pediatric TBI, ideally when associated with head CT examination and clinical decision protocols. Further large-scale longitudinal studies addressing TBI biomarkers in children are required to establish more accurate diagnostic protocols and prognostic tools.
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Porto L, Bartels MB, Zwaschka J, You SJ, Polkowski C, Luetkens J, Endler C, Kieslich M, Hattingen E. Abusive head trauma: experience improves diagnosis. Neuroradiology 2021; 63:417-430. [PMID: 33079214 PMCID: PMC7880981 DOI: 10.1007/s00234-020-02564-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/31/2020] [Indexed: 11/01/2022]
Abstract
PURPOSE The diagnosis of abusive head trauma (AHT) is complex and neuroimaging plays a crucial role. Our goal was to determine whether non-neuroradiologists with standard neuroradiology knowledge perform as well as neuroradiologists with experience in pediatric neuroimaging in interpreting MRI in cases of presumptive AHT (pAHT). METHODS Twenty children were retrospectively evaluated. Patients had been diagnosed with pAHT (6 patients), non-abusive head trauma-NAHT (5 patients), metabolic diseases (3 patients), and benign enlargement of the subarachnoid spaces (BESS) (6 patients). The MRI was assessed blindly, i.e., no clinical history was given to the 3 non-neuroradiologists and 3 neuroradiologists from 2 different institutions. RESULTS Blindly, neuroradiologists demonstrated higher levels of sensitivity and positive predictive value in the diagnosis of pAHT (89%) than non-neuroradiologists (50%). Neuroradiologists chose correctly pAHT as the most probable diagnosis 16 out of 18 times; in contrast, non-neuroradiologists only chose 9 out of 18 times. In our series, the foremost important misdiagnosis for pAHT was NAHT (neuroradiologists twice and non-neuroradiologists 5 times). Only victims of motor vehicle accidents were blindly misdiagnosed as pAHT. No usual household NAHT was not misdiagnosed as pAHT. Neuroradiologists correctly ruled out pAHT in all cases of metabolic diseases and BESS. CONCLUSION MRI in cases of suspected AHT should be evaluated by neuroradiologists with experience in pediatric neuroimaging. Neuroradiologists looked beyond the subdural hemorrhage (SDH) and were more precise in the assessment of pAHT and its differential diagnosis than non-neuroradiologists were. It seems that non-neuroradiologists mainly assess whether or not a pAHT is present depending on the presence or absence of SDH.
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Affiliation(s)
- Luciana Porto
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany.
| | - Marco Baz Bartels
- Department of Paediatric Neurology, Hospital of Goethe University, Frankfurt am Main, Germany
| | - Jonas Zwaschka
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
| | - Se-Jong You
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
| | - Christoph Polkowski
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
| | - Julian Luetkens
- Institute of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Christoph Endler
- Institute of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Kieslich
- Department of Paediatric Neurology, Hospital of Goethe University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
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Kazmir S, Rosado N. Abusive Head Trauma: A Review of Current Knowledge. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nonaccidental trauma in pediatric patients: evidence-based screening criteria for ophthalmologic examination. J AAPOS 2020; 24:226.e1-226.e5. [PMID: 32822853 DOI: 10.1016/j.jaapos.2020.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ophthalmologic examination is included in the work-up for pediatric nonaccidental trauma (NAT) when there is concern for retinal hemorrhage. However, dilated fundus examination entails patient discomfort and prohibition of assessment of pupillary response. Previous studies have suggested that patients without neuroimaging abnormalities are unlikely to have retinal hemorrhage. The purpose of the current study was to analyze the findings in patients who received NAT evaluation with eye examination at our institution, and to propose screening criteria for inclusion of ophthalmologic examination in NAT evaluation. METHODS The medical records of patients who received NAT evaluation with ophthalmologic examination at The Johns Hopkins Children's Center Pediatric Emergency Department from August 2014 to July 2018 were reviewed retrospectively. Data collected included demographics, presenting symptoms, imaging findings, and ophthalmologic examination findings. The main outcome measure was presence of retinal hemorrhage. RESULTS A total of 192 evaluations with ophthalmologic examination were included, representing 190 unique individuals of mean age 8.4 ± 9.5 months at presentation. In approximately half (54%) of the evaluations, there were abnormal findings on neuroimaging. Fifteen children (8%) had retinal hemorrhage, all of whom also had abnormal neuroimaging. Abnormal neuroimaging was associated with presence of retinal hemorrhage, with an odds ratio of 21.0 (95% CI, 3.47-∞; P < 0.001). Of the 15 children with retinal hemorrhage, 14 had subdural hemorrhage. CONCLUSIONS When neuroimaging abnormalities are present, ophthalmologic examination should be performed as part of the pediatric NAT evaluation. When there is no evidence of head injury on neuroimaging, ophthalmologic examination should not be routine.
