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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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Berthold O, Fegert JM, Brähler E, Jud A, Clemens V. Abusive head trauma: The body of the iceberg - A population-based survey on prevalence and perpetrators. CHILD ABUSE & NEGLECT 2024; 149:106660. [PMID: 38295606 DOI: 10.1016/j.chiabu.2024.106660] [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: 06/20/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Research on abusive head trauma (AHT) is usually research on clinically identified cases, while population-based studies, having the potential to identify cases of shaking that did not end with hospital admission, are missing to date. OBJECTIVE Thus, we aimed to assess the prevalence of AHT and associated risk factors in a representative sample of the German population. PARTICIPANTS AND SETTING We conducted a cross-sectional, observational study in Germany from July to October 2021. Using different sampling steps including a random route procedure, a probability sample of the German population was generated. The final sample consisted of 2503 persons (50.2 % female, mean age: 49.5 years). METHODS Participants were asked about sociodemographic information in a face-to-face interview and whether they had been ever responsible for the care of an infant and whether they had ever performed potential harmful methods including shaking to calm it, intimate partner violence (IPV) and adverse childhood experiences (ACEs) using a questionnaire. RESULTS In total, 1.4 % of women (N = 18) and 1.1 % of men (N = 13) reported to have at least once shaken an infant to calm it. Ever having used a potential harmful parenting method in calming an infant was reported by 4.9 % of women (N = 61) and 3.1 % (N = 39) of men. No gender differences were seen. A low income, living with someone under 16 in the household and victimization and perpetration of IPV and ACEs are associated with increased risks of shaking and other potential harmful methods to calm an infant. CONCLUSIONS Our data suggest that despite better knowledge on the dangers of shaking, the percentage of women that shake infants might be higher than previously thought. Also, intimate partner violence and ACEs are key risk factor for shaking and harmful parenting behaviors in general. This has important implications for future prevention programs.
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Affiliation(s)
- Oliver Berthold
- Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany; Child Abuse Clinic, DRK Kliniken Berlin, Spandauer Damm 130, 14050 Berlin, Germany.
| | - Jörg M Fegert
- Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Elmar Brähler
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany; Integrated Research and Treatment Center Adiposity Diseases, Behavioral Medicine Unit, Department of Psychosomatic Medicine and Psychotherapy, Leipzig University Medical Center, Leipzig, Germany
| | - Andreas Jud
- Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
| | - Vera Clemens
- Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075 Ulm, Germany
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Loredo-Abdalá A, Casas-Muñoz A, Villanueva-Clift HJ, Aguilar-Ceniceros A, González-Garay AG, Gutiérrez-Leyva CDJ, Juarez Olguin H. Pediatric Abusive Head Trauma: Multicentric Experience in Mexico. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:644-658. [PMID: 32306826 DOI: 10.1177/0886260520916283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Abusive head trauma (AHT) is one of the most severe forms of child abuse due to its morbidity and mortality. However, AHT is still misdiagnosed in developing countries because of its nonspecific clinical picture and limited knowledge of it on the part of physicians. The aim of this study was to describe some characteristics of children with AHT, their families, and caregivers, as well as the clinical data that could serve as signs for its suspicion and the medical-legal resolution of the cases. Children suspect with AHT in emergency rooms in three Mexican hospitals were included after obtaining informed consent from the parents. All information was obtained from the parents by means of a questionnaire and from different clinical and radiological evaluations of the clinical records of the patients. 15 children, with a median age of 5 months and predominantly males (73.33%), were included in the study. 66% reported a history of irritability periods, and most of the patients (73.33%) had more than one habitual caregiver. The diagnosis of AHT was suspected in only 33.33% on admission in the Emergency Services. Acute symptomatology was present in 53.33%, while less severe symptoms were reported in the rest. Special attention should be paid on babies with history of irritable periods. When a child who is previously healthy and suddenly presents with a seizure or cardiorespiratory dysfunction or brought to the hospital dead, the diagnosis of AHT should be considered as a priority.
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Ayton D, Pritchard E, Tsindos T. Acquired Brain Injury in the Context of Family Violence: A Systematic Scoping Review of Incidence, Prevalence, and Contributing Factors. TRAUMA, VIOLENCE & ABUSE 2021; 22:3-17. [PMID: 30651050 DOI: 10.1177/1524838018821951] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Brain injury is often a precursor to, or result of, family violence. Yet there is little research identifying the connection of these two phenomena. The health cost (personal or societal) of brain injury within the family violence context is difficult to ascertain. Family violence can lead to lifelong psychological or physical scars and even death. A systematic review was conducted over three databases using Medical Subject Heading terms to investigate incidence, prevalence, and contributing factors of brain injury within a family violence context. Inclusion criteria were primary studies, any person who experienced traumatic brain injury in a familial context. Seven hundred and seven studies of varied designs were initially identified with 43 meeting inclusion criteria. Data were extracted and a deductive narrative synthesis was performed. The accuracy and generalizability of incidence and prevalence statistics was hindered by underreporting of family violence and the specificity of some of the population groups (e.g., female inmates). The factors contributing to brain injury within the family violence context had multifactorial causation and varied greatly across the populations studied. Five social determinants of health were identified: biological, behavioral, structural, social, and environmental. These factors included age and gender of parent/baby, crying as an antecedent of family violence, previous exposure to abuse as a child, hostile living environments, previous trauma, financial pressures, employment status, housing availability, and exposure to natural disasters. Future investigation into the nexus between brain injury and family violence is required; however, this is complicated due to global inconsistency of definitions, assessment tools, and research methods used.
