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Crumm CE, Brown ECB, Uspal NG, Caglar D, von Saint Andre-von Arnim A, Barry D, Hartford EA. A Study of Skeletal Survey Disparity in Pediatric Head Injury in the Emergency Department. CHILD MALTREATMENT 2024:10775595241282321. [PMID: 39288188 DOI: 10.1177/10775595241282321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
The objective of this study was to evaluate disparities in skeletal survey (SS) use for pediatric. head injury patients in the emergency department (ED). This was a multi-site retrospective. cohort study of children <24 months with concern for head injury and injury on head CT from. 7/1/12 - 1/1/22. We determined adjusted associations between SS completion and race, ethnicity, language for care, insurance type, and income, with sub-analysis of children <6 months and with complex injury. We evaluated occult fracture prevalence. Two-hundred seventy children met criteria and 88 had SS. No statistical association was found between skeletal survey completion and race or ethnicity, language for care, private insurance, median census tract income, or in sub-analyses. Two of 88 (2.3%) patients had occult fracture; both had risk factors for NAT. In conclusion, no statistical association was found between SS completion and demographics. Occult fracture was uncommon. SS use can likely be decreased in lower risk patients.
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Affiliation(s)
- Caitlin E Crumm
- Department of Emergency Medicine, Seattle Children's, Seattle, WA, USA
- Department of Pediatrics, Seattle Children's, Seattle, WA, USA
| | - Emily C B Brown
- Department of Pediatrics, Seattle Children's, Seattle, WA, USA
| | - Neil G Uspal
- Department of Emergency Medicine, Seattle Children's, Seattle, WA, USA
| | - Derya Caglar
- Department of Emergency Medicine, Seattle Children's, Seattle, WA, USA
| | | | - Dwight Barry
- Seattle Children's Research Institute, Seattle Children's, Seattle, WA, USA
| | - Emily A Hartford
- Department of Emergency Medicine, Seattle Children's, Seattle, WA, USA
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Held S, Cheseaux JJ, Tolsa JF, Depallens S. Prosecuting cases of abusive head trauma in Switzerland: a descriptive study of the impact of medical documentation and delay of reporting on judicial outcome. Int J Legal Med 2024; 138:1645-1651. [PMID: 38546867 PMCID: PMC11164792 DOI: 10.1007/s00414-024-03212-4] [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] [Received: 10/11/2023] [Accepted: 03/13/2024] [Indexed: 06/12/2024]
Abstract
Abusive head trauma (AHT) is a criminal offence that is prosecuted ex officio, following report to the police from physicians or child protection services. The aim of this study was to assess whether the judicial outcome (dismissal vs indictment) was influenced by the quality of the medical documentation and/or the time span between AHT diagnosis and reporting child abuse to the police. The cohort was divided in two groups: 13/23 dismissals (57%) and 10/23 indictments (43%). The diagnostic probability of the AHT cases was certain for both groups. Nonetheless, in fraction of dismissed cases, alternative explanations for the observed lesions seemed plausible to the public prosecutor. Legal files of only 3/12 dismissed cases had a forensic report, while 6/10 cases that were indicted included a forensic report. Further, the legal file of several dismissed cases entirely lacked medical documentation (3/12), which was not the cases for indicted cases. The period between AHT diagnosis and reporting to the police was not different for dismissals (29 ± 19 days) and indictments (7 ± 4 days) (p = 0.32). Physicians filed reports more rapidly (6 ± 1 days) compared to childhood protection service (70 ± 46 days) (p = 0.01) and that may increase the rate of indictments (9/18) compared to reporting via the childhood protection service (1/5). Despite diagnostic certainty, other causes for the lesions were considered as plausible alternative explanations to judicial professionals in several dismissed cases. These seemed to have less medical documentation and forensic evaluations. In addition, more rapid reporting to the police by physicians seems to increase the likelihood of indictments.
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Affiliation(s)
- Sarah Held
- Faculté de Biologie Et de Médecine, UNIL, Lausanne, Switzerland.
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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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Yock-Corrales A, Lee JH, Domínguez-Rojas JÁ, Caporal P, Roa JD, Fernandez-Sarmiento J, González-Dambrauskas S, Zhu Y, Abbas Q, Kazzaz Y, Dewi DS, Chong SL. A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma. J Pediatr Surg 2024; 59:494-499. [PMID: 37867044 DOI: 10.1016/j.jpedsurg.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT. METHODS We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT. RESULTS 47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT. CONCLUSIONS AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT. TYPE OF STUDY Observational cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adriana Yock-Corrales
- Emergency Department.Hospital Nacional de Niños ¨Dr. Carlos Sáenz Herrera. CCSS San José, Costa Rica.
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital. Singapore
| | | | - Paula Caporal
- Hospital Interzonal Especializado en Pediatría "Sor María Ludovica", Buenos Aires, Argentina
| | - Juan D Roa
- Fundación Homi, Universidad Nacional de Colombia - FUCS, Bogotá, Colombia
| | - Jaime Fernandez-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana. Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República Montevideo, Uruguay
| | - Yanan Zhu
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation. Singapore
| | - Qalab Abbas
- Department of Paediatrics and Child Health Aga Khan University Karachi Pakistan Karachi, Karachi City, Sindh, Pakistan
| | - Yasser Kazzaz
- Department of Paediatrics, Ministry of National Guards Health Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre Riyadh, Saudi Arabia
| | - Dianna Sri Dewi
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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Doswell A, Killough E, Zinkus TP, Sherman A, Anderst J. Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury. CHILD ABUSE & NEGLECT 2023; 144:106371. [PMID: 37536244 DOI: 10.1016/j.chiabu.2023.106371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists. OBJECTIVES To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs). PARTICIPANTS AND SETTING Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career. METHODS This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons. RESULTS There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example. CONCLUSIONS Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.
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Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - Emily Killough
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Timothy P Zinkus
- Division of Pediatric Radiology, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, University of Kansas School of Medicine, Saint Louis University School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Ashley Sherman
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
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Mullen JE. Recognizing Child Abuse. AACN Adv Crit Care 2023; 34:240-245. [PMID: 37644630 DOI: 10.4037/aacnacc2023779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Jodi E Mullen
- Jodi E. Mullen is Senior Quality Improvement Specialist, Department of Clinical Quality and Patient Safety, UF Health Shands Hospital, 3300 SW Williston Rd, Gainesville, FL 32608
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Naik-Mathuria B, Johnson BL, Todd HF, Donaruma-Kwoh M, Bachim A, Rubalcava D, Vogel AM, Chen L, Escobar MA. Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department. J Pediatr Surg 2023; 58:1789-1795. [PMID: 36841704 DOI: 10.1016/j.jpedsurg.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/11/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk. METHODS A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data. RESULTS Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211). CONCLUSION The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bindi Naik-Mathuria
- Department of Surgery, Division of Pediatric Surgery, University of Texas Medical Branch, Galveston, TX, USA.
