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.

A challenging decision for emergency physicians: Routine repeat computed brain tomography of the brain in head trauma in infants and neonates.

Head trauma is a leading cause of death and disability. While standard treatment protocols exist for severe head trauma, no clear follow-up standards are available for mild head trauma with positive imaging findings in infants and newborns. Although routine follow-up brain computed tomography (CT) imaging is not recommended for children with moderate and mild head trauma, the necessity for follow-up imaging in infants and newborns remains uncertain. Our study is a retrospective, observational, and descriptive study. Infants under 1 year old presenting to the emergency department with isolated head trauma were reviewed with the approval of the Ethics Committee of Ankara Etlik City Hospital. Inclusion criteria included presentation to the emergency department, undergoing more than one brain CT scan, and sustaining mild head trauma (Glasgow Coma Scale [GCS] >13). Patients with incomplete follow-up data or multiple traumas were excluded. Age, gender, mechanism of trauma, initial and follow-up brain CT findings, hospital admission, and surgical procedures were recorded and analyzed using the SPSS statistical package. Out of 238 screened patients, 154 were included in the study. Of these, 66.9% were male and the average age was 5.99 months. The most common presenting symptom was swelling at the trauma site, observed in 79.2% of cases. The most common mechanism of injury was falling from a height of less than 90 cm, accounting for 85.1% of cases. Pathological progression on follow-up CT was observed in 5.2% of the patients, and only 1.9% required surgical treatment. A total of 34.4% of the patients required hospitalization. Patients with parenchymal brain pathology had a higher rate of pathological progression on follow-up CT and a longer hospital stay. Follow-up CT scans in infants with mild head trauma do not alter patient outcomes except in cases with brain parenchymal pathology. Study data indicated that repeat imaging is not beneficial for isolated skull fractures. Imaging artifacts often necessitated repeated scans, contributing to increased radiation exposure. Unnecessary repeat imaging escalates radiation exposure and healthcare costs. Only a small percentage of patients exhibited progression of intracranial pathology, justifying follow-up imaging solely in the presence of brain parenchymal injury. Larger prospective studies are necessary to confirm these findings.

RAM Cannula versus Short Binasal Prongs for Non-invasive Ventilation in Preterm Infants: An Updated Systematic Review and Meta-analysis.

To compare the efficacy and safety of RAM cannula with short binasal prongs (SBPs) as nasal interfaces in preterm infants requiring nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV). The authors searched electronic databases (Medline, Embase, and Web of Science) and trial registries from inception until March 15, 2024, for randomized controlled trials (RCTs) comparing the RAM cannula with SBP for delivering nCPAP/NIPPV. They performed a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was failure of nCPAP/NIPPV. Secondary outcomes included nasal injury, mechanical ventilation, air leaks, and mortality. Five RCTs (825 participants) were included. There was no significant difference in nCPAP/NIPPV failure (RR: 1.04; 95%CI: 0.58 to 1.87) or the need for invasive mechanical ventilation (RR: 1.23; 95%CI: 0.75 to 2.01) between the RAM cannula and SBP groups (low to very low certainty). Compared with infants in the SBP group, those in the RAM cannula group had a significantly lower incidence of moderate to severe nasal injury [(5 RCTs, 825 participants; RR: 0.34; 95%CI: 0.18 to 0.66); low certainty] and any nasal injury [(RR: 0.44; 95%CI: 0.26 to 0.76; very low certainty)]. There was no significant difference in the other clinical outcomes. In comparison to SBP, the RAM cannula may have little to no effect on nCPAP/NIPPV failure, but the evidence is very uncertain. Low-certainty evidence suggests that the use of RAM cannula possibly results in reduction in moderate to severe nasal trauma in preterm infants receiving nCPAP/NIPPV.

Identifying skull fractures after head trauma in infants with ultrasonography: is that possible?

