Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review

Neuroimaging considerations in abusive head trauma

This focused review on abusive head trauma describes the injuries to the head, brain and/or spine of an infant or young child from inflicted trauma and their neuroimaging correlates. Accurate recognition and diagnosis of abusive head trauma is paramount to prevent repeated injury, provide timely treatment, and ensure that accidental or underlying medical contributors have been considered. In this article, we aim to discuss the various findings on neuroimaging that have been associated with AHT, compared to those that are more consistent with accidental injuries or with underlying medical causes that may also be on the differential.

Electroencephalogram pattern predicting neurological outcomes of children with seizures secondary to abusive head trauma

BACKGROUND

The clinical presentations of abusive head trauma can abruptly worsen, so the occurrence of seizures and changes of EEG can be variable according to patients' conditions. Since the changes of EEG background waves reflect the cortical function of children, we aimed to find out whether the timing of EEG background, epileptiform discharges and seizure patterns were associated with the outcomes of patients with AHT.

MATERIAL AND METHODS

Using seizure type and acute stage electroencephalographic (EEG) characteristics to assess adverse neurological outcomes in children with seizures secondary to abusive head trauma (AHT). Children who were hospitalized with AHT at a tertiary referral hospital from October 2000 to April 2010 were evaluated retrospectively. A total of 50 children below 6 years of age admitted due to AHT were included. KOSCHI outcome scale was used to evaluate the primary outcome and neurological impairment was used as secondary outcome after 6 months discharge.

RESULTS

Children with apnea, cardiac arrest, reverse blood flow and skull fracture in clinic had a higher mortality rate even in the no-seizure group (3/5 [60%] vs. 3/45 [6.7%], odds ratio [OR] = 11; 95% CI = 2.3-52; p = 0.025). Seizure occurrence reduced mostly at the second day after admission in seizure groups; but children with persistent seizures for 1 week showed poor neurological outcomes. The occurrence of initial seizure was frequency associated with younger age; focal seizure, diffuse cortical dysfunction in acute-stage EEG, and low Glasgow Coma Scale (GCS) score were significantly related to poor outcomes after 6 months. Diffuse cortical dysfunction was also associated with motor, speech, and cognitive dysfunction.

CONCLUSIONS

Diffuse cortical dysfunction in acute-stage EEG combined with low GCS score and focal seizure may related to poor outcomes and neurological dysfunctions in children with AHT.

Pediatric Traumatic Brain Injury: Impact on the Developing Brain

Traumatic brain injury (TBI) is a serious public health concern impacting millions of children and adolescents each year. Experiencing a brain injury during key critical periods of brain development can affect the normal formation of brain networks that are responsible for a range of complex neurocognitive outcomes. In addition, there are multiple pre- and postinjury factors that influence the trajectory of recovery and outcomes. In this review, we will focus on the current state of the literature within pediatric TBI; systematically review the available research on developmental aspects of TBI in children, focusing on the pathophysiology of the injury and its impact on the developing brain; and highlight knowledge gaps for further exploration.

Comparisons of characteristics and outcome between abusive head trauma and non-abusive head trauma in a pediatric intensive care unit

BACKGROUND

Abusive head trauma (AHT) is the leading cause of death in infants with traumatic brain injury (TBI). Early recognition of AHT is important for improving outcomes, but it can be challenging due to its similar presentations with non-abusive head trauma (nAHT). This study aims to compare clinical presentations and outcomes between infants with AHT and nAHT, and to identify the risk factors for poor outcomes of AHT.

METHODS

We retrospectively analyzed infants of TBI in our pediatric intensive care unit from January 2014 to December 2020. Clinical manifestations and outcomes were compared between patients with AHT and nAHT. Risk factors for poor outcomes in AHT patients were also analyzed.

RESULTS

60 patients were enrolled for this analysis, including 18 of AHT (30%) and 42 of nAHT (70%). Compared with those with nAHT, patients with AHT were more likely to have conscious change, seizures, limb weakness, and respiratory failure, but with a fewer incidence of skull fractures. Additionally, clinical outcomes of AHT patients were worse, with more cases undergoing neurosurgery, higher Pediatric Overall Performance Category score at discharge, and more anti-epileptic drug (AED) use after discharge. For AHT patients, conscious change is an independent risk factor for a composite poor outcome of mortality, ventilator dependence, or AED use (OR = 21.9, P = 0.04) CONCLUSION: AHT has a worse outcome than nAHT. Conscious change, seizures and limb weaknesses but not skull fractures are more common in AHT. Conscious change is both an early reminder of AHT and a risk factor for its poor outcomes.

Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury

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.

