Head Trauma In Young Children Research Articles

How Antiscience Creates Confusion About the Diagnosis of Abusive Head Trauma

This Viewpoint exposes the antiscience and misinformation used to generate skepticism about abusive head trauma in young children, putting this vulnerable population at risk.

Association of Cytomegalovirus Infection with Lenticulostriate Stroke After Mild Head Trauma in Young Children.

The development of lenticulostriate stroke following mild head trauma accounts for 3% of traumatic brain injuries in children. Nevertheless, the pathogenesis of infantile lenticulostriate stroke with lenticulostriate calcification is poorly understood. In this study, we explored the association of a recent viral infection with the development of infantile lenticulostriate stroke with lenticulostriate calcification following mild head trauma in children. We examined the records for 49 children (<36 months old) diagnosed with infantile stroke following mild head trauma at the First Hospital of Jilin University between January 2007 and August 2019. The demographic characteristics, clinical manifestations, and laboratory and imaging results were collected and analyzed. Antibodies against Epstein-Barr virus, herpes simplex virus, and cytomegalovirus in the patient sera were assessed. A total of 18 patients with lenticulostriate stroke and calcification were included in the Patient group (16.61 ± 10.57 months), and 14 patients without calcification were included in the Control group (13.07 ± 7.66 months). Imaging findings demonstrated the presence of lenticulostriate stroke in all patients. There were no significant differences in the demographic characteristics or clinical manifestations of stroke between both groups (P > .05). Similarly, no significant differences were observed in the Epstein-Barr virus and herpes simplex virus-1 antibody positivity in both groups. In contrast, cytomegalovirus antibody was significantly more abundant in the Patient group (P < .05). All patients were hospitalized for conservative treatment with favorable prognoses. Our results suggest that cytomegalovirus infection may be associated with the development of lenticulostriate strokes in pediatric patients following minor head injury.

Long-term impact of abusive head trauma in young children: Outcomes at 5 and 11 years old

Background: Abusive head trauma (AHT) is a leading cause of morbidity and mortality among young children. We aimed to evaluate the long-term impact of AHT. Methods: Using administrative claims from 2000–2018, children <3 years old with documented AHT who had follow-up through ages 5 and 11 years were identified. The primary outcome was incidence of neurodevelopmental disability and the secondary outcome was the effect of age at time of AHT on long-term outcomes. Results: 1,165 children were identified with follow-up through age 5; 358 also had follow-up through age 11. The incidence of neurodevelopmental disability was 68.0% (792/1165) at 5 years of age and 81.6% (292/358) at 11 years of age. The incidence of disability significantly increased for the 358 children followed from 5 to 11 years old (+14.3 percentage points, p<0.0001). Children <1 year old at the time of AHT were more likely to develop disabilities when compared to 2 year olds. Conclusions: AHT is associated with significant long-term disability by age 5 and the incidence increased by age 11 years. There is an association between age at time of AHT and long-term outcomes. Efforts to improve comprehensive follow-up as children continue to age is important. Level of Evidence: IV

Long-term impact of abusive head trauma in young children.

Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs). We used the Truven Health MarketScan Research Claims Database (2000-2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes. The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance. AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.

Validation of the Sainte-Justine Head Trauma Pathway for children younger than two years of age

The Sainte-Justine Head Trauma Pathway helps physicians' decision-making in the evaluation of head trauma in young children. We evaluated the pathway to identify clinically important traumatic brain injury (ciTBI) among children younger than two years who presented to a pediatric emergency department for a head trauma. The primary outcome was ciTBI, defined as a TBI complicated by death, neurosurgery, intubation or hospitalization for more than one night. Among 2258 children, we reviewed the charts of all hospitalized children (n = 100) and a random sample of nonhospitalized children (n = 101) and found a ciTBI in 26 patients. The Sainte-Justine Head Trauma Pathway and the Pediatric Emergency Care Applied Research Network Pediatric Head Injury Prediction Rule both had a sensitivity of 96% (95% confidence interval 81%-100%). We found that the Sainte-Justine Head Trauma Pathway does not improve the identification of ciTBI among young children with head trauma.