Management of pediatric head trauma requires a delicate balance between accuracy and safety, with a dual emphasis on prompt diagnosis while minimizing radiation exposure. Ultrasonography (US) shows promise in this regard. A case study involving a 10-month-old infant with acute right parietal swelling revealed the utility of US in detecting a corresponding hypoechoic lesion, along with an underlying suspected fracture line of the vault and subdural hematoma. Subsequent CT confirmed the fracture, while MRI confirmed the subdural hematoma. At one-month follow-up, MRI demonstrated hematoma reabsorption, while US revealed a bone callus in its advanced phase. Although US is not yet standard practice for pediatric head trauma, its ability to detect fractures in infants suggests its potential role: when a fracture is evident on US, it may serve as an indication to perform neuroimaging. Potentially, adoption of US could contribute to mitigation of children’s exposure to ionizing radiation.

Evidence-based advances in minimally invasive surgery in infants with congenital gastrointestinal anomalies: a narrative review.

Minimally invasive surgery (MIS) has been widely utilized to manage congenital gastrointestinal (GI) anomalies in children during the last two decades. Currently, MIS has a proven track-record for its feasibility and provides multiple benefits including better cosmesis, less trauma, and faster recovery in neonates and infants. However, it remains controversial whether MIS provides better definitive outcomes in pediatric patients with GI anomalies, especially among neonates. We aim to review the recent developments of MIS in infants with GI defects, assisting surgeons in making decisions and improving patient outcomes. A comprehensive literature search of PubMed and Web of Science's core collection was performed using terms of MIS techniques and congenital GI anomalies. This review summarizes recent evidence-based advances of MIS in infants with congenital GI defects and potential future strategies based on evidence. Better cosmetic results, less postoperative pain, and an accelerated recovery have been shown to be common advantages of MIS relative to open approaches. Technical hurdles and metabolic disturbance were reported to be the main reasons for the decisions of open approach. Advanced techniques of MIS have made more precise manipulations and better outcomes possible, even for newborns. At the same time, surgeons should not be afraid to use an open approach in certain circumstances due to technical limitations or patient tolerance. The difficulty infants face in expressing their true feelings underscores the need for systematic and objective assessment tools to evaluate surgical outcomes.

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.

Infantile traumatic pericallosal aneurysm: illustrative case.

Traumatic aneurysms are a rare sequela of nonaccidental head trauma in infants. The rate of nonaccidental trauma (NAT) in the pediatric population is increasing; therefore, traumatic aneurysms are an important consideration in the evaluation of pediatric patients with abusive head trauma. A 24-day-old infant with no significant past medical or birth history presented with twitching and poor oral intake for 1 day. The patient was found to have bilateral subdural hematomas, multifocal contusions, and traumatic subarachnoid hemorrhage. NAT work-up was remarkable for a period of repeated and prolonged abuse. Magnetic resonance angiography revealed a right pericallosal traumatic aneurysm that was treated by means of coil and Onyx embolization. Traumatic intracranial aneurysms are a rare but serious sequela of pediatric abusive trauma. Traumatic intracranial aneurysms should be considered in the setting of intracranial pathology associated with high-energy trauma. Despite new methods for the management of traumatic aneurysms, this pathology remains challenging to identify and treat, and the prognosis remains poor because of the diffuse injury often involved in these patients.

Development of A Micro-CT Scanner with Dual-Energy Option and Endovascular Contrast Agent Administration Protocol for Fetal and Neonatal Virtual Autopsy.

The rate of parental consent for fetal and perinatal autopsy is decreasing, whereas parents are more likely to agree to virtual autopsy by non-invasive imaging methods. Fetal and perinatal virtual autopsy needs high-resolution and good soft-tissue contrast for investigation of the cause of death and underlying trauma or pathology in fetuses and stillborn infants. This is offered by micro-computed tomography (CT), as opposed to the limited resolution provided by clinical CT scanners, and this is one of the most promising tools for non-invasive perinatal postmortem imaging. We developed and optimized a micro-CT scanner with a dual-energy imaging option. It is dedicated to post-mortem CT angiography and virtual autopsy of fetuses and stillborn infants in that the chamber can be cooled down to around 5 °C; this increases tissue rigidity and slows decomposition of the native specimen. This, together with the dedicated gantry-based architecture, attempts to reduce potential motion artifacts. The developed methodology is based on prior endovascular injection of a BaSO4-based contrast agent. We explain the design choices and considerations for this scanner prototype. We give details of the treatment of the optimization of the dual-energy and virtual mono-energetic imaging option that has been based on minimizing noise propagation and maximizing the contrast-to-noise ratio for vascular features. We demonstrate the scanner capabilities with proof-of-concept experiments on phantoms and stillborn piglets.

