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Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children.
To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis.
Retrospective chart review of cases of head trauma...
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Objective
Misdiagnosis of abusive head trauma (AHT) has serious consequences for children and families. This systematic review identifies and compares clinical prediction rules (CPredRs) assisting clinicians in assessing suspected AHT.
Design
We searched MEDLINE, Embase, PubMed and Cochrane databases (January 1996 to August 2016). Externally valid...
Introduction Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive case...
To improve the understanding of child physical abuse, assess its magnitude, and identify the presentations and the characteristics of the victims, their families and the offenders, we carried out a retrospective review of 237 child physical abuse cases evaluated over 10 years (2000-2009) in a tertiary hospital in Bahrain. Mean age of the children w...
Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has...
Citations
... AHT is one of the most severe forms of TBI in young children, with higher mortality and morbidity than accidental injury [16][17][18][19]. Our recent study demonstrated that the SHs of complement cascades and those involved in neurodevelopment, such as Lecithin-was not certified by peer review) is the author/funder. ...
... It is most likely that molecular interactions or post-traumatic biophysical changes (e.g., blood pH, temperature) that evolve over time after injury are responsible for the dysregulated enzyme activities in the serum of severe AHT cases. We expect that the metabolic activity of the enzymes that can be measured in serum using our approach will serve as good indicators of serum changes in patients with head injury or ICH, particularly in complicated forms of paediatric AHT, which are often misdiagnosed in clinical practice [16]. In contrast to severe cases of AHT (Glasgow Coma Scale score, 3-9), moderate/mild forms of AHT in infants (Glasgow Coma Scale score, [9][10][11][12][13][14][15] are frequently misdiagnosed because caretakers often provide was not certified by peer review) is the author/funder. ...
... No reuse allowed without permission. [17,18,47] and infants present symptoms non-specific to TBI [16]. ...
Purpose
Traumatic brain injury (TBI), including pediatric abusive head trauma (AHT), is the leading cause of death and disability in children and young adults worldwide. The current understanding of trauma-induced molecular changes in the brain of human subjects with intracranial haemorrhage (ICH) remains inadequate and requires further investigation to improve the outcome and management of TBI in the clinic. Calcium-mediated damage at the site of brain injury has been shown to activate several catalytic enzymes.
Experimental design
Serine hydrolases (SHs) are major catalytic enzymes involved in the biochemical pathways of blood coagulation, systemic inflammation and neuronal signaling. Here we investigated activity-based protein profiling (ABPP) by measuring the activity status of SH enzymes in the serum of infants with severe ICH as a consequence of AHT or atraumatic infants who died of sudden infant death syndrome (SIDS).
Results
Our proof-of-principle study revealed significantly reduced physiological activity of dozens of metabolic SHs in the serum of infants with severe AHT compared to the SIDS group, with some of the enzymes being related to neurodevelopment and basic brain metabolism.
Conclusions and clinical relevance
To our knowledge, this is the first study to investigate the ABPP of the SHs enzyme family to detect changes in their physiological activity in blood serum in severe TBI. We used antemortem (AM) serum from infants under the age of 2 years who were victims of AHT with a severe form of ICH. The analytical approach used in the proof-of-principle study shows reduced activities of serum serine lipases in AHT cases and could be further investigated in mild forms of AHT, which currently show 30% of misdiagnosed cases in clinics.
... Cases of abuse are very diverse and have a wide spectrum of presentation even within their own groups. It is also common for several different types of maltreatment to occur simultaneously [10]. In our study, more than one exposure to maltreatment was detected in 48 patients. ...
... In our study, 12 (3.2%) patients were admitted to PED with various complaints of recurrent bleeding and fever and 1 15/F Admissions with complaints of recurrent abdominal pain due to family pressure to get married 2 10/F Recurrent pseudoseizure admissions due to abuse by stepfather 3 4 m/M Admission due to being found with a bottle tied to his mouth on the patient bed in the emergency service observation room 4 17/M Admission due to recurrent cologne drinking as a result of trauma after sexual abuse 5 2/F Recurrent admissions of a home care patient with a tracheostomy who is weaned off the ventilator 6 9 m-2/M The same patient admitted with a pacifier string wrapped around his neck, and the patient had a clothesline wrapped around his neck 7 5/M Admission with a diaper on because the baby is not yet toilet trained 8 12/F Although had no complaint before sexual abuse, admitted for the last year due to incontinence 9 9/M Admission as a result of the teacher noticing that the father was punishing his child by pressing his child's legs with a spoon 10 14/F Admission with hallucinations that started with staying with uncle because school was closer to uncle's house 11 12/M Admission with adrenal crisis due to a diagnosis of adrenal insufficiency and lack of medication 12 16/F Diabetes mellitus diagnosis and admission with ketoacidosis due to lack of insulin administration 13 13/M Admission with epilepsy diagnosis and lack of medication 14 1/M Admission as a result of recurrent hematemesis complaint and contamination of the caregiver's blood into the child's mouth were diagnosed with MCA during the follow-up period. In cases where recurrent nose, mouth, and urinary bleeding are reported that are incompatible with the clinical findings, it would be beneficial for these patients to be hospitalized, to be diagnosed during the follow-up period, and to be monitored by the Child Protection Unit. ...