| | - Brittany L Johnson
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Hannah F Todd
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Marcella Donaruma-Kwoh
- Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Angela Bachim
- Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Rubalcava
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital Baylor College of Medicine, Houston, TX, USA
| | - Adam M Vogel
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Liang Chen
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Mauricio A Escobar
- Department of Pediatric Surgery and Pediatric Trauma, Mary Bridge Children's Hospital, Tacoma, WA, USA
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Knappstein J, Reed PW, Kelly P. ICD-10 codes for surveillance of non-fatal abusive head trauma in Aotearoa New Zealand: a retrospective cohort study. BMJ Open 2023; 13:e069199. [PMID: 37277218 DOI: 10.1136/bmjopen-2022-069199] [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] [Indexed: 06/07/2023] Open
Abstract
OBJECTIVES To assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New Zealand. DESIGN A retrospective cohort study of hospital inpatient records. SETTING A tertiary children's hospital in Auckland, New Zealand. PARTICIPANTS 1731 children less than 5 years of age who were discharged after a non-fatal head trauma event over a 10-year period from 1 January 2010 to 31 December 2019. OUTCOME MEASURES The outcome of assessment by the hospital's multidisciplinary child protection team (CPT) was compared with the outcome of ICD, Tenth Revision (ICD-10) discharge coding for non-fatal abusive head trauma (AHT). The ICD-10 code definition of AHT was derived from an ICD, Ninth Revision, Clinical Modification definition developed by the Centers for Disease Control, Atlanta, Georgia, which requires both a clinical diagnosis code and a cause-of-injury code. RESULTS There were 1755 head trauma events with 117 determined as AHT by the CPT. The ICD-10 code definition had a sensitivity of 66.7% (95% CI 57.4 to 75.1) and specificity of 99.8% (95% CI 99.5 to 100). There were only three false positives but 39 false negatives, with 18 of the false negatives coded with X59 (exposure to unspecified factor). CONCLUSIONS The ICD-10 code broad definition of AHT is a reasonable epidemiological tool for passive surveillance of AHT in New Zealand but it underestimates the incidence. Its performance could be improved by clear documentation of child protection conclusions in clinical notes, clarifying coding practice and removing the exclusion criteria from the definition.
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Affiliation(s)
- Joanne Knappstein
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Te Toka Tumai, Te Whatu Ora, Health New Zealand, Auckland, New Zealand
- Department of Paediatrics, Hauora a Toi Bay of Plenty, Te Whatu Ora, Health New Zealand, Tauranga, New Zealand
| | | | - Patrick Kelly
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Te Toka Tumai, Te Whatu Ora, Health New Zealand, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
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Raissaki M, Adamsbaum C, Argyropoulou MI, Choudhary AK, Jeanes A, Mankad K, Mannes I, Van Rijn RR, Offiah AC. Benign enlargement of the subarachnoid spaces and subdural collections-when to evaluate for abuse. Pediatr Radiol 2023; 53:752-767. [PMID: 36856756 PMCID: PMC10027800 DOI: 10.1007/s00247-023-05611-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 03/02/2023]
Abstract
In infants without a history of trauma, subdural haemorrhages should raise the concern for an abusive head injury, particularly when they are associated with bridging vein clotting/rupture or with septations. However, non-haemorrhagic, fluid-appearing subdural collections (also called hygromas) may also be the result of abuse. Subdural collections have also been uncommonly observed in patients with benign enlargement of the subarachnoid spaces (BESS) and a few large-scale studies accurately investigate the incidence and the significance. Currently, there is a wide variation of practices in children with BESS and subdural collections. Due to the social risks associated with abuse evaluation and the perceived risk of radiation exposure, there might be a reluctance to fully evaluate these children in some centres. The diagnosis of physical abuse cannot be substantiated nor safely excluded in infants with BESS and subdural collection(s), without investigation for concomitant traumatic findings. The exact prevalence of occult injuries and abuse in these infants is unknown. In macrocephalic infants with subdural collections and imaging features of BESS, thorough investigations for abuse are warranted and paediatricians should consider performing full skeletal surveys even when fundoscopy, social work consult, and detailed clinical evaluation are unremarkable.
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Affiliation(s)
- Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece.
| | - Catherine Adamsbaum
- Emeritus Pediatric Radiologist, Faculty of Medicine, Paris-Saclay University, 63 Rue Gabriel Péri, 94270, Le Kremlin Bicêtre, France
| | - Maria I Argyropoulou
- Department of Clinical Radiology and Imaging, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Arabinda K Choudhary
- Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Inès Mannes
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin‑Bicêtre, France
| | - Rick R Van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
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El Beltagy MA, Elbaroody M. The diagnosis and management of abusive head injuries in infancy in Egypt. Childs Nerv Syst 2022; 38:2365-2369. [PMID: 36588129 DOI: 10.1007/s00381-022-05806-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/14/2022] [Indexed: 01/03/2023]
Abstract
Child death owed to abuse and negligence is not uncommon, and its real incidence is unknown. The most common cause of fatal child abuse is head trauma. Abusive head injuries (AHI) most often involve brain injury of infants and young children. The outcomes of AHI vary from complete recovery to severe brain damage and death. This article highlights the diagnosis and management of AHI in infancy in Egypt, with a special focus on the social, medical, and legal aspects. The authors emphasize the importance of reporting cases suspected of AHI to the relevant authorities; this will guard against the recurrence of abuse to the child and will have a positive impact on the community.
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Affiliation(s)
- Mohamed A El Beltagy
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt.
- Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt.
| | - Mohammad Elbaroody
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
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11
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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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12
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Even KM, Hymel KP, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Liang M, Wang M. The association of subcortical brain injury and abusive head trauma. CHILD ABUSE & NEGLECT 2022; 134:105917. [PMID: 36308893 DOI: 10.1016/j.chiabu.2022.105917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) remains a major pediatric problem with diagnostic challenges. A small pilot study previously associated subcortical brain injury with AHT. OBJECTIVES To investigate the association of subcortical injury on neuroimaging with the diagnosis of AHT. PARTICIPANTS AND SETTING Children <3 years with acute TBI admitted to 18 PICUs between 2011 and 2021. METHODS Secondary analysis of existing, combined, de-identified, cross-sectional dataset. RESULTS Deepest location of visible injury was characterized as scalp/skull/epidural (n = 170), subarachnoid/subdural (n = 386), cortical brain (n = 170), or subcortical brain (n = 247) (total n = 973). Subcortical injury was significantly associated with AHT using both physicians' diagnostic impression (OR: 8.41 [95 % CI: 5.82-12.44]) and a priori definitional criteria (OR: 5.99 [95 % CI: 4.31-8.43]). Caregiver reports consistent with the child's gross motor skills and historically consistent with repetition decreased as deepest location of injury increased, p < 0.001. Patients with subcortical injuries were significantly more likely to have traumatic extracranial injuries such as rib fractures (OR 3.36, 95 % CI 2.30-4.92) or retinal hemorrhages (OR 5.97, 95 % CI 4.35-8.24), respiratory compromise (OR 12.12, 95 % CI 8.49-17.62), circulatory compromise (OR 6.71, 95 % CI 4.87-9.29), seizures (OR 3.18, 95 % CI 2.35-4.29), and acute encephalopathy (OR 12.44, 95 % CI 8.16-19.68). CONCLUSIONS Subcortical injury is associated with a diagnosis of AHT, historical inaccuracies concerning for abuse, traumatic extracranial injuries, and increased severity of illness including respiratory and circulatory compromise, seizures, and prolonged loss of consciousness. Presence of subcortical injury should be considered as one component of the complex AHT diagnostic process.