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Nuño M, Shelley CD, Ugiliweneza B, Schmidt AJ, Magaña JN. Differences in Incidence and Case Fatality of Abusive Head Trauma. CHILD ABUSE & NEGLECT 2020; 104:104488. [PMID: 32334138 DOI: 10.1016/j.chiabu.2020.104488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/25/2020] [Accepted: 03/30/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) in children older than 1 and younger than 5 years old is thought uncommon and rarely studied. OBJECTIVE This study estimates national incidence and case fatality rate of abusive head trauma (AHT), and evaluates differences by age, sex, race, and region, with a focus on children of 2-4 years. PARTICIPANTS AND SETTING Hospital discharges were extracted from The Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000, 2003, 2006, 2009, and 2012 using the CDC's narrow definition of AHT. METHODS Survey-weighted chi-square tests were used to assess differences in incidence and case fatality rates. RESULTS The average annual incidence per 100,000 children was highest in <1 year-olds (27), followed by age 1 (4), age 2 (3), and age 3-4 (1). Average annual incidence varied significantly by sex (p = 0.0001), race (p < 0.0001), and region (p = 0.0002) within each age category. The average annual case fatality rate increased significantly with age, with a rate of 0.10 among children age <1 year, 0.15 for age 1, 0.23 for age 2, and 0.20 for age 3-4 years. The average annual case fatality rate was higher in the South (0.12) than West (0.10), Midwest (0.09), and Northeast (0.08) among children <1 year of age. CONCLUSIONS Black and Hispanic children and hospitals in the Midwest experienced higher incidence of AHT than White children and Northeast hospitals, respectively, especially in cases <1 year of age. Case fatality rates increased significantly with age, and the South experienced the highest rates for infants <1 year.
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Affiliation(s)
- Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA.
| | - Courtney D Shelley
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA
| | | | - Alec J Schmidt
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, USA
| | - Julia N Magaña
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, USA
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Abstract
BACKGROUND Abusive head trauma (AHT) peaks during early infancy and decreases in toddler years. Infants and toddlers experience different injuries, possibly impacting the risk of mortality. We aimed to evaluate the association of age with mortality. METHODS We conducted a retrospective study of AHT hospitalizations in 2000, 2003, 2006, 2009, and 2012 from the Kid's Inpatient Claims Database. An accidental head trauma cohort was included to hypothesize that the association between age and mortality is unique to abuse. A nested multivariable logistic regression was used to perform the analysis. RESULTS Children aged 2 years to 4 years experienced higher mortality than those younger than 2 years (22% vs. 10%, p < 0.0001; adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2). The presence of subarachnoid hemorrhage (OR, 1.9; 95% CI, 1.3-2.9), cerebral edema (OR, 4.0; 95% CI, 2.9-5.4), and retinal hemorrhage (OR, 1.9; 95% CI, 1.5-2.5) were associated with an increase risk in mortality. Children younger than 2 years experienced more fractures and hemorrhage (subdural, subarachnoid, retinal) while children aged 2 years to 4 years encountered more internal injuries and cerebral edema.In children with accidental head trauma, those aged 2 years to 4 years have a lower mortality compared with those younger than 2 years (OR, 0.4; 95% CI, 0.3-0.6). Among children younger than 2 years, AHT and accidental trauma had comparable risk of mortality (OR, 0.9; 95% CI, 0.6-1.3). However, among those aged 22 years to 4 years, AHT had a higher risk of mortality than accidental trauma (OR, 3.3; 95% CI, 2.1-5.1). CONCLUSION There is a considerable risk of mortality associated with age at diagnosis in children with AHT.Children younger than 2 years and those aged 2 years to 4 years present with different types of injuries. The high risk of mortality in the children aged 2 years to 4 years is unique to AHT. Efforts should be made to increase awareness about the risk of mortality and identify factors that can aide in a timely accurate diagnosis. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
