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Ahmad D, Small A, Gibson A, Kissoon N. Developmental outcomes in abusive head trauma. Semin Pediatr Neurol 2024; 50:101142. [PMID: 38964813 DOI: 10.1016/j.spen.2024.101142] [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: 01/30/2024] [Revised: 04/25/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Abusive head trauma (AHT) is associated with high mortality and poorer outcomes compared to accidental head injuries. The short and long-term developmental outcomes for AHT are not well identified. Variability in outcome measures, small sample sizes, difficulty in measuring domain-specific developmental skills, co-existence of comorbidities, genetic and environmental factors and high attrition rates all contribute to the challenges on providing data in this area. The objective of this article is to review the scientific literature on the developmental outcomes of AHT, highlighting factors that affect outcomes, the available assessment tools, and short and long-term developmental outcomes, recommended follow up, societal costs, and future opportunities for research. Authors searched OVID Medline and PubMed for articles published between 2013 and 2023 using the terms "abuse", "craniocerebral trauma" and "development". Fifty-five records were included for this review. The data shows that injuries sustained from AHT result in a spectrum of outcomes ranging from normal development to death. There are more than 100 outcome assessment tools limiting the ability to compare studies. More than half of patients are left with disabilities post discharge. Gross motor and cognition/academics are the 2 most common domains studied. Advancement in surgical and neurocritical care management has influenced AHT outcomes. Close long-term follow up is recommended to maximize each child's developmental potential, irrespective of the presence of disability at discharge. We suggest that future research should focus on adopting a consistent diagnostic and assessment approach and explore the social environmental factors that can affect recovery.
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Affiliation(s)
- Dina Ahmad
- UTHealth Houston (The University of Texas Health Science Center at Houston), USA.
| | | | - Ashley Gibson
- UTHealth Houston (The University of Texas Health Science Center at Houston), USA
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Hartman L, Greene HM. Acute presentation of abusive head trauma. Semin Pediatr Neurol 2024; 50:101135. [PMID: 38964810 DOI: 10.1016/j.spen.2024.101135] [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: 02/01/2024] [Revised: 04/22/2024] [Accepted: 05/07/2024] [Indexed: 07/06/2024]
Abstract
Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.
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Affiliation(s)
- Luke Hartman
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205.
| | - H Michelle Greene
- Division of Child and Family Advocacy, Department of Pediatrics, Nationwide Children's Hospital, 655 E Livingston Ave, Columbus, OH 43205
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Raut A, Pierce MC. Cranial Imaging in the Youngest Infants: Worth the Risk. Pediatrics 2024; 153:e2023065511. [PMID: 38813619 DOI: 10.1542/peds.2023-065511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/31/2024] Open
Affiliation(s)
- Audrey Raut
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Mary Clyde Pierce
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
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Lin K, Khan SS, Truong T, Parsikia A, Mbekeani JN. Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome. Childs Nerv Syst 2024:10.1007/s00381-024-06441-5. [PMID: 38709256 DOI: 10.1007/s00381-024-06441-5] [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: 11/15/2023] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. METHODS We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. RESULTS Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. CONCLUSIONS Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.
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Affiliation(s)
- Kira Lin
- Medical School Program, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabine S Khan
- Department of Surgery (Ophthalmology), Jacobi Medical Center,1400, 1400 Pelham Parkway, Bronx, NY, 10461, USA
- Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy Truong
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
| | - Afshin Parsikia
- Department of Research Services, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce N Mbekeani
- Department of Surgery (Ophthalmology), Jacobi Medical Center,1400, 1400 Pelham Parkway, Bronx, NY, 10461, USA.
- Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine, Bronx, NY, USA.
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Harris S, Chinnery HR, Semple BD, Mychasiuk R. Shaking Up Our Approach: The Need for Characterization and Optimization of Pre-clinical Models of Infant Abusive Head Trauma. J Neurotrauma 2024. [PMID: 38497766 DOI: 10.1089/neu.2023.0598] [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: 03/19/2024] Open
Abstract
Traumatic brain injuries (TBIs) are a large societal and individual burden. In the first year of life, the vast majority of these injuries are the result of inflicted abusive events by a trusted caregiver. Abusive head trauma (AHT) in infants, formerly known as shaken baby syndrome, is the leading cause of inflicted mortality and morbidity in this population. In this review we address clinical diagnosis, symptoms, prognosis, and neuropathology of AHT, emphasizing the burden of repetitive AHT. Next, we consider existing animal models of AHT, and we evaluate key features of an ideal model, highlighting important developmental milestones in children most vulnerable to AHT. We draw on insights from other injury models, such as repetitive, mild TBIs (RmTBIs), post-traumatic epilepsy (PTE), hypoxic-ischemic injuries, and maternal neglect, to speculate on key knowledge gaps and underline important new opportunities in pre-clinical AHT research. Finally, potential treatment options to facilitate healthy development in children following an AHT are considered. Together, this review aims to drive the field toward optimized, well-characterized animal models of AHT, which will allow for greater insight into the underlying neuropathological and neurobehavioral consequences of AHT.
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Affiliation(s)
- Sydney Harris
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Holly R Chinnery
- Department of Optometry and Vision Science, University of Melbourne, Parkville, Victoria, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Prahran, Victoria, Australia
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Prahran, Victoria, Australia
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Squier W. Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence. Dev Med Child Neurol 2024; 66:290-297. [PMID: 37353945 DOI: 10.1111/dmcn.15676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 06/25/2023]
Abstract
The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine.
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Affiliation(s)
- Waney Squier
- Department of Neuropathology, John Radcliffe Hospital, Oxford, UK
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Hutchinson K, van Zandwijk JP, Vester MEM, Seth A, Bilo RAC, van Rijn RR, Loeve AJ. Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Update to parts I&II: A systematic review of animal, mathematical and physical models. Forensic Sci Med Pathol 2024:10.1007/s12024-023-00765-5. [PMID: 38236351 DOI: 10.1007/s12024-023-00765-5] [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: 12/12/2023] [Indexed: 01/19/2024]
Abstract
Inflicted shaking trauma can cause injury in infants, but exact injury mechanisms remain unclear. Controversy exists, particularly in courts, whether additional causes such as impact are required to produce injuries found in cases of (suspected) shaking. Publication rates of studies on animal and biomechanical models of inflicted head injury by shaking trauma (IHI-ST) in infants continue rising. Dissention on the topic, combined with its legal relevance, makes maintaining an up-to-date, clear and accessible overview of the current knowledge-base on IHI-ST essential. The current work reviews recent (2017-2023) studies using models of IHI-ST, serving as an update to two previously published reviews. A systematic review was conducted in Scopus and PubMed for articles using animal, physical and mathematical models for IHI-ST. Using the PRISMA methodology, two researchers independently screened the publications. Two, five, and ten publications were included on animal, physical, and mathematical models of IHI-ST, respectively. Both animal model studies used rodents. It is unknown to what degree these can accurately represent IHI-ST. Physical models were used mostly to investigate gross head-kinematics during shaking. Most mathematical models were used to study local effects on the eye and the head's internal structures. All injury thresholds and material properties used were based on scaled adult or animal data. Shaking motions used as inputs for animal, physical and mathematical models were mostly greatly simplified. Future research should focus on using more accurate shaking inputs for models, and on developing or and validating accurate injury thresholds applicable for shaking.
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Affiliation(s)
- Kim Hutchinson
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands
| | - Jan Peter van Zandwijk
- Division of Digital and Biometric Traces, Netherlands Forensic Institute, Laan Van Ypenburg 6, 2497, The Hague, GB, Netherlands
| | - Marloes E M Vester
- Care Needs Assessment Centre CIZ, Orteliuslaan 1000, 3500 GR, Utrecht, Netherlands
| | - Ajay Seth
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands
| | - Rob A C Bilo
- Veilig Thuis Rotterdam Rijnmond (Center for the Reporting of Child Abuse, Domestic Violence and Elder Abuse), Paul Krugerstraat 181, 3072 GJ, Rotterdam, Netherlands
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Academic Medical Center Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, Netherlands
- Department of Forensic Medicine, Netherlands Forensic Institute, Laan Van Ypenburg 6, 2497, The Hague, GB, Netherlands
| | - Arjo J Loeve
- Department of BioMechanical Engineering, Faculty of Mechanical, Maritime & Materials Engineering, Delft University of Technology, Mekelweg 2, 2628, Delft, CD, Netherlands.