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Affiliation(s)
- Katelyn M Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Menglu Liang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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13
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Hemophilia and non-accidental head trauma in two siblings: lessons and legal implications. Childs Nerv Syst 2022; 38:2415-2423. [PMID: 36303077 DOI: 10.1007/s00381-022-05713-2] [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: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 11/03/2022]
Abstract
Non-accidental head trauma (NAHT) is a common cause of traumatic brain injury in childhood, origin of profound and disabling neurological sequalae, and in the most disgraceful cases, ultimately death.Subdural hematoma (SDH) is the most common intracranial finding in NAHT. On the other hand, congenital bleeding disorders are a minor but a significant cause of ICH in the neonate and toddler. Not uncommonly, intracranial bleeding is the first sign of a severe inherited coagulation disorder. In the presence of an unexpected intracranial bleeding after a minor trauma or without a clear history of the related events, physicians and caregivers may be confronted to the dilemma of a possible child abuse. It must be bear in mind that physical abuse and bleeding disorders can co-exist in the same child.We report here the case of two siblings in whom a diagnosis of hemophilia coexisted with the presumption of a non-accidental head trauma. Child abuses were inflicted in both children with a spare time of 2 years. A diagnosis of mild hemophilia was prompted in the first sibling after initial NAHT, while inflicted trauma was evident in the second sibling after neuroimaging findings and concomitant lesions. Lessons from this case in co-existing bleeding disorders and inflicted trauma and legal implications derived will be discussed thereafter.The possibility of a bleeding disorder should be considered in all children presenting with unexplained bleeding at a critical site in the setting of suspected physical maltreatment, particularly intracranial hemorrhage (ICH).
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14
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Carpenter SL, Abshire TC, Killough E, Anderst JD. Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding. Pediatrics 2022; 150:189508. [PMID: 36120799 DOI: 10.1542/peds.2022-059277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising or bleeding and should be considered when evaluating for abusive injury.
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Affiliation(s)
- Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CTSI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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15
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Hymel KP, Boos SC, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Even K, Wang M. An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma. CHILD ABUSE & NEGLECT 2022; 129:105666. [PMID: 35567958 PMCID: PMC10724711 DOI: 10.1016/j.chiabu.2022.105666] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms. OBJECTIVES To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT. PARTICIPANTS AND SETTING Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021. METHODS Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values. RESULTS Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96. CONCLUSIONS The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Stephen C Boos
- Department of Pediatrics, UMass Chan Medical School-Baystate Health, 759 Chestnut Street, Springfield, MA 01199, USA.
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Katelyn Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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16
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Eysenbach L, Leventhal JM, Gaither JR, Bechtel K. Circumstances of injury in children with abusive versus non-abusive injuries. CHILD ABUSE & NEGLECT 2022; 128:105604. [PMID: 35339797 DOI: 10.1016/j.chiabu.2022.105604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Although previous studies have examined differences in the characteristics of abusive versus non-abusive injuries, no study has focused on the differences in the circumstances surrounding these injuries, such as whether the event that caused the injury was witnessed or heard, or EMS was called. OBJECTIVE To determine predictors related to the circumstances of the injury (COI) for distinguishing abusive versus non-abusive injuries. PARTICIPANTS/SETTING Children younger than 3-years-old who were hospitalized with either a head injury or a fracture and evaluated by the child abuse consultation service between June 1, 2008 and June 30, 2017. METHODS In this case-control study, abusive (cases) and non-abusive (controls) injuries were determined by a consensus of two experts blinded to the COI. Multivariable logistic regression was used to identify COI predictors of abusive injuries. RESULTS We identified 302 children: 80 cases (26.5%) and 222 controls (73.5%). Abused children were less likely to have a clear event described (p < .001). Of the 251 with a clear event, we found that the significant variables for abuse were father's presence (adjusted odds ratio [aOR] 8.37; 95% CI 3.35-20.92), delay ≥24 h in seeking care (aOR 6.23; 95% CI 1.95-19.92) and calling EMS (aOR 3.21; 95% CI 1.10-9.36). In contrast, the event being heard (aOR 0.22; 95% CI 0.08-0.0.59) and the child being dropped (aOR 0.09; 95% CI 0.01-0.77) were less likely to be abusive. CONCLUSION We identified five COI predictors that may help clinicians in determining whether a child's injuries are due to abuse.
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Affiliation(s)
- Lindsay Eysenbach
- University of Washington Affiliated Hospitals, United States of America
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17
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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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18
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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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19
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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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20
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Hymel KP, Karst W, Marinello M, Herman BE, Frazier TN, Carroll CL, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Pashai A, Wang M. Screening for pediatric abusive head trauma: Are three variables enough? CHILD ABUSE & NEGLECT 2022; 125:105518. [PMID: 35082111 PMCID: PMC8842560 DOI: 10.1016/j.chiabu.2022.105518] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND The PediBIRN 4-variable clinical decision rule (CDR) detects abusive head trauma (AHT) with 96% sensitivity in pediatric intensive care (PICU) settings. Preliminary analysis of its performance in Pediatric Emergency Department settings found that elimination of its fourth predictor variable enhanced screening accuracy. OBJECTIVE To compare the AHT screening performances of the "PediBIRN-4" CDR vs. the simplified 3-variable CDR in PICU settings. PARTICIPANTS AND SETTINGS 973 acutely head-injured children <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. METHODS Retrospective, secondary analysis of the combined, prospective PediBIRN data sets. AHT definitional criteria and physicians' diagnoses were applied iteratively to sort patients into abusive vs. other head trauma cohorts. Outcome measures of CDR performance included sensitivity, specificity, predictive values, likelihood ratios, ROC AUC, and the correlation between each CDR's patient-specific estimates of AHT probability and the overall positive yield of patients' completed abuse evaluations. RESULTS Applied accurately and consistently, both CDR's would have performed with sensitivity ≥93% and negative predictive value ≥91%. Eliminating the PediBIRN-4's fourth predictor variable resulted in significantly higher specificity (↑'d ≥19%), positive predictive value (↑'d ≥8%), and ROC AUC (↑'d ≥5%), but a 3% reduction in sensitivity. Both CDRs provided patient-specific estimates of abuse probability very strongly correlated with the positive yield of patients' completed abuse evaluations (Pearson's r = 0.95 and 0.91, p = .13). CONCLUSION The PediBIRN 3-variable CDR performed with greater AHT screening accuracy than the 4-variable CDR. Both are good predictors of the results of patients' subsequent completed abuse evaluations.