Subdural hemorrhages and severe retinal hemorrhages in a short fall with a rotational component

We present the case of a 5-month-old referred for child abuse investigation with subdural hemorrhages and extensive retinal hemorrhages following a short fall from a swivel chair seen on video footage. Subdural hemorrhages with extensive retinal hemorrhages are not typically seen as the result of short household falls. Reviewing the footage, contributing factors may have included increased rotational and deceleration forces.

Combined rapid sequence MRI protocol and skull radiography as an alternative to head CT in the evaluation of abusive head trauma in children: a pilot study

The aim of our pilot study was to compare the performance of the RS-MRI protocol combined with skull radiography versus CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage in patients with abusive head trauma (AHT). Additionally, our study aimed to determine whether the presence of scalp hematoma predicts concurrent skull fracture. We conducted a pilot study through retrospective chart review of 24 patients between ages 0 and 15 months who experienced AHT and who received CT, MRI, and skull radiography between May 2020 and August 2021. Two blinded board certified neuroradiologists reviewed the skull radiographs alongside the rapid trauma MRI. Their impressions were documented and compared with findings derived from CT. Combination imaging detected ten out of the 12 skull fractures noted on CT (sensitivity 83.3%, specificity 100%, p=0.48). RS-MRI detected 15 out of the 16 intracranial hemorrhages detected by CT (sensitivity 93.75%, p >0.9). When scalp hematoma was detected on RS-MRI, nine out of the 12 had associated skull fractures when reviewed by radiologist 1 (sensitivity 75%, specificity 100%, p=0.22), and seven out of the 12 had associated skull fractures when reviewed by radiologist 2 (sensitivity 58%, specificity 92%, p=0.25). In pediatric patients with suspected AHT, we found that RS-MRI combined with skull radiographs was not significantly different than CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage. This combination has the potential to replace the use of CT as a screening tool for abusive head trauma, while avoiding the risks of sedation often required for routine MRI.

New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review

(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.

Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review

BACKGROUND

Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking.

OBJECTIVE

This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample.

PARTICIPANTS AND SETTING

Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions.

METHODS

Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses.

RESULTS

For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001).

CONCLUSIONS

A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.

Imaging of Abusive Head Trauma in Children

In this article, we describe relevant anatomy, mechanisms of injury, and imaging findings of abusive head trauma (AHT). We also briefly address certain mimics of AHT, controversies, pearls, and pitfalls. Concepts of injury, its evolution, and complex nature of certain cases are highlighted with the help of case vignettes.

Benign enlargement of the subarachnoid spaces and subdural collections-when to evaluate for abuse

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.

Abusive Head Trauma Animal Models: Focus on Biomarkers

Abusive head trauma (AHT) is a serious traumatic brain injury and the leading cause of death in children younger than 2 years. The development of experimental animal models to simulate clinical AHT cases is challenging. Several animal models have been designed to mimic the pathophysiological and behavioral changes in pediatric AHT, ranging from lissencephalic rodents to gyrencephalic piglets, lambs, and non-human primates. These models can provide helpful information for AHT, but many studies utilizing them lack consistent and rigorous characterization of brain changes and have low reproducibility of the inflicted trauma. Clinical translatability of animal models is also limited due to significant structural differences between developing infant human brains and the brains of animals, and an insufficient ability to mimic the effects of long-term degenerative diseases and to model how secondary injuries impact the development of the brain in children. Nevertheless, animal models can provide clues on biochemical effectors that mediate secondary brain injury after AHT including neuroinflammation, excitotoxicity, reactive oxygen toxicity, axonal damage, and neuronal death. They also allow for investigation of the interdependency of injured neurons and analysis of the cell types involved in neuronal degeneration and malfunction. This review first focuses on the clinical challenges in diagnosing AHT and describes various biomarkers in clinical AHT cases. Then typical preclinical biomarkers such as microglia and astrocytes, reactive oxygen species, and activated N-methyl-D-aspartate receptors in AHT are described, and the value and limitations of animal models in preclinical drug discovery for AHT are discussed.

Identifying abusive head trauma and its mimics: diagnostic nuances

BACKGROUND

Abusive head trauma (AHT) is the most serious injury inflicted to the nervous system of neonate an infant with a high incidence of disabilities. The authors present two cases in which the initial manifestations and neurologic status were misinterpreted and stress that clinical presentation and imaging can be variable and confuse the examiner.

DISCUSSION

Subdural hemorrhage (SDH) in this age group raises high suspicion of non-accidental trauma but have been reported in other situations such as several bleeding disorders. Although rare, hematological diseases should be considered when other data of maltreatment are lacking.

CONCLUSION

Differential diagnosis is important to avoid underdiagnosing AHT and to prevent morbidity if a pre-existing hematological disease is misdiagnosed.