Modeling of inflicted head injury by shaking trauma in children: what can we learn? : Update to parts I&II: A systematic review of animal, mathematical and physical models.

Inflicted shaking trauma can cause injury in infants, but exact injury mechanisms remain unclear. Controversy exists, particularly in courts, whether additional causes such as impact are required to produce injuries found in cases of (suspected) shaking. Publication rates of studies on animal and biomechanical models of inflicted head injury by shaking trauma (IHI-ST) in infants continue rising. Dissention on the topic, combined with its legal relevance, makes maintaining an up-to-date, clear and accessible overview of the current knowledge-base on IHI-ST essential. The current work reviews recent (2017-2023) studies using models of IHI-ST, serving as an update to two previously published reviews. A systematic review was conducted in Scopus and PubMed for articles using animal, physical and mathematical models for IHI-ST. Using the PRISMA methodology, two researchers independently screened the publications. Two, five, and ten publications were included on animal, physical, and mathematical models of IHI-ST, respectively. Both animal model studies used rodents. It is unknown to what degree these can accurately represent IHI-ST. Physical models were used mostly to investigate gross head-kinematics during shaking. Most mathematical models were used to study local effects on the eye and the head's internal structures. All injury thresholds and material properties used were based on scaled adult or animal data. Shaking motions used as inputs for animal, physical and mathematical models were mostly greatly simplified. Future research should focus on using more accurate shaking inputs for models, and on developing or and validating accurate injury thresholds applicable for shaking.

Femoral fractures and abuse in children under 36 months old: a Swiss case series.

Abuse should be suspected in infant femoral fractures without significant trauma, especially if the child is non-ambulatory. Review the epidemiological and radiological characteristics of femoral fractures in children under 36 months old to identify those potentially related to child abuse. Cases involving 102 patients presenting with 103 femoral fractures between January 1990 and December 2020 were investigated, paying close attention to mechanisms of injury, fracture patterns, and their possible relations to child abuse. The annual incidence of femoral fractures in patients under 36 months old was estimated at 24.6 per 100 000; the incidence in infants under 13 months was significantly higher than among children between 13 and 36 months old. Most infants under 13 months suffered from transverse or oblique metaphyseal/diaphyseal fractures (93.2%), whereas 67.8% of older children presented with spiral shaft fractures. Data confirmed child abuse in 4.9% of all patients (one with bilateral fractures); femoral fractures were incompatible with their reported mechanisms of injury in 31 patients (30.4%), whereas 12 fractures (11.8%) occurred in unexplained circumstances. More than 50% of femoral fractures occurred with low-energy trauma. The difference in patterns according to patients' ages suggested different mechanisms of trauma in ambulatory and non-ambulatory infants. Confirmed abuses and unclear or inconsistent mechanisms of trauma, raised potential total child abuse cases to 47.1% of our cohort. Level of evidence: Level IV.

Inflicted head-injury by shaking-trauma in infants: the importance of spatiotemporal variations of the head’s rotation center

Inflicted head injury by shaking trauma (IHI-ST) in infants is a type of abusive head trauma often simulated computationally to investigate causalities between violent shaking and injury. This is commonly done with the head’s rotation center kept fixed over time. However, due to the flexibility of the infant’s neck and the external shaking motion imposed by the perpetrator it is unlikely that the rotation center is static. Using a test-dummy, shaken by volunteers, we demonstrated experimentally that the location of the head’s rotation center moves considerably over time. We further showed that implementation of a spatiotemporal-varying rotation center in an improved kinematic model resulted in strongly improved replication of shaking compared to existing methods. Hence, we stress that the validity of current infant shaking injury risk assessments and the injury thresholds on which these assessments are based, both often used in court cases, should be re-evaluated.