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Kachelski C, Gavin K, Head H, Horton D, Anderst J. A lucid interval in a victim of abusive head trauma with multiple parenchymal lacerations. J Forensic Leg Med 2024; 101:102638. [PMID: 38185064 DOI: 10.1016/j.jflm.2023.102638] [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: 10/01/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
Abusive head trauma (AHT) is a leading cause of abusive deaths in children under age one. AHT can include intracranial hemorrhages, hypoxic ischemic injury, or parenchymal lacerations. Most infants with parenchymal lacerations present with acute neurological symptoms. There has been some published literature on lucid intervals in cases of AHT; however, there has not been a described lucid interval with parenchymal lacerations. Parenchymal lacerations typically present with acute symptomatology such as seizures, alteration in mental status, or increased fussiness/lethargy given the damage to neurons and brain structure. We present a case of a healthy 2-month-old who ultimately was diagnosed with AHT and three parenchymal lacerations and had a 2.5 hour period of normal neurological status prior to acute decompensation.
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Affiliation(s)
- Cree Kachelski
- Division of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Clinic Center for Safe and Healthy Children and Adolescents, Mayo Clinic, Rochester, MN, USA.
| | - Kelsey Gavin
- Graduate Medical Education, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Hayden Head
- Division of Radiology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Danielle Horton
- Division of Child Adversity and Resilience, Children's Mercy Kansas City, Kansas City, MO, USA
| | - James Anderst
- Division of Child Adversity and Resilience, Children's Mercy Kansas City, Kansas City, MO, USA
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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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Jones MU, Banaag A, Nafea SS, Koehlmoos TP. Evaluation of Racial Disparities in Suspected Child Abuse among Insured Children with Head Injury. CHILD MALTREATMENT 2023; 28:713-722. [PMID: 36571822 DOI: 10.1177/10775595221148424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Previous studies demonstrate racial disparities in child abuse evaluations even after controlling for health insurance coverage. We conducted a cross-sectional study using the Military Health System Data Repository (MDR) of Military Health System (MHS) beneficiaries born between fiscal years 2016 and 2018 to evaluate racial disparities and other factors in the suspicion of child abuse. We observed beneficiaries for 2.5 years after birth and assessed the incidence of head injury using diagnostic codes. Among children with head injury codes, we performed a multivariable logistic regression analysis to measure the association between race and the concurrent use of the diagnostic code for suspected child abuse (SCA) or for the performance of a skeletal survey. There were 195,893 infants included and 45,269 (23.1%) underwent evaluations for head injury. Less than one percent (n = 424) concurrently had the diagnostic code for SCA or a skeletal survey performed within 2 weeks of the head injury evaluation. When controlling for other factors, race was not associated with SCA. Higher military rank was independently associated with decreased odds of SCA. Racial disparities in SCA may be mitigated in the MHS, and further evaluation is needed. Military rank could be a factor in SCA disparities and warrants further study.
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Affiliation(s)
- Milissa U Jones
- Department of Pediatrics, Uniformed Services University, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Amanda Banaag
- Department of Pediatrics, Tripler Army Medical Center, Tripler Army Medical Center, HI, USA
| | - Shamim S Nafea
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA
| | - Tracey Perez Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA
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Timonov P, Fasova A, Braynova I, Novakov I, Poryazova E. Difficulties Encountered by Forensic Pathologists in Proving Abusive Head Trauma in Children: A Case Report. Cureus 2023; 15:e49697. [PMID: 38161932 PMCID: PMC10757269 DOI: 10.7759/cureus.49697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Shaken baby syndrome (SBS) or abusive head trauma (AHT) is one of the most common causes of death or serious neurological injury resulting from child abuse. AHT is defined as injury to the skull or intracranial contents of an infant or child younger than five years due to intentional abrupt impact and/or violent shaking. It is characterized by acute encephalopathy with subdural and retinal hemorrhages. We present a case of AHT that does not show the typical clinical triad. We describe one case of a pediatric patient addressed for forensic autopsy and where suspicion of AHT has arisen. The injury mechanism involved in the production of this syndrome and its clinical manifestation are sources of debate in forensic medicine. Thus, forensic pathologists must analyze all findings to determine SBS/AHT.
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Affiliation(s)
- Pavel Timonov
- Forensic Medicine, University Hospital St. George, Plovdiv, BGR
- Forensic Medicine and Deontology, Medical University Plovdiv, Plovdiv, BGR
| | - Antoaneta Fasova
- Anatomy, Histology and Embryology, Medical University Plovdiv, Plovdiv, BGR
| | - Ilina Braynova
- Forensic Medicine and Deontology, Medical University Sofia, Sofia, BGR
| | - Ivan Novakov
- Special Surgery, Medical University Plovdiv, Plovdiv, BGR
| | - Elena Poryazova
- General and Clinical Pathology, Medical University Plovdiv, Plovdiv, BGR
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Lai CD, Marret MJ, Jayanath S, Azanan MS. Abusive head trauma in infants: An observational single centre study comparing developmental and functional outcome between 18 months and 5 years. CHILD ABUSE & NEGLECT 2023; 145:106434. [PMID: 37657172 DOI: 10.1016/j.chiabu.2023.106434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/08/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) is a major cause of traumatic brain injury in infancy. This exploratory study compared standardized developmental assessment versus functional outcome assessment between 18 months and 5 years of age following AHT in infancy. METHODS Observational cross-sectional study after surviving AHT in infancy. Seventeen children between 18 months and 5 years of age underwent clinical examination, developmental assessment using the Schedule of Growing Skills II (SGS II) and functional assessment using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds). Additional clinical information was extracted from medical records. RESULTS Age at assessment ranged from 19 to 53 months (median 26 months). Most (n = 14) were delayed in at least 1 domain, even without neurological or visual impairment or visible cortical injury on neuroimaging, including 8 children with favourable GOS-E Peds scores. The most affected domain was hearing and language. Delay in the manipulative domain (n = 6) was associated with visual and/or neurological impairment and greater severity of delay across multiple domains. Eleven (64.7 %) had GOS-E Peds scores indicating good recovery, with positive correlation between GOS-Peds scores and number of domains delayed (r = 0.805, p < 0.05). CONCLUSION The SGS-II detects behavioural and cognitive deficits not picked up by the GOS-E Peds. Combining both tools for assessment of AHT survivors under 5 years of age provides a comprehensive profile which addresses multiple domains of development and function, facilitating targeted intervention. Detection of developmental problems in the majority of survivors makes AHT prevention a public health priority.
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Affiliation(s)
- Charles Dekun Lai
- Department of Paediatrics, University of Malaya, 50603 Kuala Lumpur, Malaysia; Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300 Kota Samarahan, Sarawak.
| | - Mary J Marret
- Department of Paediatrics, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Subhashini Jayanath
- Department of Paediatrics, University of Malaya, 50603 Kuala Lumpur, Malaysia.
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Sacco MA, Gualtieri S, Tarda L, Ricci P, Aquila I. Clinical and Forensic Investigation Protocols for Diagnosing Abusive Head Trauma: A Literature Review. Diagnostics (Basel) 2023; 13:3093. [PMID: 37835835 PMCID: PMC10572508 DOI: 10.3390/diagnostics13193093] [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: 08/27/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Abusive head trauma (AHT) represents a very serious global public health problem. Prevention of these episodes is essential to reduce the morbidity and mortality of this phenomenon. All healthcare professionals should be able to recognize the signs of abuse. However, diagnosis is very complex as the signs are often blurred and cannot be recognized with certainty without carrying out adequate instrumental investigations. It has been calculated that approximately one-third of AHT cases remain undetected and require more than one medical visit to be correctly interpreted and diagnosed. On the other hand, the literature has recently also emphasized the problems related to possible false diagnoses of abuse and the numerous family and personal repercussions that follow from this issue. For these reasons, correct and timely recognition is essential to avoid the risk of recurrence of AHT and to start proper forensic investigations, in order to identify the offender or exonerate a suspect. The present work explores the most recent evidence of recent years in the field of AHT diagnostics through a literature review. The purpose of this article is to provide forensic pathologists with clear tools for diagnosis based on the literature. To this end, the review suggests clinical and forensic protocols aimed at the timely diagnosis of AHT in order to prevent abuse from remaining undetected.
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Affiliation(s)
| | | | | | | | - Isabella Aquila
- Institute of Legal Medicine, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (M.A.S.); (S.G.); (L.T.); (P.R.)