Comparison of abusive head trauma versus non-inflicted subdural haematoma in infants: A retrospective cohort study

OBJECTIVES

To compare the characteristics of subdural haematoma (SDH) in children under the age of 2 years, between inflicted, otherwise known as abusive head trauma (AHT), and non-inflicted aetiologies.

METHODS

This was a retrospective cohort study of 37 cases of SDH in children under the age of 2 years presenting to the ED at an Australian tertiary children's hospital between January 2009 and December 2012 and been assessed by the Child Protection Unit. SDH aetiology was classified into AHT and non-inflicted groups, based on child protection interagency outcome. These groups were compared to determine clinical associations with AHT.

RESULTS

Of the 37 infants with SDH, 20 cases were deemed due to AHT, whereas 17 cases were determined to be non-inflicted SDH (15 cases due to accidental trauma and two cases due to congenital benign enlargement of the subarachnoid space). SDH due to AHT was associated with antenatal maternal drug use, previous Department of Child Safety involvement, delayed presentation, history of seizures, floppiness or altered level of consciousness; extracranial findings of fractures, bruising or retinal haemorrhages; radiological findings of >5 mm depth, bilateral, inter-hemispheric blood, posterior fossa blood and diffusion restriction; and outcomes of death or permanent disability. Non-inflicted SDH was associated with witnessed injury, falls and scalp haematoma on imaging.

CONCLUSIONS

Infant SDH due to AHT accounts for high mortality and morbidity. Early identification of these patients in the ED with referral to specialised units that investigate for potential child abuse is essential.

Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding

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.

Abusive Head Trauma in Infants During the COVID-19 Pandemic in the Paris Metropolitan Area

Importance

The COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse.

Objective

To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic.

Design, Setting, and Participants

In a time-series analysis of a longitudinal, population-based, cohort study, all consecutive cases of AHT in infants younger than 12 months old referred between January 2017 and December 2021 to Necker Hospital for Sick Children, the single regional pediatric neurosurgery center for the Paris metropolitan area, were included. AHT was defined as 1 or more subdural hemorrhage and a positive multidisciplinary evaluation after a social, clinical, biological, and radiological workup. Data were analyzed from January to March 2022.

Main Outcomes and Measures

The primary outcome was the monthly incidence of AHT, which was analyzed using Poisson regression modeling. Secondary outcomes included mortality and severe morbidity and were studied with logistic and linear regressions. The monthly incidence of neurosurgical interventions for hydrocephalus was used as a control series.

Results

Among the 99 included infants with AHT (median [IQR] age, 4 [3-6] months; 64 boys [65%]), 86 of 99 (87%) had bridging vein thrombosis, 74 of 99 (75%) had retinal hemorrhages, 23 of 72 (32%) had fractures, 26 of 99 (26%) had status epilepticus, 20 of 99 (20%) had skin injuries, 53 of 99 (54%) underwent neurosurgical interventions, and 13 of 99 (13%) died. Compared with the prepandemic period (2017-2019), AHT incidence was stable in 2020 (adjusted incidence rate ratio, 1.02; 95% CI, 0.59-1.77) and then significantly increased in 2021 (adjusted incidence rate ratio, 1.92; 95% CI, 1.23-2.99). The severity of AHT worsened in 2021 in terms of mortality (odds ratio 9.39; 95% CI, 1.88-47.00). Other secondary outcomes and the control series were not significantly modified.

Conclusions and Relevance

In this cohort study, a marked increase in AHT incidence and severity occurred during the COVID-19 pandemic in the Paris metropolitan area. These results suggest the need for clinical awareness and preventive actions.

Magnetic Resonance Imaging Findings in Infants with Severe Traumatic Brain Injury and Associations with Abusive Head Trauma

Young children with severe traumatic brain injury (TBI) have frequently been excluded from studies due to age and/or mechanism of injury. Magnetic resonance imaging (MRI) is now frequently being utilized to detect parenchymal injuries and early cerebral edema. We sought to assess MRI findings in infants with severe TBI, and to determine the association between specific MRI findings and mechanisms of injury, including abusive head trauma (AHT). MRI scans performed within the first 30 days after injury were collected and coded according to NIH/NINDS Common Data Elements (CDEs) for Neuroimaging in subjects age < 2 years old with severe TBI enrolled in the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial. Demographics and injury characteristics were analyzed. A total of 81 children were included from ADAPT sites with MRI scans. Median age was 0.77 years and 57% were male. Most common MRI finding was ischemia, present in 57/81 subjects (70%), in a median of 7 brain regions per subject. Contusion 46/81 (57%) and diffuse axonal injury (DAI) 36/81 (44.4%) subjects followed. Children were dichotomized based on likelihood of AHT with 43/81 subjects classified as AHT. Ischemia was found to be significantly associated with AHT (p = 0.001) and “inflicted” injury mechanism (p = 0.0003). In conclusion, the most common intracerebral injury seen on MRI of infants with severe TBI was ischemia, followed by contusion and DAI. Ischemia was associated with AHT, and ischemia affecting > 4 brain regions was predictive of AHT.

