Trauma In Infants Research Articles

Neuroimaging of abusive head trauma

The diagnostic process for evaluating suspected abusive head trauma in infants and children has evolved with technological advances in neuroimaging. Since Caffey first described a series of children with chronic subdural hematomas and multiple long bone fractures, radiologists have played an important role, along with pediatricians and pathologists, in evaluating abused children. Neuroimaging modalities include ultrasound, CT scans, and MRI technology. Each has distinct clinical applications, as well as practical uses in the clinical diagnostic process of AHT. Importantly, neuroimaging assists in the process of differential diagnosis of other conditions which may mimic AHT. Collaboration between neuroradiologists, clinicians, and pathologists remains critical to making the appropriate diagnosis. Careful history, physical examination, and investigation by legal authorities form the components that result in accurate assessment of any case. This paper reviews pertinent neuroimaging modalities currently utilized in the diagnosis of AHT, describing clinical indications and a collaborative approach to this process.

Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases

The diagnosis of inflicted head injury (IHI) or accidental trauma (AT) in infants is based on clinical, radiological, and/or ophthalmological findings such as subdural hematoma (SDH), encephalopathy, retinal hemorrhage (RH), and signs of impact. As a consequence, the diagnostic value of these criteria is difficult to assess because of a circularity bias. In order to assess the predictive value of these diagnostic criteria avoiding circularity, we studied prospectively corroborated cases of head injuries in infants, comparing IHI with AT. We selected 45 cases of confessed IHI and 39 cases of AT having occurred in public places. Patients were systematically evaluated clinically, with computed tomography scanner and ophthalmological evaluation by a trained ophthalmologist. RH was rated as absent, mild, and severe, according to the depth and extent of the RH. Brain ischemia was found in 26.7% of IHI; the most prominent elements in favor of IHI were SDH, severe RH, and absence of signs of impact; the predictive diagnostic values of these three features were 0.685, 0.961, and 0.830, respectively; however, only severe RH in the absence of ocular impact was specific of IHI. When all three features were combined, the specificity was 100%, but the sensitivity was only 24.4%. Our study confirms the high diagnostic value of RH, SDH, and signs of impact for the differential diagnosis between AT and IHI. The evaluation of head injuries in infants requires a high level of awareness and thorough and systematic examination by a trained multidisciplinary team.

Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography?

To determine the clinical evolution of children with skull fractures as a result of a minor head trauma from a witnessed accidental fall that have been studied by transfontanellar ultrasound (TFUS). Observational study for 2 years (2004-2006) of children up to 1 year of age who suffered a skull fracture after minor head trauma and for whom a TFUS was carried out as the first neuroimaging test to rule out intracranial injuries. One hundred and twenty-three children were evaluated. The mean age was 5.7 months (SD 2.9) and the most common mechanism of injury was rolling off the bed. In seven (5.7%) patients, a computed tomography (CT) was eventually performed after TFUS; in two of these patients, this was because of the detection of possible intracranial alterations and in the others, it was because of a small fontanelle. Both patients with abnormal TFUS had a small epidural haematoma on the CT scan that did not need surgery. The clinical course for all patients was uneventful. TFUS is a valid and reliable alternative to CT for minor head trauma in infants with skull fractures. Its innocuousness and cost-effectiveness in comparison with CT makes it a good choice in this situation.

Abusive Head Trauma in Infants and Children

Shaken baby syndrome is a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children. Although the term is well known and has been used for a number of decades, advances in the understanding of the mechanisms and clinical spectrum of injury associated with abusive head trauma compel us to modify our terminology to keep pace with our understanding of pathologic mechanisms. Although shaking an infant has the potential to cause neurologic injury, blunt impact or a combination of shaking and blunt impact cause injury as well. Spinal cord injury and secondary hypoxic ischemic injury can contribute to poor outcomes of victims. The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required. The American Academy of Pediatrics recommends that pediatricians develop skills in the recognition of signs and symptoms of abusive head injury, including those caused by both shaking and blunt impact, consult with pediatric subspecialists when necessary, and embrace a less mechanistic term, abusive head trauma, when describing an inflicted injury to the head and its contents.