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Wouter Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, PO Box 24044, 2490, AA, The Hague, the Netherlands
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Afshin Pashai
- Department of Health Administration and Policy, George Mason University, 4400 University Drive, Fairfax, VA 22030, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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21
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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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22
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Wongkittichote P, Kondis JS, Peglar LM, Strahle JM, Miller-Thomas M, Abell KB. Pathogenic variant in NFIA associated with subdural hematomas mimicking nonaccidental trauma. Am J Med Genet A 2022; 188:1538-1544. [PMID: 35006644 DOI: 10.1002/ajmg.a.62647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/18/2021] [Accepted: 12/26/2021] [Indexed: 11/09/2022]
Abstract
Subdural hematoma (SDH) in infants raises the concern for nonaccidental trauma (NAT), especially when presenting with associated injuries. However, isolated SDH could be caused by multiple etiologies. NFIA (MIM# 600727) encodes nuclear factor I A protein (NFI-A), a transcription factor which plays important roles in gliogenesis. Loss-of-function variants in NFIA are associated with autosomal dominant brain malformations with or without urinary tract defects (MIM# 613735). Intracranial hemorrhage of various types besides SDH has been reported in patients with this condition. Here, we report a patient with a heterozygous novel NFIA pathogenic variant affecting splicing who initially presented with SDH concerning for NAT. We also review previous NFIA-related disorder cases with intracranial hemorrhage. This report emphasizes the importance of genetic evaluation in infants presenting with isolated SDH.
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Affiliation(s)
- Parith Wongkittichote
- Division of Genetics and Genomic Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jamie S Kondis
- Child Abuse Pediatrics, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lindsay M Peglar
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Michelle Miller-Thomas
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Katherine B Abell
- Division of Genetics and Genomic Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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23
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Boos SC, Wang M, Karst WA, Hymel KP. Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis. Pediatrics 2022; 149:183816. [PMID: 34890450 PMCID: PMC9645685 DOI: 10.1542/peds.2021-051742] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Data guiding abusive head trauma (AHT) diagnosis rest on case-control studies that have been criticized for circularity. We wished to sort children with neurologic injury using mathematical algorithms, without reference to physicians' diagnoses or predetermined diagnostic criteria, and to compare the results to existing AHT data, physicians' diagnoses, and a proposed triad of findings. METHODS Unsupervised cluster analysis of an existing data set regarding 500 young patients with acute head injury hospitalized for intensive care. Three cluster algorithms were used to sort (partition) patients into subpopulations (clusters) on the basis of 32 reliable (κ > 0.6) clinical and radiologic variables. P values and odds ratios (ORs) identified variables most predictive of partitioning. RESULTS The full cohort partitioned into 2 clusters. Variables substantially (P < .001 and OR > 10 in all 3 cluster algorithms) more prevalent in cluster 1 were imaging indications of brain hypoxemia, ischemia, and/or swelling; acute encephalopathy, particularly when lasting >24 hours; respiratory compromise; subdural hemorrhage or fluid collection; and ophthalmologist-confirmed retinoschisis. Variables substantially (P < .001 and OR < 0.10 in any cluster algorithm) more prevalent in cluster 2 were linear parietal skull fracture and epidural hematoma. Postpartitioning analysis revealed that cluster 1 had a high prevalence of physician-diagnosed abuse. CONCLUSIONS Three cluster algorithms partitioned the population into 2 clusters without reference to predetermined diagnostic criteria or clinical opinion about the nature of AHT. Clinical difference between clusters replicated differences previously described in comparisons of AHT with non-AHT. Algorithmic partition was predictive of physician diagnosis and of the triad of findings heavily discussed in AHT literature.
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Affiliation(s)
- Stephen C. Boos
- Department of Pediatrics, University of Massachusetts Chan Medical School—Baystate, Baystate Medical Center, Springfield, Massachusetts,Address correspondence to Stephen C. Boos, MD, Baystate Medical Center, Family Advocacy Center, 300 Carew St, Springfield, MA 01199. E-mail:
| | - Ming Wang
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Wouter A. Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, Netherlands
| | - Kent P. Hymel
- Department of Pediatrics, College of Medicine, Pennsylvania State University and Penn State Health Children’s Hospital, Hershey, Pennsylvania
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24
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Abstract
OBJECTIVES Abusive head trauma (AHT) is the leading cause of death from trauma in children less than 2 years of age. A delay in presentation for care has been reported as a risk factor for abuse; however, there has been limited research on this topic. We compare children diagnosed with AHT to children diagnosed with accidental head trauma to determine if there is a delay in presentation. METHODS We retrospectively studied children less than 6 years old who had acute head injury and were admitted to the pediatric intensive care unit at a pediatric hospital from 2013 to 2017. Cases were reviewed to determine the duration from symptom onset to presentation to care and the nature of the head injury (abusive vs accidental). RESULTS A total of 59 children met inclusion criteria. Patients who had AHT were significantly more likely to present to care more than 30 minutes after symptom onset (P = 0.0015). Children who had AHT were more likely to be younger (median, 4 vs 31 months; P < 0.0001) and receive Medicaid (P < 0.0001) than those who had accidental head trauma. Patients who had AHT were more likely to have a longer length of stay (median, 11 vs 3 days; P < 0.0001) and were less likely to be discharged home than patients who had accidental head trauma (38% vs 84%; P = 0.0005). CONCLUSIONS Children who had AHT were more likely to have a delayed presentation for care as compared with children whose head trauma was accidental. A delay in care should prompt clinicians to strongly consider a workup for abusive injury.
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Affiliation(s)
| | | | | | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
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Vinchon M, Karnoub MA, Noulé N, Lampin ME. Confessed versus denied inflicted head injuries in infants: similarities and differences. Childs Nerv Syst 2022; 38:147-152. [PMID: 34608530 DOI: 10.1007/s00381-021-05381-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Abusive head injuries (AHI), and in particular shaken baby syndrome (SBS), are common causes of mortality and morbidity in infants. Although SBS is a well-established entity, based on clinical experience and experimental data, and confirmed by the perpetrators' confessions, a growing number of publications challenge the diagnostic criteria, and even the validity of the perpetrators' confession. We decided to study AHI in infants and compare cases with and without confession. MATERIAL AND METHODS We collected prospectively all cases of infantile traumatic head injuries hospitalized in our institution between 2001 and 2021. From this database, we selected victims of AHI, comparing cases for which the perpetrator confessed during police inquiry ("confession" group) versus cases without confession ("denial" group). RESULTS We studied 350 cases of AHI in infants; 137 of these (39.1%) were confessed. We found no statistically significant difference between the two groups regarding the child's previous history, as well as the personality and previous history of the caretakers. However, the "confession" group showed significantly more severe clinical presentation, cerebral lesions, retinal hemorrhages, and a more pejorative outcome. CONCLUSIONS We conclude that the diagnosis of AHI was confirmed by the confession in a large number of cases, indicating that the diagnostic criteria of AHI are robust. We also found that denial, although possibly sincere, was likely ill-founded, and that the perpetrators' decision to confess or deny was markedly influenced by the severity of the inflicted lesions.
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Affiliation(s)
- Matthieu Vinchon
- Department of Pediatric Neurosurgery, Lille University Hospital, Lille, France.