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Modeling Hypertension as a Contributor to Retinal Hemorrhaging from Abusive Head Trauma. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:4714927. [PMID: 32566113 PMCID: PMC7256766 DOI: 10.1155/2020/4714927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 12/31/2019] [Accepted: 01/20/2020] [Indexed: 12/05/2022]
Abstract
Retinal hemorrhaging (RH) is indicative and prevalent in abusive head trauma (AHT)—yet the direct cause of the RH from AHT is unknown. Our hypothesis is that RH in AHT is the combination of shaking forces and hypertension. This combination of effects explains why RH is not normally observed in common childhood accidents but is nearly exclusively observed in AHT. An experimental model using porcine eyes was designed to ascertain the required pressure change for sudden RH and, via a computer model, the subsequent stress increase in blood vessels. The porcine eyes were cannulated via the maxillary artery and pressurized until perfusion and RH were observed. Fluid was injected into the head with a computer-controlled continuous flow syringe pump; video of the fundus was recorded during perfusion; and the pressure of the fluid entering the eye was recorded as well. A computer model was created in COMSOL to simulate loading from hypertension, shaking, and the combination of the forces. This model was validated via experimental data collected from the porcine model. It was found that hypertension or shaking alone did not cause an increase in stress required to cause RH. But when the loading of shaking and hypertension was combined, as would occur in AHT, the stress increases were greater than those extrapolated from the porcine model and would cause RH.
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29
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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30
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Kelly JP, Feldman K, Wright J, Ganti S, Metz JB, Weiss A. Retinal and visual function in infants with non-accidental trauma and retinal hemorrhages. Doc Ophthalmol 2020; 141:111-126. [PMID: 32052259 DOI: 10.1007/s10633-020-09756-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/06/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate retinal function and visual outcomes in infants with retinal hemorrhages due to non-accidental trauma (NAT). METHODS This is a retrospective review of full-field or multifocal electroretinogram (ERG) recordings, visual acuity in log minimum angle of resolution (logMAR), clinical status, and neuroimaging. Multifocal ERGs from the central 40° were compared to corresponding fundus imaging. Visual acuity was measured by Teller cards at follow-up. ERGs were compared to controls recorded under anesthesia. RESULTS Sixteen children met inclusion criteria (14 recorded during the acute phase and 2 during long-term follow-up). During the acute phase, ERGs (n = 4 full field; n = 10 multifocal ERG) showed abnormal amplitude, latency, or both in at least one eye. Ten subjects had significantly reduced responses in both eyes, 3 of which had an ERG dominated by a negative waveform (absent b-wave or P1). The remaining six subjects had responses in one eye that were near normal (≥ 50% of controls). ERGs were sometimes abnormal in local areas without hemorrhage. ERGs could be preserved in local areas adjacent to traumatic retinoschisis. Two subjects with reduced visual acuity had belated ERGs: One had an abnormal macular ERG and the other had a normal macular ERG implying cortical visual impairment. At follow-up, 10 of 14 subjects had significant visual acuity loss (≥ 0.7 age-corrected logMAR); four subjects had mild vision loss (≤ 0.5 age-corrected logMAR). Visual acuity outcome was not reliably associated with the fundus appearance in the acute phase. All subjects with a negative ERG waveform had severe vision loss on follow-up. CONCLUSIONS Retinal dysfunction was common during the acute phase of NAT. A near normal appearing fundus did not imply normal retinal function, and ERG abnormality did not always predict a poor visual acuity outcome. However, a negative ERG waveform was associated severe visual acuity loss. Potential artifacts of retinal hemorrhages and anesthesia could not fully account for multifocal ERG abnormalities. Retinal function can be preserved in areas adjacent to traumatic retinoschisis.
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Affiliation(s)
- John P Kelly
- Roger H. Johnson Vision Clinic, Seattle Children's Hospital, Division of Ophthalmology, OA.5.342, Seattle, WA, 98105, USA.
