Abusive Head Trauma Research Articles

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.

Early-Onset Ventilator-Associated Pneumonia in Pediatric Severe Traumatic Brain Injury.

Early-onset ventilator-associated pneumonia (VAP) is associated with poor outcomes in patients with severe traumatic brain injury (TBI). The primary aim of this study was to describe VAP, including the microbiology of VAP and differences in frequency of VAP when various definitions are applied. The secondary aim was to determine the clinical variables associated with the development of VAP in children with severe TBI. This is a retrospective cohort study at a quaternary referral children's hospital with a level I trauma center designation. Inclusion criteria were patients aged 0-18years admitted to the pediatric intensive care unit between 2015 and 2020 with severe TBI requiring at least 2days of invasive ventilation. VAP was defined by using Center of Disease Control (CDC) definition or clinical VAP, based on physician diagnosis. We compared general demographics, reviewed trauma and injury data, and outcomes to assess any differences between patients with VAP and non-VAP patients. Associations were tested with regression models. After applying all inclusion and exclusion criteria, 90 patients were included in the analysis. Patients with VAP were older (8.5 vs. 5.6years, P = 0.03). Patients with VAP were less likely to have suffered from abusive head trauma (P = 0.01). Patients who received continuous neuromuscular blockade or targeted temperature management did not have different frequencies of VAP. CDC-defined VAP was diagnosed in 27% of patients. Number of patients with VAP increased to 41% for physician-diagnosed or clinical VAP. Methicillin-sensitive Staphylococcus aureus was the most common isolate grown, followed by Hemophilus influenza, with most VAP occurring on days 2-5 of intubation. VAP was not associated with mortality but was associated with worse functional status scale in patients who survived to discharge (8 vs. 7.5, P = 0.048). Over a cumulative period of days, nebulized 3% and albuterol were associated with decreased incidence of VAP. Ventilator-associated pneumonia occurs commonly in children with severe TBI, with rates of 27-41%, depending on CDC-defined VAP or clinical VAP. The discrepancy between clinical VAP and CDC-defined VAP further illustrates the need for a standardized definition for VAP. Although most interventions were not associated with VAP, nebulized 3% saline and albuterol were associated with reduced incidence of VAP; future investigation is needed to determine whether mucolytic agents can decrease the rate of VAP in children with severe TBI.

Abusive Head Trauma in Child Maltreatment-Related Homicide Cases in the United States: An Analysis of the National Violent Death Reporting System Data- 2012–2017

Abusive Head Trauma in Child Maltreatment-Related Homicide Cases in the United States: An Analysis of the National Violent Death Reporting System Data- 2012–2017

Let’s make the most out of 2023!

Archives of Pediatric Neurosurgery, the official journal of the Brazilian Society of Pediatric Neurosurgery, was established in 2019 and, since then, has had exponential growth!
 From our first indexing at Google Academics to Latin American and Caribbean Health Sciences Literature (LILACS), in which we are in the final validation process, much has been built and worked in our journal.
 Since 2019 we received 117 papers and published 88 articles. In the last year, we had a rejection rate of 19% with 23 days to the first editorial decision.
 In 2022 we successfully experimented with a new formula, publishing two special issues with 10 papers in each: Craniofacial and Arachnoid cyst. 
 Besides that, 2022 was a year of international growth. This year we published many articles from China, Egypt, Malaysia, and Mexico!
 We also evolved in digital technology by inserting the platform in the "Lepidus" administrator and submission by FORMS, which improved the entire system's performance.
 
 On this special occasion, the editorial office would like to extend their greatest appreciation to all editors, and reviewers who have been supportive, and devoted much of their time and effort to nurturing APN. The journal, in particular, would like to thank the authors for submitting their papers to APN. The editorial board thanks you, and the work continues so that we can reach new indexing bases and consolidate as a reference in Word Pediatric neurosurgery. 
 
 Let's grow together!! 
 
 Happy New year and long life for everyone!
 