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George CL, Harper NS. Computer Algorithms Support Physician Decisions in Traumatic Head Injury. Pediatrics 2022; 149:183817. [PMID: 34890452 PMCID: PMC9645695 DOI: 10.1542/peds.2021-054009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Caroline L.S. George
- Address correspondence to Caroline L.S. George, MD, Otto Bremer Trust Center for Safe and Healthy Children, University of Minnesota, 2512 S 7th St, Suite R107, Minneapolis, MN 55454. E-mail:
| | - Nancy S. Harper
- Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children’s Hospital, Minneapolis
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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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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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Hymel KP, Armijo-Garcia V, Musick M, Marinello M, Herman BE, Weeks K, Haney SB, Frazier TN, Carroll CL, Kissoon NN, Isaac R, Foster R, Campbell KA, Tieves KS, Livingston N, Bucher A, Woosley MC, Escamilla-Padilla D, Jaimon N, Kustka L, Wang M, Chinchilli VM, Dias MS, Noll J. A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings. J Pediatr 2021; 236:260-268.e3. [PMID: 33798512 PMCID: PMC8403132 DOI: 10.1016/j.jpeds.2021.03.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22). CONCLUSIONS PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT03162354.
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Affiliation(s)
- Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | | | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Mark Marinello
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Suzanne B. Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Terra N. Frazier
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Natalie N. Kissoon
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Reena Isaac
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Robin Foster
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Kristine A. Campbell
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kelly S. Tieves
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Nina Livingston
- Department of Pediatrics, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Ashley Bucher
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Maria C. Woosley
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | | | - Nancy Jaimon
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Lucinda Kustka
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Mark S. Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jennie Noll
- Department of Human Development and Family Studies, Penn State University, State College, Pennsylvania
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Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol 2021; 51:853-860. [PMID: 33999229 DOI: 10.1007/s00247-020-04864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
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Affiliation(s)
- Colleen E Bennett
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Cindy W Christian
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Maiese A, Iannaccone F, Scatena A, Del Fante Z, Oliva A, Frati P, Fineschi V. Pediatric Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11040734. [PMID: 33924220 PMCID: PMC8074611 DOI: 10.3390/diagnostics11040734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023] Open
Abstract
Abusive head trauma (AHT) represents a commonly misdiagnosed condition. In fact, there is no pathognomonic sign that allows the diagnosis in children. Therefore, it is such an important medico-legal challenge to evaluate reliable diagnostic tools. The aim of this review is to evaluate the current scientific evidence to assess what the best practice is in order to diagnose AHT. We have focused particularly on evaluating the importance of circumstantial evidence, clinical history, the use of postmortem radiological examinations (such as CT and MRI), and the performance of the autopsy. After autopsy, histological examination of the eye and brain play an important role, with attention paid to correlation with symptoms found in vivo.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
| | - Francesca Iannaccone
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Andrea Scatena
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Zoe Del Fante
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, 00100 Rome, Italy;
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
- Correspondence: ; Tel.: +39-064-991-2722
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Amagasa S, Uematsu S, Tsuji S. Occurrence of traumatic brain injury due to short falls with or without a witness by a nonrelative in children younger than 2 years. J Neurosurg Pediatr 2020; 26:696-700. [PMID: 32916651 DOI: 10.3171/2020.6.peds20314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is disagreement about the occurrence of severe traumatic brain injury, especially subdural hematoma, caused by short falls in very young children. To verify intracranial injury due to these falls and examine its characteristics, the authors compared infants and toddlers with head trauma witnessed by a nonrelative with those whose injuries were not witnessed by a nonrelative. METHODS The authors retrospectively reviewed clinical records of children younger than 2 years with head trauma due to a short fall who visited the emergency department of the National Center for Child Health and Development in Japan between April 2015 and March 2018. Patients were classified into two groups: falls that were witnessed by a nonrelative and falls not witnessed by a nonrelative. The authors compared the age in months, sex, mechanism of injury, fall height, prevalence rate of intracranial injury, skull fracture, type of traumatic brain injury, retinal hemorrhage, rib or long-bone fracture, and outcomes between patients whose fall was witnessed by a nonrelative and those whose fall was not witnessed by a nonrelative. RESULTS Among 1494 patients included in the present analysis, 392 patients were classified into the group of falls witnessed by a nonrelative, and 1102 patients were classified into the group of falls that were not witnessed by a nonrelative. The prevalence rates of intracranial injury, skull fracture, epidural hematoma, and subarachnoid hemorrhage were equal between the groups. The prevalence rate of subdural hematoma in the group whose falls were witnessed by a nonrelative was significantly lower than that of the other group (p = 0.027). There were no patients with subdural hematoma, retinal hemorrhage, or neurological sequelae in the group whose fall was witnessed by a nonrelative. CONCLUSIONS Subdural hematoma, retinal hemorrhage, and neurological sequelae due to short falls were not seen after witnessed falls in the present study.
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Thiblin I, Andersson J, Wester K, Wikström J, Högberg G, Högberg U. Medical findings and symptoms in infants exposed to witnessed or admitted abusive shaking: A nationwide registry study. PLoS One 2020; 15:e0240182. [PMID: 33048994 PMCID: PMC7553301 DOI: 10.1371/journal.pone.0240182] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/11/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high. METHODS Infants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions. RESULTS All identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma. CONCLUSIONS The present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors.
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Affiliation(s)
- Ingemar Thiblin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jacob Andersson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - Johan Wikström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Ulf Högberg
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Martinkevich P, Larsen LL, Græsholt-Knudsen T, Hesthaven G, Hellfritzsch MB, Petersen KK, Møller-Madsen B, Rölfing JD. Physical child abuse demands increased awareness during health and socioeconomic crises like COVID-19. Acta Orthop 2020; 91:527-533. [PMID: 32573297 PMCID: PMC8023935 DOI: 10.1080/17453674.2020.1782012] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation.Methods - We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities.Results - Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016.Interpretation - The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.
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Affiliation(s)
- Polina Martinkevich
- Department of Orthopaedics, Aarhus University Hospital
- Danish Paediatric Orthopaedic Research
| | - Lise Langeland Larsen
- Department of Orthopaedics, Aarhus University Hospital
- Danish Paediatric Orthopaedic Research
| | | | | | | | | | - Bjarne Møller-Madsen
- Department of Orthopaedics, Aarhus University Hospital
- Danish Paediatric Orthopaedic Research
- Department of Clinical Medicine, Aarhus University
| | - Jan Duedal Rölfing
- Department of Orthopaedics, Aarhus University Hospital
- Danish Paediatric Orthopaedic Research
- Department of Clinical Medicine, Aarhus University
- Corporate HR, MidtSim, Central Denmark Region, Denmark
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Henry MK, Lindberg DM, Wood JN. More data, more questions: No simple answer about which children should undergo screening neuroimaging for clinically occult abusive head trauma. CHILD ABUSE & NEGLECT 2020; 107:104561. [PMID: 32544698 DOI: 10.1016/j.chiabu.2020.104561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 06/11/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal child physical abuse. Victims may initially present with clinically occult AHT without overt signs of head trauma or with only subtle, nonspecific symptoms, which can make timely recognition of AHT challenging. Research has shown missed opportunities for early detection of AHT in the medical setting are common and can lead to repeated injury. Neuroimaging is needed to diagnose clinically occult AHT but is not without risk. Researchers have worked to understand the yield of neuroimaging in detection of clinically occult AHT and to identify risk factors, yet findings have varied widely across studies. Identifying which children undergoing physical abuse evaluations are at highest risk of clinically occult AHT is key to development of evidence-based imaging decision support tools for clinicians. Here we discuss the recent literature, identify potential reasons for variation across studies, and offer opportunities for future research.