- Department of Ophthalmology, University of Washington, Seattle, USA.
| | - Kenneth Feldman
- Seattle Children's Hospital, Children's Protection Program, Seattle, USA
- Division of General Pediatrics, University of Washington, Seattle, USA
| | - Jason Wright
- Division of Radiology, Seattle Children's Hospital, Seattle, USA
| | - Sheila Ganti
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, USA
| | - James B Metz
- Department of Pediatrics, University of Vermont, Burlington, USA
| | - Avery Weiss
- Department of Ophthalmology, University of Washington, Seattle, USA
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31
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Lee EP, Zhao LL, Hsia SH, Lee J, Chan OW, Lin CY, Su YT, Lin JJ, Wu HP. Clinical Significance of Nadir Hemoglobin in Predicting Neurologic Outcome in Infants With Abused Head Trauma. Front Pediatr 2020; 8:140. [PMID: 32318527 PMCID: PMC7147474 DOI: 10.3389/fped.2020.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 03/11/2020] [Indexed: 12/02/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality and is categorized as abusive head trauma (AHT) and accidental head injury. A retrospective chart review of 124 children aged <1 year diagnosed with TBI were analyzed. Outcomes were evaluated at discharge and 6 months later by using the Pediatric Cerebral Performance Category (PCPC) Scale. The receiver operating characteristic (ROC) curve was applied to determine the cutoff values for hemoglobin (HB) levels. In the study, 50 infants (40.3%) achieved a favorable neurologic outcome (PCPC ≦ 2) and 74 (59.7%) had poor neurologic outcomes (PCPC ≧ 3). Infants with poor neurologic outcomes had lower HB on admission and nadir HB (p < 0.05). Based on multivariate logistic regression analysis, the nadir HB was a predictor of poor neurologic outcomes at discharge and 6 months later in both AHT and accidental head injury. Nadir HB had the largest area under the ROC curve for predicting poor neurologic outcomes. We determined the appropriate cutoff value of nadir HB as 9.35 g/dl for predicting neurologic outcomes in infants with TBI. Furthermore, the cutoff value of nadir HB in predicting poor neurologic outcomes in infants caused by AHT and accidental head injury were taken as 9.36 and 8.75 g/dl, respectively.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lu-Lu Zhao
- Department of Pediatrics, Taipei Tzu Chi Hospital, New Taipei, Taiwan.,Department of Medicine, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jung Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Ying Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Ting Su
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,Department of Pediatric Emergency Medicine, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
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32
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Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr 2019; 24:481-488. [PMID: 31675688 DOI: 10.3171/2019.7.peds18394] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
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Affiliation(s)
- Ann-Christine Duhaime
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Cindy W Christian
- 2Department of Pediatrics, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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33
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Silloca‐Cabana EO, Hathuc VM, Harrison WT, Lantz PE. Hemorrhagic Retinopathy and Optic Nerve Sheath Hemorrhage Associated With Fatal Subarachnoid Hemorrhage from a Ruptured Intracranial Aneurysm Due to Segmental Fibromuscular Dysplasia. J Forensic Sci 2019; 65:649-654. [DOI: 10.1111/1556-4029.14196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/21/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - Vivian M. Hathuc
- Department of Pathology Ascension Genesys Hospital 1 Genesys Pkwy Grand Blanc MI 48439
| | - William T. Harrison
- Department of Pathology Wake Forest Baptist Health Medical Center Blvd. Winston Salem NC 27157
| | - Patrick E. Lantz
- Department of Pathology Wake Forest Baptist Health Medical Center Blvd. Winston Salem NC 27157
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Donaldson L, Isaza G, Baird B, Chaudhary V. Ophthalmology referral as part of a multidisciplinary approach to suspected abusive head trauma. Can J Ophthalmol 2019; 55:172-178. [PMID: 31712016 DOI: 10.1016/j.jcjo.2019.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/20/2019] [Accepted: 07/18/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the use of ophthalmology consultation as part of investigation of children with suspected abusive head trauma (AHT). METHODS Retrospective chart review of children under age 3 years evaluated at McMaster Children's Hospital for suspected AHT from January 2011 to December 2017. RESULTS Fifty-seven children were investigated, and 29 (50.9%) of these were determined to have likely AHT. Eleven (19.3%) had other nonaccidental injuries. A mean of 3.6 consulting services were involved. Neuroimaging was performed for 52 patients (91.2%), including all patients in the AHT group. Intracranial hemorrhage (ICH) was present in 21 of the 29 AHT children (72.4%). All 57 patients had a dilated fundus examination, and retinal hemorrhages (RH) were seen in 23 patients (40.4%), including 16 (55.2%) in the AHT group. All patients with RH in AHT also had ICH. In the AHT group, there were more cases of hemorrhages too numerous to count (68.8% vs 28.6%), multilayered hemorrhages (75.0% vs 57.1%), and hemorrhages in the posterior pole and periphery (87.5% vs 42.9%) when compared with patients with RH from other etiologies. Retinoschisis was seen in the AHT group only in 3 patients (18.8%). CONCLUSIONS A multidisciplinary approach is important when investigating suspected AHT. Not every child with RH had suffered AHT; however, children with AHT showed more widespread and more multilayered RH. The only finding specific to AHT was retinoschisis.