 Regard to the last 12 months:
 
 -MOST DOWNLOADED PDF ARTICLE: Jucá et al. Prenatal myelomeningocele repair: report of an inaugural case and considerations about the implementation of a new fetal neurosurgery program
 
 -MOST READ ABSTRACT: De Paula et al. Shaken Baby Syndrome: literature review in the last 5 years
 
 -2020-21 Impact factor 0.24

Awareness of parents about shaken baby syndrome in Makkah, Saudi Arabia

Awareness of parents about shaken baby syndrome in Makkah, Saudi Arabia

Unambiguous definition of ambiguous loss: Exploring conceptual boundaries of physical and psychological types through content analysis

The article aims to extend our understanding of physical and psychological types of ambiguous loss through a systematic review based on content and psycholinguistic analysis. The study encompassed articles aligned with ambiguous loss published between 2019-2023, retrieved from PsycINFO, Web of Science (WoS), and Scopus. To eliminate the bias in the literature review, the study extracted published articles, dissertations, book chapters, and preprints with titles containing the search term “ambiguous loss”. Two reviewers (the first and the third authors worked independently) examined titles and abstracts and identified papers highlighting physical (n=34) or psychological (n=23) types of ambiguous loss. The physical type results from physical absence of meaningful persons (e.g. abducted, missing, adopted), while the psychological type results from psychological absence of meaningful persons (e.g. dementia, mental illness, addiction). The study applies the conceptual and relational content analysis of Leximancer (version 4.5) to develop three cluster maps and lists of concepts separately for physical and psychological types and all selected papers published between 2019-2023. The results show that the physical type primarily encompasses situations related to adoption, potentially leading to the ambiguous loss experienced by both biological parents and children when facing forced separation. Psychological type includes parents of children with disabilities, shaken baby syndrome, and caregivers of individuals with brain injuries and cancer. The present study indicates that the conceptual boundaries between physical and psychological types of ambiguous loss are not only expanding but also erasing, giving way to new applications in settings such as the COVID-19 pandemic, organ donor families, and sexual and gender minority.

Evaluation of Mothers Knowledge about Shaken Baby Syndrome

Evaluation of Mothers Knowledge about Shaken Baby Syndrome

Battered baby syndrome

Battered child syndrome, shaken baby syndrome, non accidental injuries of childhood, etc. are all variants of forms of child abuse that has many names but a single outcome – the child is injured at the hands of perpetrators. A four- months old female child was brought to the hospital with multiple bruises, left upper and right lower limb swelling with an open wound over right leg. On detailed examination and investigations, multiple fractures found in radius, ulna & amp; humorous in left hand and fracture of femur with tibia epiphyseal separation in right leg. The etiology was unclear at presentation. History obtained from the mother and father, was of conflicting nature. Inter-caste love marriage of mother and father, poor family support, poverty, presence of multiple bruises over the body, blue black discoloration of skin over right leg with multiple fractures revealed in X - Ray scan lead to the diagnosis of bettered baby syndrome.

Evidence for significant misdiagnosis of abusive head trauma in pediBIRN data

Independently witnessed events are used as a reference standard to robustly categorize accidental or non-abusive head trauma (non-AHT) cases in the pediBIRN data set of acutely symptomatic infants with closed head injuries. Findings in such independently witnessed non-AHT cases are compared to findings in cases that were diagnosed as AHT but were not independently witnessed. The data shows that 14% of independently witnessed non-AHT cases are misdiagnosed as AHT, and that risk factors for misdiagnosis include acute encephalopathy, bilateral or interhemispheric SDH, and/or severe retinal hemorrhages, findings that are commonly associated with AHT. The data also shows that “dense retinal hemorrhages extending to the periphery” are not highly suggestive of AHT, as they also occur in independently witnessed non-AHT cases.

Why admitted cases of AHT make a low quality reference standard: A survey of people accused of AHT in France

Several influential articles that attempt to establish diagnostic methods for Abusive Head Trauma (AHT) use admitted cases as a reference standard. This study analyses a survey of people accused of AHT in France, to understand the environment and situations in which such admissions are made. Multiple reasons to question the reliability of admissions to AHT are demonstrated in the responses, including reduced sentences, the return of children to the family home, a desire to stop accusations being leveled at a partner and for legal proceedings to end. These factors must be considered in the context of proceedings that are long, expensive and stressful, leading to depression and financial hardship, and that seem to be inevitably heading towards conviction. The ineluctable conclusion is that admitted cases do not make a suitably reliable reference standard for undertaking scientific investigation, or for validating the diagnostic methods used for AHT.