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14
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Raghupathi R, Prasad R, Fox D, Huh JW. Repeated mild closed head injury in neonatal rats results in sustained cognitive deficits associated with chronic microglial activation and neurodegeneration. J Neuropathol Exp Neurol 2023; 82:707-721. [PMID: 37390808 PMCID: PMC10357947 DOI: 10.1093/jnen/nlad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023] Open
Abstract
Abusive head trauma in infants is a consequence of multiple episodes of abuse and results in axonal injury, brain atrophy, and chronic cognitive deficits. Anesthetized 11-day-old rats, neurologically equivalent to infants, were subjected to 1 impact/day to the intact skull for 3 successive days. Repeated, but not single impact(s) resulted in spatial learning deficits (p < 0.05 compared to sham-injured animals) up to 5 weeks postinjury. In the first week following single or repetitive brain injury, axonal and neuronal degeneration, and microglial activation were observed in the cortex, white matter, thalamus, and subiculum; the extent of the histopathologic damage was significantly greater in the repetitive-injured animals compared to single-injured animals. At 40 days postinjury, loss of cortical, white matter and hippocampal tissue was evident only in the repetitive-injured animals, along with evidence of microglial activation in the white matter tracts and thalamus. Axonal injury and neurodegeneration were evident in the thalamus up to 40 days postinjury in the repetitive-injured rats. These data demonstrate that while single closed head injury in the neonate rat is associated with pathologic alterations in the acute post-traumatic period, repetitive closed head injury results in sustained behavioral and pathologic deficits reminiscent of infants with abusive head trauma.
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Affiliation(s)
- Ramesh Raghupathi
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Rupal Prasad
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas Fox
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Sarmiento CA, Wyrwa JM, Chambliss AV, Stearns-Yoder KA, Hoffberg AS, Appel A, Brenner BO, Brenner LA. Developmental Outcomes Following Abusive Head Trauma in Infancy: A Systematic Review. J Head Trauma Rehabil 2023; 38:283-293. [PMID: 36730957 DOI: 10.1097/htr.0000000000000808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A systematic review of the literature was conducted to identify measures used to evaluate developmental outcomes after abusive head trauma (AHT), as well as describe outcomes among those with AHT, and explore factors and interventions influencing such outcomes. DESIGN This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol is in PROSPERO, registration number CRD42020179592. On April 17, 2020, OVID Medline, Embase, OVID PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were searched (since inception). Inclusion criteria included original, peer-reviewed study data; AHT exposure; infants younger than 24 months at time of AHT; and evaluation of developmental outcomes. Reviewers independently evaluated studies for inclusion and assessed risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. A descriptive synthesis approach was utilized as variability of study designs, follow-up periods, and outcome assessment tools precluded a meta-analytic approach. RESULTS Fifty-nine studies were included; 115 assessment tools were used to evaluate developmental outcomes; and 42 studies examined factors influencing outcomes. Two studies evaluated interventions. Five percent of studies ( n = 3) were rated low risk of bias. CONCLUSIONS Notable variation was observed in terms of case ascertainment criteria. Developmental outcomes after AHT have been assessed in a manner that limits understanding of how AHT impacts development, as well as the efficacy of interventions intended to improve outcomes. Researchers and clinicians are encouraged to adopt consistent diagnostic and assessment approaches.
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Affiliation(s)
- Cristina A Sarmiento
- Departments of Pediatric Rehabilitation Medicine (Drs Sarmiento, Wyrwa, Chambliss, and Appel) and Pediatrics (Drs Chambliss and Appel), Children's Hospital Colorado, Aurora; Departments of Physical Medicine and Rehabilitation (Drs Sarmiento, Wyrwa, Chambliss, Appel, and Brenner and Ms Stearns-Yoder) and Psychiatry and Neurology (Dr Brenner), University of Colorado Anschutz School of Medicine, Aurora; Veterans Health Administration Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado (Ms Stearns-Yoder, Mr Hoffberg, and Dr Brenner); and Brandeis University, Waltham, Massachusetts (Mr Brenner)
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Macorano E, Gentile M, Stellacci G, Manzionna M, Mele F, Calvano M, Leonardelli M, Duma S, De Gabriele G, Cristalli A, Minella R, Di Fazio A, Introna F. 'Compressed Baby Head': A New 'Abusive Head Trauma' Entity? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1003. [PMID: 37371236 DOI: 10.3390/children10061003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. DISCUSSION The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. CONCLUSIONS To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.
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Affiliation(s)
- Enrica Macorano
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mattia Gentile
- Medical Genetics, Maternal and Child Department, Hospital of Venus, 70012 Bari, Italy
| | | | - Mariano Manzionna
- Complex Operating Unit, Paediatric and Neonatology, San Paolo Hospital, ASL Bari, 70100 Bari, Italy
| | - Federica Mele
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mariagrazia Calvano
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Mirko Leonardelli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Stefano Duma
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Giovanni De Gabriele
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Alessandro Cristalli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
| | - Raffaella Minella
- School of Biological and Environmental Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
| | - Aldo Di Fazio
- Regional Complex Intercompany Institute of Legal Medicine, 85100 Potenza, Italy
| | - Francesco Introna
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari 'Aldo Moro', 70124 Bari, Italy
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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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Alzahrani F, Al-Jabri BA, Ramadan SAL, Alshehri AM, Alsheikh AS, Mushaeb HH, Albisher SF, AlSwealh MS. Parental Knowledge and Awareness about Shaken Baby Syndrome in Jeddah, Saudi Arabia: A Cross-Sectional Study. Pediatr Rep 2023; 15:311-322. [PMID: 37218927 DOI: 10.3390/pediatric15020027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/19/2023] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Despite the serious consequences of shaken baby syndrome (SBS), previous studies revealed a low level of knowledge among Saudi parents. METHODS This is a cross-sectional study. An electronic questionnaire was distributed through social media platforms to parents of pediatric age group children in Jeddah, Saudi Arabia. A total of 524 responses were received. Data about participants' demographics, knowledge, attitude, and practice regarding SBS were collected through convenient random sampling. RESULTS A total of 524 responses were received; 30.7% of the participants were familiar with SBS. The Internet and the social media platforms were the most common sources of information. There was no statistically significant correlation between knowledge levels and participants' sociodemographic factors; only 32.3% of individuals had good knowledge. Of them, 84% had a positive attitude towards learning more about SBS, and 40.1% and 34.3% were interested in learning more about SBS before and during pregnancy, respectively. Carrying the baby and shaking were the actions most frequently taken when a baby was crying. Of them, 23.9% forcefully shake their child, while 41.4% of them throw their infant up in the air and catch it. CONCLUSIONS It is important to conduct health education programs on SBS for mothers throughout the prenatal period.
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Affiliation(s)
- Fatma Alzahrani
- Pediatric Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Basma A Al-Jabri
- Pediatric Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia
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Obry S, Roman E, Tavernier E, Boutry N, Delval A, Blouet M, Tanase A, De Milly MN, Alison M, Vial J, Saint Martin P, Adamsbaum C, Morel B. The monthly incidence of abusive head trauma, inflicted skeletal trauma, and unexplained skin lesion in children in six French university hospitals during the COVID-19 pandemic. CHILD ABUSE & NEGLECT 2023; 138:106063. [PMID: 36758374 PMCID: PMC9884623 DOI: 10.1016/j.chiabu.2023.106063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The COVID-19 pandemic was a stressful period. Lockdowns may have added to parental difficulty leading to an increase in violence. This study aimed to compare the monthly incidence of high suspicion of child physical abuse before and during the COVID-19 pandemic. MATERIAL We have retrospectively reviewed imaging examinations of children having a skeletal X-ray examination in six university hospitals with high suspicion of abusive head traumatism (AHT), inflicted skeletal trauma (IST) and unexplained skin lesions (USL) between March 2020 and June 2021 and compared with the similar period from 2018 to 2019. The monthly incidence of the different physical maltreatment was analyzed using a QuasiPoisson regression model. RESULTS We included 178 children (n = 127 boys, 71.3 %), 110 during the pandemic period, median age 5 months. AHT was diagnosed in 91 children, 55 had inflicted skeletal trauma (IST) and 46 had unexplained skin lesions (USL). Among the 91 patients with AHT, 86 had a subdural hematoma (95.6 %) and 40 had bridging veins thrombosis (44 %). The ophthalmological examination performed on 89 children (97.9 %) revealed retinal hemorrhages in 57 children (89.8 %). The incidence of AHT doubled during the months of COVID-19 lockdowns (rate ratio = 2; 95 % CI [1.1; 3.6], p = 0.03). No difference in monthly incidence was observed for IST and USL groups. CONCLUSION A significant increase in AHT was observed during the months with lockdowns and curfews during the COVID-19 pandemic. This highlights the need for developing a national strategy to prevent physical abuse in children in this context.