Managing isolated head trauma in young children

See also page [1202][1] and [www.cmaj.ca/lookup/doi/10.1503/cmaj.150540][2] In a linked paper, Gravel and colleagues have developed and validated a clinical decision rule for the use of radiologic evaluation to identify skull fracture in young children following an isolated head trauma.[1][3] Head

Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma.

There is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography. We performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score < 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning. A total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%-99%) and a specificity of 86% (95% CI 84%-89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase. The clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%.

Variation in the use of skull radiographs by emergency physicians in young children with minor head trauma.

Minor head trauma in young children is a major cause of emergency department visits. Conflicting guidelines exist regarding radiologic evaluation in such cases. To determine the practice pattern among Canadian emergency physicians for ordering skull radiographs in young children suffering from minor head trauma. Physicians were also surveyed on their willingness to use a clinical decision rule in such cases. A self-administered email questionnaire was sent to all members of the Pediatric Emergency Research Canada (PERC) group. It consisted of clinical vignettes followed by multiple-option answers on the management plan. The study was conducted using the principles of the Dillman Tailored Design method and included multiple emailings to maximize the response rate. The research protocol received Institutional Review Board approval. A total of 158 of 295 (54%) PERC members responded. Most participants were trained in pediatric emergency medicine and assessed more than 500 children per year. Imaging management for the vignettes was highly variable: 6 of the 11 case scenarios had a proportion of radiograph ordering between 20 and 80%. Ninety-five percent of respondents stated that they would apply a validated clinical decision rule for the detection of skull fracture in young children with minor head trauma. The minimum sensitivity deemed acceptable for such a rule was 98%. Canadian emergency physicians have a wide variation in skull radiography ordering in young children with minor head trauma. This variation, along with the need expressed by physicians, suggests that further research to develop a clinical decision rule is warranted.

Abusive Head Trauma in Young Children

The objectives of this study were to provide population-based incidence estimate of abusive head trauma (AHT) in children aged 0 to 5 years from inpatient and emergency department (ED) and identify risk characteristics for recognizing high-risk children to improve public health surveillance. This was a retrospective cohort study based on children's first encounter in ED or hospital admission with a diagnosis of head trauma (HT), 2000-2010. The relationship between clinical markers and AHT was examined controlling for covariables in the model using Cox hazards regression. Kaplan-Meier incidence probability was plotted, and the number of weeks elapsing from date of birth to the first encounter with HT established the survival time (T). Twenty-six thousand six hundred eighty-one children had HT, 502 (1.8%) resulted from abuse; 42.4% was captured from ED. Incidence varied from 28.9 (95% confidence interval [CI], 27.9-37.4) in infants to 4.1 (95% CI, 2.4-5.7) in 5-year-olds per 100,000 per year. Adjusted hazard ratio was 20.3 (95% CI, 10.9-38.0) for intracranial bleeding and 11.4 (95% CI, 8.57-15.21) for retinal hemorrhage. Incidence estimates of AHT are incomplete without including ED. Intracranial bleeding is a cardinal feature of AHT to be considered in case ascertainment to improve public health surveillance.

Head injury and unclear mechanism of injury: Initial hematocrit less than 30 is predictive of abusive head trauma in young children

PurposeHead injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT. MethodsA retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002–2011. ResultsA total of 1129 patients (mean age 1.7±1.7years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤30% was predictive of AHT as the cause of injury (P<.0001), as was a platelet count of greater than 400,000 (P<.0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P<.05). ConclusionsIn the setting of head injury and unclear history of trauma, a hematocrit of ≤30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5years.

Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse

We investigated the prevalence of risk factors for and the prevalence of prior abuse in abusive head trauma victims in the Netherlands. We performed a retrospective file review of all abusive head trauma cases in the Netherlands in which forensic medical expertise was requested by the courts, between 2005 and 2010. Outcome measures were risk factors and indicators for prior abuse. Eighty-nine cases were included; 62% boys, median age 3.5months. Impact trauma was found in 48% of cases, with a male perpetrator in 79%. Prematurity, dysmaturity and twins/triplets were found in 27%, 23% and 10% of cases, respectively, maternal age under 20years in 17%. Of the parents, 60% had completed only primary or secondary education, 38% of the families were known to child welfare authorities. There was evidence for prior abuse in 81% of the cases. The high number of families with prior abuse indicates that both the healthcare system and child welfare authorities failed to protect some of the children that have been in their care. Our results highlight the importance of training healthcare and child welfare professionals in recognizing physical abuse, as well as the importance of optimizing abusive head trauma prevention strategies.