Prevalence and factors associated to dental trauma in infants 1–3 years of age

The aims of this study were to assess the epidemiology of traumatic dental injuries (TDI) to primary teeth in infants and toddlers between 1 and 3 years of age and investigate whether TDI was related to biological and social factors. A representative sample of infants and toddlers in the city of Belo Horizonte, Minas Gerais, Brazil (n = 519) was examined during a vaccination campaign. The evaluation of clinical signs of previous dental trauma was performed by nine previously calibrated examiners (intra-examiner Kappa = 0.95%; inter-examiner Kappa = 0.88%). Data were analysed through descriptive analysis, the chi-squared test (P < 0.050) and logistic regression. The prevalence of dental trauma was 41.6%. Among the 519 children examined, 193 (37.2%) had enamel fractures, 30 (5.7%) had enamel-dentin fractures and only three (0.6%) had enamel-dentin fractures involving the pulp. Dental care had been performed within the first 24 h in 4.1% of the sample and after 36 h in 0.8% of the sample. There was no statistically significant difference between genders. The most reported aetiologies were falls (28.8%) and collisions (6.8%). There were no statistically significant associations between the prevalence of dental trauma and non-nutritive sucking habits, dental caries or lip incompetence (P > 0.050). Children of mothers with low levels of schooling (0-6 years of study) had a greater prevalence of TDI (P = 0.001). The results of the logistic regression also demonstrated a significant association between dental injury and the Social Vulnerability Index (P = 0.045). Children from families with high social vulnerability (worse living conditions) had a 1.51 (95% confidence interval 1.0-2.2) greater chance of exhibiting TDI. These results can help guide the implementation of health promotion policies.

A Prospective Observational Study of 1000 Vacuum Assisted Deliveries With the OmniCup Device

ObjectiveTo determine the maternal and perinatal outcomes associated with delivery by the rigid plastic OmniCup vacuum delivery device. MethodsWe conducted a prospective observational study of 1000 consecutive vacuum-assisted deliveries using the OmniCup vacuum device in singleton pregnancies. The relationship of the cup application to the flexion point was independently observed after delivery and related to the neonatal outcome, including scalp trauma. ResultsOf the 1000 women, 70% were nulliparous and 30% parous (≥ para 1). In 87.1% of the women, vacuum-assisted delivery was completed; spontaneous or forceps delivery occurred in 10.9%, and Caesarean section was performed in 2%. The vacuum was applied for ≤10 minutes in 97.4% of deliveries, ≤3 pulls were required in 95.6%, and ≤ 25 lb traction force was required in 85.7% of cases. There was a statistically significant relationship between unfavourable cup applications (deflexing and paramedian) and scalp trauma in infants born to nulliparous women (P ≤ 0.01). Four cases of neonatal intracranial hemorrhage (0.4%) were identified, and three of these infants were subsequently neurodevelopmentally normal. There was one subgaleal hemorrhage. ConclusionsThere is a relationship between unfavourable cup application during vacuum assisted delivery and neonatal scalp trauma in infants born to nulliparous women.

The role echoencephalography in neurological emergencies in infants and neonates

Echoencefalography is a screening methode in emergengy diseases in pediatrics. It offers very important data and aloud a good diagnosis bvefore CT scan and MRI, concerning pericerebral spaces, lateral ventriculi, brain and signs of intracerebral hypertension. Hydrocephalus and subdural collection are the most rapidly diagnosed by echoencephalography. Subdural hematoma in infants is in the majority of cases the result of a cranial trauma and very often is bilateraly present. We presented our experience aquired in the Emergency Department in a period of three years, between 2005–2007. There were analysed all the crani-cerebral trauma in infants and children up to 18 months old. Echoencephalography was performed in a total number of 327 cases of cerebral trauma at the mentioned ages. In 295 cases there were not ultrasound changes. In 18 cases there were subdural hematoma, in 8 cases intracerebral hemorage cases and 6 cases intraventricular hemorage.