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Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine. 12401 E. 17th Ave., Aurora, CO 80238, United States; The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave., Aurora, CO 80238, United States
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; PolicyLab, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States
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Cowley LE, Pfeiffer H, Babl F, Kemp AM. In reply: Predicting abusive head trauma. Emerg Med J 2020; 37:388-389. [PMID: 32253196 DOI: 10.1136/emermed-2020-209657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | - Helena Pfeiffer
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
- Emergency Medicine, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Franz Babl
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Alison Mary Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Abstract
Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.
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Affiliation(s)
- Sandeep K Narang
- Division of Child Abuse Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - Amanda Fingarson
- Division of Child Abuse Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - James Lukefahr
- Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Iqbal O'Meara AM, Sequeira J, Miller Ferguson N. Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature. Front Neurol 2020; 11:118. [PMID: 32153494 PMCID: PMC7044347 DOI: 10.3389/fneur.2020.00118] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Abstract
Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.
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Affiliation(s)
- A M Iqbal O'Meara
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Jake Sequeira
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
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Pfeiffer H, Cowley LE, Kemp AM, Dalziel SR, Smith A, Cheek JA, Borland ML, O'Brien S, Bonisch M, Neutze J, Oakley E, Crowe LM, Hearps S, Lyttle MD, Bressan S, Babl FE. Validation of the PredAHT-2 prediction tool for abusive head trauma. Emerg Med J 2020; 37:119-126. [PMID: 31932397 DOI: 10.1136/emermed-2019-208893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/22/2019] [Accepted: 12/12/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool calculates the probability of abusive head trauma (AHT) in children <3 years of age who have sustained intracranial injuries (ICIs) identified on neuroimaging, based on combinations of six clinical features: head/neck bruising, seizures, apnoea, rib fracture, long bone fracture and retinal haemorrhages. PredAHT version 2 enables a probability calculation when information regarding any of the six features is absent. We aimed to externally validate PredAHT-2 in an Australian/New Zealand population. METHODS This is a secondary analysis of a prospective multicentre study of paediatric head injuries conducted between April 2011 and November 2014. We extracted data on patients with possible AHT at five tertiary paediatric centres and included all children <3 years of age admitted to hospital who had sustained ICI identified on neuroimaging. We assigned cases as positive for AHT, negative for AHT or having indeterminate outcome following multidisciplinary review. The estimated probability of AHT for each case was calculated using PredAHT-2, blinded to outcome. Tool performance measures were calculated, with 95% CIs. RESULTS Of 87 ICI cases, 27 (31%) were positive for AHT; 45 (52%) were negative for AHT and 15 (17%) had indeterminate outcome. Using a probability cut-off of 50%, excluding indeterminate cases, PredAHT-2 had a sensitivity of 74% (95% CI 54% t o89%) and a specificity of 87% (95% CI 73% to 95%) for AHT. Positive predictive value was 77% (95% CI 56% to 91%), negative predictive value was 85% (95% CI 71% to 94%) and the area under the curve was 0.80 (95% CI 0.68 to 0.92). CONCLUSION PredAHT-2 demonstrated reasonably high point sensitivity and specificity when externally validated in an Australian/New Zealand population. Performance was similar to that in the original validation study. TRIAL REGISTRATION NUMBER ACTRN12614000463673.
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Affiliation(s)
- Helena Pfeiffer
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Laura Elizabeth Cowley
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Alison Mary Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Anne Smith
- Victorian Forensic Paediatric Medical Service, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John Alexander Cheek
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Meredith L Borland
- Department of Emergency Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Sharon O'Brien
- Department of Emergency Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Megan Bonisch
- Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Jocelyn Neutze
- Department of Emergency Medicine, Kidzfirst Middlemore Hospital, Otahuhu, New Zealand
| | - Ed Oakley
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Louise M Crowe
- Department of Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Stephen Hearps
- Department of Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Academic Department of Emergency Care, University of the West of England, Bristol, Avon, UK
| | - Silvia Bressan
- Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics and Child Health, University of Padova, Padova, Italy
| | - Franz E Babl
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia .,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
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Högberg U, Winbo J, Fellman V. Population-based register study of children born in Sweden from 1997 to 2014 showed an increase in rickets during infancy. Acta Paediatr 2019; 108:2034-2040. [PMID: 31050835 DOI: 10.1111/apa.14835] [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: 11/29/2018] [Revised: 04/27/2019] [Accepted: 04/29/2019] [Indexed: 01/18/2023]
Abstract
AIM This population-based study assessed the incidence of rickets in infants up to age of one born in Sweden from 1997 to 2014. We also examined maternal and perinatal factors and co-morbidity. METHODS We used Swedish National Board of Health and Welfare registers and data from Statistics Sweden. The outcome measure was an International Classification of Diseases, Tenth Revision, code for rickets. RESULTS There were 273 cases of rickets, with an incidence of 14.7 per 100 000 and a 10-fold incidence increase between 1997 and 2014. The majority (78.4%) were born preterm, half were small-for-gestational age (SGA) (birthweight <10th percentile), 4.8% were born to Asian-born mothers and 3.5% to African-born mothers. The adjusted odds ratios by birth week were 182 (95% CI: 121-272) before 32 weeks and 10.8 (95% CI: 6.72-17.4) by 32-36 weeks. Preterm infants with necrotising enterocolitis had very high odds for rickets and so did SGA term-born infants and those born to African-born mothers. The odds for rickets among preterm infants increased considerably during the later years. CONCLUSION Rickets increased 10-fold in Sweden from 1997 to 2014 and was mainly associated with prematurity, SGA and foreign-born mothers. Possible reasons may include increased preterm survival rates and improved clinical detection and registration.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Jenny Winbo
- Department of Gynaecology and Obstetrics Region Gävleborg Gävle Sweden
| | - Vineta Fellman
- Department of Clinical Sciences, Lund, Pediatrics Lund University Lund Sweden
- Children's Hospital University of Helsinki and Folkhälsan Research Center Helsinki Finland
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42
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Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr 2019; 24:481-488. [PMID: 31675688 DOI: 10.3171/2019.7.peds18394] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
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Affiliation(s)
- Ann-Christine Duhaime
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Cindy W Christian