Descriptive factors of abusive head trauma in young children—United States, 2000–2009

ObjectiveAbusive head trauma (AHT) is a leading cause of severe injury in maltreated children in the United States. There is little research from nationally representative datasets available to characterize young children who had AHT compared to non-abusive head trauma (NAHT). MethodsUsing the recent CDC AHT case definition, we performed a retrospective analysis of 2000, 2003, 2006 and 2009 hospitalization data using the Kids’ Inpatient Database (KID) from the Healthcare Cost and Utilization Project. Logistic regression was used to compare AHT to NAHT patients <2 years of age. Socio-demographic data and indicators of socioeconomic status (i.e., insurance status and household income), presence of chronic conditions, injury severity (i.e., length of hospital stay and vital status), hospital specialization (i.e., hospital type), hospital region, and season of admission were used as independent variables. ResultsA weighted sample of 7,603 AHT and 25,339 NAHT patients was identified. National rates for AHT were 39.8 per 100,000 population for children <1 year and 6.8 per 100,000 population for children 1 year old. Compared to NAHT, children with AHT were more often <1 year of age (adjusted odds ratio [aOR]=2.66; 95% confidence interval [CI]: 2.35–3.01), male (aOR=1.10; 95% CI: 1.01–1.20), enrolled in Medicaid (aOR=2.78; 95% CI: 2.49–3.11), hospitalized longer (aOR=8.26; 95% CI: 7.24–9.43), died during hospitalization (aOR=5.12; 95% CI: 4.01–6.53), and seen at children's hospitals (aOR=1.97; 95% CI: 1.63–2.38) and hospitals outside the Northeast [aOR=2.65 (95% CI: 2.10–3.33) for the Midwest, 1.90 (95% CI: 1.52–2.38) for the South and 1.93 (95% CI: 1.45–2.57) for the West, respectively]. ConclusionsThe results confirm that injuries from AHT are more severe and more often lethal than other head injuries. Socioeconomically disadvantaged families with children <1 year are an important focus for primary prevention. The associations of AHT, compared to NAHT with hospital type and hospital region warrant further investigation. Referral or reporting patterns, or true differences in the incidence may contribute to the identified associations.

Abusive Head Trauma in Young Children

The objectives of this study were to provide population-based incidence estimate of abusive head trauma (AHT) in children aged 0 to 5 years from inpatient and emergency department (ED) and identify risk characteristics for recognizing high-risk children to improve public health surveillance. This was a retrospective cohort study based on children's first encounter in ED or hospital admission with a diagnosis of head trauma (HT), 2000-2010. The relationship between clinical markers and AHT was examined controlling for covariables in the model using Cox hazards regression. Kaplan-Meier incidence probability was plotted, and the number of weeks elapsing from date of birth to the first encounter with HT established the survival time (T). Twenty-six thousand six hundred eighty-one children had HT, 502 (1.8%) resulted from abuse; 42.4% was captured from ED. Incidence varied from 28.9 (95% confidence interval [CI], 27.9-37.4) in infants to 4.1 (95% CI, 2.4-5.7) in 5-year-olds per 100,000 per year. Adjusted hazard ratio was 20.3 (95% CI, 10.9-38.0) for intracranial bleeding and 11.4 (95% CI, 8.57-15.21) for retinal hemorrhage. Incidence estimates of AHT are incomplete without including ED. Intracranial bleeding is a cardinal feature of AHT to be considered in case ascertainment to improve public health surveillance.