An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma

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."

Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma

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.

Diagnosis of Abusive Head Trauma : Neurosurgical Perspective

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.

Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants

Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.

Parenchymal Insults in Abuse—A Potential Key to Diagnosis

Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.

Documentation of paediatric head injuries in a mixed metropolitan emergency department

OBJECTIVE

Head injuries are a common presentation of children to Australian EDs. Healthcare documentation is an important tool for enhancing patient care. In our study, we aimed to assess the adequacy of paediatric head injury documentation in a mixed ED.

METHODS

A retrospective analysis of presentations to a mixed ED between 2017 and 2018. Children aged <16 years old with a primary diagnosis of head injury were included. Documentation items based on local head injury guidelines were assessed in both medical and nursing documentation. We compared cases aged <1 and ≥1 year.

RESULTS

There were 427 presentations that met the case definition. Medical documentation was present in 422 cases and nursing documentation in 310 cases. In combined medical and nursing documentation, items poorly documented include blood pressure (BP; 21.3%) and secondary survey (16.9%). In solely medical documentation, least commonly documented items are high-risk bony injuries (22.5%), high-risk soft tissue injuries (22.3%), seizure (22.0%) and non-accidental injury (3.6%). Glasgow Coma Scale (GCS) was poorly documented in cases aged <1 year (10.9%, P < 0.001).

CONCLUSIONS

The largest gaps in the documentation of paediatric head injuries were BP and paediatric GCS in infants. Future audits and educational strategies should focus on targeting clinically relevant items that are predictive of serious outcomes.

Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

Infantile subdural hematoma in Japan: A multicenter, retrospective study by the J-HITs (Japanese head injury of infants and toddlers study) group

Objective

Subdural hematoma in infants or toddlers has often been linked to abuse, but it is not clear how many cases actually occur and how many are suspected of abuse. The purpose of this study was to investigate subdural hematoma in infants and toddlers in Japan.

Methods

This multicenter, retrospective study reviewed the clinical records of children younger than 4 years with head trauma who were diagnosed with any finding on head computed tomography (CT) and/or magnetic resonance imaging (MRI), such as skull fracture and/or intracranial injury. A total of 452 children were included. The group suspected to have been abused was classified as nonaccidental, and the group considered to have been caused by an accident was classified as accidental. Subdural hematoma and other factors were examined on multivariate analysis to identify which factors increase the risk of nonaccidental injuries.

Results

Of the 452 patients, 158 were diagnosed with subdural hematoma. Subdural hematoma was the most common finding intracranial finding in head trauma in infants and toddlers. A total of 51 patients were classified into the nonaccidental group, and 107 patients were classified into the accidental group. The age of patients with subdural hematoma showed a bimodal pattern. The mean age of the accidental group with subdural hematoma was significantly older than that in the nonaccidental group (10.2 months vs 5.9 months, respectively. p < 0.001). Multivariate analysis showed that patients under 5 months old, retinal hemorrhage, and seizure were significant risk factors for nonaccidental injury (odds ratio (OR) 3.86, p = 0.0011; OR 7.63, p < 0.001; OR 2.49, p = 0.03; respectively). On the other hand, the odds ratio for subdural hematoma was 1.96, and no significant difference was observed (p = 0.34).

Conclusions

At least in Japanese children, infantile subdural hematoma was frequently observed not only in nonaccidental but also in accidental injuries. In infants with head trauma, age, the presence of retinal hemorrhage, and the presence of seizures should be considered when determining whether they were abused. Subdural hematoma is also a powerful finding to detect abuse, but care should be taken because, in some ethnic groups, such as the Japanese, there are many accidental cases.

