A Population-Based Study of Inflicted Traumatic Brain Injury in Young Children
Abstract and Figures
Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted traumatic brain injury (TBI) in US children is unknown.
To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger.
All North Carolina children aged 2 years or younger who were admitted to a pediatric intensive care unit or who died with a TBI in 2000 and 2001 were identified prospectively. Injuries were considered inflicted if accompanied by a confession or a medical and social service agency determination of abuse.
Incidence of inflicted TBI. Multivariate logistic regression models were used to compare children with inflicted injuries with those with noninflicted injuries and with the general state population aged 2 years or younger.
A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (< or =21 years), non-European American, or products of multiple births.
In this population of North Carolina children, the incidence of inflicted TBI varied by characteristics of the injured children and their mothers. These data may be helpful for informing preventive interventions.
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... Similar findings were also reported by Diaz-Olavarria et al. [13] and Rebbe et al. [52]. Many studies have also observed that children born to unmarried mothers are at higher risk, with Starling et al. [7] and Keenan et al. [5,6] observing an OR of 1.6 and 2.2, respectively. At the same time, Notrica et al. [58] found that married mothers carry a 24% risk. ...
... Unintended pregnancies are linked to a higher risk, according to Diaz-Olavarria et al. [13], observing an incidence of 85%; these females also have fewer prenatal visits (<5), further increasing the risk. Starling et al. [7] found that prenatal care initiated after the first trimester has an OR of 1.1, while Keenan et al. [5,6] observed an OR of 2.7. Similarly, Starling et al. [7] reported an OR of 2.2 for AHT if the index child is the first child, while Keenan et al. [5,6] reported an OR of 2.6. ...
... Starling et al. [7] found that prenatal care initiated after the first trimester has an OR of 1.1, while Keenan et al. [5,6] observed an OR of 2.7. Similarly, Starling et al. [7] reported an OR of 2.2 for AHT if the index child is the first child, while Keenan et al. [5,6] reported an OR of 2.6. ...
... Abusive head trauma (AHT), the most severe form of child physical abuse, is defined as "an injury to the skull or intracranial contents of an infant or young child due to inflicted blunt impact and/or violent shaking" [1]. AHT most often occurs in infants younger than 2 years, at a mean age of 2 to 4 months [2][3][4][5], and its incidence has been estimated at 14 to 34 per 100,000 infants per year in countries with developed economies (CDE) [6][7][8][9]. Perpetrators of AHT are most often adult men acting alone [10]. Persistent crying is reported as the primary trigger for most AHT perpetration [11]. ...
... Because of the lack of guidelines to identify the variables to be extracted in the analysis of prevention videos on the internet, the authors established a list based on previous research syntheses of health videos [45][46][47][48], public health behavior theoretical models [49][50][51][52], and AHT literature [2,3,6,10,12,15,25,53]. This list was revised and enriched after the visualization of a sample of 5 eligible videos and then discussed among researchers until a consensus was reached. ...
Background
Numerous strategies for preventing abusive head trauma (AHT) have been proposed, but controlled studies failed to demonstrate their effectiveness. Digital tools may improve the effectiveness of AHT prevention strategies by reaching a large proportion of the adult population.
Objective
This study aimed to describe the characteristics of videos of AHT prevention published on the internet, including their quality content, and to study their association with popularity.
Methods
From a systematic appraisal performed in June 2023, we identified videos addressing the primary prevention of AHT in children younger than 2 years that were published in English or French on the internet by public organizations or mainstream associations. We analyzed the characteristics of the videos; their quality with the Global Quality Scale (GQS); and their association with an index of popularity, the Video Power Index, using multivariable quasi-Poisson modeling.
Results
We included 53 (6.6%) of the 804 videos identified. Videos were mainly published by public organizations (43/53, 81%). The median time spent on the web was 6 (IQR 3-9) years, the median length was 202 (IQR 94-333) seconds, and the median GQS score was 4 (IQR 3-4). Infants were often depicted (42/53, 79%), including while crying (35/53, 66%) and being shaken (21/53, 40%). The characterization of shaking as an abuse and its legal consequences were cited in 47% (25/53) and 4% (2/53) of videos, respectively. The main prevention strategies in the videos were to raise awareness of the noxious outcome of shaking (49/53, 93%) and convince viewers of the effectiveness of coping strategies for infants’ cries (45/53, 85%). The Video Power Index was positively correlated with the GQS (r=0.38; P=.007) and was independently associated with depicting an infant being shaken (P=.03; β=1.74, 95% CI 1.06-2.85) and the use of text or headers (P=.04; β=2.15, 95% CI 1.08-4.26).