Risk Factors for Abusive Head Trauma in Young Children — United States, 2000–2009

Risk Factors for Abusive Head Trauma in Young Children — United States, 2000–2009

What Findings Signal Abusive Head Trauma in Young Children

In a meta-analysis of studies that compared findings between hospitalized children aged ≤6 years with abusive head trauma and those with nonabusive head trauma, researchers identified clinical and radiographic characteristics associated with abuse. A total of 19 studies involving nearly 2000 patients were deemed high quality (defined as those in which …

Characteristics that Distinguish Abusive from Nonabusive Head Trauma Among Young Children Who Underwent Head Computed Tomography in Japan: Fujiwara T, Okuyama M, Miyasaka M. Pediatrics 2008;122;e841–7

This study from Japan sought to compare the characteristics of abusive and non-abusive head trauma in young children. A comparative case series study was performed involving a retrospective medical chart and social work record review of children 0–2 years of age who visited the National Center for Child Health and Development (Tokyo, Japan) from March 1, 2002 to December 31, 2005 and underwent computed tomography scanning due to suspected intracranial injury. Patients (n = 260) were identified and classified as having either abusive or non-abusive head trauma on the basis of the published definition.

Characteristics That Distinguish Abusive From Nonabusive Head Trauma Among Young Children Who Underwent Head Computed Tomography in Japan

Distinguishing abusive head trauma in young children from other diseases by symptoms is difficult in practice. Comparisons between abusive and nonabusive head trauma in young children in Japan, where computed tomography is widely and easily available, might contribute to identifying markers of abusive head trauma that differ from that in Western countries. The objective of this study was to compare the characteristics of abusive and nonabusive head trauma in young children in Japan. A comparative case series study involving a retrospective medical chart and social work record review of children who were aged 0 to 2 years, visited the National Center for Child Health and Development (Tokyo, Japan) from March 1, 2002, to December 31, 2005, and underwent computed tomography scanning because of suspected intracranial injury was performed. Patients (N = 260) were identified and classified as having either abusive or nonabusive head trauma on the basis of the published definition. Demographic and perinatal characteristics, injury history, clinical presentation, and outcomes were compared by using chi2 and Fisher's exact tests. Patients with abusive head trauma were significantly younger than patients with nonabusive head trauma and had a peak at approximately 2 to 4 and 7 to 9 months. Patients with abusive head trauma more likely presented no injury history by the caregiver, neurologic symptoms (unconsciousness, seizure, paralysis), subdural hemorrhage, and retinal hemorrhages. Although patients with abusive head trauma had severe clinical outcomes, only 32% of them were separated from the caregiver by social welfare services. This study highlights the several clinical markers to detect abusive head trauma at a medical visit, including an absence of injury history, neurologic symptoms, subdural hemorrhage, and retinal hemorrhage. These markers can be used to detect abusive head trauma cases by physicians and social welfare workers to protect children from additional abuse.

Abusive head trauma in young children: characteristics and medical charges in a hospitalized population

Objective: To describe the presenting characteristics, hospital course, and hospital charges associated with hospital admissions for head trauma in young children at a regional pediatric trauma center, and to examine whether these factors differ among abused and non-abused subjects. Method: Comparative case series study involving a retrospective medical record review of children less than 3 years of age admitted to Children's Hospital of Pittsburgh from January 1, 1995 to December 31, 1999. Subjects ( n = 377) were identified on the basis of ICD-9-CM codes for head injury. Subjects were classified as abused or non-abused based on standard criteria using information about the type of injuries, the history provided by the caretaker, and physical and radiographic findings. Results: Eighty nine (23.6%) subjects were classified as abused and 288 (76.4%) were classified as non-abused. Abused subjects were more likely then non-abused subjects to be <1 year of age (vs. >1 year of age) (OR: 9.8; 95% CI: 5.0, 19.2), covered by Medicaid (vs. commercial insurance) (OR: 2.8; 95% CI: 1.7, 4.8), and admitted to the ICU (OR: 3.5; 95% CI: 2.1, 5.8; p < .001). The caretakers of abused subjects were more likely to give a history of no trauma or minor trauma compared to the caretakers of non-abused subjects (97% vs. 54%, p < .001). Length of stay was significantly greater for abused subjects versus non-abused subjects (mean: 9.25 days vs. 3.03 days, p < .001). Hospital charges (1999 dollars) were significantly higher for abused (mean ± SD: $40,082 ± $58,004) versus non-abused (mean ± SD: $15,671 ± $41,777) subjects. Conclusions: These results highlight the differences in the demographics, presenting characteristics and economic impact of abusive head injuries compared to non-abusive head injuries.