... Children of all ages may present to the emergency department with injuries resulting from maltreatment, but infants are at the greatest risk of sustaining serious or fatal injuries [10]. An estimated 40 thousand children are killed every year in the world, and most of them are thought to have been subjected to maltreatment beforehand [26]. ...
Child abuse and neglect includes any behavior that harms the child or hinders the child’s development. The aim of this study was to determine the demographic and clinical characteristics of patients with suspected child abuse or neglect in the pediatric emergency department. Between July 2017 and July 2022, patients admitted to our pediatric emergency department and consulted to the medical social services unit with a preliminary diagnosis of neglect and/or abuse were retrospectively scanned through the registry system. The patients were divided into five groups according to their victimization: physical, sexual, and emotional abuse; neglect; and medical child abuse (MCA)—Munchausen by proxy. A total of 371 children were included in the study. Two hundred twenty-two (59.8%) of the patients were female and the median age was 161 months [IQR (46–192)]. Then, 56.3% of the patients were in the adolescent age group. The most common admission time period was between 16.00 and 24.00 (n 163, 43.9%). Then, 24.2% of the patients were exposed to physical abuse, 8.8% to sexual abuse, 26.1% to emotional abuse, 50.4% to neglect, and 3.2% to MCA. One hundred eight (29.1%) patients were followed up as inpatients in the pediatric intensive care unit. Four of the patients (1%) had out-of-hospital cardiac arrest, and the deaths were in patients under 2 years of age.
Conclusion: Pediatric emergency departments are one of the important units visited by child maltreatment patients. Victimized children may reflect their silent screams with various clinical presentations. Infants are at the greatest risk of suffering serious or fatal injuries. Health professionals working in the emergency department have an important role in detecting, treating, and preventing recurrence of child neglect and abuse. What is Known:
• The pediatric emergency department is an important entry point in the health care system for children who experience maltreatment.
• It has a wide spectrum of physical, sexual, emotional abuse and neglect.
What is New:
• A high index of suspicion is required to diagnose cases of child maltreatment.
• Infants are at the greatest risk of suffering serious or fatal injuries.
... Previous studies have demonstrated the worrisome impact of provider bias in the evaluation and reporting of child abuse (Hymel et al. 2018). Specifically, a missed abuse diagnosis is more likely in a white child and skeletal surveys to identify occult fractures are more likely to be completed in underrepresented minority children (Jenny et al. 1999;Lane et al. 2002). In this study, we found that universal screening increased the number of white and privately insured children identified as potential victims of abuse. ...
Background
Early identification of child abuse is critical to prevent death and disability. Studies suggest implicit bias of providers may lead to overrepresentation of minority and impoverished children in child abuse reporting. At our institution, universal screening for sexual and physical abuse for all children under 18 years of age was implemented in 2016. A rigorous, objective evaluation protocol focusing on the mechanism of injury and exam findings to improve recognition and eliminate bias was implemented in 2019.
Findings
Demographics and clinical characteristics of patients less than 18 years of age were abstracted by chart review (2014–2015) and from a forensic database (2016–2022). International Classification of Diseases codes 995.5 (version 9) and T76.12XA (version 10) were used to identify patients before the establishment of forensic database. Relative frequency and patient characteristics of the three time periods (pre universal screening: 2014–2015, post universal screening: 2016–2019, post protocol implementation: 2020–2022) were compared using Chi-square tests and modified Poisson regression. Universal screening significantly increased the number of cases identified. The demographic profile of potential victims by race significantly changed over the reporting periods with an increased number of white children identified, consistent with state demographics. The proportion of publicly insured patients trended down with universal screening and protocol implementation, despite a significant increase in the number of children publicly insured in the state during this time.
Conclusion
These single institutional results lend support to objective, evidence-based protocols to help eliminate bias surrounding race and poverty.