Conclusions
AHT prevention videos had high quality but did not frequently deal with parental risk factors. The characteristics identified as being associated with the popularity of AHT prevention videos could help improve the impact of future prevention programs by enhancing their popularity.
... As the most severe form of child abuse, AHT carries devastating consequences, with a mortality rate of 20% and long-term neurological impairment rates reaching up to 50% [2]. A population-based study in the United States revealed an incidence rate of approximately 30 cases per 100,000 person-years in children [3]. In Taiwan, AHT emerged as the predominant form of injury among abused children, particularly affecting infants under one year of age. ...
... The remaining 372 cases were then filtered by cases heard by district courts, which produced a subset of 192 cases. Additional exclusion criteria were applied, thus excluding cases including civil protection orders (72), forcible abduction [1], larceny [1], forging instruments or seals [1], offenses against personal freedom [3], and offenses against marriage and family [1]. Cases unrelated to children's welfare [11] were also excluded. ...
Background
Child abuse in Taiwan is a major societal concern that severely affects the well-being of children. Despite the complexity in detecting abuse, reports of child abuse are increasing, evidenced by a rise in cases and heightened awareness. This study utilizes judicial judgments as a lens to understand the varied interpretations of child abuse by clinical and forensic experts and explores the broader epidemiological trends of such abuse within the declining youth population of Taiwan.
Methods
We conducted a retrospective study by analyzing official court judgments on child abuse allegations judged from 2008 to 2022 from the online database of Judicial Yuan. Furthermore, the study analyzed demographic factors, injury patterns, and opinions from various experts.
Results
The results reveal that severe criminal cases of child abuse predominantly involve biological fathers as the primary offenders and physical abuse as the most common form of maltreatment. Victims are typically aged less than 5 years, which frequently leads to an unfavorable prognosis. Analysis also highlights the TEN-4-FACESp acronym as a highly predictive indicator of child abuse and underscores the prevalence of abusive head trauma (AHT). Moreover, the findings emphasize ongoing disparities in opinions between forensic medical examiners and clinical physicians, especially in AHT cases, which potentially influences judicial decisions.
Conclusions
In summary, the study reveals ongoing disagreements between forensic medical examiners and clinical physicians, especially in cases of AHT, which may impact judicial decisions. Promoting consensus through interdisciplinary collaboration and improved communication can aid in revealing the truth in child abuse cases.
... Falls are the most common cause of injury and the leading cause of traumatic brain injury in children aged 0-4 years [4]. Abusive head trauma (AHT) is more common in infants under two years, with 30 out of 100,000 infants under one year hospitalized annually [5]. Male patients are more likely to receive emergency care and be hospitalized than female patients [6]. ...
Objectives: Pediatric head and spinal traumas are challenging for healthcare professionals due to their potential for severe consequences. Understanding optimal management methods is crucial to prevent complications and improve outcomes. Head and spinal injuries are common in children, with falls and motor vehicle collisions as the leading causes. Common clinical features include altered mental status, vomiting, and neurological deficits. Primary injuries may involve the scalp, skull, brain, and spinal cord. Severity is classified using the Glasgow Coma Scale (GCS).
Methods: This study included pediatric patients (<18 years) presenting to the emergency department with traumatic head or spinal injuries. Data collection included patients' medical history, demographic details, trauma mechanisms, clinical presentations, treatment modalities, and laboratory findings.
Results: A total of 303 patients were analyzed, with male patients accounting for 214 (70.6%). Road traffic accidents (RTA) at 147 (48.5%) and falls at 139 (45.9%) were the most common traumas. Blunt injuries predominated, accounting for 292 cases (96.4%). The head was frequently involved 253 (83.5%). Observation was the most common treatment, used in 213 cases (70.3%), followed by intubation in 44 cases (14.5%). The mean GCS was 10.7. Most patients improved during hospitalization which stood at 272 (89.8%), with a mean length of stay of 9.02 days. Spinal trauma cases (14) showed male predominance at 12 (85.7%) and falls were the most common cause at 7 (50%). Conservative management was prevalent at 11 (78.6%), and most cases achieved survival at 13 (92.9%).
Conclusions: Prompt diagnosis and management are essential to reduce mortality and morbidity in pediatric head and spinal injuries. Accurate evaluation of injury type, location, and mechanism is crucial for effective treatment. This study highlights the importance of optimal management strategies and emphasizes the need for further research to explore factors affecting mortality and morbidity. Limitations include the small number of spinal injury cases and regional generalization.
... Keenan et al. studied population-based incidence of AHT in the USA and reported that the incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 per 100,000 person-years. Infants in the first year of life had a higher incidence than children in the second year of life (29.7 vs. 3.8 per 100,000 person-years) (3). However, this incidence is believed to be much higher than reported because milder forms of AHT may resolve without a hospital visit (4). ...