- 2Department of Pediatrics, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Högberg U, Sennerstam R, Wester K, Högberg G, Andersson J, Thiblin I. Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study. Health Sci Rep 2019; 2:e133. [PMID: 31463369 PMCID: PMC6707026 DOI: 10.1002/hsr2.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/10/2019] [Accepted: 05/17/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND AIMS Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out-of-home care. The objective of this study was to analyse infants placed in out-of-home care in Sweden by incidence, medical diagnoses, and perinatal factors. METHODS This was a population-based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out-of-home care categories: (a) "Problems Related to Social Environment/Upbringing", (b) "Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture", and (c) "SDH, RH, rib fracture, or long bone fracture." As a reference population, we randomly selected infants without medical diagnoses born the same year. RESULTS Overall incidence of out-of-home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out-of-home care, children in category (c), "SDH, RH, rib fracture, or long bone fracture", had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08-2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32-0.75) and a smoker (aOR 0.60; 95% CI, 0.37-0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small-for-gestational age (5.2% versus 2.1%). CONCLUSION SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out-of-home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Roland Sennerstam
- Department of Oncology and Pathology, Cancer CenterKarolinska University Hospital and Karolinska InstitutetStockholmSweden
| | - Knut Wester
- Department of Clinical Medicine—K1University of BergenBergenNorway
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
| | - Göran Högberg
- Formerly Department of Women's and Children's Health, Child and Adolescent Psychiatric UnitKarolinska InstitutetStockholmSweden
| | - Jacob Andersson
- Forensic Medicine, Department of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Ingemar Thiblin
- Forensic Medicine, Department of Surgical SciencesUppsala UniversityUppsalaSweden
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Hwang SY, Ong JW, Ng ZM, Foo CY, Chua SZ, Sri D, Lee JH, Chong SL. Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study. Brain Inj 2019; 33:1420-1424. [PMID: 31314599 DOI: 10.1080/02699052.2019.1641625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Traumatic brain injury (TBI) is a significant cause of mortality and disability in the pediatric population. Non-accidental trauma (NAT) has specifically been reported to result in more severe injury as compared to accidental mechanisms of injury. We aim to investigate the long-term neurological outcomes in children with moderate to severe traumatic brain injury. Our secondary aim is to evaluate the difference in outcomes between children presenting with NAT and non-NAT, in our study population. We performed a retrospective study in a tertiary pediatric hospital between January 2008 to October 2017 of all patients with TBI <16 years old with a Glasgow Coma Scale (GCS) ≤13. The dual primary outcomes were mortality and Paediatric Functional Independence Measure (WeeFIM) scores, recorded at the start of rehabilitation, discharge, 3 months and 6 months post-injury. The secondary outcome was the development of post-traumatic epilepsy. There were 68 patients with a median age of 4.5 [interquartile range (IQR) 1.0-9.0] years old. The most common presenting symptom was vomiting for children <2 years (11/20, 55.0%) while confusion and disorientation were common for those ≥2 years (27/48, 56.3%). WeeFIM scores at the start of rehabilitation [median 122.0, IQR 33.8-126.0] improved at 6 months post-injury (median 126.0, IQR 98.5-126.0). There was a greater incidence of post-traumatic epilepsy in age <2 years (6/20, 30.0%) compared to age ≥2 years (1/48, 2.1%) (p = .002). When comparing NAT versus non-NAT survivors, cognition WeeFIM scores were significantly different at the start of rehabilitation (p = .017) and at 3 months post-injury (p = .025). NAT predicts for poorer long-term outcomes, specifically in cognition, as measured by WeeFIM scores. Younger children <2 years had a higher incidence of post-traumatic epilepsy compared to older children.
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Affiliation(s)
- Shih Yao Hwang
- a Yong Loo Lin School of Medicine, National University of Singapore , Singapore , Singapore
| | - Jia Wei Ong
- a Yong Loo Lin School of Medicine, National University of Singapore , Singapore , Singapore
| | - Zhi Min Ng
- b Department of Paediatric Medicine, KK Women's and Children's Hospital , Singapore , Singapore
| | - Ce Yu Foo
- c Department of Rehabilitation, KK Women's and Children's Hospital , Singapore , Singapore
| | - Shu Zhen Chua
- c Department of Rehabilitation, KK Women's and Children's Hospital , Singapore , Singapore
| | - Dianna Sri
- d KK Research Centre, KK Women's and Children's Hospital , Singapore , Singapore
| | - Jan Hau Lee
- e Children's Intensive Care Unit, KK Women's and Children's Hospital , Singapore , Singapore
| | - Shu-Ling Chong
- f Department of Emergency Medicine, KK Women's and Children's Hospital , Singapore , Singapore
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45
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Högberg U, Lampa E, Högberg G, Aspelin P, Serenius F, Thiblin I. Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis? Eur J Public Health 2019; 28:641-646. [PMID: 29672696 PMCID: PMC6296307 DOI: 10.1093/eurpub/cky062] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities. Conclusions Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Erik Lampa
- UCR-Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Göran Högberg
- Child and Adolescent Psychiatric Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Peter Aspelin
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Fredrik Serenius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Ingemar Thiblin
- Forensic Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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46
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Chen CC, Hsieh PC, Chen CPC, Hsieh YW, Chung CY, Lin KL. Clinical Characteristics and Predictors of Poor Hospital Discharge Outcome for Young Children with Abusive Head Trauma. J Clin Med 2019; 8:E390. [PMID: 30897787 PMCID: PMC6463187 DOI: 10.3390/jcm8030390] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 11/18/2022] Open
Abstract
Children with abusive head trauma tend to have worse outcomes than children with accidental head trauma. However, current predictors of poor outcomes for children with abusive head trauma are still limited. We aim to use clinical data to identify early predictors of poor outcome at discharge in children with abusive head trauma. In the 10-year observational retrospective cohort study, children aged between zero and four years with abusive or accidental head trauma were recruited. Multivariate logistic regression models were applied to evaluate factors associated with poor prognosis in children with abusive head trauma. The primary outcome was mortality or a Glasgow Coma Scale (GCS) motor component score of less than 6 at discharge. A total of 292 head trauma children were included. Among them, 59 children had abusive head trauma. In comparison to children with accidental head trauma, children with abusive head trauma were younger, had more severe head injuries, and experienced a higher frequency of post-traumatic seizures. Their radiologic findings showed common presence of subdural hemorrhage, cerebral edema, and less epidural hemorrhage. They were more in need of neurosurgical intervention. In the multivariate analysis for predictors of poor outcome in children with abusive head trauma, initial GCS ≤ 5 (versus GCS > 5 with the adjusted odds ratio (OR) = 25.7, 95% confidence interval (CI) = 1.5⁻432.8, p = 0.024) and older age (per year with the adjusted OR = 3.3, 95% CI = 1.2⁻9.5, p = 0.024) were independently associated with poor outcome. These findings demonstrate the characteristic clinical differences between children with abusive and accidental head trauma. Initial GCS ≤ 5 and older age are predictive of poor outcome at discharge in children with abusive head trauma.
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Affiliation(s)
- Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
| | - Carl P C Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
| | - Yu-Wei Hsieh
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, 259, Sec1, WenHua First Road, Taoyuan 333, Taiwan.
- Healthy Aging Research Center, Chang Gung University, 259, Sec1, WenHua First Road, Taoyuan 333, Taiwan.
| | - Chia-Ying Chung
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
- Study Group for Prevention and Protection Against Child Abuse and Neglect, Chang Gung Memorial Hospital, 5 Fuhsing St., Taoyuan 333, Taiwan.
