Evaluating abusive head trauma in children &lt; 5 years old: Risk factors and the importance of the social history

Notrica, David M.; Kirsch, Lisa; Misra, Shivani; Kelly, Cara; Greenberg, Jodie; Ortiz, J. Bryce; Rowe, Rachel K.; Lifshitz, Jonathan; Adelson, P. David; Stottlemyre, Rachael; Cohen, Aaron; Sayrs, Lois W.

doi:10.1016/j.jpedsurg.2020.10.019

Cited by 16 publications

(13 citation statements)

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“…Among the included infants, 87% (86 of 99 participants) had bridging vein thrombosis (77% multiple thrombosis; 66 of 86 participants), 75% (74 of 99 participants) had retinal hemorrhages (82% bilateral; 61 of 74 participants), 32% (23 of 72 participants) had fractures, and 20% (20 of 99 participants) had skin injuries. The median (IQR) Glasgow Coma Scale score at arrival in the neurosurgery department was 14 (10)(11)(12)(13)(14)(15), 26% (26 of 99 participants) of the patients had status epilepticus, 24% (24 of 99 participants) had refractory status epilepticus, 30% (…”

Section: Participantsmentioning

confidence: 99%

“…6 Among the known risk factors of AHT, several could have seen their prevalence modified by the COVID-19 pandemic and the containment and mitigation measures taken to reduce the spread of the disease 7,8 : psychosocial distress (economic loss and unemployment, frustration intolerance, adult psychiatric disorders, and intimate partner violence), 9,10 lifestyle changes (remote work from home in small collective housing, school and childcare facility closures, complete national lockdowns, and curfews), 11 and disorganized social services. 9,12 Concerns were raised early regarding a potentially marked increase in CAN (notably AHT) in association with the COVID-19 pandemic and related containment and mitigation measures. [13][14][15] Studies evaluating the association of the COVID-19 pandemic and containment and mitigation measures with the incidence and severity of CAN and AHT led to conflicting conclusions, varying from a significant increase, [16][17][18][19] a significant decrease, [20][21][22] or no change [23][24][25][26] (eTable 1 in the Supplement).…”

Section: Introductionmentioning

confidence: 99%

“…AHT is the most frequent cause of traumatic death in infants in high-income countries, and nonlethal forms are associated with severe long-term morbidity, such as neurodevelopmental impairment (microcephaly, epilepsy, motor and visual deficiencies, language disorders, intellectual disability, and behavioral abnormalities) leading to severe lifelong disabilities . Among the known risk factors of AHT, several could have seen their prevalence modified by the COVID-19 pandemic and the containment and mitigation measures taken to reduce the spread of the disease: psychosocial distress (economic loss and unemployment, frustration intolerance, adult psychiatric disorders, and intimate partner violence), lifestyle changes (remote work from home in small collective housing, school and childcare facility closures, complete national lockdowns, and curfews), and disorganized social services . Concerns were raised early regarding a potentially marked increase in CAN (notably AHT) in association with the COVID-19 pandemic and related containment and mitigation measures …”

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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IMPORTANCEThe COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse. OBJECTIVE To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTSIn a time-series analysis of a longitudinal, populationbased, 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. MAIN OUTCOMES AND MEASURESThe 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. RESULTS 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. CONCLUSIONS AND RELEVANCEIn 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.

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Section: Participantsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2022

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“…Worldwide, the rate of TBI is high, wherein a recent metaanalysis indicated the highest incidence to be in Australasia, at an estimated 415 in every 100,000 people (6). Across the lifespan, TBI is most prevalent in early-life due to domestic violence/child abuse and falls (7)(8)(9)(10), with secondary peaks in adolescence and aged individuals attributed to increased risktaking behaviors (i.e., driving) and falls, respectively (7). Due to the high prevalence of 18-to 25-year-old male individuals that sustain a TBI (7), clinical and experimental research has focused on the behavioral and neuropathological outcomes in young adult males.…”

Section: Introductionmentioning

confidence: 99%

Age-at-Injury Determines the Extent of Long-Term Neuropathology and Microgliosis After a Diffuse Brain Injury in Male Rats

et al. 2021

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Traumatic brain injury (TBI) can occur at any age, from youth to the elderly, and its contribution to age-related neuropathology remains unknown. Few studies have investigated the relationship between age-at-injury and pathophysiology at a discrete biological age. In this study, we report the immunohistochemical analysis of naïve rat brains compared to those subjected to diffuse TBI by midline fluid percussion injury (mFPI) at post-natal day (PND) 17, PND35, 2-, 4-, or 6-months of age. All brains were collected when rats were 10-months of age (n = 6–7/group). Generalized linear mixed models were fitted to analyze binomial proportion and count data with R Studio. Amyloid precursor protein (APP) and neurofilament (SMI34, SMI32) neuronal pathology were counted in the corpus callosum (CC) and primary sensory barrel field (S1BF). Phosphorylated TAR DNA-binding protein 43 (pTDP-43) neuropathology was counted in the S1BF and hippocampus. There was a significantly greater extent of APP and SMI34 axonal pathology and pTDP-43 neuropathology following a TBI compared with naïves regardless of brain region or age-at-injury. However, age-at-injury did determine the extent of dendritic neurofilament (SMI32) pathology in the CC and S1BF where all brain-injured rats exhibited a greater extent of pathology compared with naïve. No significant differences were detected in the extent of astrocyte activation between brain-injured and naïve rats. Microglia counts were conducted in the S1BF, hippocampus, ventral posteromedial (VPM) nucleus, zona incerta, and posterior hypothalamic nucleus. There was a significantly greater proportion of deramified microglia, regardless of whether the TBI was recent or remote, but this only occurred in the S1BF and hippocampus. The proportion of microglia with colocalized CD68 and TREM2 in the S1BF was greater in all brain-injured rats compared with naïve, regardless of whether the TBI was recent or remote. Only rats with recent TBI exhibited a greater proportion of CD68-positive microglia compared with naive in the hippocampus and posterior hypothalamic nucleus. Whilst, only rats with a remote brain-injury displayed a greater proportion of microglia colocalized with TREM2 in the hippocampus. Thus, chronic alterations in neuronal and microglial characteristics are evident in the injured brain despite the recency of a diffuse brain injury.

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“…Some of these include male gender of the child, lower socioeconomic status, caregiver substance abuse, caregiver mental health, and family interpersonal violence [ 58 ]. Another study of abusive head injury in children found that the following factors were significant for increased risk [ 59 ]: prior contact with Child Protective Services, prior police involvement, and an unknown number of adults in the home. A study of the recent recession (2007–2009) found a marked increase in the rate of cases of abusive head trauma [ 60 ].…”

Section: Should Social Factors Be Considered When Undertaking Workups...mentioning

confidence: 99%

Mild abusive head injury: diagnosis and pitfalls

Jenny

2022

Childs Nerv Syst

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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.

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Evaluating abusive head trauma in children < 5 years old: Risk factors and the importance of the social history

Cited by 16 publications

References 48 publications

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

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

Age-at-Injury Determines the Extent of Long-Term Neuropathology and Microgliosis After a Diffuse Brain Injury in Male Rats

Mild abusive head injury: diagnosis and pitfalls

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Evaluating abusive head trauma in children < 5 years old: Risk factors and the importance of the social history

Cited by 16 publications

References 48 publications

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

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

Age-at-Injury Determines the Extent of Long-Term Neuropathology and Microgliosis After a Diffuse Brain Injury in Male Rats

Mild abusive head injury: diagnosis and pitfalls

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Evaluating abusive head trauma in children < 5 years old: Risk factors and the importance of the social history