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Affiliation(s)
- Sandra Obry
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | - Elodie Roman
- Department of Pediatric Radiology, Jeanne de Flandre Hospital, CHU, Lille, France
| | - Elsa Tavernier
- INSERM, SPHERE, UMR1246, Université de Tours et Nantes, Tours, France
| | - Nathalie Boutry
- Department of Pediatric Radiology, Jeanne de Flandre Hospital, CHU, Lille, France
| | | | - Marie Blouet
- Department of Pediatric Imaging, Fondation Lenval Children's Hospital, Nice, France
| | - Anca Tanase
- Department of Pediatric Imaging, Robert Debré Hospital, APHP (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Marie Noelle De Milly
- Department of Pediatric Imaging, Robert Debré Hospital, APHP (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Marianne Alison
- Department of Pediatric Imaging, Robert Debré Hospital, APHP (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Julie Vial
- Department of Pediatric Radiology, Children's Hospital, CHU, Toulouse, France
| | | | - Catherine Adamsbaum
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin Bicêtre, France
| | - Baptiste Morel
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.
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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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Torimitsu S, Nishida Y, Takano T, Yajima D, Inokuchi G, Makino Y, Motomura A, Chiba F, Yamaguchi R, Hoshioka Y, Iwase H. Statistical analysis of the thickness and biomechanical properties of Japanese children's skulls. Forensic Sci Int 2023; 344:111580. [PMID: 36753838 DOI: 10.1016/j.forsciint.2023.111580] [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: 11/16/2022] [Revised: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The structure and strength of a child's skull are important in accurately determining what and how external forces were applied when examining head injuries. The aims of this study were to measure skull thickness and strength in children, evaluate sex differences, and investigate the correlation between skull thickness and strength and age. MATERIALS AND METHODS Skulls were obtained from 42 Japanese dead bodies under 20 years of age. During the autopsies, bone samples were taken from each skull. The length, width, and central thickness of the skulls were measured using calipers. Three-point bending tests were conducted, and bending load and displacement were recorded. Bending stress and bending strain were calculated, and Young's modulus, 0.2% proof stress, and maximum stress were obtained. RESULTS In cases under 1.5 years old, 14 out of 46 male samples and 20 out of 40 female samples did not fracture during the three-point bending test, though no significant sex differences were detected. No significant differences in age, sample thickness, Young's modulus, 0.2% proof stress, or maximum stress were detected between the sexes. The sample thickness, Young's modulus, 0.2% proof stress, and maximum stress increased significantly and logarithmically with age (R2 = 0.761-0.899). Although age correlated with thickness, Young's modulus, and maximum stress more in females than in males, 0.2% proof stress correlated slightly better in males than in females. CONCLUSION The skulls of preschool children, in particular, are thin, have low strength, and are at high risk of fracturing even with relatively small external forces. Unlike adults, no significant sex differences in skull thickness or strength were observed in children.
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Affiliation(s)
- Suguru Torimitsu
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Yoshifumi Nishida
- Department of Mechanical Engineering, Tokyo Institute of Technology, 2-12-1, O-okayama, Meguro-ku, Tokyo 152-8552, Japan; Artificial Intelligence Research Center (AIRC), The National Institute of Advanced Industrial Science and Technology (AIST), 2-4-7, Aomi, Koto-ku, Tokyo 135-0064, Japan.
| | - Tachio Takano
- Artificial Intelligence Research Center (AIRC), The National Institute of Advanced Industrial Science and Technology (AIST), 2-4-7, Aomi, Koto-ku, Tokyo 135-0064, Japan.
| | - Daisuke Yajima
- Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan; Department of Forensic Medicine, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan.
| | - Go Inokuchi
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Ayumi Motomura
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan; Department of Forensic Medicine, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba 286-8686, Japan.
| | - Fumiko Chiba
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Rutsuko Yamaguchi
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Yumi Hoshioka
- Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Hirotaro Iwase
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan.
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Nikam RM, Kecskemethy HH, Kandula VVR, Averill LW, Langhans SA, Yue X. Abusive Head Trauma Animal Models: Focus on Biomarkers. Int J Mol Sci 2023; 24:4463. [PMID: 36901893 PMCID: PMC10003453 DOI: 10.3390/ijms24054463] [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: 12/27/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
Abusive head trauma (AHT) is a serious traumatic brain injury and the leading cause of death in children younger than 2 years. The development of experimental animal models to simulate clinical AHT cases is challenging. Several animal models have been designed to mimic the pathophysiological and behavioral changes in pediatric AHT, ranging from lissencephalic rodents to gyrencephalic piglets, lambs, and non-human primates. These models can provide helpful information for AHT, but many studies utilizing them lack consistent and rigorous characterization of brain changes and have low reproducibility of the inflicted trauma. Clinical translatability of animal models is also limited due to significant structural differences between developing infant human brains and the brains of animals, and an insufficient ability to mimic the effects of long-term degenerative diseases and to model how secondary injuries impact the development of the brain in children. Nevertheless, animal models can provide clues on biochemical effectors that mediate secondary brain injury after AHT including neuroinflammation, excitotoxicity, reactive oxygen toxicity, axonal damage, and neuronal death. They also allow for investigation of the interdependency of injured neurons and analysis of the cell types involved in neuronal degeneration and malfunction. This review first focuses on the clinical challenges in diagnosing AHT and describes various biomarkers in clinical AHT cases. Then typical preclinical biomarkers such as microglia and astrocytes, reactive oxygen species, and activated N-methyl-D-aspartate receptors in AHT are described, and the value and limitations of animal models in preclinical drug discovery for AHT are discussed.
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Affiliation(s)
- Rahul M. Nikam
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Heidi H. Kecskemethy
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Vinay V. R. Kandula
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Lauren W. Averill
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Sigrid A. Langhans
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Nemours Biomedical Research, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Xuyi Yue
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
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23
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Ducloyer JB, Scherpereel C, Goronflot T, Le Meur G, Lebranchu P, Jossic F, Scolan V, Ducloyer M. Assessing retinal hemorrhages with non-invasive post-mortem fundus photographs in sudden unexpected death in infancy. Int J Legal Med 2023; 137:913-923. [PMID: 36823412 PMCID: PMC10085933 DOI: 10.1007/s00414-023-02964-9] [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: 07/22/2022] [Accepted: 01/31/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION In the case of sudden unexpected death in infancy (SUDI), eye examination is systematic to detect retinal hemorrhages (RH) that are a crucial hallmark for abusive head trauma (AHT). The aim of this study is to assess the ability of non-invasive post-mortem fundus photographs (PMFP) to detect RH in case of SUDI. METHODS Bicentric retrospective analysis of consecutive cases of SUDI under 2 years of age were managed by two French SUDI referral centers with PMFP by RetCam (Clarity Medical Systems USA). PMFP were reviewed randomly, twice, by three independent ophthalmologists blinded for clinical data. RESULTS Thirty cases (60 eyes) were included. Median age was 3.5 months (interquartile [1.6; 6.0]). No child died of AHT. Image quality was sufficient to assert presence or absence of RH in 50 eyes (83%). Sufficient quality rate was significantly higher when the post-mortem interval was inferior to 18 h (91%, 42/46) as opposed to over 18 h (57%, 8/14, p=0.0096). RH were found in six eyes (10%), four children (13%), with excellent inter and intra-raters' concordance (Cohen's Kappa from 0.81 [0.56-1.00] to 1.00 [1.00-1.00]). CONCLUSION PMFP can detect RH in case of SUDI and is a relevant systematic screening test to be carried out as soon as the deceased child arrives in the hospital. It can decrease the need of eye removal for pathological examination, but further studies are needed to define the best decision algorithm.