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Affiliation(s)
- Laura Donaldson
- Division of Ophthalmology, McMaster University Department of Surgery, McMaster Children's Hospital, Hamilton, Ont
| | - Gloria Isaza
- Division of Ophthalmology, McMaster University Department of Surgery, McMaster Children's Hospital, Hamilton, Ont..
| | - Burke Baird
- Division of Child Maltreatment Pediatrics, McMaster University Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ont
| | - Varun Chaudhary
- Division of Ophthalmology, McMaster University Department of Surgery, McMaster Children's Hospital, Hamilton, Ont
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Abstract
Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
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Woolf SM, Leventhal JM, Gaither JR, Hardikar P, Langhan ML, Bechtel K, Auerbach MA, Tiyyagura G. Oral injuries in children less than 24 months of age in a pediatric emergency department. CHILD ABUSE & NEGLECT 2019; 89:70-77. [PMID: 30639971 DOI: 10.1016/j.chiabu.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Oral injuries in young children may indicate physical abuse. The prevalence of oral injuries in young children presenting to the emergency department is unknown. These data would assist providers in making decisions about the need for further abuse evaluation. OBJECTIVE To determine the prevalence of oral injuries, associated chief complaints and characteristics, and frequency of abuse evaluations in children younger than 24 months presenting to a pediatric emergency department (PED). PARTICIPANTS AND SETTING Twelve pediatric emergency medicine physicians consecutively enrolled children younger than 24 months in a tertiary care PED. METHODS We performed a prospective observational study. Enrolled patients underwent a complete oral examination. Providers recorded patient demographics, type of chief complaint, oral injury details, developmental ability, and the presence of an abuse evaluation. RESULTS Oral injuries occurred in 36/1303 (2.8%, 95% CI 1.9-3.8%) and were more common in patients with traumatic (26/200, 13%) versus medical chief complaints (10/1,103, 0.9%) (p < .001). Of patients with oral injuries (36), 78% were mobile and 72% had traumatic chief complaints. Nine (25%) children with oral injuries were evaluated for abuse. Oral injuries in children 0-11 months old were more likely to be evaluated for abuse than children 12-24 months old (70.0% vs. 7.7%, p < .001). CONCLUSIONS The prevalence of oral injuries in children <24 months old presenting to a PED was low. Most occurred in mobile children and in children with traumatic chief complaints. Younger, non-mobile children with oral injuries had a higher likelihood of having an abuse evaluation.
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Affiliation(s)
- Seth M Woolf
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York Street, Suite 1F, New Haven, Connecticut, 06511, USA.
| | - John M Leventhal
- Department of Pediatrics, Section of General Pediatrics, Yale University School of Medicine, Dana Clinic Building Basement, 789 Howard Avenue, New Haven, Connecticut, 06519, USA.
| | - Julie R Gaither
- Department of Pediatrics, Section of General Pediatrics, Yale University School of Medicine, Dana Clinic Building Basement, 789 Howard Avenue, New Haven, Connecticut, 06519, USA.
| | - Priyanka Hardikar
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York Street, Suite 1F, New Haven, Connecticut, 06511, USA.
| | - Melissa L Langhan
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York Street, Suite 1F, New Haven, Connecticut, 06511, USA.
| | - Kirsten Bechtel
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York Street, Suite 1F, New Haven, Connecticut, 06511, USA.
| | - Marc A Auerbach
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York Street, Suite 1F, New Haven, Connecticut, 06511, USA.
| | - Gunjan Tiyyagura
- Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, 100 York Street, Suite 1F, New Haven, Connecticut, 06511, USA.
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Shi A, Kulkarni A, Feldman KW, Weiss A, McCourt EA, Schloff S, Partington M, Forbes B, Geddie BE, Bierbrauer K, Phillips PH, Rogers DL, Abed Alnabi W, Binenbaum G, Levin AV. Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes. Pediatrics 2019; 143:peds.2018-1182. [PMID: 30630868 PMCID: PMC6361344 DOI: 10.1542/peds.2018-1182] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP. METHODS We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded. RESULTS Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions. CONCLUSIONS Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.