... Even though the current study showed that training programs and workshops had a positive effect on participants' knowledge of CAN, it is important to stress that further education and training are still necessary. Healthcare professionals should keep up to date on the most recent findings, recommendations, and best practices for recognizing and handling CAN cases because these cases are constantly changing [18]. The confidence and skill of healthcare professionals in identifying and handling CAN can be enhanced with ongoing education [19]. ...
Introduction
Child abuse and neglect (CAN) affects many countries, including Saudi Arabia (SA). CAN in SA is more commonly detected in hospitals. Therefore, healthcare professionals must identify and report the cases. This study aims to assess knowledge and perceptions toward CAN among training physicians.
Methodology
A cross-sectional survey was conducted through a self-administrated structured questionnaire and involved 123 residents and fellows who deal with children in Jeddah, SA. The participants were recruited using convenient sampling methods. Descriptive statistics, t-test, and Chi-square test were used for statistical analysis.
Results
We found that approximately 78% would report their findings to the legal authority, document them, and assess their consistency with parents and the child's explanation. However, only 41.5% of the participants would report CAN to the proper authority. Most participants believed that CAN should be redefined according to Saudi culture and religious standards. In contrast, 68.9% of the participants believed that CAN cases are under-reported in SA. The main barrier to not reporting is the fear of consequences (63.4%). About 77% of the participants agreed to the need for further training. Identifying the CAN indicators was higher among those who handled a CAN case previously (median = 66.67, p = 0.023).
Conclusions
In conclusion, the study showed that appropriate undergraduate and postgraduate curriculum training should be developed to strengthen future healthcare practitioners in dealing with CAN cases to protect children's welfare.
... Diagnosis of assault related TBI among infants and young children is often difficult because they might not present with specific symptoms and the history of trauma is provided by the caregivers. Misdiagnosis of assault related TBI can result in severe medical complication or even death (Jenny et al. 1999). Therefore, timely diagnosis of assault related TBI in infants and children can prevent long term hospitalizations and disability. ...
Background
Traumatic brain injury (TBI) is a major cause of morbidity and mortality globally. TBI is often associated with other physical or psychological issues resulting in high hospitalization costs. TBI incidence and recovery can vary with the external cause being intentional or unintentional. It is important to monitor the rates of TBI hospitalizations related to different external causes. This study examined the annual rate, comorbidity and length of stay associated with assault-related TBI hospitalizations and compare it with other external causes, by age and sex in Canada from 2010 to 2021.
Methods
Discharge Abstract Database was used to extract cases of TBI (2010–2021). ICD-10-CA codes were used to classify all cases with TBI as per assault and other external causes (falls; transport; sport, physical activity and recreation; struck by). Additional variables, including age, sex, comorbidity and length of stay, were examined. Time trends were quantified using Joinpoint regression.
Results
The average annual percent increase for all TBI hospitalizations from 2010 to 2021 was not significant at 0.1%. Females accounted for 35.8% of these TBI hospitalizations. From 2010 to 2021, assault-related TBI hospitalizations showed a significant annual decline of 4.1% for males and a significant increase of 1.2% for females. Increase in TBI hospitalizations related to falls showed an average annual percent increase of 1.4% for males and 2.2% for females. A significant decrease was observed for TBI hospitalizations related to the other three (transport, SPAR and struck by) external causes for both sexes from 2010 to 2021. Infants and children under 10 years of age had higher percentages of cases with comorbidities and higher length of stay for assault-related TBI hospitalizations.
Conclusions
Assault-related TBI hospitalization rates decreased overall and among males, rates among females increased from 2010 to 2021. These results underscore the importance of targeted prevention efforts for TBI related to different external causes, age and sex, and continued surveillance to monitor the epidemiology of assault-related TBI.
... Cases of abuse are very diverse and have a wide spectrum of presentation even within their own groups. It is also common for several different types of maltreatment to occur simultaneously (10). In our study, more than one exposure to maltreatment was detected in 48 patients. ...
... Children of all ages may present to the emergency department with injuries resulting from maltreatment, but infants are at the greatest risk of sustaining serious or fatal injuries (10). An estimated 40 thousand children are killed every year in the world, and most of them are thought to have been subjected to maltreatment beforehand (24). ...