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Affiliation(s)
| | | | - Thomas Goronflot
- Nantes Université, CHU Nantes, Pôle Hospitalo-Universitaire 11: Santé Publique, Clinique des données, INSERM, CIC 1413, F-44000, Nantes, France
| | - Guylène Le Meur
- Nantes Université, CHU Nantes, service d'ophtalmologie, Nantes, France
| | - Pierre Lebranchu
- Nantes Université, CHU Nantes, service d'ophtalmologie, Nantes, France
| | | | | | - Mathilde Ducloyer
- Nantes Université, CHU Nantes, service de médecine légale, Nantes, France.,Nantes Université, CHU Nantes, INSERM, CIC 1413, 44000, Nantes, France
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24
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Traumatic head injury due to child maltreatment: epidemiology, cost analysis, and impact of prevention. Childs Nerv Syst 2022; 38:2281-2287. [PMID: 35680684 DOI: 10.1007/s00381-022-05560-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Traumatic head injury due to child maltreatment (THI-CM), also known as abusive head trauma (AHT), is a significant public health problem due to the wide array of consequences affecting multiple domains of a child's health and development. Several studies have evaluated its cost on healthcare systems, families, and societies. Many jurisdictions have implemented caregiver education programs to prevent THI-CM. OBJECTIVES This paper aims to provide a brief overview of the epidemiology and cost analysis of THI-CM and discuss its prevention and the intergenerational transmission of child maltreatment. METHODS Although not systematic, a literature search of original articles published from 2000 to 2022 in English and French was undertaken using the following databases: PubMed, EMBASE (Ovid), and PsycINFO (OVID). The search combined terms related to traumatic head injury and child maltreatment, with terms related to its cost and prevention. Studies of children aged 0-5 years old were included. The authors completed a screen of the titles and abstracts to determine relevance with respect to this article. RESULTS Globally, although THI-CM accounts for a small proportion of cases of child maltreatment, there is a high incidence of death and neurological sequelae compared to other causes of head trauma.The incidence of THI-CM is likely underestimated due to the lack of standardized definitions, differences in reporting, and challenges in identifying less severe cases. Cost analysis studies reveal the significant short- and long-term costs associated with THI-CM. Caregiver education programs have been studied and implemented in many centers and have shown varying but promising results. CONCLUSION A multi-pronged approach to prevention efforts should be considered to support families and help to prevent THI-CM and maltreatment throughout childhood.
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25
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Del Rio RJ, Gromadzyn GP, Cicutti S, Badaloni ME, Gonzalez Ramos JD. Abusive head trauma, protocols, and legal concerns in a South American Country. Childs Nerv Syst 2022; 38:2409-2414. [PMID: 36396772 DOI: 10.1007/s00381-022-05742-x] [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: 10/18/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
The abusive head trauma (AHT) is a form of child abuse and is a frequent entity all over de world. It is particularly unique among medical diagnoses because of the legal implications imposed by the diagnosis. Therefore, it has been the subject of much legal controversy over the decades. Knowledge of the clinical signs and imaging findings of abusive head trauma is vitally important for early diagnosis. An oriented anamnesis, as well as a complete physical examination and obtaining adequate images of the central nervous system, play a significant role in confirming the presumptive diagnosis. The interdisciplinary approach (pediatricians, neurosurgeons, neuroradiologists, social workers, and other specialists) is the key in the management of these patients. The purpose of this article is to familiarize the pediatric neurosurgeon with some of the more common medicolegal issues surrounding AHT as well as to discuss legal commitments and ethical obligations of the neurosurgeon in Argentina (South America) based on 2 clinical cases.
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Affiliation(s)
| | | | - Santiago Cicutti
- National Pediatric Hospital Juan P. Garrahan, Buenos Aires, Argentina
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26
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Regeffe F, Chevignard M, Millet A, Bellier A, Wroblewski I, Patural H, Javouhey E, Mortamet G. Factors associated with poor neurological outcome in children after abusive head trauma: A multicenter retrospective study. CHILD ABUSE & NEGLECT 2022; 131:105779. [PMID: 35816903 DOI: 10.1016/j.chiabu.2022.105779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/18/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Abusive Head Trauma (AHT) remains the leading cause of brain injury in infants. OBJECTIVE This study aims to describe a cohort of patients with AHT and identify early risk factors associated with poor neurological outcome. PARTICIPANTS AND SETTING Children under one year old admitted to a Pediatric Intensive Care Unit (PICU) with a suspected or confirmed diagnosis of AHT were included. Neurological outcome was assessed by the Pediatric Overall Performance Category score (POPC) at discharge from the hospital and at two years of follow-up. METHODS A multicentre retrospective study was conducted over 8 years (from January 2012 to December 2020). RESULTS A total of 117 patients (mean age 4.3 (+/- 2.5) months, 61 % boys) from three PICUs were included. A total of 99 (85 %) patients completed a 2-year follow-up. Sixty-one (52 %) and 47 (40 %) children with AHT had a POPC (pediatric overall performance category) score ≥ 2 at discharge from ICU and discharge from hospital, respectively (meaning they had at least a moderate disability). Fifty-one (44 %) had a POPC score ≥ 2 at 2-year follow-up, including 19 patients (19 %) with severe disabilities. The main neurological disabilities were neurodevelopmental (n = 38, 35 %), hyperactivity disorder (n = 36, 33 %) and epilepsy (n = 34, 31 %). After analysis according to the hierarchical model, the occurrence of a cardiorespiratory arrest and a low Glasgow Coma Score at admission stand out as factors of poor neurological outcome. CONCLUSION This study highlights the wide range of neurological disabilities in children with AHT. Early and multidisciplinary follow-up is crucial to limit the impact of neurological disability.
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Affiliation(s)
- Fanny Regeffe
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France; Sorbonne Université, Laboratoire d'Imagerie Biomédicale, LIB, CNRS, INSERM, F-75006 Paris, France; Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation (HaMCRe), Paris, France
| | - Anne Millet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Alexandre Bellier
- Department of medical Evaluation, Grenoble-Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, Grenoble, France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Hugues Patural
- Pediatric Intensive Care Unit, Saint-Etienne Hospital, Saint-Etienne, France
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Lyon University Hospital, Bron, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, Grenoble, France.
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27
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Lãzãrescu AM, Benichi S, Blauwblomme T, Beccaria K, Bourgeois M, Roux CJ, Vergnaud E, Montmayeur J, Meyer P, Cohen JF, Chalumeau M, Blangis F, Orliaguet G. Abusive Head Trauma in Infants During the COVID-19 Pandemic in the Paris Metropolitan Area. JAMA Netw Open 2022; 5:e2226182. [PMID: 36040743 PMCID: PMC9428740 DOI: 10.1001/jamanetworkopen.2022.26182] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse. OBJECTIVE To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS In a time-series analysis of a longitudinal, population-based, cohort study, all consecutive cases of AHT in infants younger than 12 months old referred between January 2017 and December 2021 to Necker Hospital for Sick Children, the single regional pediatric neurosurgery center for the Paris metropolitan area, were included. AHT was defined as 1 or more subdural hemorrhage and a positive multidisciplinary evaluation after a social, clinical, biological, and radiological workup. Data were analyzed from January to March 2022. MAIN OUTCOMES AND MEASURES The primary outcome was the monthly incidence of AHT, which was analyzed using Poisson regression modeling. Secondary outcomes included mortality and severe morbidity and were studied with logistic and linear regressions. The monthly incidence of neurosurgical interventions for hydrocephalus was used as a control series. RESULTS Among the 99 included infants with AHT (median [IQR] age, 4 [3-6] months; 64 boys [65%]), 86 of 99 (87%) had bridging vein thrombosis, 74 of 99 (75%) had retinal hemorrhages, 23 of 72 (32%) had fractures, 26 of 99 (26%) had status epilepticus, 20 of 99 (20%) had skin injuries, 53 of 99 (54%) underwent neurosurgical interventions, and 13 of 99 (13%) died. Compared with the prepandemic period (2017-2019), AHT incidence was stable in 2020 (adjusted incidence rate ratio, 1.02; 95% CI, 0.59-1.77) and then significantly increased in 2021 (adjusted incidence rate ratio, 1.92; 95% CI, 1.23-2.99). The severity of AHT worsened in 2021 in terms of mortality (odds ratio 9.39; 95% CI, 1.88-47.00). Other secondary outcomes and the control series were not significantly modified. CONCLUSIONS AND RELEVANCE In this cohort study, a marked increase in AHT incidence and severity occurred during the COVID-19 pandemic in the Paris metropolitan area. These results suggest the need for clinical awareness and preventive actions.