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Affiliation(s)
- Angell Shi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Abhaya Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Avery Weiss
- Ophthalmology, Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Emily A. McCourt
- Department of Ophthalmology, Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Susan Schloff
- Associated Eye Care, St Paul, Minnesota;,Department of Ophthalmology and Visual Neurosciences, Children’s Minnesota St Paul Hospital, St Paul, Minnesota
| | - Michael Partington
- Department of Neurosurgery, Gillette Children’s Specialty Healthcare, St Paul, Minnesota
| | - Brian Forbes
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brooke E. Geddie
- Division of Pediatric Ophthalmology, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - Karin Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul H. Phillips
- Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas;,Department of Ophthalmology, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - David L. Rogers
- Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Waleed Abed Alnabi
- Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and,Médecins Sans Frontieres, Amman, Jordan
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V. Levin
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania;,Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and
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Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, Engström I, Erlandsson BE. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018; 107 Suppl 472:3-23. [PMID: 30146789 PMCID: PMC6585638 DOI: 10.1111/apa.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
The Swedish Agency for Health Technology Assessment and Assesment of Social Services (SBU) is an independent national authority, tasked by the government with assessing methods used in health, medical and dental services and social service interventions from a broad perspective, covering medical, economic, ethical and social aspects. The language in SBU's reports are adjusted to a wide audience. SBU's Board of Directors has approved the conclusions in this report. The systematic review showed the following graded results: There is limited scientific evidence that the triad (Three components of a whole. The triad associated with SBS usually comprises subdural haematoma, retinal haemorrhages and encephalopathy.) and therefore, its components can be associated with traumatic shaking (low-quality evidence). There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). Limited scientific evidence (low-quality evidence) represents a combined assessment of studies of high or moderate quality which disclose factors that markedly weaken the evidence. It is important to note that limited scientific evidence for the reliability of a method or an effect does not imply complete lack of scientific support. Insufficient scientific evidence (very low-quality evidence) represents either a lack of studies or situations when available studies are of low quality or show contradictory results. Evaluation of the evidence was not based on formal grading of the evidence according to GRADE but on an evaluation of the total scientific basis.
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Affiliation(s)
- Göran Elinder
- Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, Umeå, Sweden
- The National Board of Forensic Medicine, Sweden
| | - Boubou Hallberg
- Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niels Lynøe
- Medical Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Maly Sundgren
- Diagnostic Radiology, Lund University, Lund, Sweden
- Department of Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Måns Rosén
- Health Technology Assessment, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Engström
- Child and Adolecent Psychiatry, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Abstract
Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.
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40
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Morgan LA, Fouzdar Jain S, Svec A, Svec C, Haney SB, Allbery S, High R, Suh DW. Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma. Clin Ophthalmol 2018; 12:1505-1510. [PMID: 30174411 PMCID: PMC6110291 DOI: 10.2147/opth.s163734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose Child abuse is a leading cause of death in infants, which is often associated with abusive head trauma (AHT). The purpose of this retrospective analysis was to identify ocular and systemic findings in confirmed cases of AHT and compare them to a group of non-abusive head trauma (NAHT) patients. Patients and methods A retrospective chart review of 165 patients with accidental and non-accidental trauma admitted between 2013 and 2015 to Children’s Hospital and Medical Center in Omaha, NE, USA, was performed. Diagnosis of AHT was made after the analysis of ocular and systemic findings by various subspecialists. The NAHT group consisted of accidental trauma, abusive trauma without significant apparent head involvement on initial evaluation and unconfirmed AHT cases. Results Of the 165 presenting cases, 30 patients were diagnosed with AHT and 127 were diagnosed with NAHT. Ocular findings in AHT patients were significant for retinal hemorrhages (63%) and vitreous hemorrhages (37%), while NAHT patients had no ocular findings (p<0.001). Neuroimaging revealed subdural hemorrhages (SDHs) in 29 out of 30 AHT patients (97%) and in 27 out of 127 NAHT patients (21%). Seizures were present in 43% of AHT patients (n=13) and only in 8% of NAHT patients (n=10). Conclusion AHT has statistically significant findings of retinal and vitreous hemorrhages. The absence of diffuse retinal hemorrhages, however, does not preclude the AHT diagnosis as more than one-third of AHT patients lacked retinal hemorrhages. SDHs, loss of consciousness and history of seizures also have high correlation with a diagnosis of AHT.