The aim of this study is to determine the demographic and clinical characteristics of patients suspected of child abuse or neglect in the pediatric emergency department and to draw attention to this issue, which poses a great threat to the development of children. Between July 1, 2017 and July 1, 2022, the files of 851 patients who were admitted to the emergency department of a tertiary children's hospital without a trauma center and reported to the medical social services unit with a preliminary diagnosis of neglect and/or abuse were retrospectively scanned through the registry system. The patients' age, gender, time period when they were admitted to the hospital, reason for admission, presence of recurrent admission for different reasons suggestive of maltreatment, physical examination findings, forensic reports, management of the patients, and outcome were recorded. The patients were divided into five groups according to their victimization: physical, sexual and emotional abuse, neglect and Medical Child Abuse (MCA) - Munchausen by Proxy. A total of 371 children who were found to have been subjected to child maltreatment were included in the study. 222 (59.8%) of the patients were female and the median age was 161 months [IQR (46–192)]. 56.3% of the patients were in the adolescent age group. The most common admission time period was between 16.00 and 24.00, 163 (43.9%). 24.2% of the patients were exposed to physical abuse, 8.8% to sexual abuse, 26.1% to emotional abuse, 50.4% to neglect, and 3.2% to MCA. 108 (29.1%) patients were followed up as inpatients in the pediatric intensive care unit. 4 of the patients (1%) had cardiac arrest outside the hospital, and the deaths were in patients under 2 years of age. Conclusion: Pediatric emergency departments are the units most frequently visited by patients suffering from child maltreatment. Victimized children may try to make their silent screams heard through different clinical presentations. Babies are at the greatest risk of suffering serious or fatal injuries. Health professionals working in the emergency department have an important role in detecting, treating and preventing recurrence of child neglect and abuse. Emergency department physicians must be able to hear these screams of patients while struggling with the dense crowd.
... A study on mothers in Japan yielded a high prevalence of shaking and smothering (Yamada & Fujiwara, 2014). Two main reasons might be that shaking often is repetitive and escalating in force (Adamsbaum et al., 2010;Barr, 2014;Depallens et al., 2022;Joyce et al., 2022), and that diagnosis of abusive head trauma might be missed in up to a third of the cases later diagnosed with abusive head trauma (Jenny et al., 1999;Joyce et al., 2022;Letson et al., 2016). ...
Background: Research on abusive head trauma (AHT) is usually research on clinically identified cases, while population-based studies, having the potential to identify cases of shaking that did not end with hospital admission, are missing to date. Objective: Thus, we aimed to assess the prevalence of AHT and associated risk factors in a representative sample of the German population. Participants and setting: We conducted a cross-sectional, observational study in Germany from July to October 2021. Using different sampling steps including a random route procedure, a probability sample of the German population was generated. The final sample consisted of 2503 persons (50.2 % female, mean age: 49.5 years). Methods: Participants were asked about sociodemographic information in a face-to-face interview and whether they had been ever responsible for the care of an infant and whether they had ever performed potential harmful methods including shaking to calm it, intimate partner violence (IPV) and adverse childhood experiences (ACEs) using a questionnaire. Results: In total, 1.4 % of women (N = 18) and 1.1 % of men (N = 13) reported to have at least once shaken an infant to calm it. Ever having used a potential harmful parenting method in calming an infant was reported by 4.9 % of women (N = 61) and 3.1 % (N = 39) of men. No gender differences were seen. A low income, living with someone under 16 in the household and victimization and perpetration of IPV and ACEs are associated with increased risks of shaking and other potential harmful methods to calm an infant. Conclusions: Our data suggest that despite better knowledge on the dangers of shaking, the percentage of women that shake infants might be higher than previously thought. Also, intimate partner violence and ACEs are key risk factor for shaking and harmful parenting behaviors in general. This has important implications for future prevention programs.
... A pesquisa indicou que crianças que sofreram lesões traumáticas na cabeça ou no pescoço têm um risco maior de transtorno de estresse pós-traumático (TEPT) [13] e, portanto, é necessário um alto índice de suspeita ao avaliar pacientes do sexo feminino [14]. Além disso, os testes de Um estudo descobriu que a incidência de TEPT entre vítimas de trauma era muito baixa para avaliar quaisquer diferenças de idade [17], e que vítimas de lesões intencionais, não-brancos e aqueles com resultados positivos de testes de triagem toxicológica tinham maior probabilidade de serem diagnosticados com TEPT [18 ]. ...