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Affiliation(s)
- Darshini Ayton
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Elizabeth Pritchard
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tess Tsindos
- Health Services Research Unit, Division of Health Services, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Feld K, Feld D, Karger B, Helmus J, Schwimmer-Okike N, Pfeiffer H, Banaschak S, Wittschieber D. Abusive head trauma in court: a multi-center study on criminal proceedings in Germany. Int J Legal Med 2021; 135:235-244. [PMID: 33030617 PMCID: PMC7782463 DOI: 10.1007/s00414-020-02435-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/30/2020] [Indexed: 12/03/2022]
Abstract
The shaken baby syndrome (SBS) is a common variant of abusive head trauma (AHT) in infants and toddlers. Data on the legal outcome of such cases are still sparse. By means of a retrospective multi-center analysis, 72 cases of living children diagnosed with SBS/AHT from three German university institutes of legal medicine were identified. Forty-six of these cases with 68 accused individuals were available and could be evaluated with regard to basic data on the course of the criminal proceedings as well as the profile of the defendants (sub-divided into suspects, convicts, and confessed perpetrators). Criminal proceedings predominantly commenced with a complaint by the treating hospital (62%) and were found to be closed (without judgment) in 50% of the cases, mostly due to a "lack of sufficient suspicion." Of the 23 cases with judgment, the court decided on acquittal in 4 cases (17%). Imprisonment was the most frequent sentence (16 out of 19 cases with conviction, 84%), whereby the sentence has been suspended on probation in 63% of the cases. Suspects and perpetrators were mostly male and derived from the close family environment of the injured children. All confessed perpetrators stated an "excessive demand" as the reason for the violent shaking of the child. The results of the present study are in line with data from other studies with other legal systems. As many criminal proceedings were closed and the 4 acquittals occurred because the perpetration could not be ascribed to a specific perpetrator, improving the forensic methods for such an unequivocal assignment would be desirable.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | - Nneka Schwimmer-Okike
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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Rey-Salmon C, de Boissieu P, Teglas JP, Adamsbaum C. Abusive Head Trauma in Day Care Centers. Pediatrics 2020; 146:peds.2020-013771. [PMID: 33172921 DOI: 10.1542/peds.2020-013771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Abusive head trauma (AHT) warrants particular attention in terms of prevention. One of the key questions asked is how often AHT occurs in infant day care centers compared with private parental or nonparental homes. To investigate this, we studied the caretaking arrangement and child's location at the time of injury in a cohort of cases involving AHT from the courts. METHODS This multicenter retrospective study covering an 18-year period included all medical and court records of 323 children (2.5 months to 3 years) with AHT, confirmed by the authors acting as medical experts. All markers for abuse and forensic written reports were analyzed by using a standardized data collection tool. The usual child care arrangement and the child's location at the time of injury were noted. The percentage of day care centers found in the study was compared to the expected rate in the French population (19.5%) by using the χ2 test. RESULTS In 317 AHT cases (98.5%), the assault occurred in a private home (4 in other indoor settings and 1 with missing data). In only 1 case, shaking occurred in a day care center when the nurse was alone with the infant for a few minutes. In 317 cases (98.5%), the usual child care arrangement was by a single adult in charge of 1 or more children. CONCLUSIONS The fact that AHT is an unusual occurrence in day care centers could help social service agencies make decisions in terms of prevention. Recent government policies regarding stay-at-home orders during a pandemic have given this issue new relevance.
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Affiliation(s)
- Caroline Rey-Salmon
- Pediatrics and Forensic Unit, Hôtel Dieu Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - Jean-Paul Teglas
- Centre for Research in Epidemiology and Population Health U1018, National Institute of Health and Medical Research, Paris, France
| | - Catherine Adamsbaum
- Faculty of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France .,Pediatric Radiology, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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Rosado N, Charleston E, Gregg M, Lorenz D. Characteristics of accidental versus abusive pediatric burn injuries in an urban burn center over a 14-year period. J Burn Care Res 2020; 40:437-443. [PMID: 30869138 DOI: 10.1093/jbcr/irz032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The aim of this study was to determine the demographic and associated characteristics of abusive burn injuries in children. Understanding the characteristics of burn injuries may help clinicians differentiate and recognize abusive injuries. We conducted a retrospective study of patients less than 5 years old admitted to an urban burn center from March 1999 to July 2013. Per protocol, all patients with burn injuries were evaluated by a multidisciplinary team (child abuse pediatrician, social worker, and nurse clinician). Demographic information, social risk factors, clinical presentation, caregiver at time of injury, radiographic studies and results, multidisciplinary team determination, and the Department of Children and Family Services investigation outcome were abstracted from the American Burn Association Burn Registry and patient's chart. Patient characteristics were evaluated with abuse status through Wilcoxon rank sum tests for continuous variables and chi-square tests or Fisher's exact test for categorical variables. A multiple logistic regression was fit to identify factors associated with abusive burns. One hundred and ten patients under 5 years were categorized as abuse (38) or accident (72). Demographic characteristics were similar between the abuse and accident groups. A determination of abuse was significantly associated with caregiver type (paramour), site of incident (outside of kitchen), time to seeking help (>4 hours), and the presence of nonburn skin injuries. A detailed history of the burn mechanism as well as psychosocial family risk factors are critical when evaluating pediatric patients with burn injuries, as it may assist the physician in distinguishing abusive from accidental burn injuries.