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Affiliation(s)
| | | | - Austin Svec
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Claire Svec
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Robin High
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Donny W Suh
- Children's Hospital and Medical Center, Omaha, NE, USA, .,University of Nebraska Medical Center, Omaha, NE, USA
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41
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
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Affiliation(s)
- Arabinda Kumar Choudhary
- Department of Radiology, Nemours AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Slovis
- Department of Radiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Gary L Hedlund
- Department of Medical Imaging, Primary Children's Hospital, Intermountain Healthcare, Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Cindy W Christian
- Department of Pediatrics, Child Abuse and Neglect Prevention, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Marvin D Nelson
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Susan Palasis
- Pediatric Neuroradiology, Children's Healthcare of Atlanta, Scottish Rite Campus, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Andrea Rossi
- Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, Western Bank, University of Sheffield, Sheffield, UK
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42
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SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations. Int J Legal Med 2018; 132:1719-1727. [PMID: 29982863 DOI: 10.1007/s00414-018-1889-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
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.
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43
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Bechtel K, Bhatnagar A, Auerbach M. Simulation-based research to improve infant health outcomes: Using the infant simulator to prevent infant shaking. Infant Behav Dev 2018; 56:101263. [PMID: 29903429 DOI: 10.1016/j.infbeh.2018.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Kirsten Bechtel
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States.
| | - Ambika Bhatnagar
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States
| | - Marc Auerbach
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States
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Variations in Mechanisms of Injury for Children with Concussion. J Pediatr 2018; 197:241-248.e1. [PMID: 29627189 PMCID: PMC6029621 DOI: 10.1016/j.jpeds.2018.01.075] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/22/2017] [Accepted: 01/26/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. STUDY DESIGN All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. RESULTS Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). CONCLUSIONS Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non-sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed.
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45
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Tiyyagura G, Christian C, Berger R, Lindberg D. Occult abusive injuries in children brought for care after intimate partner violence: An exploratory study. CHILD ABUSE & NEGLECT 2018; 79:136-143. [PMID: 29452932 PMCID: PMC5879001 DOI: 10.1016/j.chiabu.2018.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 01/30/2018] [Accepted: 02/06/2018] [Indexed: 05/29/2023]
Abstract
Children in homes with intimate partner violence (IPV) are at increased risk for physical abuse. We determined the frequency and injury patterns in children who underwent child abuse consultation after IPV exposure by retrospectively analyzing the "Examination of Siblings To Recognize Abuse" cohort of children referred for physical abuse. Children were selected who presented after IPV exposure. Among 2890 children evaluated by child abuse pediatricians, 61 (2.1%) patients presented after IPV exposure. Of the 61, 11 (18.0%) were exposed to IPV, but had no direct involvement in the IPV event, 36 (59.0%) sustained inadvertent trauma during IPV, and 14 (23.0%) were directly assaulted during IPV. Thirty-six patients (59.0%) had an injury: 31 (51.0%) had cutaneous injuries and 15 (24.6%) had internal injuries including fracture(s), intracranial or intra-abdominal injury. Of the 15 patients with internal injuries, 14 (93.3%) were less than 12 months old. Among the 36 patients with injuries, 16 (44.4%) had no report of direct injury, a report of a mechanism that did not explain the identified injuries, or a report of trauma without a specific mechanism. Five (13.9%) did not have physical examination findings to suggest the extent of their internal injuries. Injuries are present in a significant proportion of children presenting to Emergency Departments after IPV exposure. History and physical examination alone are insufficient to detect internal injuries especially in infants. These preliminary results support the need for future, prospective studies of occult injury in children exposed to IPV.
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Affiliation(s)
- Gunjan Tiyyagura
- Yale University School of Medicine, New Haven, CT, United States.