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Affiliation(s)
- Alina-Marilena Lãzãrescu
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Sandro Benichi
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Kévin Beccaria
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Marie Bourgeois
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Charles-Joris Roux
- Department of Pediatric Radiology, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Estelle Vergnaud
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Juliette Montmayeur
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Philippe Meyer
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Gilles Orliaguet
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Unit EA7323 Evaluation of Therapeutics and Pharmacology in Perinatality and Pediatrics, Université Paris Cité, Paris, France
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28
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Horton D, Burrell T, Moffatt ME, Puls HT, Selvarangan R, Hultman L, Anderst JD. Differences Between Viral Meningitis and Abusive Head Trauma. Pediatrics 2022; 150:188256. [PMID: 35673951 DOI: 10.1542/peds.2021-054544] [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] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the hypothesis that viral meningitis may mimic abusive head trauma (AHT) by comparing the history of present illness (HPI) and clinical presentation of young children with proven viral meningitis to those with AHT and those with subdural hemorrhage (SDH) only. We hypothesized that significant differences would exist between viral meningitis and the comparison groups. METHODS We performed a 5-year retrospective case-control study of subjects aged <2 years, comparing those with confirmed viral meningitis (controls) to those with SDH evaluated by the hospital child abuse pediatrics team (cases). Cases were classified as SDH with concomitant suspicious injuries (AHT) and without concomitant suspicious injuries (SDH-only). Groups were compared across demographic (5 measures), HPI (11 measures), and clinical (9 measures) domains. Odds ratios were calculated for measures within each domain. RESULTS Of 550 subjects, there were 397 viral meningitis, 118 AHT, and 35 SDH-only subjects. Viral meningitis differed significantly from AHT subjects on all demographic measures, and from SDH-only subjects on age. Viral meningitis differed significantly from AHT subjects in all HPI measures with odds ratios ranging from 2.7 to 322.5, and from SDH-only subjects in 9 HPI measures with odds ratios ranging from 4.6 to 485.2. In the clinical domain, viral meningitis differed significantly from AHT subjects in all measures, with odds ratios ranging from 2.5 to 74.0, and from SDH-only subjects in 5 measures with odds ratios ranging from 2.9 to 16.8. CONCLUSIONS Viral meningitis is not supported as a mimic of AHT.
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Affiliation(s)
| | | | - Mary E Moffatt
- Divisions of Child Adversity and Resilience.,Emergency Medicine
| | | | - Rangaraj Selvarangan
- Pathology and Laboratory Medicine, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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29
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Wallace J, Metz JB, Otjen J, Perez FA, Done S, Brown ECB, Wiester RT, Boos SC, Ganti S, Feldman KW. Extra-axial haemorrhages in young children with skull fractures: abuse or accident? Arch Dis Child 2022; 107:650-655. [PMID: 35190379 DOI: 10.1136/archdischild-2021-322327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 01/20/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Infant and toddler subdural haemorrhages (SDH) are often considered indicative of abuse or major trauma. However, accidental impact events, such as falls, cause contact extra-axial haemorrhages (EAHs). The current study sought to determine frequency and clinical behaviour of EAHs with infant and toddler accidental and abusive skull fractures. PATIENTS AND METHODS Children aged <4 years with accidental skull fractures and abusive fractures identified by CT at two paediatric tertiary care centres. Clinical data were abstracted by child abuse paediatricians and images were reviewed by paediatric radiologists. Data were analysed using univariate and multivariate logistic regression as well as descriptive statistics. RESULTS Among 227 subjects, 86 (37.9%) had EAHs. EAH was present in 73 (34.8%) accidental and 13 (76.5%) of the abusive injuries. Intracranial haemorrhage rates were not different for children with major or minor accidents but were fewer than abused. EAH was equally common with falls <4 and >4 ft. EAH depths did not differ by mechanism, but 69% of accidental EAHs were localised solely at fracture sites vs 38% abuse. Widespread and multifocal EAHs were more common with abuse. Children with abuse or major accidental injuries presented with lower initial Glasgow Coma Scales than those with minor accidents. Abused children had initial loss of consciousness more often than those with either minor or major accidents. CONCLUSIONS Simple contact EAHs were common among children with minor and major accidental skull fractures. Accidental EAHs were more localised with less neurological dysfunction than abusive.
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Affiliation(s)
- Jordan Wallace
- Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - James Benson Metz
- Pediatrics, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jeffrey Otjen
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Stephen Done
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Emily C B Brown
- Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
| | - Rebecca T Wiester
- Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
| | - Stephen C Boos
- Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Sheila Ganti
- Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
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30
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Neonatal Abusive Head Trauma without External Injuries: Suspicion Improves Diagnosis. CHILDREN 2022; 9:children9060808. [PMID: 35740745 PMCID: PMC9221573 DOI: 10.3390/children9060808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022]
Abstract
The term “shaken baby syndrome” has been replaced by “abusive head trauma (AHT)” based on the mechanism of injury. The reported mortality rate of AHT ranges from 10% to 30%. Up to two-thirds of survivors suffer from serious long-term disabilities. Thus, an expeditious and accurate diagnosis is crucial to prevent further abuse that might result in death or serious disabilities. It remains a challenge for physicians to diagnose AHT when parents do not give a history of trauma in preverbal infants without any external signs. Here, we report a case of a 14-day-old boy who presented with a febrile convulsion without evident external injuries nor history of trauma according to his parents. He was diagnosed with AHT based on MRI findings of subacute subdural hemorrhage, multiple cortical hemorrhages, cerebral edema, and diffuse axonal injury. In conclusion, health care providers should keep in mind that the history of trauma provided by the parents or caregivers might not always be true and that reasonable suspicion of abuse is the most important in the diagnosis of AHT, although neuroimaging plays a pivotal role. Reasonable suspicion of AHT in combination with a thorough physical examination, neuroimaging, and skilled neuroradiologist can improve diagnosis and help victims in a timely manner.
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31
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Sayrs LW, Ortiz JB, Notrica DM, Kirsch L, Kelly C, Stottlemyre R, Cohen A, Misra S, Green TR, Adelson PD, Lifshitz J, Rowe RK. Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP6785-NP6812. [PMID: 33092447 DOI: 10.1177/0886260520967151] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(β) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.
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Affiliation(s)
- Lois W Sayrs
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - J Bryce Ortiz
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - David M Notrica
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Lisa Kirsch
- Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Cara Kelly
- Phoenix Children's Hospital, Phoenix, AZ, USA
- Arizona State University School of Social Work, Phoenix, AZ, USA
| | | | - Aaron Cohen
- Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Shivani Misra
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Tabitha R Green
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - P David Adelson
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Jonathan Lifshitz
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
- Phoenix Veteran Affairs Health Care System, Phoenix, AZ, USA
| | - Rachel K Rowe
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
- Phoenix Veteran Affairs Health Care System, Phoenix, AZ, USA
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32
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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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33
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Kwak YH. Diagnosis of Abusive Head Trauma : Neurosurgical Perspective. J Korean Neurosurg Soc 2022; 65:370-379. [PMID: 35468707 PMCID: PMC9082129 DOI: 10.3340/jkns.2021.0284] [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: 11/30/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.
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Affiliation(s)
- Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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Park YS. Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants. J Korean Neurosurg Soc 2022; 65:385-396. [PMID: 35468708 PMCID: PMC9082116 DOI: 10.3340/jkns.2021.0289] [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: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.
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Affiliation(s)
- Young Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University, Kashihara, Japan
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Orman G, Kralik SF, Desai NK, Singer TG, Kwabena S, Risen S, Huisman TAGM. An In-Depth Analysis of Brain and Spine Neuroimaging in Children with Abusive Head Trauma: Beyond the Classic Imaging Findings. AJNR Am J Neuroradiol 2022; 43:764-768. [PMID: 35393363 PMCID: PMC9089255 DOI: 10.3174/ajnr.a7492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/23/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Abusive head trauma is the leading cause of morbidity and mortality in young children. Radiology provides valuable information for this challenging diagnosis, but no single neuroimaging finding is independently diagnostic of abusive head trauma. Our purposes were to describe the prevalence of brain and spine neuroimaging findings and to analyze the association of neuroimaging findings with clinical factors to determine which neuroimaging findings may be used as prognostic indicators. MATERIALS AND METHODS Children with a confirmed abusive head trauma diagnosis between January 2018 to February 2021 were included in this single-center retrospective study. Patient demographics, survival, Glasgow Coma Scale score on admission, length of hospital stay, and intensive care unit stay were examined. Brain neuroimaging findings were categorized as classic and nonclassic findings. Spine MRIs were also assessed for spinal ligamentous injury, compression fracture, and hemorrhage. The χ2 test or the Wilcoxon rank-sum test was used for the analysis. RESULTS One hundred two children (male/female ratio: 75:27; average age, 9.49; range, 0.27-53.8 months) were included. Subdural hematoma was the most common (83.3%) classic neuroimaging finding. Bridging vein thrombosis was the most common (30.4%) nonclassic neuroimaging finding. Spinal ligamentous injury was seen in 23/49 patients. Hypoxic-ischemic injury was significantly higher in deceased children (P = .0001). The Glasgow Coma Scale score was lower if hypoxic-ischemic injury (P < .0001) or spinal ligamentous injury were present (P = .017). The length of hospital stay was longer if intraventricular hemorrhage (P = .04), diffuse axonal injury (P = .017), hypoxic-ischemic injury (P = .001), or arterial stroke (P = .0003) was present. The intensive care unit stay was longer if intraventricular hemorrhage (P = .02), diffuse axonal injury (P = .01), hypoxic-ischemic injury (P < .0001), or spinal ligamentous injury (P = .03) was present. CONCLUSIONS Our results may suggest that a combination of intraventricular hemorrhage, diffuse axonal injury, hypoxic-ischemic injury, arterial stroke, and/or spinal ligamentous injury on neuroimaging at presentation may be used as potential poor prognostic indicators in children with abusive head trauma.
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Affiliation(s)
- G Orman
- From the Edward B. Singleton Department of Radiology (G.O., S.F.K., N.K.D., T.A.G.M.H.)
| | - S F Kralik
- From the Edward B. Singleton Department of Radiology (G.O., S.F.K., N.K.D., T.A.G.M.H.)
| | - N K Desai
- From the Edward B. Singleton Department of Radiology (G.O., S.F.K., N.K.D., T.A.G.M.H.)
| | - T G Singer
- Global Child Health Residency (T.G.S.).,Division of General Surgery (T.G.S.), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | - S Risen
- Division of Public Health Pediatrics, and Department of Pediatrics (S.R.), Division of Child Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - T A G M Huisman
- From the Edward B. Singleton Department of Radiology (G.O., S.F.K., N.K.D., T.A.G.M.H.)
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6 Monate/w mit wiederholtem Erbrechen und plötzlichem Tonusverlust. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01450-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Högberg U. Transfer of knowledge to diagnose infant abuse and its incidence - a time-series analysis from Sweden. Implement Sci 2022; 17:15. [PMID: 35120543 PMCID: PMC8815122 DOI: 10.1186/s13012-022-01188-6] [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: 09/13/2021] [Accepted: 01/05/2022] [Indexed: 12/04/2022] Open
Abstract
Aim To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault). Methods Design: retrospective population-based and quasi-experimental. Setting: Sweden 1987–2019. Patients: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm. Main outcome measure: Abuse diagnoses (maltreatment or assault). Analyses: Incidence rate, incidence rate ratio (IRR). Results The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987–2019. It was rather stable 1987–2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002–2007, peaking in 2008–2013 [IRR 1.63 (95% confidence interval 1.34–1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014–2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71–0.99)]. Conclusion An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01188-6.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's Health, Uppsala University, SE-751 85, Uppsala, Sweden. .,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
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Eismann EA, Theuerling J, Makoroff KL. The role of household composition of children diagnosed with abusive head trauma. CHILD ABUSE & NEGLECT 2022; 124:105481. [PMID: 35007972 DOI: 10.1016/j.chiabu.2021.105481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/27/2021] [Accepted: 12/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND To prevent abusive head trauma (AHT), many studies focus on understanding the risk factors. Few studies assess the role of household composition. OBJECTIVE To describe the household composition of children diagnosed with AHT and assess the relationships between patient and household characteristics, perpetration, and fatality. PARTICIPANTS AND SETTING Children admitted to a large pediatric hospital with AHT between January 1, 2010 and December 31, 2019. METHODS The diagnosis of AHT was made at initial hospitalization by a child abuse pediatrician with a multidisciplinary team review. The electronic medical records of identified patients were reviewed to identify demographic information, the number and ages of all of their siblings and the number and relationship to patients of all adults who were reported as being present at the time of AHT and therefore considered to be possible perpetrators. Descriptive statistics were used to characterize the sample. Comparisons were made using Fisher exact tests and Mann-Whitney tests. RESULTS Children with AHT who were under 12 months of age and had siblings in the home, particularly siblings under age 5, had greater odds of being injured by a biological parent. Children 12 months or older and children without siblings had greater odds of being injured by a boyfriend or girlfriend of their parent or guardian. CONCLUSIONS In cases of AHT, the possible perpetrator differed based on the presence of young siblings living in the home, which has important implications for AHT prevention.
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Affiliation(s)
- Emily A Eismann
- Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Jack Theuerling
- Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kathi L Makoroff
- Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
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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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Abstract
Background: Abusive head trauma (AHT) in children has recently been associated with findings on cervical spine MRI. Objective: To evaluate whether whole-spine MRI in children suspected of AHT shows additional abnormalities not identified on cervical spine MRI. Methods: This retrospective study included 256 children young than 3 years (170 boys, 86 girls; mean age, 5.9 months) who underwent skeletal survey and head MRI for suspected child abuse from January 2019 to December 2020. Per institutional protocol, children with suspected AHT also underwent whole-spine MRI. AHT diagnoses were established by combination of clinical information from medical record review and injuries described in reports from skeletal survey, head MRI, and head CT (if performed). Two pediatric neuroradiologists independently reviewed whole-spine MRI examinations for presence and level of intraspinal hemorrhage (classified as subarachnoid, subdural, or epidural), ligamentous injury, spinal cord edema, and vertebral fractures; subdural hematoma, epidural hematoma, ligamentous injury, and fracture unidentified by skeletal survey were considered major findings. Interreader agreement was assessed; a third radiologist resolved discrepancies. Findings were summarized with attention to injuries isolated to the thoracolumbar spine. Results: A total of 148/256 (57.8%) children underwent whole-spine MRI. AHT was diagnosed in 79/148 (53.4%) children who underwent whole-spine MRI, versus in 2/108 (1.9%) who did not undergo whole-spine MRI (p<.001). Interobserver agreement. expressed as kappa, was 0.90 for intraspinal hemorrhage, 0.69 for ligamentous injury, 0.66 for spinal cord edema, and 0.95 for fracture. A total of 57/148 (38.5%) whole-spine MRI examinations demonstrated injuries; 34/148 (23.0%) demonstrated injuries localized to the thoracolumbar spine. A total of 47/148 (31.8%) whole-spine MRI examinations demonstrated major findings, of which 24/47 (51.1%) were localized to the thoracolumbar spine. Isolated thoracolumbar injuries included 23 of 34 subdural hematomas, 2 of 3 epidural hematomas, and 9 of 11 fractures, including 5 fractures not identified by skeletal survey. Diagnosis of AHT was more common in children with positive, versus negative, whole-spine MRI examinations (76.8% vs 39.1%, p<.001). Conclusion: In children with suspected AHT, whole-spine MRI commonly demonstrates isolated thoracolumbar injuries. Clinical Impact: The results support performing whole-spine MRI rather than cervical spine MRI in children with suspected AHT.
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Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-021-00221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).
Recent Findings
Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.
Summary
Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.
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Agreements and disagreements regarding "shaken baby syndrome". Childs Nerv Syst 2022; 38:2047-2049. [PMID: 35945338 PMCID: PMC9617842 DOI: 10.1007/s00381-022-05621-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/23/2022] [Indexed: 11/13/2022]
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Abstract
BACKGROUND Abusive head trauma (AHT), previously known as the shaken baby syndrome, is a severe and potentially fatal form of traumatic brain injury in infant children who have been shaken, and sometimes also sustained an additional head impact. The clinical and autopsy findings in AHT are not pathognomonic and, due to frequent obfuscation by perpetrators, the circumstances surrounding the alleged abuse are often unclear. The concept has evolved that the finding of the combination of subdural hemorrhage, brain injury, and retinal hemorrhages ("the triad") is the result of shaking of an infant ("shaken baby syndrome") and has led to the ongoing controversy whether shaking alone is able to generate sufficient force to produce these lesions. OBJECTIVE In an attempt to investigate whether shaking can engender this lesion triad, animal models have been developed in laboratory rodents and domestic animal species. This review assesses the utility of these animal models to reliably reproduce human AHT pathology and evaluate the effects of shaking on the immature brain. RESULTS Due largely to irreconcilable anatomic species differences between these animal brains and human infants, and a lack of resemblance of the experimental head shaking induced by mechanical devices to real-world human neurotrauma, no animal model has been able to reliably reproduce the full range of neuropathologic AHT changes. CONCLUSION Some animal models can simulate specific brain and ophthalmic lesions found in human AHT cases and provide useful information on their pathogenesis. Moreover, one animal model demonstrated that shaking of a freely mobile head, without an additional head impact, could be lethal, and produce significant brain pathology.