Characterization of subdural collections in initial neuroimaging of abusive head trauma: Implications for forensic age diagnostics and clinical decision-making

PurposeSubdural collections (SDCs) represent a key finding in abusive head trauma (AHT), a serious form of child physical abuse. Common SDC entities in this context are subdural hematoma (SDH), subdural hygroma (SDHy), subdural hematohygroma (SDHHy), and chronic subdural hematoma (cSDH). The present study examines the prevalence of the different SDC entities and investigates the influence of the SDC diagnosis on the forensic age estimation of the injury. MethodsIn this retrospective multi-center study from three German university hospitals of a 10-year period, the initial neuroimaging material (CT or MRI) of 56 children (36 males, 20 females; age median 3.9 months) with medico-legally well-documented AHT was analyzed. SDCs were characterized by determining presence, location, extension, and visual appearance, by assigning to one of the five entities, and by categorizing with three different classification systems, one of which represents a novel system based on focality and Mixed Appearance Pattern and especially developed for children with AHT. The data were correlated with demographic and clinical data. By means of court files, AHT cases were also sub-divided into confession (n = 14) and non-confession cases (n = 42) and then compared. ResultsMost cases showed a multifocal presence of SDCs (96.4%) and the presence of a Mixed Appearance Pattern (82.1%). The most common SDC entity was the heterogeneous variant of the SDHHy (66.1%). The cSDH occurred infrequently only (3.6%). Our novel classification system illustrates that unifocal SDCs rarely occur in AHT, and that more complex SDC patterns are common. In nearly all cases (94.6%), additional signs of recently caused brain injury were present beside the SDCs. Comparison between confession and non-confession groups did not reveal any significant differences, indicating that the diagnostic criteria of AHT are robust. ConclusionsAlthough precise dating of SDCs based on initial neuroimaging alone remains unrealistic, the exact diagnosis of the SDC entity provide an important basis for differentiation between acute trauma and chronic post-traumatic state. Therefore, especially the confirmation or exclusion of subdural neomembranes, that define the cSDH, should be considered indispensable.

Awareness of Child Abuse and Neglect Among the General Public in Saudi Arabia: A Systematic Review.

Child abuse represents a serious problem worldwide. In Arab countries, the problem is complicated because abuse may be perceived as a method of discipline. This review aimed to describe awareness of the public in Saudi Arabia regarding child abuse. A search was performed in the databases of MEDLINE/PubMed, Scopus, Academic Search Complete (EBSCOhost), and Web of Science for articles published in English from the 1st of January, 2000, to the 14thof November, 2022.The search was conducted during the period from the 7thto the 14th of November 2022. The used search words were {"Child Abuse"} AND {"Saudi Arabia"} AND {"awareness"}. The risk of bias (ROB) was assessed using the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices. Six studies were included in this review. Most studies had high ROB in recruiting the participants, designing the questionnaires, and stating the rate of response. The awareness regarding physical abuse seemed fair in most studies, but the awareness about shaken baby syndrome was poor. Also, there was a misconception about the parent'srightto discipline their children through corporal punishment. Most participants did not perceive a need for establishing protective laws or programs. Public awareness about emotional abuse and neglect was lower than in cases of physical abuse. The overall knowledge about child abuse seems to be fair, but poor knowledge was observed in some forms, such as shaken baby syndrome. The public concepts about physical punishment and the need for protective laws and programs are also negative and require more efforts to alter them.

Neurointensive Care of Traumatic Brain Injury Patients Based on Coagulation and Fibrinolytic Parameter Monitoring.