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Affiliation(s)
- Norell Rosado
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Elizabeth Charleston
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Mary Gregg
- Department of Bioinformatics and Biostatistics, University of Louisville, Kentucky
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Kentucky
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Ajmera S, Motiwala M, Weeks M, Oravec CS, Hersh DS, Fraser BD, Vaughn B, Klimo P. What Variables Correlate With Different Clinical Outcomes of Abusive Head Injury? Neurosurgery 2020; 87:803-810. [PMID: 32243538 DOI: 10.1093/neuros/nyaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/29/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The spectrum of injury severity for abusive head trauma (AHT) severity is broad, but outcomes are unequivocally worse than accidental trauma. There are few publications that analyze different outcomes of AHT. OBJECTIVE To determine variables associated with different outcomes of AHT. METHODS Patients were identified using our AHT database. Three different, but not mutually exclusive, outcomes of AHT were modeled: (1) death or hemispheric stroke (diffuse loss of grey-white differentiation); (2) stroke(s) of any size; and (3) need for a neurosurgical operation. Demographic and clinical variables were collected and correlations to the 3 outcomes of interest were identified using bivariate and multivariable analysis. RESULTS From January 2009 to December 2017, 305 children were identified through a prospectively maintained AHT database. These children were typically male (60%), African American (54%), and had public or no insurance (90%). A total of 29 children (9.5%) died or suffered a massive hemispheric stroke, 57 (18.7%) required a neurosurgical operation, and 91 (29.8%) sustained 1 or more stroke. Death or hemispheric stroke was statistically associated with the pupillary exam (odds ratio [OR] = 45.7) and admission international normalized ratio (INR) (OR = 17.3); stroke was associated with the pupillary exam (OR = 13.2), seizures (OR = 14.8), admission hematocrit (OR = 0.92), and INR (9.4), and need for surgery was associated with seizures (OR = 8.6). CONCLUSION We have identified several demographic and clinical variables that correlate with 3 clinically applicable outcomes of abusive head injury.
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Affiliation(s)
- Sonia Ajmera
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Chesney S Oravec
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David S Hersh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey Clinic, Memphis, Tennessee
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Edwards GA, Maguire SA, Gaither JR, Leventhal JM. What Do Confessions Reveal About Abusive Head Trauma? A Systematic Review. CHILD ABUSE REVIEW (CHICHESTER, ENGLAND : 1992) 2020; 29:253-268. [PMID: 37982093 PMCID: PMC10655946 DOI: 10.1002/car.2627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/26/2020] [Indexed: 11/21/2023]
Abstract
Although confessions related to abusive head trauma (AHT) are reported, no detailed analysis exists. Therefore, we systematically reviewed studies of AHT confessions and examined the details, including country of origin, mechanisms and perpetrators' characteristics [PUBLISHER - THE PRECEDING UNDERLINED TEXT IS FOR THE MARGIN]. Employing 36 search terms across three search engines, we searched Medline and CINAHL from 1963 to 2018. All relevant studies underwent two independent reviews and data extraction. Descriptive statistics were used to characterise the sample; chi square and Fisher's exact tests were used to assess differences in demographic and clinical characteristics. Of 6759 identified studies, 157 full texts were reviewed and 55 articles from 15 countries spanning four continents were included. Included articles contained 434 confessions. The mechanisms of abuse included shaking alone (64.1%), impact alone (17.1%), shaking plus impact (18.0%) and other (0.9%). There was no statistically significant difference in the percentage of confessions reporting shaking alone when comparing continents: North America (64.0%), Europe (64.2%) and Oceania (60.0%; P=.92), or when comparing circumstances in which the confession was obtained: medical evaluation (74.6%) vs police or judicial investigations (63.4%; P=.11). Of 119 cases with identified perpetrators, 67.2 per cent were cases with males alone. Confessions reveal striking similarities in the mechanism of AHT (predominantly shaking) and occur across the globe.
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Affiliation(s)
- George A Edwards
- Formerly of Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | | | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - John M Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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11
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Berthold O, Clemens V, Witt A, Brähler E, Plener PL, Fegert JM. Awareness of abusive head trauma in a German population-based sample: implications for prevention. Pediatr Res 2019; 86:537-541. [PMID: 31212304 DOI: 10.1038/s41390-019-0467-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/04/2019] [Accepted: 06/08/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite efforts to reduce the incidence of abusive head trauma (AHT), incidence rates remain high. One cause is that prevention programs mostly aim to educate mothers of newborns on AHT and infant crying. However, mothers commonly have already a high knowledge and constitute only a minority among identified AHT perpetrators. The hypothesis was that there are great differences in AHT awareness in different subgroups. To assess awareness of AHT, a population-based study was performed. METHODS A population-based representative sample of the German population aged >14 years (N = 2510) was assessed in a cross-sectional observational survey. The sample was selected in a random route approach between November 2017 and February 2018. RESULTS Overall knowledge of AHT was higher in women (67.9%) than in men (48.8%, p < 0.001). Female gender, having children, higher age, and level of education were predictors for the awareness of AHT. A majority of participants reported to have heard about AHT from the media. CONCLUSIONS Awareness of AHT differs significantly within the population. In groups at higher risk to perpetrate AHT, including men, young caregivers, and those with low educational level, awareness of AHT was low. These subgroups should be targeted by tailored education programs for prevention.