Aim: Abusive head trauma (AHT) is the most common cause of death as the result of child abuse. A task force is planned to provide training on AHT to professionals in different disciplines on clinical presentation, diagnostic workup, and organization of multidisciplinary evaluation at the hospital and community levels. This study reports on the preliminary findings of the pre-intervention phase of a larger study. Materials and Methods: This is a descriptive, retrospective study exploring the rates of documentation of relevant data in charts, including risk factors for abuse, family demographics, completeness of diagnostic workup, and case finding. Results: Overall, 345 cases were found in hospital databases that were eligible for the retrospective study from 10 participating hospitals. In total, 305 cases (88.4%) were younger than 2 years of age. The most common documented risk factors were low parental education level in 82 families (23.8%), more than three children under 7 years of age in 76 families (22.0%), and bad child temper in 16 families (4.6%), among others. The rate of complete diagnostic workup in hospitals with a multidisciplinary team (MDT) (25.7%) was statistically significantly higher than in hospitals without an MDT (2.9%) (p=0.001). Etiology was identified as inflicted in 78 cases (22.6%), possibly inflicted in 24 (7.0%), undetermined in 79 (22.9%), and accidental in 164 (47.5%) by the researchers, compared to only three cases (0.8%) diagnosed as inflicted by the treating physicians (p<0.0001). In two of the three cases, the perpetrator was convicted; in one, the prosecutor closed the case without a trial on the basis of "no confession" despite the death of the child and medical evidence. Conclusion: Clinicians' knowledge of the diagnosis of AHT should be increased to improve case finding, which will allow determination of more accurate in-cidence/prevalence. This can be accomplished via the establishment of an MDT in teaching hospitals as well as staff training on how to recognize suspicious cases, how to utilize MDT services, and how to report and manage cases on a community level multidisciplinary basis. (Eurasian J Emerg Med 2016; 15: 24-9)
... Abusive head trauma (AHT) describes a potentially fatal head injury of children due to either forceful shaking (shaken baby syndrome, SBS), blunt force trauma, or a combination of both [1][2][3]. With about 20-30 cases in 100,000 live births, AHT is a relatively common phenomenon and the predominant cause of morbidity and mortality in children younger than 2 years with traumatic brain injury [4][5][6]. ...
Objectives
Estimating the age of injury in pediatric abusive head trauma (AHT) is a challenging task but potentially valuable for the identification of perpetrators. The aims of the study are (1) to describe the temporal development of different imaging features of subdural collections (SDCs), and (2) to provide novel age-diagnostic reference data for forensic-radiological expert reports.
Methods
Using a multi-center approach and a 10-year study period, serial neuroimaging studies of 13 comprehensively investigated AHT cases (8 CT and 26 MRI scans) were analyzed regarding several subdural imaging parameters (SDC appearances, entities, components, and associated findings). Due to confessions by perpetrators, the time points of the trauma were presumed unique and known in all cases facilitating correlation of imaging findings with time.
Results
Hyperdense SDCs in CT were found up to 9 d post-injury (p.i.), CSF-like SDCs in CT or MRI as early as from the 3rd hour p.i., and subdural membrane formation as late as from day 283. The heterogeneous variant of the subdural hematohygroma was observed to be the dominant SDC entity between 3 h and 22 d p.i. The tadpole sign was detected in MRI between 3 h and 46 d p.i.
Conclusion
Certain subdural imaging findings may be helpful for estimating the age of injury in AHT. Subdural membrane formation is demonstrated to be a late finding and the tadpole sign is an early phenomenon p.i. The data corroborated that the sediment but not the supernatant has the potential for being valuable for age-diagnostic aspects.
Key Points
Question Reliable evidence-based data on the development of SDCs is sparse but required for expert opinions on pediatric AHT .
Findings Reference data on the evolution of the imaging appearance of SDCs and associated phenomena in confirmed cases of AHT are provided .
Clinical relevance As there is a great need for estimating the age of injury in criminal and civil proceedings, many clinical radiologists are confronted with the diagnostic and forensic aspects of AHT that are addressed in the present study .
Several recent studies1-5 have focused on the pathophysiological features, diagnostic procedures, and criteria of the shaken baby syndrome. Brenner et al6 noted that demographic information on shaken infants and their families is scarce. We were impressed with the seemingly large proportion of children of military families (military dependents) in the population of shaken infants seen at our hospital. Limited prior research has produced divergent conclusions as to whether military dependents are at higher risk of child maltreatment.7 The purpose of our study was to investigate whether military dependents were overrepresented among children hospitalized with shaken baby syndrome and if their pattern of injury or outcomes differed from those of children in the civilian population.