A pesquisa aborda a relevância do atendimento otorrinolaringológico em vítimas de violência doméstica, salientando a prevalência global do problema. A investigação concentra-se nas lesões na região dos ouvidos, nariz e garganta (ENT), ressaltando a necessidade crítica de um cuidado adequado para essas vítimas. O estudo tem como objetivo explorar a importância do atendimento otorrinolaringológico, considerando aspectos específicos para o diagnóstico e tratamento de lesões ENT em vítimas de violência doméstica. Além disso, examina técnicas diagnósticas, opções terapêuticas e medidas de segurança para promover melhores resultados a longo prazo. A pesquisa consiste em uma revisão de literatura, com enfoque na produção científica de 2023, utilizando descritores específicos em bases renomadas como PubMed, Scopus e Scielo. A abordagem adotada é exploratória descritiva, seguindo diretrizes metodológicas estabelecidas para a seleção e análise dos artigos pertinentes. O estudo destaca a importância do atendimento otorrinolaringológico em casos de estrangulamento manual, evidenciando a evolução na conscientização a partir de marcos na pesquisa, como o trabalho de Stanley e Hanson (1983). Considerações específicas para o diagnóstico e tratamento são discutidas, abordando a necessidade de reconhecer padrões sutis de lesão e complicações potencialmente fatais. O trabalho contribui significativamente para o avanço do conhecimento em otorrinolaringologia, destacando a importância do atendimento específico para vítimas de violência doméstica. Apesar de algumas limitações, o estudo ressalta a necessidade contínua de protocolos de triagem positivos, evidenciando o papel crucial dos profissionais de saúde na promoção do bem-estar das vítimas e estimulando futuras investigações na área.
... However, numerous studies have evaluated SDH and RH without fracture for the clinical prediction of child abuse. 6,7,11,15 For example, Duhaime et al. classically characterized 48 cases of infants and children afflicted by shaken baby syndrome. 6,7 From those 48 victims, 9 (18.8%) had SDH or subarachnoid hemorrhage alone and 39 (81.3%) had RH + SDH or subarachnoid hemorrhage. ...
OBJECTIVE
Nonaccidental trauma (NAT) is a major cause of traumatic death during infancy and early childhood. Several findings are known to raise the index of clinical suspicion: subdural hematoma (SDH), retinal hemorrhage (RH), fracture, and external trauma. Combinations of certain injury types, determined via statistical frequency associations, may assist clinical diagnostic tools when child abuse is suspected. The present study sought to assess the statistical validity of the clinical triad (SDH + RH + fracture) in the diagnosis of child abuse and by extension pediatric NAT.
METHODS
A retrospective review of The University of Arizona Trauma Database was performed. All patients were evaluated for the presence or absence of the components of the clinical triad according to specific International Classification of Diseases (ICD)–10 codes. Injury type combinations included some variation of SDH, RH, all fractures, noncranial fracture, and cranial fracture. Each injury type was then correlated with the ICD-10 codes for child abuse or injury comment keywords. Statistical analysis via contingency tables was then conducted for test characteristics such as sensitivity, specificity, positive predictive value, and negative predictive value.
RESULTS
There were 3149 patients younger than 18 years of age included in the quantitative analysis, all of whom had at least one component of the clinical triad. From these, 372 patients (11.8%) had a diagnosis of child abuse. When compared to a single diagnosis of either SDH, RH, all fractures, noncranial fracture, or cranial fracture, the clinical triad had a significantly greater correlation with the diagnosis of child abuse (100% of cases) (p < 0.0001). The dyad of SDH + RH also had a significantly greater correlation with a child abuse diagnosis compared to single diagnoses (88.9%) (p < 0.0001). The clinical triad of SDH + RH + fracture had a sensitivity of 88.8% (95% CI 87.6%–89.9%), specificity of 100% (95% CI 83.9%–100%), and positive predictive value of 100% (95% CI 99.9%–100%). The dyad of SDH + RH had a sensitivity of 89.1% (95% CI 87.9%–90.1%), specificity of 88.9% (95% CI 74.7%–95.6%), and positive predictive value of 99.9% (95% CI 99.6%–100%). All patients with the clinical triad were younger than 3 years of age.
CONCLUSIONS
When SDH, RH, and fracture were present together, child abuse and by extension pediatric NAT were highly likely to have occurred.
... Mezi nejčastější projevy týrání dětí patří podkožní hematomy a fraktury (29). Pokud není týrání dítěte odhaleno včas, mnohdy se opakuje a časová prodleva může vést k dalšímu poranění (10,17,20,24). Aby bylo týrání odhaleno, musejí lékaři po známkách násilí aktivně pátrat. ...
... 4), hrozí, že nebude týrání odhaleno a dítěti nebude poskytnuta náležitá ochrana (24). Ze studií přitom vyplývá, že není-li týrání včas rozpoznáno, může se opakovat a vést k dalšímu poranění dítěte nebo jeho úmrtí (10,17,20,24). ...