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.

Burn trauma in infants

BackgroundA wealth of data exists concerning pediatric burn epidemiology in general, but more is explicitly needed in infants under 1 year of age, a particular group in which mobility begins to develop.MethodsIn this study,206 patients followed up for burns in Diyarbakır Gazi Yaşargil Training and Research Hospital Burn Center between January 2016 and September 2021 were included in the study.ResultsOf the patients, 120 (58.3%) were male, and 86 (41.7%) were female. The mean age was 10.0 ± 2.0 months. The total number of cases ranged from 3 to 12 months, with the incidence of burns peaking at 12 months.When we look at the etiology of burns, scalding burns were the most common, with 184 (89.3%) cases. Most of the burns occurred in the kitchen because their mothers and children spent a lot of time there.It was positive in 23.8% of the wound culture results obtained with a punch biopsy. Staphylococcus aureus was the most abundant microorganism in wound culture results, with 5.8%. The mean hospital stay of the patients was 4.99 ± 3.67 days. Our mortality rate was 1.94% (n:4).ConclusionIn conclusion, As preventive measures, it is necessary to increase protective measures at home and to raise awareness of families about burn etiologies.

Repeated mild closed head injury in neonatal rats results in sustained cognitive deficits associated with chronic microglial activation and neurodegeneration.

Abusive head trauma in infants is a consequence of multiple episodes of abuse and results in axonal injury, brain atrophy, and chronic cognitive deficits. Anesthetized 11-day-old rats, neurologically equivalent to infants, were subjected to 1 impact/day to the intact skull for 3 successive days. Repeated, but not single impact(s) resulted in spatial learning deficits (p < 0.05 compared to sham-injured animals) up to 5 weeks postinjury. In the first week following single or repetitive brain injury, axonal and neuronal degeneration, and microglial activation were observed in the cortex, white matter, thalamus, and subiculum; the extent of the histopathologic damage was significantly greater in the repetitive-injured animals compared to single-injured animals. At 40 days postinjury, loss of cortical, white matter and hippocampal tissue was evident only in the repetitive-injured animals, along with evidence of microglial activation in the white matter tracts and thalamus. Axonal injury and neurodegeneration were evident in the thalamus up to 40 days postinjury in the repetitive-injured rats. These data demonstrate that while single closed head injury in the neonate rat is associated with pathologic alterations in the acute post-traumatic period, repetitive closed head injury results in sustained behavioral and pathologic deficits reminiscent of infants with abusive head trauma.

Minor head trauma in infants — how accurate is cranial ultrasound performed by trained radiologists?

Correct management of infants after minor head trauma is crucial to minimize the risk to miss clinically important traumatic brain injury (ciTBI). Current practices typically involve CT or in-hospital surveillance. Cranial ultrasound (CUS) provides a radiation-free and fast alternative. This study examines the accuracy of radiologist-performed CUS to detect skull fracture (SF) and/or intracranial hemorrhage (ICH). An inconspicuous CUS followed by an uneventful clinical course would allow exclusion of ciTBI with a great certainty. This monocentric, retrospective, observational study analyzed CUS in infants (< 12 months) after minor head trauma at Bern University Children’s Hospital, between 7/2013 and 8/2020. The primary outcome was the sensitivity and specificity of CUS in detecting SF and/or ICH by comparison to the clinical course and to additional neuroimaging. Out of a total of 325 patients, 73% (n = 241) had a normal CUS, 17% (n = 54) were found with SF, and ICH was diagnosed in 2.2% patients (n = 7). Two patients needed neurosurgery and three patients deteriorated clinically during surveillance. Additional imaging was performed in 35 patients. The sensitivity of CUS was 93% ([0.83, 0.97] 95% CI) and the specificity 98% ([0.95, 0.99] 95% CI). All false-negative cases originated in missed SF without clinical deterioration; no ICH was missed. Conclusion: This study shows high accuracy of CUS in exclusion of SF and ICH, which can cause ciTBI. Therefore, CUS offers a reliable method of neuroimaging in infants after minor head trauma and gives reassurance to reduce the duration of in-hospital surveillance.What is Known:• Minor head trauma can cause clinically important traumatic brain injury in infants, and the management of these cases is a challenge for the treating physician. • Cranial ultrasound (CUS) is regularly used in neonatology, but its accuracy after head trauma in infants is controversial. What is New:• CUS performed by a trained radiologist can exclude findings related to clinically important traumatic brain injury (ciTBI) with high sensitivity and specificity. It therefore offers reassurance in the management of infants after minor head trauma.

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.

Masks versus prongs as interfaces for nasal continuous positive airway pressure in preterm infants.

Nasal masks and nasal prongs are used as interfaces for providing continuous positive airway pressure (CPAP) for preterm infants with or at risk of respiratory distress, either as primary support after birth or as ongoing support after endotracheal extubation from mechanical ventilation. It is unclear which type of interface is associated with lower rates of CPAP treatment failure, nasal trauma, or mortality and other morbidity. To assess the benefits and harms of nasal masks versus nasal prongs for reducing CPAP treatment failure, nasal trauma, or mortality and other morbidity in newborn preterm infants with or at risk of respiratory distress. We used standard, extensive Cochrane search methods. The latest search date was October 2021. We included randomised controlled trials comparing masks versus prongs as interfaces for delivery of nasal CPAP in newborn preterm infants (less than 37 weeks' gestation) with or at risk of respiratory distress. We used standard Cochrane methods. Our primary outcomes were 1. treatment failure, 2. all-cause mortality, and 3. neurodevelopmental impairment. Our secondary outcomes were 4. pneumothorax, 5. moderate-severe nasal trauma, 6. bronchopulmonary dysplasia, 7. duration of CPAP use, 8. duration of oxygen supplementation, 9. duration of hospitalisation, 10. patent ductus arteriosus receiving medical or surgical treatment, 11. necrotising enterocolitis, 12. severe intraventricular haemorrhage, and 13. severe retinopathy of prematurity. We used the GRADE approach to assess the certainty of the evidence. We included 12 trials with 1604 infants. All trials were small (median number of participants 118). The trials occurred after 2001 in care facilities internationally, predominantly in India (eight trials). Most participants were preterm infants of 26 to 34 weeks' gestation who received nasal CPAP as the primary form of respiratory support after birth. The studied interfaces included commonly used commercially available masks and prongs. Lack of measures to blind caregivers or investigators was a potential source of performance and detection bias in all the trials. Meta-analyses suggested that use of masks compared with prongs may reduce CPAP treatment failure (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 8 trials, 919 infants; low certainty). The type of interface may not affect mortality prior to hospital discharge (RR 0.83, 95% CI 0.56 to 1.22; 7 trials, 814 infants; low certainty). There are no data on neurodevelopmental impairment. Meta-analyses suggest that the choice of interface may result in little or no difference in the risk of pneumothorax (RR 0.93, 95% CI 0.45 to 1.93; 5 trials, 625 infants; low certainty). Use of masks rather than prongs may reduce the risk of moderate-severe nasal injury (RR 0.55, 95% CI 0.44 to 0.71; 10 trials, 1058 infants; low certainty). The evidence is very uncertain about the effect on bronchopulmonary dysplasia (RR 0.69, 95% CI 0.46 to 1.03; 7 trials, 843 infants; very low certainty). The available trial data provide low-certainty evidence that use of masks compared with prongs as the nasal CPAP interface may reduce treatment failure and nasal injury, and may have little or no effect on mortality or the risk of pneumothorax in newborn preterm infants with or at risk of respiratory distress. The effect on bronchopulmonary dysplasia is very uncertain. Large, high-quality trials would be needed to provide evidence of sufficient validity and applicability to inform policy and practice.

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.

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

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. 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. 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. 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.

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.