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Affiliation(s)
- Oliver Berthold
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany. .,Child Abuse Clinic, Department of Pediatrics, DRK Kliniken Berlin
- Westend, Spandauer Damm 130, 14050, Berlin, Germany.
| | - Vera Clemens
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
| | - Andreas Witt
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
| | - Elmar Brähler
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.,University Medical Center of Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
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12
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Fingarson AK, Pierce MC, Lorenz DJ, Kaczor K, Bennett B, Berger R, Currie M, Herr S, Hickey S, Magana J, Makoroff K, Williams M, Young A, Zuckerbraun N. Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury. J Pediatr 2019; 212:180-187.e1. [PMID: 31255388 PMCID: PMC6707841 DOI: 10.1016/j.jpeds.2019.05.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. STUDY DESIGN Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner. RESULTS Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships <1 year were also associated with an increased risk of abuse. CONCLUSIONS We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.
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Affiliation(s)
- Amanda K Fingarson
- Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Pediatric Injury Research Lab (PIRL), Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mary Clyde Pierce
- Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Pediatric Injury Research Lab (PIRL), Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Douglas J Lorenz
- Pediatric Injury Research Lab (PIRL), Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY
| | - Kim Kaczor
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Pediatric Injury Research Lab (PIRL), Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Berkeley Bennett
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rachel Berger
- Department of Pediatrics, University of Pittsburgh, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Melissa Currie
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | - Sandy Herr
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | - Sheila Hickey
- Department of Social Work, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Julia Magana
- Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, CA; Rady Children's Hospital San Diego, San Diego, CA
| | - Kathi Makoroff
- Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Marcia Williams
- Public Service Administrator, Illinois Department of Children and Family Services, Division of Child Protection, Chicago, IL
| | - Audrey Young
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Noel Zuckerbraun
- Department of Pediatrics, University of Pittsburgh, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
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When soothing succeeds: Simulating a risk for repeated shaking in abusive head trauma in infants. Infant Behav Dev 2019; 56:101246. [DOI: 10.1016/j.infbeh.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 01/20/2018] [Accepted: 02/11/2018] [Indexed: 11/22/2022]
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Lynøe N, Juth N, Eriksson A. From Child Protection to Paradigm Protection-The Genesis, Development, and Defense of a Scientific Paradigm. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 44:378-390. [PMID: 30184158 PMCID: PMC6525473 DOI: 10.1093/jmp/jhy015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome (SBS) paradigm. The point of departure of the analysis is a recently conducted systematic literature review, which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present (and no other "acceptable" explanations are provided) the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of "groupthink," aggravating the difficulties in considering critics' questioning the criteria established by the teams.
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Berthold O, Witt A, Clemens V, Brähler E, Plener PL, Fegert JM. Do we get the message through? Difficulties in the prevention of abusive head trauma. Eur J Pediatr 2019; 178:139-146. [PMID: 30353222 DOI: 10.1007/s00431-018-3273-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 12/20/2022]
Abstract
Many programs aim to prevent abusive head trauma throughout the USA, Europe, and in many other regions of the world. Most of these programs inform mothers shortly after delivery about the dangers of abusive head trauma. Effectiveness of these programs usually is measured by the increase of knowledge on abusive head trauma. Recent research showed, however that for effective primary prevention, a much broader approach might be necessary. But so far, there is no data that reports the knowledge on key messages on abusive head trauma in the general public as a baseline. We conducted a representative population-based survey on abusive head trauma knowledge in Germany. Whereas the dangers are generally well known, a majority might be ambivalent towards the recommendation to leave a crying infant alone for a few minutes when the caregiver becomes too stressed or frustrated. Furthermore, a majority prefers being informed on abusive head trauma before birth.Conclusion: Future preventive programs should focus on educating adolescents (potential baby sitters) and young adults when they do not yet have children of their own. What is known: • Most programs for primary prevention of abusive head trauma (AHT) focus on mothers shortly after delivery • There are no analyses so far of the quality of education programs in the general public, as educating mothers might not be sufficient to reduce incidence rates What is new: • Our study is the first population-based survey to measure the knowledge on AHT in a representative population sample and to provide the data base for targeted prevention programs. • The introduction of broader prevention programs might be necessary.
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Affiliation(s)
- Oliver Berthold
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany. .,Child Abuse Clinic, DRK Kliniken Berlin
- Westend, Spandauer Damm 130, Berlin, Germany.
| | - Andreas Witt
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
| | - Vera Clemens
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
| | - Elmar Brähler
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of Johannes Gutenberg University of Mainz, Mainz, Germany.,Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
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16
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The medical and social outcome in 2016 of infants who were victims of shaken baby syndrome between 2005 and 2013. Arch Pediatr 2018; 26:21-29. [PMID: 30554853 DOI: 10.1016/j.arcped.2018.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/02/2018] [Accepted: 10/14/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION There are few studies that have investigated the long-term outcome of children who have been victims of shaken baby syndrome (SBS). However, the consequences appear to be significant and the data available from a social point of view are scarce. The main objective of this study was to define the medical and social outcome in 2016 of the infants who were victims of SBS and admitted to one of the Marseille university hospitals. The number of patients followed by a specialized team was evaluated along with their clinical state, living conditions, and whether a social support system such as the Child welfare system had been put into place. METHOD The study was retrospective and descriptive. Patients under 1 year of age who were hospitalized between January 2005 and December 2013 and manifested clinical and paraclinical characteristics enabling the diagnosis of SBS were included in the study. The diagnosis was certain, probable, or possible according to the definitions given by the consensus of the 2011 shaken baby health authority conference (HAS). RESULTS Eighty babies qualified for the study, three of whom died in intensive care. Only ten of these patients (12.9%) had regular (annual) neuropediatric check-up during the whole study period. Thirty-seven patients (48%) had an annual neuropediatric check-up during the first 2 years only following the diagnosis. Only 12 of the children (15.6%) were still being followed after the age of 6. The children were followed up on average for 2.5 years (29.6 months). In 24 cases (31%), the last medical visit revealed an abnormal neurological examination including multiple disabilities due to spastic quadriplegia and severe intellectual deficit, which led to total dependency in half of these cases. Forty-four patients (57%) had a normal neurological examination. Concerning the babies' social outcome, 50 patients (64.9%) had returned home, 12 (15.6%) benefited, from educational assistance at the patient's home (AEMO) following the ruling of a children's judge, and 19 (24.7%) were still placed in foster care (ASE). The average foster care placement lasted 34.7 months. DISCUSSION AND CONCLUSION Long-term medical follow-up for children having sustained serious head injury as a result of abuse is inadequate. Sequelae such as multiple disabilities are less frequent than described in the literature. According to this study, a longer-term follow-up is necessary for children suffering from sequelae such as learning disabilities than what is actually possible in our center.
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Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, Engström I, Erlandsson BE. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018; 107 Suppl 472:3-23. [PMID: 30146789 PMCID: PMC6585638 DOI: 10.1111/apa.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
The Swedish Agency for Health Technology Assessment and Assesment of Social Services (SBU) is an independent national authority, tasked by the government with assessing methods used in health, medical and dental services and social service interventions from a broad perspective, covering medical, economic, ethical and social aspects. The language in SBU's reports are adjusted to a wide audience. SBU's Board of Directors has approved the conclusions in this report. The systematic review showed the following graded results: There is limited scientific evidence that the triad (Three components of a whole. The triad associated with SBS usually comprises subdural haematoma, retinal haemorrhages and encephalopathy.) and therefore, its components can be associated with traumatic shaking (low-quality evidence). There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). Limited scientific evidence (low-quality evidence) represents a combined assessment of studies of high or moderate quality which disclose factors that markedly weaken the evidence. It is important to note that limited scientific evidence for the reliability of a method or an effect does not imply complete lack of scientific support. Insufficient scientific evidence (very low-quality evidence) represents either a lack of studies or situations when available studies are of low quality or show contradictory results. Evaluation of the evidence was not based on formal grading of the evidence according to GRADE but on an evaluation of the total scientific basis.
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Affiliation(s)
- Göran Elinder
- Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, Umeå, Sweden
- The National Board of Forensic Medicine, Sweden
| | - Boubou Hallberg
- Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niels Lynøe
- Medical Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Maly Sundgren
- Diagnostic Radiology, Lund University, Lund, Sweden
- Department of Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Måns Rosén
- Health Technology Assessment, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Engström
- Child and Adolecent Psychiatry, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Lintern TO, Nash MP, Kelly P, Bloomfield FH, Taberner AJ, Nielsen PMF. Probabilistic description of infant head kinematics in abusive head trauma. Comput Methods Biomech Biomed Engin 2017; 20:1633-1642. [DOI: 10.1080/10255842.2017.1403593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- T. O. Lintern
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - M. P. Nash
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - P. Kelly
- Te Puaruruhau (Child Abuse Assessment Unit), Starship Children’s Hospital, Auckland, New Zealand
| | - F. H. Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - A. J. Taberner
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - P. M. F. Nielsen
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Engineering Science, University of Auckland, Auckland, New Zealand
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Vadivelu S, Rekate HL, Esernio-Jenssen D, Mittler MA, Schneider SJ. Hydrocephalus associated with childhood nonaccidental head trauma. Neurosurg Focus 2016; 41:E8. [DOI: 10.3171/2016.8.focus16266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The incidence of posttraumatic ventriculomegaly (PTV) and shunt-dependent hydrocephalus after nonaccidental head trauma (NAHT) is unknown. In the present study, the authors assessed the timing of PTV development, the relationship between PTV and decompressive craniectomy (DC), and whether PTV necessitated placement of a permanent shunt. Also, NAHT/PTV cases were categorized into a temporal profile of delay in admission and evaluated for association with outcomes at discharge.
METHODS
The authors retrospectively reviewed the cases of patients diagnosed with NAHT throughout a 10-year period. Cases in which sequential CT scans had been obtained (n = 28) were evaluated for Evans' index to determine the earliest time ventricular dilation was observed. Discharge outcomes were assessed using the King's Outcome Scale for Childhood Head Injury score.
RESULTS
Thirty-nine percent (11 of 28) of the patients developed PTV. A low admission Glasgow Coma Scale (GCS) score predicted early PTV presentation (within < 3 days) versus a high GCS score (> 1 week). A majority of PTV/NAHT patients presented with a subdural hematoma (both convexity and interhemispheric) and ischemic stroke, but subarachnoid hemorrhage was significantly associated with PTV/NAHT (p = 0.011). Of 6 patients undergoing a DC for intractable intracranial pressure, 4 (67%) developed PTV (p = 0.0366). These patients tended to present with lower GCS scores and develop ventriculomegaly early. Only 2 patients developed hydrocephalus requiring shunt placement.
CONCLUSIONS
PTV presents early after NAHT, particularly after a DC has been performed. However, the authors found that only a few PTV/NAHT patients developed shunt-dependent hydrocephalus.
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Affiliation(s)
- Sudhakar Vadivelu
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
| | - Harold L. Rekate
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
| | - Debra Esernio-Jenssen
- 2Department of Pediatrics, University of Florida School of Medicine at Shands Children's Hospital, Gainesville, Florida
| | - Mark A. Mittler
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
| | - Steven J. Schneider
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
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20
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Abstract
OBJECTIVE Research on pediatric abusive head trauma (AHT) has largely focused on clinical presentation and management. The authors sought to review a single-institution experience from a public health perspective to gain a better understanding of the local population affected, determine overall incidence and seasonal trends, and provide details on the initial hospitalization, including extent of injuries, neurosurgical interventions, and hospital charges. METHODS All cases of AHT involving patients who presented to Le Bonheur Children's Hospital (LBCH) from 2009 through 2014 were identified. AHT was defined as skull fracture or intracranial hemorrhage in a child under the age of 5 years with a suspicious mechanism or evidence of other intentional injuries, such as retinal hemorrhages, old or new fractures, or soft-tissue bruising. Injuries were categorized as Grade I (skull fracture only), Grade II (intracranial hemorrhage or edema not requiring surgical intervention), or Grade III (intracranial hemorrhage requiring intervention or death due to brain injury). RESULTS Two hundred thirteen AHT cases were identified. The demographics of the study population are similar to those reported in the literature: the majority of the patients involved were 6 months of age or younger (55%), male (61%), African American (47%), and publicly insured (82%). One hundred one neurosurgical procedures were performed in 58 children, with the most common being bur hole placement for treatment of subdural collections (25%) and decompressive hemicraniectomy (22%). The annual incidence rate rose from 2009 (19.6 cases per 100,000 in the population under 5 years of age) to 2014 (47.4 cases per 100,000) and showed seasonal peaks in January, July, and October (6-year average single-month incidence, respectively, 24.7, 21.7, and 24.7 per 100,000). The total hospital charges were $13,014,584, with a median cost of $27,939. Treatment costs for children who required surgical intervention (i.e., those with Grade III) were up to 10 times those of children with less severe injuries. CONCLUSIONS In the authors' local population, victims of AHT are overwhelmingly infants, are more often male than female, and are disproportionately from lower socioeconomic ranks. The incidence is increasing and initial hospitalization charges are substantial and variable. The authors introduce a simple 3-tiered injury classification scheme that adequately stratifies length of hospital stay and cost.
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Affiliation(s)
- Scott Boop
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mary Axente
- Neuroscience Institute, Le Bonheur Children's Hospital
| | | | - Paul Klimo
- Neuroscience Institute, Le Bonheur Children's Hospital.,Department of Neurosurgery, University of Tennessee Health Science Center; and.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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21
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Bartlett E, McMahon C. The cognitive, affective and physiological impact of infant crying: a comparison of two laboratory methodologies. J Reprod Infant Psychol 2015. [DOI: 10.1080/02646838.2015.1113515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Vadivelu S, Esernio-Jenssen D, Rekate HL, Narayan RK, Mittler MA, Schneider SJ. Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes. World Neurosurg 2015; 84:1340-6. [PMID: 26118721 DOI: 10.1016/j.wneu.2015.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/12/2015] [Accepted: 06/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation. OBJECTIVE Extent of delay in seeking medical attention may be related to patient outcome. METHODS A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6-12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case. RESULTS All children were 3 years of age or younger (2.1-34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay. CONCLUSION Patients presenting to medical care 6-12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.
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Affiliation(s)
- Sudhakar Vadivelu
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA.
| | - Debra Esernio-Jenssen
- Department of Pediatrics, University of Florida School of Medicine at Shands Children's Hospital, Gainesville, Florida, USA
| | - Harold L Rekate
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Raj K Narayan
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Mark A Mittler
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Steven J Schneider
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
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Abstract
Shaken Baby Syndrome occurs in infants as a result of the brain pushing against the skull due to severe acceleration-deceleration forces. Symptoms of Shaken Baby Syndrome include subdural, subarachnoid, and retinal hemorrhages. MRI and ocular examinations are used to determine the extent of mental and visual damage and β-amyloid precursor protein immunohistochemical staining is used to detect axonal injuries. Surgeries such as Subdural hemorrhage (SDH) evacuation surgery and the Burr hole craniotomy are used to treat Shaken Baby Syndrome; however, the prognosis is poor in many cases. Because of the severity of Shaken Baby Syndrome and its traumatic and sometimes fatal effects, it is important to educate new parents, nurses, and doctors on the syndrome in order to prevent incidents.
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Affiliation(s)
- Maha Mian
- 1SUNY Stony Brook, Physiology and Biophysics, Stony Brook , New York , USA
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Hinds T, Shalaby-Rana E, Jackson AM, Khademian Z. Aspects of abuse: abusive head trauma. Curr Probl Pediatr Adolesc Health Care 2015; 45:71-9. [PMID: 25771265 DOI: 10.1016/j.cppeds.2015.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abusive Head Trauma (AHT) is a form of child physical abuse that involves inflicted injury to the brain and its associated structures. Abusive Head Trauma, colloquially called Shaken Baby Syndrome, is the most common cause of serious or fatal brain injuries in children aged 2 years and younger. The American Academy of Pediatrics recommends the term Abusive Head Trauma, as opposed to Shaken Baby Syndrome, as the former term encompasses multiple forms of inflicted head injury (inertial, contact, and hypoxic-ischemic) and a range of clinical presentations and radiologic findings and their sequelae. Children diagnosed with AHT are 5 times more likely to die compared with accidentally head-injured children, yet signs and symptoms are not always obvious, and therefore the diagnosis can be overlooked. Therefore, the American Academy of Pediatrics has tasked pediatricians with knowing how and when to begin an evaluation of children with signs and symptoms that could possibly be due to AHT. Overall, a detailed history of present illness and medical history, recognition of physical and radiological findings, and careful interpretation of retinal pathology are important aspects of formulating the differential diagnoses and increasing or decreasing the index of suspicion for AHT.
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Affiliation(s)
- Tanya Hinds
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eglal Shalaby-Rana
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Allison M Jackson
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Zarir Khademian
- Children׳s National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Dayton CJ, Walsh TB, Oh W, Volling B. Hush now baby: mothers' and fathers' strategies for soothing their infants and associated parenting outcomes. J Pediatr Health Care 2015; 29:145-55. [PMID: 25440811 PMCID: PMC4336595 DOI: 10.1016/j.pedhc.2014.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/23/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the types of soothing behaviors used by mothers and fathers of infants, differences in use trajectories over time, and associated parenting outcomes. METHODS A longitudinal study of 241 families expecting their second child was performed. Data were collected at 1, 4, and 8 postnatal months and included measures of parental soothing techniques, involvement in soothing, distress in response to infant crying, and parenting self-efficacy. RESULTS The average number of soothing techniques used was 7.7 for mothers and 5.9 for fathers. Soothing frequency decreased over time, and change patterns of soothing differed over time by gender. In couples who shared responsibility for soothing, fathers felt more efficacious in parenting and mothers were less upset by infant crying. DISCUSSION Clinicians are encouraged to support fathers' engagement in infant soothing, facilitate the development of fathers' parenting confidence, and promote fathers' involvement in children's health and health care.
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Westrick AC, Moore M, Monk S, Greeno A, Shannon C. Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience. Pediatr Neurosurg 2015; 50:179-86. [PMID: 26068322 DOI: 10.1159/000430846] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/21/2015] [Indexed: 11/19/2022]
Abstract
Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children's Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children's Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children's Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT.
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Affiliation(s)
- Ashly C Westrick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tenn., USA
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27
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Reese LS, Heiden EO, Kim KQ, Yang J. Evaluation of Period of PURPLE Crying, an Abusive Head Trauma Prevention Program. J Obstet Gynecol Neonatal Nurs 2014; 43:752-61. [DOI: 10.1111/1552-6909.12495] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Matschke J, Büttner A, Bergmann M, Hagel C, Püschel K, Glatzel M. Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers. Int J Legal Med 2014; 129:105-14. [DOI: 10.1007/s00414-014-1060-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/30/2014] [Indexed: 12/01/2022]
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Scribano PV, Makoroff KL, Feldman KW, Berger RP. Association of perpetrator relationship to abusive head trauma clinical outcomes. CHILD ABUSE & NEGLECT 2013; 37:771-777. [PMID: 23735871 DOI: 10.1016/j.chiabu.2013.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 04/22/2013] [Accepted: 04/25/2013] [Indexed: 06/02/2023]
Abstract
The diagnosis of abusive head trauma (AHT) remains a significant public health problem with limited prevention success. Providing protection from further harm is often challenged by the difficulty in identifying the alleged perpetrator (AP) responsible for this pediatric trauma. The objective of this study was to evaluate demographic and clinical characteristics of children with AHT and the relationship between APs and their victims in a large, multi-site sample. Understanding the AHT risks from various caregivers may help to inform current prevention strategies. A retrospective review of all cases of AHT diagnosed by child protection teams (CPT) from 1/1/04 to 6/30/09 at four children's hospitals was conducted. Clinical characteristics of children with AHT injured by non-parental perpetrators (NPP) were compared to parental perpetrators (PP). There were 459 children with AHT; 313 (68%) had an identified AP. The majority of the 313 children were <1 year of age (76%), Caucasian (63%), male (58%), receiving public assistance (80%), and presented without a history of trauma (62%); mortality was 19%. Overall, APs were: father (53%), parent partner (22%), mother (8%), babysitter (8%), other adult caregiver (5%); NPP accounted for 39% of APs. NPPs were more likely to cause AHT in children ≥ 1 year (77% vs. 23%, p<0.001) compared to PP. Independent associations to NPP included: older child, absence of a history of trauma, retinal hemorrhages, and male perpetrator gender. While fathers were the most common AP in AHT victims, there is a significant association for increased risk of AHT by NPPs in the older child, who presents with retinal hemorrhages, in the hands of a male AP. Further enhancement of current prevention strategies to address AHT risks of non-parental adults who provide care to children, especially in the post-infancy age seems warranted.
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Affiliation(s)
- Philip V Scribano
- The Children's Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104, USA
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Childhood death attributable to trauma: is there a difference between accidental and abusive fatal injuries? J Emerg Med 2013; 45:332-7. [PMID: 23797026 DOI: 10.1016/j.jemermed.2013.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 11/28/2012] [Accepted: 03/15/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Trauma is a leading cause of death among children worldwide. Detailed knowledge of the epidemiology of childhood fatal injuries is necessary for preventing injuries. OBJECTIVE To determine clinical differences between children who were treated in an emergency department for accidental or abusive injuries. METHODS A retrospective review of all deceased patients who were treated in two urban pediatric emergency departments between 1998 and 2010 was performed. Patients were categorized into two groups, accidental and abusive, for comparison. RESULTS A total of 1498 patients died during the study period, with 124 deaths being attributable to injury for a rate of 9.5 injury-related deaths per year. Most fatal injuries were accidental. Children with abusive fatal injuries were younger and more likely to have been seen for an injury in a clinic or emergency department within 2 months of their death. Eighty-two percent of abusive fatal injuries had documented subdural hematomas, whereas only 7.2% of accidental fatal injuries had a subdural hematoma documented. Nearly 50% of abusive fatal injuries had retinal hemorrhages reported, although no child with an accidental fatal injury had this type of injury documented. CONCLUSION Younger children, especially those previously seen in an emergency department or clinic for injury, are more likely to sustain an abusive fatal injury. Sentinel physical findings associated with abusive fatal injuries include subdural hematomas and retinal hemorrhages, and the presence of these findings should prompt an investigation into the circumstances of injury.
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Gaffar MA, Esernio-Jenssen D, Kodsi SR. Incidence of retinal hemorrhages in abusive head trauma. J Pediatr Ophthalmol Strabismus 2013; 50:169-73. [PMID: 23380029 DOI: 10.3928/01913913-20130129-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 11/26/2012] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate whether a relationship exists between the presence of retinal hemorrhages and confessions and/or identified perpetrators in cases of abusive head trauma. METHODS A retrospective chart review was conducted of all abusive head trauma cases. All cases that met criteria for abusive head trauma were placed into one of three categories: perpetrator confessed (category A), perpetrator identified without confession (category B), and no perpetrator identified (category C). RESULTS Forty-eight cases met the criteria for abusive head trauma, with 18, 16, and 14 cases in categories A, B, and C, respectively. Retinal hemorrhages were identified in 16 of 18 (88%) cases in category A, 12 of 16 (75%) in category B, and 6 of 14 (43%) in category C. A statistically significant difference regarding the presence of retinal hemorrhages was seen for perpetrator identified (28 of 34 or 82%) compared to no perpetrator identified (6 of 14 or 43%) (P = .034). The difference in retinal hemorrhages was correlated to the higher incidence of acute presentation in the perpetrator identified group (31 of 34 or 91%) compared to that in the perpetrator not identified group (9 of 14 or 64%) (P = .023). CONCLUSION The incidence of retinal hemorrhages in abusive head trauma for identified perpetrators, regardless of a confession, is similar. However, there is a statistically significant decrease in the incidence of retinal hemorrhages in abusive head trauma when comparing identified perpetrators to non-identified perpetrators. This decreased incidence of retinal hemorrhages was statistically correlated to a lower incidence of acute presentation in victims of abusive head trauma without an identified perpetrator.[J Pediatr Ophthalmol Strabismus 2013;50(3):169-172.].
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Affiliation(s)
- Majida A Gaffar
- Department of North Shore-Long Island Jewish Health Systems, Hofstra North Shore-LIJ School of Medicine at Hofstra University, -Long Island Jewish Health Systems, Great Neck, NY 11021, USA.
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Abstract
PURPOSE OF REVIEW This review is designed to update the general pediatrician with information about current child maltreatment literature. The authors have selected salient articles, which inform daily practice of any professional involved in the care of children who may be at risk of child abuse. RECENT FINDINGS The field of child abuse pediatrics continues to engender controversy in both medical journals and courtrooms. As scrutiny about the basis for the diagnosis increases, clinicians and researchers work to build a solid base of scientific evidence with thorough and well-designed studies. This is most evident with regards to abusive head trauma, wherein both lay and scientific press challenge the possibility that infants can be severely injured or killed by shaking, blunt force trauma, or both. SUMMARY Child abuse pediatrics is a well-established and credible medical field. Although child physical and sexual abuse are age-old problems, public acknowledgement and intervention models are relatively new, and medical literature continues to reflect an increasing and deeper understanding of the impact of abuse throughout the world.
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Abstract
Abusive head trauma is a significant and tragic cause of morbidity and mortality in infants and its victims often have a poor prognosis. With such high rates of morbidity and mortality, health care providers and parents are often faced with the decision to continue or discontinue life support for an affected child. Sadly, however, this decision becomes complicated when parents are accused of causing the victim-child's current state. In this situation, if life support is withdrawn, criminal charges for the accused may escalate from assault to murder. This escalation of legal charges creates a conflict of interest for accused parents. As a result, parents have a strong incentive to avoid murder charges by using their parental decision-making rights to keep the child alive, even when treatment is deemed futile or inhumane. In this article, we discuss the legal challenges health care providers may face when parents place their interest above their child's. We also propose solutions that give greater deference to the rights and interest of these critically ill children while still preserving protected parental rights.
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