| | - Cindy Christian
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Rachel Berger
- Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Daniel Lindberg
- University of Colorado School of Medicine, Aurora, CO, United States
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46
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Kim SY, Morgan LA, Baldwin AJ, Suh DW. Comparison of the characteristics of retinal hemorrhages in abusive head trauma versus normal vaginal delivery. J AAPOS 2018; 22:139-144. [PMID: 29548839 DOI: 10.1016/j.jaapos.2017.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 12/06/2017] [Accepted: 12/19/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Retinal hemorrhage (RH) is one of the hallmarks of abusive head trauma (AHT); however, RH is also encountered with normal vaginal deliveries (NVD) and thus presents the clinician with a diagnostic dilemma. The purpose of this study was to compare RHs in AHT with those of NVD. METHODS Records of with AHT and NVD infants with RH evaluated from 2013 to 2015 were reviewed retrospectively. Pattern, size, extent, and severity were compared using RetCam images. Severities were calculated using the RH grading scale. RESULTS A total of 20 patients with AHT and 200 NVD infants were included. RH size was significantly larger in AHT patients compared to the NVD group (3.1 ± 0.512 vs 0.96 ± 0.046 disk diameters, resp.). The AHT group also demonstrated a higher RH incidence involving all three retinal layers compared to the NVD group (60% vs 0.6%, resp. [P < 0.001]). Vitreous hemorrhages were more common in the AHT group compared to the NVD group (54.3% vs 1.5% [P < 0.001]). Also, the grading scale demonstrated higher scores in the AHT group than the NVD group (7.15 ± 0.948 vs 3.59 ± 0.274, resp.). CONCLUSIONS AHT and NVD share similar retinal findings, but they also have unique differentiators. In our subjects, AHT presented with more severe retinal findings than NVD, including larger RH size, a higher percentage involving all three retinal layers, a higher percentage of vitreous hemorrhages, and higher RH grading scale scores. Also, NVD retinal hemorrhages resolved quickly, within 4 weeks of birth in 95% of the patients.
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Affiliation(s)
- So Young Kim
- Children's Hospital and Medical Center, Omaha, Nebraska
| | - Linda A Morgan
- Children's Hospital and Medical Center, Omaha, Nebraska.
| | | | - Donny W Suh
- Children's Hospital and Medical Center, Omaha, Nebraska; University of Nebraska Medical Center, Omaha, Nebraska
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47
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Chong CF, Misra SL, Escardo-Paton JA, Dai S. Predictors of long-term neurological outcomes in non-accidental head injury. Eye (Lond) 2017; 32:608-614. [PMID: 29219962 DOI: 10.1038/eye.2017.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/25/2017] [Indexed: 11/09/2022] Open
Abstract
BackgroundNon-accidental head injury (NAI) is an inflicted injury usually on a child, often resulting in long-term neurological impairment and occasionally death. This study aimed to investigate the predictive values of acute findings, especially ocular, for long-term neurological outcomes.MethodsMedical records including retinal images of all children who attended the local Children's hospital with a diagnosis of NAI from over a period of 5 years were reviewed and data collected via the electronic patient record system. Patient demographics, injuries sustained, wide-field digital retinal images, visual acuity and sequalae, neurological function, and global function was noted. IBM SPSS software program was used for statistical analysis.ResultsOf the 38 patients (24 males, 14 females), 12 children died acutely from the head injury with the remaining 26 children available for long-term follow-up. A younger age of injury (P=0.004) was the only statistically significant predictor of good neurological outcome as compared with absence of macular retinoschisis, unilateral retinal haemorrhage, and unilateral subdural haemorrhage. Of the 38 children, 17 children had retinoschisis; 9 children with macular retinoschisis died acutely while 4 suffered a degree of developmental delay and only 4 were developmentally normal at the last follow-up. Long-term visual acuity data was available for 18 of the 26 survivors (range: NPL to Snellen 6/5). A statistical significance was noted between retinoschisis and worsened visual acuity (P<0.05).ConclusionsBilateral macular retinoschisis on acute presentation of NAI is associated with a seven-fold and unilateral with a four-fold increase in the development of a poor neurological outcome and eventual death. Conflicting to other studies, younger children presented better neurological outcomes.
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Affiliation(s)
- C F Chong
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, New Zealand.,Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S L Misra
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - S Dai
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, New Zealand.,Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury. Crit Care Med 2017; 45:1398-1407. [PMID: 28430697 DOI: 10.1097/ccm.0000000000002378] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Maguire S. Commentary on: Research priorities for a multicenter child abuse pediatrics network - CAPNET by Lindberg D et al., 2017: Need for internationally agreed definitions of Child Maltreatment for research purposes. CHILD ABUSE & NEGLECT 2017; 70:411-413. [PMID: 28420492 DOI: 10.1016/j.chiabu.2017.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/23/2017] [Accepted: 03/28/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Sabine Maguire
- School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4XN, United Kingdom.
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50
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The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. J Trauma Acute Care Surg 2017; 82:1147-1157. [DOI: 10.1097/ta.0000000000001441] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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