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Hymel KP, Wang M, Chinchilli VM, Karst WA, Willson DF, Dias MS, Herman BE, Carroll CL, Haney SB, Isaac R. Estimating the probability of abusive head trauma after abuse evaluation. CHILD ABUSE & NEGLECT 2019; 88:266-274. [PMID: 30551063 PMCID: PMC6333504 DOI: 10.1016/j.chiabu.2018.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 06/02/2023]
Abstract
BACKGROUND Evidence-based, patient-specific estimates of abusive head trauma probability can inform physicians' decisions to evaluate, confirm, exclude, and/or report suspected child abuse. OBJECTIVE To derive a clinical prediction rule for pediatric abusive head trauma that incorporates the (positive or negative) predictive contributions of patients' completed skeletal surveys and retinal exams. PARTICIPANTS AND SETTING 500 acutely head-injured children under three years of age hospitalized for intensive care at one of 18 sites between 2010 and 2013. METHODS Secondary analysis of an existing, cross-sectional, prospective dataset, including (1) multivariable logistic regression to impute the results of abuse evaluations never ordered or completed, (2) regularized logistic regression to derive a novel clinical prediction rule that incorporates the results of completed abuse evaluations, and (3) application of the new prediction rule to calculate patient-specific estimates of abusive head trauma probability for observed combinations of its predictor variables. RESULTS Applying a mean probability threshold of >0.5 to classify patients as abused, the 7-variable clinical prediction rule derived in this study demonstrated sensitivity 0.73 (95% CI: 0.66-0.79) and specificity 0.87 (95% CI: 0.82-0.90). The area under the receiver operating characteristics curve was 0.88 (95% CI: 0.85-0.92). Patient-specific estimates of abusive head trauma probability for 72 observed combinations of its seven predictor variables ranged from 0.04 (95% CI: 0.02-0.08) to 0.98 (95% CI: 0.96-0.99). CONCLUSIONS Seven variables facilitate patient-specific estimation of abusive head trauma probability after abuse evaluation in intensive care settings.
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, United States.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Wouter A Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, the Netherlands
| | - Douglas F Willson
- Department of Pediatrics, Children's Hospital of Richmond, Richmond, VA, United States
| | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, PA, United States
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, UT, United States
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, United States
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States
| | - Reena Isaac
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
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Högberg U, Andersson J, Högberg G, Thiblin I. Metabolic bone disease risk factors strongly contributing to long bone and rib fractures during early infancy: A population register study. PLoS One 2018; 13:e0208033. [PMID: 30566429 PMCID: PMC6300197 DOI: 10.1371/journal.pone.0208033] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to assess the incidence of fractures in infancy, overall and by type of fracture, its association with accidents, metabolic bone disease risk factors, and abuse diagnosis. Methods The design was a population-based register study in Sweden. Participants: Children born 1997–2014, 0–1 years of age diagnosed with fracture-diagnosis according to International Classification of Diseases (ICD10) were retrieved from the National Patient Register and linked to the Swedish Medical Birth Register and the Death Cause Register. Main outcome measures were fractures of the skull, long bone, clavicle and ribs, categorized by age (younger or older than 6 months), and accident or not. Findings The incidence of fractures during infancy was 251 per 100 000 infants (n = 4663). Major fracture localisations were long bone (44·9%), skull (31·7%), and clavicle (18·6%), while rib fractures were few (1·4%). Fall accidents were reported among 71·4%. One-third occurred during the first 6 months. Metabolic bone disease risk factors, such as maternal obesity, preterm birth, vitamin D deficiency, rickets, and calcium metabolic disturbances, had increased odds of fractures of long bones and ribs in early infancy (0–6 months): birth 32–36 weeks and long bone fracture [AOR 2·13 (95%CI 1·67–2·93)] and rib fracture [AOR 4·24 (95%CI 1·40–12·8)]. Diagnosis of vitamin D deficiency/rickets/disorders of calcium metabolism had increased odds of long bone fracture [AOR 49·5 (95%CI 18·3–134)] and rib fracture [AOR 617 (95%CI 162–2506)]. Fractures without a reported accident had higher odds of metabolic risk factors than those with reported accidents. Abuse diagnosis was registered in 105 infants, with overrepresentation of preterm births, multiple births and small-for-gestational age. Interpretation Metabolic bone disease risk factors are strongly associated with fractures of long bone and ribs in early infancy. Fracture cases with abuse diagnosis had a metabolic bone risk factor profile.
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Affiliation(s)
- Ulf Högberg
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Jacob Andersson
- Forensic Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Göran Högberg
- Formerly Department of Women’s and Children’s Health, Child and Adolescent Psychiatric Unit, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Thiblin
- Forensic Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Abstract
OBJECTIVES Falls are commonly reported in children who present with both accidental and inflicted brain injuries. Short falls rarely result in serious or life-threatening injuries. Our purpose is to describe a series of cases of short falls with occipital impact leading to subdural hemorrhage (SDH). METHODS We present a series of 8 witnessed accounts of young children diagnosed as having SDHs after striking the back of their heads during a short fall. Child-abuse physicians were surveyed to determine if they had evaluated a child younger than 24 months diagnosed as having SDH, with or without retinal hemorrhages, following a witnessed fall with occipital impact. Submitted cases were analyzed. RESULTS The median age of the children was 12.5 months. All fell backward from a standing or seated position onto a hard surface and immediately developed symptoms. There was an average of 4 witnesses per case. Physical examinations were normal; however, the majority of children had enlarged head circumferences. All were previously healthy. Six of 8 children had unilateral convexity SDH. All children had varying degrees of retinal hemorrhage but no retinoschisis. The majority of children had returned to their baseline within 24 hours of hospitalization. CONCLUSIONS Although a larger study is needed to identify the full spectrum of injuries, we postulate that, if a history of a fall with an occipital impact is elicited during a trauma workup, accidental injury should be considered.
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Shouldice M, Al-Khattabi F, Thau A, McIntyre S, Ng WKY, Levin AV. Traumatic macular retinoschisis in infants and children. J AAPOS 2018; 22:433-437.e2. [PMID: 30394342 DOI: 10.1016/j.jaapos.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide detailed description of pediatric traumatic retinoschisis. METHODS The medical records of children with either abusive head trauma and traumatic macular retinoschisis seen at a single center from 1993 to 2006 were reviewed retrospectively. Clinical details were extracted from the record and photographic documentation. Evaluation regarding abuse excluded ophthalmology findings to avoid circular reasoning. RESULTS Of 134 patients with suspected abusive head trauma, 31 had retinoschisis. Mean age was 9 months. Of the 31, 22 (71%) offered a history of injury, and 9 (29%) were found unresponsive without history of injury; 6 were reportedly shaken. All patients had seizures, vomiting, and/or altered responsiveness. All had subdural hemorrhage, with cerebral edema in 17 (55%). In 10 (32%), there were findings of blunt force head injuries; in 4 of these there was no impact history. Retinal hemorrhages were present in all cases. Agreement between sidedness of retinoschisis and subdural hemorrhage was poor. Eleven patients had retinal folds, 3 of which had a hemorrhagic edge to the schisis. Nine patients had extracranial manifestations of abuse. Multidisciplinary team adjudications were as follows: of the 31 cases, 18 were suspicious for abuse, 11 were indeterminate, and 2 were possibly accounted for by accidental severe crush injury. Three children died, and 11 suffered neurological sequelae. CONCLUSIONS Traumatic retinoschisis in children is highly associated with subdural hemorrhage, neurologic symptoms, and poor outcomes. Even with a conservative approach to opinion formulation, traumatic retinoschisis was associated with likely abuse.
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Affiliation(s)
| | - Fadiah Al-Khattabi
- College of Medicine at Alfaisal University, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Avrey Thau
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan McIntyre
- Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Wendy K Y Ng
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Alex V Levin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania.
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