Whole spine MRI in children with suspected child abuse

Background: Abusive head trauma (AHT) in children has recently been associated with findings on cervical spine MRI. Objective: To evaluate whether whole-spine MRI in children suspected of AHT shows additional abnormalities not identified on cervical spine MRI. Methods: This retrospective study included 256 children young than 3 years (170 boys, 86 girls; mean age, 5.9 months) who underwent skeletal survey and head MRI for suspected child abuse from January 2019 to December 2020. Per institutional protocol, children with suspected AHT also underwent whole-spine MRI. AHT diagnoses were established by combination of clinical information from medical record review and injuries described in reports from skeletal survey, head MRI, and head CT (if performed). Two pediatric neuroradiologists independently reviewed whole-spine MRI examinations for presence and level of intraspinal hemorrhage (classified as subarachnoid, subdural, or epidural), ligamentous injury, spinal cord edema, and vertebral fractures; subdural hematoma, epidural hematoma, ligamentous injury, and fracture unidentified by skeletal survey were considered major findings. Interreader agreement was assessed; a third radiologist resolved discrepancies. Findings were summarized with attention to injuries isolated to the thoracolumbar spine. Results: A total of 148/256 (57.8%) children underwent whole-spine MRI. AHT was diagnosed in 79/148 (53.4%) children who underwent whole-spine MRI, versus in 2/108 (1.9%) who did not undergo whole-spine MRI (p<.001). Interobserver agreement. expressed as kappa, was 0.90 for intraspinal hemorrhage, 0.69 for ligamentous injury, 0.66 for spinal cord edema, and 0.95 for fracture. A total of 57/148 (38.5%) whole-spine MRI examinations demonstrated injuries; 34/148 (23.0%) demonstrated injuries localized to the thoracolumbar spine. A total of 47/148 (31.8%) whole-spine MRI examinations demonstrated major findings, of which 24/47 (51.1%) were localized to the thoracolumbar spine. Isolated thoracolumbar injuries included 23 of 34 subdural hematomas, 2 of 3 epidural hematomas, and 9 of 11 fractures, including 5 fractures not identified by skeletal survey. Diagnosis of AHT was more common in children with positive, versus negative, whole-spine MRI examinations (76.8% vs 39.1%, p<.001). Conclusion: In children with suspected AHT, whole-spine MRI commonly demonstrates isolated thoracolumbar injuries. Clinical Impact: The results support performing whole-spine MRI rather than cervical spine MRI in children with suspected AHT.

Pathogenic variant in NFIA associated with subdural hematomas mimicking nonaccidental trauma

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.

Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are Associated With Clinically Important Traumatic Brain Injury, Classification as Abuse, and Poor Prognosis?

BACKGROUND

Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED).

OBJECTIVE

The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge.

PARTICIPANTS AND SETTING

Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included.

METHODS

Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification.

RESULTS

On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge.

CONCLUSIONS

No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.

Underestimating isolated bilateral hygroma as non-accidental head injury with dramatic consequences: a case presentation

OBJECTIVE

Abusive head injury (AHI) in infancy is associated with significantly worse outcomes compared to accidental traumatic brain injury. The decision-making of the diagnosis of AHI is challenging especially if the clinical signs are not presenting as a multifactorial pattern.

METHOD

We present a case of isolated bilateral hygroma in which this differential diagnosis of AHI was evaluated but primarily not seen as such leading subsequently to extensive secondary AHI with fatal brain injury.

RESULTS

The case of an 8-week-old infant with apparently isolated bilateral hygroma without any external signs of abuse and no retinal hemorrhages was interpreted in causative correlation to the perinatal complex course of delivery. At a second readmission of the case, severe brain injury with bilateral cortical hypoxia, subarachnoid and subdural hemorrhages, and skull and extremity fractures led to severe disability of the affected infant.

CONCLUSION

Any early suspicion of AHI with at least one factor possibly being associated with abusive trauma should be discussed in multidisciplinary team conferences to find the best strategy to protect the child. Beside clinical factors, social factors within the family household may additionally be evaluated to determine stress-related risk for traumatic child abuse. In general, prevention programs will be essential in future perspective.

Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis

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.

A regional multidisciplinary network enhances child abuse case management

BACKGROUND

We previously reported an inadequate response to intracranial hemorrhage (ICH) cases under 24 months of age in Yokohama from 2011 to 2013. Hence, it is very important to evaluate how the establishment of a regional multidisciplinary network for child abuse affects the response to ICH cases in medical institutions.

METHODS

We conducted a questionnaire survey of ICH cases under 24 months of age from 2014 to 2016 using a regional multidisciplinary network for child abuse established in Yokohama in September 2013. We investigated the patients' characteristics, examinations to identify inflicted injury, and reports made to the hospital-based child protection team (CPT) or regional child protective service (CPS), and compared the results of a previous study and the current study, which corresponds to before and after the establishment of the regional network, respectively.

RESULTS

The total number of ICH cases was 50 in 3 years. The number of cases surveyed for covert fracture and fundus hemorrhage increased significantly after the establishment of the regional network (P = 0.0001 and P = 0.0182, respectively). The number of cases reported as suspected child abuse was 41 (82%) to the hospital-based CPTs and 27 (54%) to the regional CPSs. There were significant differences between before and after the establishment of the regional network regarding CPT (P = 0.0062) and CPS (P = 0.0215) reports.

CONCLUSIONS

A regional multidisciplinary network can enhance response and cooperation to address child abuse. It deepens our understanding of such care and improves awareness by hospital personnel of child abuse.

Characteristics That Distinguish Abusive From Nonabusive Causes of Sudden Unexpected Infant Deaths

BACKGROUND

Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department.

METHODS

Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes.

RESULTS

We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30).

CONCLUSIONS

Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.

Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review

OBJECTIVE

Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk.

METHODS

A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk.

RESULTS

A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup).

CONCLUSIONS

Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

Understanding the Five-Year Outcomes of Abusive Head Trauma in Children: A Retrospective Cohort Study

Understanding the long-term medical and developmental outcomes for children who survive abusive head trauma (AHT) is important to ensure necessary supports and services are available. This study examined the retrospective global and specific medical and developmental outcomes of 55 children with AHT who were treated at The Children's Hospital at Westmead. Global outcomes were assessed using the Kings Outcome Scale of Childhood Head Injury (KOSCHI). Five years post-injury, one child had died and two had made a complete recovery. Forty-five children (81.8%) had a moderate or severe disability, an increase from 64.5% at acute discharge. At follow-up, the main impairments were behavioral problems (53%), vision impairment (44%), fine motor difficulties (26%), gross motor problems (26%), communication problems (24%) and 16% had seizures. A Spearman's Rank correlation revealed that only 41% of variance in KOSCHI scores five years post-injury could be accounted for KOSCHI scores at the time of acute discharge (rs(55) = 0.638, p < .001), and many children's presentation was worse at follow-up. Therefore, all children presenting with AHT need long term follow up regardless of early indications of good recovery.

Fatal intracranial hemorrhage due to infantile acute lymphoblastic leukemia mimicking abusive head trauma

We report the case of a 2-month-old infant who was found moribund in her crib. Postmortem computed tomography (PMCT) was performed before autopsy. As the baby had a severe subdural hematoma, retinal hemorrhage, and encephalopathy on PMCT, abusive head trauma (AHT) was tentatively diagnosed. At autopsy, no scalp hemorrhages or skull fractures were found; however, the classic triad of AHT was present, mainly on the right side. Additionally, there was dark red discoloration around the heart, and the liver, spleen, and pancreas were enlarged. Peripheral blood was macroscopically cloudy with marked leukocytosis. After careful histological examination, B-cell precursor acute lymphoblastic leukemia (ALL) was diagnosed. All the macroscopic lesions could be attributed to ALL. The manner of death was natural. To the best of our knowledge, this is the first report of infantile ALL mimicking AHT on PMCT images. This case demonstrates the importance of a comprehensive systematic approach to considering differential diagnosis when PMCT shows multiple intracranial hemorrhages suggestive of AHT in an infant.

Abusive head trauma: neuroimaging mimics and diagnostic complexities

Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.

Macrocephaly and subdural collections

Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.

Providers' Ability to Identify Sentinel Injuries Concerning for Physical Abuse in Infants

OBJECTIVES

The objectives of this study were to assess the ability of pediatric health care providers and social workers to recognize sentinel injuries in infants under 6 months of age and to determine what factors influence their decision to evaluate for physical abuse.

METHODS

A statewide collaborative focused on sentinel injuries administered a survey to pediatric health care providers and social workers in the emergency department, urgent care, and primary care. The survey contained 8 case scenarios of infants under 6 months of age with an injury, and respondents were asked if they would consider the injury to be a sentinel injury requiring a physical abuse evaluation. Respondents were then presented with several factors and asked how much each influences the decision to perform a physical abuse evaluation.

RESULTS

A total of 565 providers completed the survey. Providers had moderate interrater reliability on their classification of the cases as sentinel injuries or not (κ = 0.57). Nearly all respondents (97%) recognized genital bruising as a sentinel injury, whereas 77% of respondents recognized intraoral injuries. Agreement was highest among social workers (κ = 0.76) and physicians with categorical pediatrics training and pediatric emergency medicine fellowship (κ = 0.63) and lowest among nurse practitioners (κ = 0.48) and residents (κ = 0.51). Concern over missing the diagnosis of abuse had the greatest influence on the decision to perform a physical abuse evaluation.

CONCLUSIONS

Sentinel injuries are not uniformly recognized as potential signs of child abuse requiring further evaluation by pediatric health care providers. Additional evidence and education are needed regarding sentinel injuries.

Parenchymal brain injuries in abusive head trauma

The consequences of abusive head trauma (AHT) can be devastating for both the individual child and for wider society. Death is undoubtedly a very real possibility, but even for those children who survive, there is often very significant morbidity with the potential for gross motor and cognitive impairment, behavioural problems, blindness and epilepsy, which can greatly affect their quality of life. Caring for such children places a vast financial and infrastructural burden on society that frequently extends well into adulthood. While few struggle to have any sympathy for the perpetrator, frequently the infant's father, it should be noted that a single solitary and momentary loss of complete control can have horrific and unforeseen consequences. A number of papers within this edition describe features of AHT and include descriptions of skull fractures and extra-axial haemorrhage, along with mimics of such phenomena. However, in this review we concentrate our attention on the myriad of parenchymal findings that can occur. Such parenchymal injuries include hypoxic-ischaemic damage, clefts, contusion and focal haemorrhage. We offer our perspectives on current thinking on these entities and put them in the context of the immensely important question - how do we recognise abusive head trauma?

Pediatric Abusive Head Trauma: A Systematic Review

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.

An evaluation of the differences in paediatric skeletal trauma between fatal simple short falls and physical abuse blunt impact loads: An international multicentre pilot study

In cases where a deceased child exhibits trauma as a result of a physical abuse blunt impact load, a parent/caregiver may provide a simple short fall (SSF) as the justification for that trauma. The skeletal fractures remain difficult to differentiate between a SSF and physical abuse however, as both are the result of a blunt impact load, and are therefore biomechanically alike, and the rare nature of these fatalities means only anecdotal research has been available to validate such claims. The aim of this pilot study was to investigate if there may be differences in the skeletal fracture patterns and types resulting from SSFs compared with those resulting from physical abuse blunt impacts. Paediatric (<10 years) cases of fatal SSFs (≤1.5 m) and physical abuse were collected from the Victorian Institute of Forensic Medicine (Australia), Institut Médico-Légal de Paris (France), University of Pretoria (South Africa) and Great Ormond Street Hospital (England). For each case the intrinsic and extrinsic variables were recorded from medico-legal reports and skeletal trauma was documented using post-mortem computed tomography scans and/or skeletal surveys. Three SSFs and 18 physical abuse cases were identified. Of the SSF cases, two exhibited fractures; both of which were simple linear neurocranial fractures. Comparatively, 12 of the physical abuse cases exhibited fractures and these were distributed across the skeleton; 58% located only in the skull, 17% only in the post-cranial and 25% located in both. Skull fracture types were single linear, multiple linear and comminuted. This pilot study suggests, anecdotally, there may be differences in the fracture patterns and types between blunt impact loads resulting from a SSF and physical abuse. This data will form the foundation of the Registry of Paediatric Fatal Fractures (RPFF) which, with further multicentre contributions, would allow this finding to be validated.

Abusive head trauma: experience improves diagnosis

PURPOSE

The diagnosis of abusive head trauma (AHT) is complex and neuroimaging plays a crucial role. Our goal was to determine whether non-neuroradiologists with standard neuroradiology knowledge perform as well as neuroradiologists with experience in pediatric neuroimaging in interpreting MRI in cases of presumptive AHT (pAHT).

METHODS

Twenty children were retrospectively evaluated. Patients had been diagnosed with pAHT (6 patients), non-abusive head trauma-NAHT (5 patients), metabolic diseases (3 patients), and benign enlargement of the subarachnoid spaces (BESS) (6 patients). The MRI was assessed blindly, i.e., no clinical history was given to the 3 non-neuroradiologists and 3 neuroradiologists from 2 different institutions.

RESULTS

Blindly, neuroradiologists demonstrated higher levels of sensitivity and positive predictive value in the diagnosis of pAHT (89%) than non-neuroradiologists (50%). Neuroradiologists chose correctly pAHT as the most probable diagnosis 16 out of 18 times; in contrast, non-neuroradiologists only chose 9 out of 18 times. In our series, the foremost important misdiagnosis for pAHT was NAHT (neuroradiologists twice and non-neuroradiologists 5 times). Only victims of motor vehicle accidents were blindly misdiagnosed as pAHT. No usual household NAHT was not misdiagnosed as pAHT. Neuroradiologists correctly ruled out pAHT in all cases of metabolic diseases and BESS.

CONCLUSION

MRI in cases of suspected AHT should be evaluated by neuroradiologists with experience in pediatric neuroimaging. Neuroradiologists looked beyond the subdural hemorrhage (SDH) and were more precise in the assessment of pAHT and its differential diagnosis than non-neuroradiologists were. It seems that non-neuroradiologists mainly assess whether or not a pAHT is present depending on the presence or absence of SDH.

Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history

BACKGROUND

Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT.

METHODS

A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity.

RESULTS

Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity.

CONCLUSIONS

To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT.

STUDY TYPE/LEVEL OF EVIDENCE

Prognostic, Level III.

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

OBJECTIVES

Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age.

METHODS

A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.

RESULTS

Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.

CONCLUSION

Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).

Post-Traumatic West Syndrome due to Abusive Head Trauma in Two Infants with Different Brain Imaging Findings

Abusive head trauma (AHT), commonly known as shaken baby syndrome, is a cranial injury of infants and young children. AHT is an important cause of morbidity and mortality in young children, particularly those younger than 12 months of age. We describe two patients who developed West syndrome, which is a severe epilepsy syndrome composed of the triad of infantile spasms, hypsarrhythmia on electroencephalography, and developmental arrest or regression, possibly attributable to AHT. Case 1 was a 5-month-old boy presented with generalized convulsive status epilepticus when a babysitter had cared for him. Brain magnetic resonance imaging (MRI) exhibited a subdural hemorrhage with diffuse brain edema and a midline shift highly suggestive of AHT. He developed West syndrome at the age of 10 months. Case 2 was a 6-month-old girl presented infantile spasms and diagnosed with West syndrome. Although she had poor weight gain due to inadequate care by her mother, there were no history of trauma, no cutaneous finding, and no developmental delay. Brain MRI performed when West syndrome was diagnosed revealed contusional tears highly suggestive of AHT. The MRI finding indicated that contusional tears had occurred 1~2 months before the development of West syndrome. There are no reports of West syndrome due to contusional tears. AHT may be an important risk factor for postnatal West syndrome. It is noteworthy that evidence of AHT was found only after West syndrome onset, as in Case 2. The onset of West syndrome may contribute to the finding that AHT had occurred earlier.

Patterns of Osteopontin Expression in Abusive Head Trauma Compared with Other Causes of Pediatric Traumatic Brain Injury

OBJECTIVE

To examine levels of plasma osteopontin (OPN), a recently described neuroinflammatory biomarker, in children with abusive head trauma (AHT) compared with children with other types of traumatic brain injury (TBI).

STUDY DESIGN

The study cohort comprised children aged <4 years diagnosed with TBI and seen in the intensive care unit in a tertiary children's hospital. Patients were classified as having confirmed or suspected AHT or TBI by other mechanisms (eg, motor vehicle accidents), as identified by a Child Protection Team clinician. Serial blood samples were collected at admission and at 24, 48, and 72 hours after admission. Levels of OPN were compared across groups.

RESULTS

Of 77 patients identified, 24 had confirmed AHT, 12 had suspected AHT, and 41 had TBI. There were no differences in the Glasgow Coma Scale score between the patients with confirmed AHT and those with suspected AHT and those with TBI (median score, 4.5 vs 4 and 7; P = .39). At admission to the emergency department, OPN levels were significantly higher in children with confirmed AHT compared with the other 2 groups (mean confirmed AHT, 471.5 ng/mL; median suspected AHT, 322.3 ng/mL; mean TBI, 278.0 ng/mL; P = .03). Furthermore, the adjusted mean trajectory levels of OPN were significantly higher in the confirmed AHT group compared with the other 2 groups across all subsequent time points (P = <.01).

CONCLUSIONS

OPN is significantly elevated in children with confirmed AHT compared with those with suspected AHT and those with other types of TBI. OPN expression may help identify children with suspected AHT to aid resource stratification and triage of appropriate interventions for children who are potential victims of abuse.

Occurrence of traumatic brain injury due to short falls with or without a witness by a nonrelative in children younger than 2 years

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.

Intracranial Injury Among Children with Abuse-Related Long Bone Fractures

Background

Objectives

Methods

Results

Conclusions

A verified period of normal neurologic status in a young victim of abusive head trauma

Abusive head trauma (AHT) is the leading cause of child physical abuse fatalities, and survivors frequently face life-long consequences. Victims of AHT are typically infants, and many are subjected to repeat AHT if not accurately identified and protected. Identifying the timing of AHT is often a medical-forensic process, and investigative personnel use the determination of timing of AHT to guide safety decisions for the child victim. If the medical-forensic timing of AHT is incorrect, a child could be inappropriately placed and/or an innocent caregiver could be subject to prosecution. Victims of AHT who suffer severe/permanent injury are felt to demonstrate symptoms immediately after the trauma, and AHT victims with milder injury are thought to generally have persistent or recurrent clinical signs shortly after the trauma. Periods of normal neurologic appearance, in which a victim of AHT is completely asymptomatic for an extended time after the trauma, are felt to be rare and have not been well characterized in the literature. This case involves a 2-month-old infant victim of AHT who presented to medical care with mild neurologic symptoms that resolved without intervention from medical personnel. While hospitalized, the infant had an asymptomatic period of approximately 38 hours prior to more severe neurologic decompensation, then later returned to neurologic baseline. This case highlights the challenges in accurately timing AHT in very young victims who return to neurologic baseline by characterizing a verifiable prolonged period of normal neurologic appearance and function after AHT.