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A review of the life of John Plunkett (1947–2018). Forensic Sci Int Synerg 2022. [PMCID: PMC9474863 DOI: 10.1016/j.fsisyn.2022.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The unusual forensic pathologist John Plunkett began life in a family steeped in legal tradition, his father becoming a judge at age 29, bringing his 8-year old John to court to observe. A man of the people, Dr. Plunkett had a mind intolerant of deviations from objective truth, which he used to establish factual innocence. Initially diagnosing 2 cases as Shaken Baby Syndrome (SBS) himself, his critical mind and ability to learn made him an early apostate from SBS beliefs. He worked on 948 medico-legal cases throughout his career. While helping others, he himself was sued by a prosecutor to silence him, but Dr. Plunkett was unbowed, and found not guilty by a judge. Not a natural academic, he nevertheless published highly cited articles on basic, oft-forgotten truths such as the lethality of short falls and the existence of lucid intervals. His articles have stood the test of time. He knew science is not a democracy, and counselled other physicians attacked in courts due to holding minority views. Plunkett influenced the lives of many accused and their children, eventually becoming expert in the thinking that could lead to false allegations of child abuse. This eventually defined him, as featured in a documentary movie, The Syndrome.
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Pendharkar H, Jabeen S, Pruthi N, Narasinga Rao KVLN, Shukla D, Kamble N, Jangam KV, Kommu JVS, Kandavel T, Amudhan S. Abusive head trauma in India: imaging raises the curtain. Int J Inj Contr Saf Promot 2021; 29:103-111. [PMID: 34913839 DOI: 10.1080/17457300.2021.2007955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.
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Affiliation(s)
- Hima Pendharkar
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Shumyla Jabeen
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India.,Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - K V L N Narasinga Rao
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Nitish Kamble
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India.,Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Kavita V Jangam
- Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - John Vijay Sagar Kommu
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Thennarasu Kandavel
- Department of Biostatistics, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Senthil Amudhan
- Department of Epidemiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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Zhu X, Cai X, Zhou X, Li Y, Yang C. Retinal vein occlusion with cerebral infarction in a preterm neonate: a case report. BMC Pediatr 2021; 21:511. [PMID: 34784915 PMCID: PMC8594150 DOI: 10.1186/s12887-021-02989-2] [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: 03/02/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retinal vein occlusion (RVO) is a common disease that causes blindness in elderly patients, and cerebral infarction is also a severe disorder impairing the health of individuals. Both diseases are not common in neonates and are related to thrombosis. To date, only one case of simultaneous occurrence of RVO with intracranial haemorrhage in a full-term neonate has been reported. CASE PRESENTATION A preterm neonate was diagnosed with cerebral infarction and RVO. Retinal haemorrhage and macular oedema were detected in the left eye after the onset of ipsilateral stroke. Although the retinal conditions in this case resolved spontaneously without ocular treatment, the long-term effect on visual function is still unknown. CONCLUSIONS Given that ocular fundus examinations are rarely performed in paediatric stroke patients, a screening fundus examination in these newborns with stroke might be worth considering.
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Affiliation(s)
- Xiuyu Zhu
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Xiaojing Cai
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Xiaohong Zhou
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Yian Li
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Chenhao Yang
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China.
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Wilson TA, Gospodarev V, Hendrix S, Minasian T. Pediatric abusive head trauma: ThinkFirst national injury prevention foundation. Surg Neurol Int 2021; 12:526. [PMID: 34754576 PMCID: PMC8571401 DOI: 10.25259/sni_194_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/27/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Pediatric abusive head trauma (AHT) represents 80% of nonaccidental trauma deaths, remaining a lead cause of death among infants and young children. Furthermore, neurosurgical intervention can ameliorate damage from secondary injury, but we are currently unable to alter the impact of the primary injury. Thus, prevention through increased public awareness is imperative. This study identifies injuries and predictors of outcomes in pediatric AHT and highlights the importance of partnering with our community through ThinkFirst, a national injury prevention foundation, to educate parents and caregivers about prevention. Methods: This single-institution retrospective review identifies injuries and predictors of outcomes in pediatric AHT and highlights the importance of partnering with our community to raise awareness and educate parents and caregivers about prevention. Results: The number of pediatric AHT cases continues to steadily increase over time (P < 0.001), and over 70% of these patients are <1 year of age (P < 0.001). Patients suffering AHT have a mortality rate of nearly 10%. In addition to morbidity and mortality, the economic burden of caring for abused children is high as they often require high levels of care, long hospital stays, and extensive rehabilitation. Furthermore, Medicaid pays for nearly 80% of these patients. Conclusion: The population of patients with AHT is unique, and one that will benefit from continued efforts at increased multidisciplinary and public awareness. Prevention of AHT through awareness is critical. Through partnering with ThinkFirst, a national injury prevention foundation, we aim to educate parents and caregivers about prevention.
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Affiliation(s)
- Taylor Anne Wilson
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Vadim Gospodarev
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Sean Hendrix
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Tanya Minasian
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
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Katch LE, Burkhardt T. Development and validation of the infant crying and parent well-being screening tool. JOURNAL OF COMMUNITY PSYCHOLOGY 2021; 49:1579-1597. [PMID: 34033694 DOI: 10.1002/jcop.22599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/14/2021] [Accepted: 04/21/2021] [Indexed: 06/12/2023]
Abstract
This article describes the development and validation of the infant crying and parent well-being (ICPW) screening tool, developed to provide an effective and efficient way of identifying families struggling with infant crying and soothing. Construct validity for the ICPW was assessed using survey data from 290 parents of infants. Scores on the ICPW were associated with parental depression, parenting stress, and low co-parent confidence. Parents with positive ICPW screens-indicating additional support is needed-were more likely to have high or clinical levels of parenting stress than parents with negative screens. Inconsolable and excessive infant crying negatively impacts the well-being of parents, and most importantly, is the primary trigger for infant abuse. The ICPW is a unique, efficient tool that allows providers to screen for families who may need additional support around infant crying and soothing.
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Affiliation(s)
- Leslie E Katch
- Early Childhood Education, National Louis University, Chicago, Illinois, USA
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Unuma K, Makino Y, Yamamoto K, Hattori S, Arai N, Sakai K, Kitagawa M, Uemura K, Kanegane H. Fatal intracranial hemorrhage due to infantile acute lymphoblastic leukemia mimicking abusive head trauma. J Forensic Sci 2021; 66:2504-2510. [PMID: 34296766 DOI: 10.1111/1556-4029.14815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
We report the case of a 2-month-old infant who was found moribund in her crib. Postmortem computed tomography (PMCT) was performed before autopsy. As the baby had a severe subdural hematoma, retinal hemorrhage, and encephalopathy on PMCT, abusive head trauma (AHT) was tentatively diagnosed. At autopsy, no scalp hemorrhages or skull fractures were found; however, the classic triad of AHT was present, mainly on the right side. Additionally, there was dark red discoloration around the heart, and the liver, spleen, and pancreas were enlarged. Peripheral blood was macroscopically cloudy with marked leukocytosis. After careful histological examination, B-cell precursor acute lymphoblastic leukemia (ALL) was diagnosed. All the macroscopic lesions could be attributed to ALL. The manner of death was natural. To the best of our knowledge, this is the first report of infantile ALL mimicking AHT on PMCT images. This case demonstrates the importance of a comprehensive systematic approach to considering differential diagnosis when PMCT shows multiple intracranial hemorrhages suggestive of AHT in an infant.
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Affiliation(s)
- Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Shinya Hattori
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Nobutaka Arai
- Laboratory of Neuropathology, Tokyo Metropolitan Institute of Medical Science, Setagaya-ku, Tokyo, Japan
| | - Kentaro Sakai
- Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, Bunkyo-ku, Tokyo, Japan
| | - Masanobu Kitagawa
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Koichi Uemura
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
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Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:529-540. [PMID: 33908266 DOI: 10.2214/ajr.21.25655] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.
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