“The Roentgen Manifestations of Unrecognized Skeletal Trauma in Infants”—A Commentary

559 or thoracic compression and is often seen in infants dying of inflicted head injury [4]. In all three cases, he noted metaphyseal lesions, curious injuries that Caffey [5] latter classified as “corner” and “bucket-handle” fractures. These classic metaphyseal lesions have distinctive radiologic and histopathologic features and in otherwise normal infants are strong indicators of inflicted injury [6]. Silverman’s [1] description in case one of a proximal femoral epiphyseal separation illustrates how this injury can easily be confused with a dislocated hip when the femoral head is not yet ossified—without the aid of sonography or MRI! He stressed the importance of followup radiography to document injuries that are inapparent or confusing on initial radiographs. Subsequent studies have shown the utility of follow-up skeletal surveys in suspected infant abuse, and this approach is now recommended by the American College of Radiology and the American Academy of Pediatrics [7, 8]. Despite a rigorous clinical approach to his subject, one cannot mistake the deep personal interest shown by Silverman [1] in these three injured infants. In case two, he noted, “The roentgen diagnosis of traumatic lesions in the skeleton was strongly resisted by pediatricians and orthopedists interested in the child.” This led him to a personal interview with the parents, during which a “long series of episodes of trauma was discovered.” These seminal observations were followed by Silverman’s collaboration with the noted pediatrician, Henry Kempe, and their work culminated with the landmark article, “The Battered Child Syndrome” published in 1962 in the Journal of the American Medical Association [9]. “The Roentgen Manifestations of Unrecognized Skeletal Trauma in Infants”—A Commentary

Shaken Baby Syndrome

Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.

Selected Internet Resources Relating to Trauma and Violence in Women and Infants

Selected Internet Resources Relating to Trauma and Violence in Women and Infants

Intracranial hemorrhage in infants after massaged by a traditional birth attendant

Background The overall incidence of birth related injuries declineswith the improvement in obstetrics. However, the incidence ofhead trauma in infants after massaged by a traditional birthattendant (TBA) is still unknown.Objective To study the characteristics of intracranial hemorrhagein infants after massaged by a TBA.Methods A retrospective study was conducted in Sardjito Hospital,Yogyakarta, Indonesia between October 2001 and May 2005.Infants with intracranial hemorrhage after massaged by a TBAwere included. Data on patients’ demography, history of massagingby TBA, clinical presentation, and injury characteristics such asanemia, clotting time (CT), bleeding time (BT), prothrombin time(PT) and activated partial thromboplastin time (APTT) werenoted. Computed cranial tomography (CT) scans were performed.Results A total of seven infants were diagnosed with intracranialhemorrhage after massaged by a TBA. There were four malesand three females (mean age 46 days; range 27-60 days). Allinfants were referred to Sardjito Hospital, Yogyakarta, Indonesiawith bad condition and anemia; mean hemoglobin level was 5.5g/dl (range 3.7-8.3 g/dl). All infants presented with seizures.Coagulation screening showed normal results in five patients. Theremaining patients had a prolonged CT and PT. CT scan showedsubdural hemorrhage in four patients, intracerebral hemorrhagein four, epidural hemorrhage in two, and subarachnoid hemorrhagein one. Two patients had chronic hemorrhage, while the rest hadacute hemorrhage. Four of them underwent craniotomy, twopatients were under an observation only, and one patient was nottreated due to parental refusal. Six patients survived and the onewho refused to be treated died.Conclusions The parents, midwives, and doctors have to be awareof head massaging since it may harm infants.

Nonaccidental head trauma in infants

Nonaccidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest inflicted head trauma include the triad of the so-called shaken baby syndrome, consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Studies have shown that, in general, the average short fall in the home is extremely unlikely to produce either subdural or retinal hemorrhage, although focal injuries such as skull fractures and epidural hemorrhage may be seen. Acceleration/deceleration, especially of the rotational type, is believed to be the most probable mechanism of injury in cases of nonaccidental head trauma. Damage to the cervicomedullary junction and the respiratory centers, with subsequent hypoxia and intracerebral edema, has also been implicated. After the initial trauma and hemorrhage, loss of cerebral autoregulation, breakdown of the blood-brain barrier, and disruption of ionic homeostasis occur, leading to brain edema and cytotoxicity. Cellular damage can involve large volumes of tissue, without respecting vascular territories. Overall, a satisfactory biomechanical model is lacking, and the criminal nature of abusive injury makes it difficult to perform systematic, controlled studies. Unfortunately, outcomes are poor, and the rate of repeated abusive episodes is high. Future research should focus on the development of a satisfactory research model and on prevention strategies.