Coagulopathy, a common complication of traumatic brain injury (TBI), is characterized by a hypercoagulable state developing immediately after injury, with hyperfibrinolysis and bleeding tendency peaking 3 h after injury, followed by fibrinolysis shutdown. Reflecting this timeframe, the coagulation factor fibrinogen is first consumed and then degraded after TBI, its concentration rapidly decreasing by 3 h post-TBI. The fibrinolytic marker D-dimer reaches its maximum concentration at the same time. Hyperfibrinolysis in the acute phase of TBI is associated with poor prognosis via hematoma expansion. In the acute phase, the coagulation and fibrinolysis parameters must be monitored to determine the treatment strategy. The combination of D-dimer plasma level at admission and the level of consciousness upon arrival at the hospital can be used to predict the patients who will "talk and deteriorate." Fibrinogen and D-dimer levels should determine case selection and the amount of fresh frozen plasma required for transfusion. Surgery around 3 h after injury, when fibrinolysis and bleeding diathesis peak, should be avoided if possible. In recent years, attempts have been made to estimate the time of injury from the time course of coagulation and fibrinolysis parameter levels, which has been particularly useful in some cases of pediatric abusive head trauma patients.

Shaken Baby Syndrome Education for Mothers Awaiting Appointments in Rural OB/GYN Office

ABSTRACT A partnership between a nursing program and a rural obstetric office provided education to pregnant and postpartum women about coping with infant crying and the dangers of shaking a baby. Undergraduate nursing students delivered the Period of PURPLE Crying (PURPLE) educational program to 148 mothers. Change in knowledge about infant crying and the community clinical experience was evaluated. Pre and post intervention data were collected. Descriptive statistics indicated higher scores on mothers’ posttest for knowledge about normal newborn crying behaviors and coping strategies. Students further developed the role of educator and researcher. These findings suggest the intervention contributed to mothers’ improved knowledge about infant crying. Results of the pilot study are encouraging because the intervention had a significant effect on mothers’ knowledge about infant crying and Shaken Baby Syndrome (SBS).

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.

Mild abusive head injury: diagnosis and pitfalls.

Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury.An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries.Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.

Identifying abusive head trauma and its mimics: diagnostic nuances.

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

Increased severity of abusive head trauma during the first year of the COVID-19 pandemic

BackgroundAbusive head trauma (AHT) is the leading cause of death from physical abuse in children. Reports regarding the impact of the COVID-19 pandemic on rates and severity of AHT are limited and with conflicting results. ObjectiveTo determine the number and clinical characteristics of AHT cases presenting to a pediatric tertiary care center during the first year of the COVID-19 pandemic compared to the two prior years. Participants and settingWe performed a retrospective cohort study of patients <5 years old diagnosed with AHT at a single pediatric tertiary care center over a three-year period. MethodsData were obtained for the pandemic year and two years before, including demographics, length of stay, physical and retinal examination findings, radiologic studies, electroencephalogram results, and mortality. ResultsThere were 27 cases of AHT during the first year of the pandemic and 55 during the two pre-pandemic years. Length of stay was similar for the two cohorts. The mortality rate was higher during the pandemic (29.6 % vs. 3.6 %; p < .01), as were the proportion of patients with retinal hemorrhages (84.6 % vs. 41.5 %; p < .01) and abnormal cervical spine imaging (52.6 % vs. 21.2 %; p = .02). There were no differences in age, sex, race, abnormalities on dermatological exam, skeletal surveys, and electroencephalograms. ConclusionsWe did not observe an increase in the number of patients with AHT during the pandemic but did see an increase in mortality, patients with retinal hemorrhages, and patients with abnormalities on cervical spine imaging. These data suggest a higher severity of AHT presenting to a pediatric tertiary care center during the pandemic.

Abusive head trauma, protocols, and legal concerns in a South American Country.

The abusive head trauma (AHT) is a form of child abuse and is a frequent entity all over de world. It is particularly unique among medical diagnoses because of the legal implications imposed by the diagnosis. Therefore, it has been the subject of much legal controversy over the decades. Knowledge of the clinical signs and imaging findings of abusive head trauma is vitally important for early diagnosis. An oriented anamnesis, as well as a complete physical examination and obtaining adequate images of the central nervous system, play a significant role in confirming the presumptive diagnosis. The interdisciplinary approach (pediatricians, neurosurgeons, neuroradiologists, social workers, and other specialists) is the key in the management of these patients. The purpose of this article is to familiarize the pediatric neurosurgeon with some of the more common medicolegal issues surrounding AHT as well as to discuss legal commitments and ethical obligations of the neurosurgeon in Argentina (South America) based on 2 clinical cases.

Skull Fracture Healing in Children Up to 36 Months - A Cohort Analysis

During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism.