Abusive Head Trauma In Infants Research Articles

Rapid Amplification of Cerebrospinal Fluid Pressure as a Possible Mechanism for Optic Nerve Sheath Bleeding in Infants With Nonaccidental Head Injury.

Subdural hemorrhage along the optic nerve (ON) is a histopathological indicator of abusive head trauma (AHT) in infants. We sought to determine if this bleeding could be caused by an abrupt increase in intracranial pressure transmitted to cerebrospinal fluid (CSF) at the optic foramen (OF). A theoretical model is developed to simulate the effect of a pressure perturbation of maximal amplitude P applied at the optic foramen for a short duration T on the CSF-filled ON subarachnoid space (ONSAS). The ONSAS is modelled as a fluid-filled channel with an elastic wall representing the flexible ONSAS-arachnoid/dura interface. A constitutive law describing the relationship between CSF pressure and ONSAS deformation is inferred from published measurements. CSF pressure profiles along the ONSAS are examined systematically over a broad range of P and T. The pressure perturbation initiated at the OF produces a pressure wave that stretches the ONSAS. This wave propagates rapidly along the ONSAS toward the scleral end of the ON, where it is reflected back toward the brain. For sufficiently small T a shock wave with amplification up to six times larger than P over a timescale of tens of milliseconds is observed at the scleral end of the ON. Comparatively smaller amplifications are observed for slower perturbations. A sudden increase in CSF pressure in the cranial cavity can cause a rapid expansion of the ONSAS, which may lead to rupture of the bridging blood vessels. Our study predicts a plausible mechanism for subdural hemorrhage that occurs in abusive head trauma in infants.

Shaking Up Our Approach: The Need for Characterization and Optimization of Pre-clinical Models of Infant Abusive Head Trauma.

Traumatic brain injuries (TBIs) are a large societal and individual burden. In the first year of life, the vast majority of these injuries are the result of inflicted abusive events by a trusted caregiver. Abusive head trauma (AHT) in infants, formerly known as shaken baby syndrome, is the leading cause of inflicted mortality and morbidity in this population. In this review we address clinical diagnosis, symptoms, prognosis, and neuropathology of AHT, emphasizing the burden of repetitive AHT. Next, we consider existing animal models of AHT, and we evaluate key features of an ideal model, highlighting important developmental milestones in children most vulnerable to AHT. We draw on insights from other injury models, such as repetitive, mild TBIs (RmTBIs), post-traumatic epilepsy (PTE), hypoxic-ischemic injuries, and maternal neglect, to speculate on key knowledge gaps and underline important new opportunities in pre-clinical AHT research. Finally, potential treatment options to facilitate healthy development in children following an AHT are considered. Together, this review aims to drive the field toward optimized, well-characterized animal models of AHT, which will allow for greater insight into the underlying neuropathological and neurobehavioral consequences of AHT.

Abusive head trauma in infants: An observational single centre study comparing developmental and functional outcome between 18 months and 5 years

BackgroundAbusive head trauma (AHT) is a major cause of traumatic brain injury in infancy. This exploratory study compared standardized developmental assessment versus functional outcome assessment between 18 months and 5 years of age following AHT in infancy. MethodsObservational cross-sectional study after surviving AHT in infancy. Seventeen children between 18 months and 5 years of age underwent clinical examination, developmental assessment using the Schedule of Growing Skills II (SGS II) and functional assessment using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds). Additional clinical information was extracted from medical records. ResultsAge at assessment ranged from 19 to 53 months (median 26 months). Most (n = 14) were delayed in at least 1 domain, even without neurological or visual impairment or visible cortical injury on neuroimaging, including 8 children with favourable GOS-E Peds scores. The most affected domain was hearing and language. Delay in the manipulative domain (n = 6) was associated with visual and/or neurological impairment and greater severity of delay across multiple domains. Eleven (64.7 %) had GOS-E Peds scores indicating good recovery, with positive correlation between GOS-Peds scores and number of domains delayed (r = 0.805, p < 0.05). ConclusionThe SGS-II detects behavioural and cognitive deficits not picked up by the GOS-E Peds. Combining both tools for assessment of AHT survivors under 5 years of age provides a comprehensive profile which addresses multiple domains of development and function, facilitating targeted intervention. Detection of developmental problems in the majority of survivors makes AHT prevention a public health priority.

Blood proteome of Acute Intracranial Hemorrhage in infant victims of Abusive Head Trauma.

Abusive head trauma (AHT) is a leading cause of mortality and morbidity in infants. While the reported incidence is close to 40 cases per 100'000 births/year, misdiagnoses are commonly observed in cases with atypical, subacute or chronic presentation. Currently, standard clinical evaluation of inflicted intracranial hemorrhagic injury (ICH) in infants urgently requires a screening test able to identify infants who need additional investigations. Blood biomarkers characteristic of AHT may assist in detecting these infants, improving prognosis through early medical care. To date, the application of innovative omics technologies in retrospective studies of AHT in infants is rare, due also to the blood serum and cerebrospinal fluid of AHT cases being scarce and not systematically accessible. Here, we explored the circulating blood proteomes of infants with severe AHT and their atraumatic controls. We discovered 165 circulating serum proteins that display differential changes in AHT cases compared with atraumatic controls. The peripheral blood proteomes of pediatric AHT commonly reflect: i) potentially secreted proteome from injured brain, and ii) proteome dysregulated in the system's circulation by successive biological events following acute ICH. This study opens up a novel opportunity for research efforts in clinical screening of AHT cases. This article is protected by copyright. All rights reserved.

BENIGN ENLARGEMENT OF SUBARACHNOID SPACES IN INFANTS

Benign enlargement of subarachnoid spaces (BESS) constitutes is one of the most frequent neurosonographic findings in infancy and is considered to regress spontaneously by the age of 2 years. Although the majority of children with BESS demonstrate normal developmental milestones, some patients may experience a transient psychomotor delay under the age of 2 year. Besides clinical andneuroimaging findings, the long-term impact of BESS is of great interest (learning difficulties at school, language delay, impairmentsin social-cognitive abilities, reduced quality of life, decreased attention skills and poor visual-motor performance, increased risk ofautism spectrum disorders as well as a higher incidence of epilepsy). It is considered that the risk of long-term consequences may be associated with pathogenetic features of dilation of extra-axial cerebrospinal fluid spaces. In this review, we describe potentialpathogenetic mechanisms of dilatation of the subarachnoid space and its pathological sequelae in children. Generally, numerous pathogenetic hypotheses about developing BESS have been proposed as follows: remarkable physiological imbalance between the skull and brain growth in infants aged from three months to one year; manifestation of cerebral trophy; communicating hydrocephalus due to a distal block with a valve mechanism; a delay in maturation of arachnoid villi/granulations until two years of age; the result of abusive head trauma in infants. However, the hypothesis about pathological consequences of BESS in the long run due to abnormalvenous hemodynamics has emerged in recent years. Impaired venous outflow is the main driving factor of subarachnomegaly and the more severe pathological changes the more significant symptoms of subarachnomegaly. We also highlight the role of impaired cerebralvenous circulation in the development of subarachnomegaly. Further studies are needed to investigate the clinical relevance of chronic increased intracranial pressure due to venous outflow disturbance in infants with enlarged subarachnoid spaces.Тhe subject for future research should be to determine a diagnostic algorithm to help distinguish patients with BESS from those who are at risk of impairedneurological development and require additional diagnostic and therapeutic interventions.

Educational interventions to prevent paediatric abusive head trauma in babies younger than one year old: A systematic review and meta-analyses

BackgroundPaediatric abusive head trauma (AHT) occurs in young children due to violent shaking or blunt impact. Educational and behavioural programmes modifying parent/infant interactions may aid primary prevention. This systematic review aims to assess the effectiveness of such interventions to prevent AHT in infants. MethodsWe searched Embase, MEDLINE, PsycINFO, The Cochrane library, CINAHL databases and trial registries to September 2021, for studies assessing the effectiveness of educational and behavioural interventions in preventing AHT. Eligible interventions had to include messaging about avoiding or dangers of infant shaking. Randomised controlled trials (RCTs) reporting results for primary (AHT, infant shaking) or secondary outcomes (including parental responses to infant crying, mental wellbeing), and non-randomised studies (NRSs) reporting primary outcomes were included. Evidence from combinable studies was synthesised using random-effects meta-analyses. Certainty of evidence was assessed using GRADE framework. PROSPERO registration CRD42020195644. FindingsOf 25 identified studies, 16 were included in meta-analyses. Five NRSs reported results for AHT, of which four were meta-analysed (summary odds ratio [OR] 0.95, 95 % confidence intervals [CI] 0.80–1.13). Two studies assessed self-reported shaking (one cluster-RCT, OR 0.11, 95 % CI 0.02–0.53; one cohort study, OR 0.36, 95 % CI 0.20–0.64, not pooled). Meta-analyses of secondary outcomes demonstrated marginal improvements in parental response to inconsolable crying (summary mean difference 1.58, 95 % CI 0.11–3.06, on a 100-point scale) and weak evidence that interventions increased walking away from crying infants (summary incidence rate ratio 1.52, 95 % CI 0.94–2.45). No intervention effects were found in meta-analyses of parental mental wellbeing or other responses to crying. InterpretationLow certainty evidence suggests that educational programmes for AHT prevention are not effective in preventing AHT. There is low to moderate certainty evidence that educational interventions have no effect or only marginally improve some parental responses to infant crying.

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

The COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse. To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic. 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. 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. 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. 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.

Abusive Head Trauma in Infants and Children in Japan

Subdural hematoma in infants can be caused by abuse, and is thought to be more likely if subdural hematoma is associated with retinal hemorrhage and cerebral edema. In Japan, few doctors disagree that cases of subdural hematoma with retinal hemorrhage and cerebral edema with multiple findings on the body are more likely to have been caused by abuse rather than by household accident. On the other hand, in cases where there are no other significant physical findings, only subdural hematoma and retinal hemorrhage, there is a difference of opinion as to whether the injury was caused by an accident or abuse. The reason for this is that neurosurgeons in Japan promoted the concept that infants can develop subdural hematomas and retinal hemorrages due to minor trauma at home before the concept of abusive head trauma became known. In addition, the age distribution of subdural hematomas in Japan differs from that in other countries, with peaks at around 8 months, and the reason for this remains unclear. Therefore, the etiology of infant subdural hematoma in Japan needs to be investigated in greater detail.

Abusive Head Trauma in Infants and Children: Identifying Presenting Variables Associated With Outcome

Despite the high incidence of AHT, study of these patients is largely limited to descriptors of small cohorts identified retrospectively. Age at the time of inflicted injury and presenting Glasgow Coma Score (GCS) are reported as variables predictive of poor outcome at discharge.

The impact of the consensus statement on abusive head trauma in infants and young children.

It seems paradoxical that facts, data and science are still considered controversial despite the harrowing death of a multitude of people from coronavirus disease 2019 (COVID-19), an unparalleled health care crisis of our lifetime. In addition, while scientists are desperately attempting to produce a vaccine for COVID-19, a large segment of the populace still believes in conspiracies related to vaccines. Therefore, it is not surprising that the diagnosis of abusive head trauma (AHT) faces similar challenges — the difference being that AHT challenges are mostly in the realms of law courts rather than actual clinical management of these infants. Against this backdrop, the Child Abuse Imaging Committee of the Society for Pediatric Radiology (SPR) collaborated with other leading experts to develop the consensus statement on AHT. This consensus statement has had a significant impact since its publication. It is now endorsed by 17 multinational, multidisciplinary organizations. The consensus statement has helped educate the diverse stakeholders of AHT and has helped further our understanding of AHT and the issues related to it. This could serve as the template for developing future consensus documents.

The Effect of Impact Angle and Fall Height on Skull Fracture Patterns in Infants.

Skull fracture is a common finding for both accidental and abusive head trauma in infants and young children, and may provide important clues as to the energy and directionality of the event leading to the skull fracture. However, little is understood regarding the mechanics of skull fracture in the pediatric skull, and how accidental fall parameters contribute to skull fracture patterns. The objectives of this research were to utilize a newly developed linear elastic fracture mechanics finite element model of infant skull fracture to investigate the effect of impact angle and fall height on the predictions of skull fracture patterns in infants. Nine impact angles of right parietal bone impacts were simulated from three different heights onto a rigid plate. The average ± standard deviation of the distance between the impact location and fracture initiation site was 8.0 ± 5.9 mm. Impact angle significantly affected the fracture initiation site (p < 0.0001) and orientation (p < 0.0001). A 15 deg variation in impact angle changed the initiation site up to 47 mm. The orientation of the fracture pattern was dependent on the impact location and ran either horizontal or vertical toward the ossification center of the bone. Fall height significantly affected the fracture length (p = 0.0356). Specifically, at the same impact angle, a 0.3 m increase in fall height increased the skull fracture length by 21.39 ± 34.26 mm. These data indicate that environmental variability needs to be carefully considered when evaluating infant skull fracture patterns from low-height falls.

Early developmental, behavioral, and quality of life outcomes following abusive head trauma in infants

BackgroundDevelopmental delays following pediatric abusive head trauma are common. ObjectiveTo assess early developmental, behavioral, and quality of life outcomes following infant abusive head trauma and evaluate injury severity and early therapeutic intervention as potential predictors. Participants and settingInfants under 12 months old who were admitted to a large pediatric hospital with abusive head trauma between October 2010 and October 2017 and followed at a multidisciplinary post-injury clinic were included. MethodsInjury severity groups were classified based on days in the Pediatric Intensive Care Unit. Participation in early intervention services and/or physical or occupational therapy by the first clinic visit was documented. Development was assessed using the Mullen Scales of Early Learning, which 47 patients completed at approximately 6 month intervals up to 3 years of age (an average of 19 months post-injury). Behavior and quality of life were assessed around age 2 using the Child Behavior Checklist (n = 24) and PedsQL™ (n = 27), respectively. ResultsOverall cognitive development, fine motor function, and expressive language significantly declined with age up to 3 years (p < 0.05). The changes in these developmental scales with age differed significantly between injury severity groups (p < 0.05). Internalizing behaviors were also greater in patients with moderate than mild injuries (t = 2.37, p = 0.037). Quality of life was comparable to healthy populations. Early therapeutic intervention was not significantly associated with developmental, behavioral, or quality of life outcomes (p > 0.05). ConclusionsLong-term comprehensive follow-up is recommended for children following abusive head trauma, as developmental delays and behavioral problems may present at later ages.

Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma

Case PresentationAn eight-week-old infant presented to the emergency department in cardiac arrest. Return of spontaneous circulation was obtained and the patient subsequently began seizing. Point-of-care ultrasound of the anterior fontanelle revealed an extra-axial fluid collection consistent with subdural hematoma (SDH).DiscussionAbusive head trauma is still frequently missed on initial presentation. In addition to validated screening clinical prediction rules, point-of-care cranial ultrasound can be used as a noninvasive adjunct for detection of SDH related to abusive head trauma in infants with an open fontanelle.

Abusive Head Trauma in Infants: Incidence and Detection of Prior Brain Injury

Diagnosis of abusive head trauma (AHT) is challenging; clinical signs are non‐specific and perpetrator confessions are rare. Moreover, many infants sustain multiple episodes of abuse before presenting to medical practitioners. The objective of this study was to quantify the incidence of prior presentations with features of brain injury in AHT, and to compare these figures to those in non‐abusive head trauma (non‐AHT). Data on children under the age of two years who were assessed for AHT by the Child Protection Unit of Sydney Children's Hospital between 2008 and 2017 were collected, and AHT cases were compared with non‐abusive cases. Of the 167 cases assessed for head trauma, 26 per cent had at least one prior presentation to medical care. This was 42 per cent of the AHT cases, and 11 per cent of the non‐AHT cases. Odds ratio calculations revealed infants with AHT were 5.7 times more likely to have had a prior presentation than children with non‐AHT (CI = 2.4–13.17, p &lt; 0.001). Infants with AHT are much more likely than infants with non‐AHT to have presented previously to medical practitioners. This difference suggests that there is an early diagnostic window within which abuse can be detected before it continues or escalates. Careful evaluation of an infant is of paramount importance, and may save a life.‘[Aims] to quantify the incidence of prior presentations with features of brain injury in AHT, and to compare these figures to those in non‐abusive head trauma’Key Practitioner Messages Medical practitioners should consider the possibility of brain injury in a child presenting with non‐specific symptoms, and consider that this brain injury could be abusive in nature. Suspicions of abusive head trauma should be increased if the child has presented with signs consistent with brain injury before. Suspicions of abusive head trauma should be increased if there is no mechanism of an injury provided by the child's carer.

Impact of the Take 5 Safety Plan for Crying on the Occurrence of Abusive Head Trauma in Infants

Since 2008, medical providers have offered the Take 5 Safety Plan for Crying (Take 5) to caregivers of newborns at Yale New Haven Hospital (YNHH); it focuses on five steps to manage caregiver frustration with infant crying and to prevent a caregiver from hurting an infant. We sought to determine whether Take 5 reduced the occurrence of abusive head trauma (AHT). Using a case–control design, we reviewed the Electronic Medical Records (EMRs) of infants younger than 12 months old who were admitted to YNHH with a head injury from June 2008 to June 2017, were evaluated by the Child Abuse Service and were born at YNHH. Cases had a diagnosis of AHT, and controls had a diagnosis of non‐abusive head trauma. Exposure to Take 5 was based on documentation in the EMR at newborn hospital discharge. We used Firth's penalised likelihood logistic regression to calculate unadjusted and adjusted odds ratios (AORs). Of the cases, 11.1 per cent received Take 5 vs. 47.1 per cent of controls. In the adjusted models, we found that infants whose caregivers received Take 5 were 79 per cent less likely to have suffered AHT (AOR 0.21, 95% CI 0.02–0.99). These results suggest that Take 5 has the potential to prevent AHT in infants.‘We sought to determine whether Take 5 reduced the occurrence of abusive head trauma’Key Practitioner Messages Abusive head trauma (AHT) is an extreme form of child abuse. Crying is often a trigger for a caregiver to shake an infant, resulting in AHT. Safety planning for caregiver frustration with infant crying can help reduce the likelihood of AHT.

Abusive Head Trauma in Infants and Children.

Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.

Abusive head trauma in infants and children

Abusive head trauma in infants and children

Outside the Echo Chamber: A Response to the 'Consensus Statement on Abusive Head Trauma in Infants and Young Children'

Since the 1980s, thousands of parents and caretakers have been convicted of criminal offenses or had their children taken from them based on a forensic medical diagnosis known as Shaken Baby Syndrome (SBS) or Abusive Head Trauma (AHT). The diagnosis has become very controversial, yet continues to be made by pediatric physicians and utilized in court. A recent paper, titled as a “Consensus Statement on Abusive Head Trauma in Infants and Young Children,” argues there is no legitimate controversy over the diagnosis and seeks to reassure courts that the diagnosis is reliable. This response to the Consensus Statement demonstrates that the diagnosis is indeed highly controversial in the medical and scientific communities and that its key premises are uncertain or unreliable. Accordingly, courts should carefully scrutinize any case or testimony based on the diagnosis.

Consensus Statement: Abusive Head Trauma in Infants and Young Children.

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic–ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

Consensus statement on abusive head trauma in infants and young children.

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.