Head Trauma in Infants

Head Trauma in Infants

Head Trauma in Infants

Head Trauma in Infants

Accidental and nonaccidental head injuries in infants: a prospective study

Head injury is a major cause of morbidity and death in infants, and child abuse is among its chief causes. Retinal hemorrhages (RHs) are of paramount importance for the diagnosis of child abuse; however, their sensitivity and specificity are poorly estimated. Subdural hematoma (SDH) is a common feature; however, its incidence and causative factors are poorly documented. To study the epidemiology of head injuries in infants, factors predisposing to SDH, value of RH for the diagnosis of child abuse, and prognostic factors, the authors prospectively collected data from cases of head injury in infants who were hospitalized at their institution over a 3-year period. One hundred fifty cases were collected, 57 of which were due to child abuse. This prospective study allows the comparison of clinical, radiological, and ophthalmological features in accidental and nonaccidental trauma in infants. Subdural hematomas were significantly correlated with RH and with child abuse but not with idiopathic macrocranium. The sensitivity and specificity of RH for the diagnosis of child abuse were 75 and 93.2%, respectively. Retinal hemorrhages associated with accidental trauma were always mild, and the specificity of more severe RH for the diagnosis of child abuse was 100%. The grading of RH requires the expertise of a trained neuroophthalmologist. Child abuse was also significantly associated with antecedents of perinatal illness, absence of signs of impact, and seizures on presentation. Although child abuse represented just 38% of traumas, it was the cause of 71% of deaths and 90% of severe disability in this series. Abuse and the clinical severity on presentation were two significant and independent factors conditioning outcome.

Mechanistic hypothesis for eye injury in infant shaking : An experimental and computational study.

The terms abusive head injury and shaken baby syndrome are used to describe a unique pattern of nonaccidental traumatic injuries occurring in children that many clinicians and researchers have good reason to believe is caused by violent shaking. Typical injuries include severe brain injury, with intracranial and retinal hemorrhages, but the pathogenesis of injuries is poorly understood. A major paradox in head trauma in infants is that the injuries induced by a shaking event are much more severe than those caused by even very violent single-impact head trauma, despite the relatively low accelerations in shaking.We have developed a finite element computer model of the eye, orbit, and orbital bone and used it to simulate the effects of single-impact and oscillatory motion inputs. The model was informed by data from semiquantitative in vitro anatomical traction experiments on in situ rabbit eyes. The new results reported here strongly suggest that suction between the eye and its surrounding fat dominates the dynamical stability of the system composed of the eye, its socket, and the components and material supporting the eye. Computer simulations incorporating this functional anatomical relationship show that deceleration of the head generates pressure gradients inside and outside the eye; these could cause damaging shear stresses in structures such as the retina and blood vessels. Simulations also show that oscillating the bone of the orbit causes the eye to move anteriorly and posteriorly with an increasing amplitude, building up the stresses within the eye over time. This is the first time that any biomechanical mechanism has been identified that might explain the disproportionally severe injuries caused by an oscillatory mechanism such as violent shaking of an abused infant. However, further study is required and this conclusion is therefore preliminary and provisional.

Don’t forget the “single chromosome polymorphism”: A need for gender-stratification in pediatric patients? *

Pediatric Critical Care Medicine: March 2004 - Volume 5 - Issue 2 - p 193-194 doi: 10.1097/01.PCC.0000115621.73210.B9

Guidelines for Referral to Pediatric Surgical Specialists

The Surgical Advisory Panel of the American Academy of Pediatrics (AAP), in response to a recommendation from the AAP Subspecialty Work Group and with the collaboration of the Surgical Sections of the AAP, has created referral guidelines intended to serve as voluntary practice parameters to assist general pediatricians in determining when and where to refer their patients to pediatric surgical specialists. It is recognized that the guidelines here may be difficult to achieve. Communities vary. Specialties overlap, and more than 1 type of pediatric or other surgical specialist may be qualified to manage a particular problem. Many complex pediatric problems are optimally managed by a medical-surgical team rather than an individual surgical specialist. This does not negate the value of the guidelines, however, because the child who needs specialized surgical care is best served by the skills of the appropriate pediatric surgical specialist. Major congenital anomalies, malignancies, major trauma, and chronic illnesses in infants and children should be managed by pediatric medical and surgical specialists at pediatric referral centers. Such centers dedicated to children can provide expertise in many areas, including the pediatric medical and surgical specialties, pediatric radiology, pediatric anesthesiology, pediatric pathology, and pediatric intensive care. The optimal management of the child with complex problems, chronic illness, or disabilities requires coordination, communication, and cooperation of the pediatric surgical specialist with the child’s primary care pediatrician or physician. When a surgical condition has been identified, ideally, a pediatric surgical specialist should be called to address the issues related to this condition with the family and the respective pediatrician. In rural areas where it would be a hardship to the family and the child to travel long distances, the family in conjunction with the primary care pediatrician/physician should weigh the advantages of traveling to a center with a pediatric surgical specialist …

Systolic hypertension and the response to blunt trauma in infants and children

Objectives: To describe age-related systolic blood pressures and pulse rates in children following blunt injury. To compare these variables with standard reference values for uninjured children at rest and with reference ranges from the Advanced Paediatric Life Support (APLS) guidelines. Design: Secondary analysis of a prospective cohort. Setting: Emergency departments throughout England and Wales. Participants: 12 906 children presenting with acute blunt traumatic injury from August 1989 to September 1998. Main outcome measures: Systolic blood pressure and pulse rate on arrival. Results: Injured children had higher systolic blood pressures than the standard quoted ‘norms’. Standard reference values of systolic blood pressure for children at rest always appeared below the 50th percentile for our cohort of injured children (range 7th–27th percentiles). Pulse rates for children at rest were always towards the mid-range for injured children (range 41st–54th percentiles). These results appeared unrelated to injury severity. Age related APLS reference ranges for systolic blood pressure and pulse rate resembled the standard reference values for uninjured children at rest. Conclusions: Injured children have a relative systolic hypertension compared with children at rest. Pulse rates in the two groups are comparable. Following injury, children with apparently ‘normal’ age-specific systolic blood pressures on arrival in the Emergency Department are relatively hypotensive and should be carefully assessed.

A Theoretical Model of Benign External Hydrocephalus That Predicts a Predisposition towards Extra-Axial Hemorrhage after Minor Head Trauma

Introduction: There is controversy over whether there exists a predisposition towards bleeding into the subdural space in infants with benign external hydrocephalus (BEH) or other enlargement of the extra-axial space (e.g. subdural hygroma). The presumed etiology implicates shear forces in over-stretching the extra-axial blood vessels. We have created a model of the intracranial space that approximates certain aspects of BEH. Using this model, we predict situations where children with BEH will bleed into the extra-axial space when normal infants will not. Methods: The cranial model consists of two spheres representing the brain and the skull. The distance between them represents the width of the extra-axial space. The spheres are concentric (with interspheric distance equal to N) in the normal condition and nonconcentric in BEH. In BEH, the distance between the two spheres varies from N to Q (0 < N ≤ Q) over a 906 M ≤ Q, with the translation orthogonal to the vector of N and parallel to that of M or vice versa), then the final length V_f of a vein V is V_f = (N² + M)^1/2, and the stretch ratio V_f/V_i is: V_f/V_i = (N² + M²)^1/2/N·S_i, with S_i the slack factor, where i represents either n for normal or b for BEH and M = N in the normal condition. Results: Given an equivalent capacity of veins to resist stretch injury (based on the proportion of change in length), for brain translations after a low-impact head injury, stretch ratios for BEH veins range from 1.677 to 3.436, whereas in the normal condition they range from 1.061 to 1.179. Therefore, for an increase in subarachnoid space from 3 (normal) to 6 mm (BEH), brain translocation in BEH will stretch veins beyond an average breaking point when the translation for the normal condition will not. Conclusions: Mathematical modeling of the cranial vault produces a relationship between venous stretch and the width of the extra-axial space. These equations predict an increased frequency of venous stretch injury in the situation of widened extra-axial space. Such venous injury is consistent with forces generated by minor trauma. This relationship, as predicted by our model, could underlie a predisposition towards extra-axial bleeding after minor head trauma in infants with BEH.