Methods. We reviewed the charts of all infants with a diagnosis of shaken baby syndrome between January 1, 1989, and February 28, 1993, at the University of North Carolina Hospitals, Chapel Hill. Patients
%Objective: Previous studies have concluded that shaken baby syndrome occurs more often among Whites than among Blacks. The purpose of this study was to determine whether race is a predictive factor in Shaken Baby Syndrome when population and referral patterns are considered.Methods: A retrospective medical record review of closed head injuries due to child abuse during the time period January 1992 to July 1997 was conducted at three pediatric tertiary care medical centers in North Carolina. Patients included children, ages 0–4 years, identified from medical record reviews and child abuse databases. Only North Carolina residents were included. The specific rates of shaken baby syndrome in Whites versus non-Whites in the referral area were computed.Results: The difference in the rate of shaken baby syndrome from the referral area was not statistically significant among Whites versus non-Whites (26.7/100,000 versus 38.6/100,000, p = .089) Most of the perpetrators were male (68%), and most victims (76%), lived with their mothers and biologic father or mother’s boyfriend.Conclusion: Race was not a significant factor in predicting shaken baby syndrome in the referral area studied, and therefore is not a useful factor in targeting groups for intervention.
• Shaking as a mechanism of severe brain injury in infants has been challenged on a theoretical basis as insufficient to explain the magnitude of observed injuries. Computed tomography and magnetic resonance imaging, developed since shaken baby syndrome was first described, are helpful in establishing whether external trauma occurred for infants thought to have been shaken. We compiled data from 24 infants initially diagnosed as having shaken baby syndrome, including physical examination, roentgenograms, computed tomography or magnetic resonance imaging, and autopsy (when applicable). Half of the patients showed no evidence of direct impact, and evidence of external trauma was not predictive of a fatal outcome. These findings indicate that shaking by itself is sufficient to cause severe or fatal intracranial injury and that the shaken baby syndrome reflects a spectrum of such child abuse injuries that may include direct trauma or only shaking.
(AJDC. 1990;144:724-726)
The medical records and computed tomography (CT) scans of all children less than 1 year of age admitted to the hospital with head injury over a 2-year period were reviewed. Sixty-four percent of all head injuries, excluding uncomplicated skull fracture, and 95% of serious intracranial injuries were the result of child abuse. The occurrence of intracranial injury in infants, in the absence of a history of significant accidental trauma, such as a motor vehicle accident, constitutes grounds for an official child abuse investigation.
Twenty cases of shaken baby syndrome are reviewed to determine important signs, symptoms, physical findings, laboratory parameters, and prognosis. The signs and symptoms of this form of head trauma are nonspecific. The findings may mimic infection, intoxication, or metabolic abnormalities. Diagnosis depends on a high index of suspicion and the physical findings of a bulging fontanelle, head circumference greater than the 90th percentile, and retinal hemorrhage. The finding of bloody fluid from a lumbar or subdural tap is also highly suggestive. Computed cranial tomography findings confirm the diagnosis. The prognosis in the shaken baby syndrome is poor. Three of our 20 patients died and ten others sustained significant morbidity. The emergency physician must be alert to making this diagnosis in order to promptly institute therapy for acute head trauma.
Close spacing of children may be a significant risk factor for subsequent abuse in some families. Twin births are an extreme example of close spacing. Therefore, the authors hypothesized that twin births may predispose to an increased incidence of child abuse. Thirty-eight families with twins were compared with 97 single birth families and matched for birthdate, maternal age, race, and socioeconomic status. Families with twins experienced a significantly higher incidence of child abuse and neglect than did those with single births (p less than .003). A written questionnaire designed to study mothers' feelings and perceptions of support systems showed a significant difference only in greater difficulty in feeding twins as compared with single infants (p less than .001). Mothers of abused children were more likely not to answer the questionnaire at all (p less than .005). Neither mothers of single births nor those of twins felt that health professionals provided adequate education or support following the birth of their infants.
Abusive head trauma is the most common cause of morbidity and mortality in physically abused infants. Effective prevention requires the identification of potential perpetrators. No study has specifically addressed the relationship of the perpetrators of abusive head trauma ("shaken baby syndrome") to their victims. The objectives of this study were to identify the abusers and their relationship to victims in these cases.
We reviewed the medical charts of 151 infants who suffered abusive head trauma to determine the perpetrator of the abuse. Caretakers were classified by level of certainty: confession to the crime, legal actions taken, or strong suspicion by the staff. The relationship of abusers to victims was analyzed.
Male victims accounted for 60.3% of the cases. Twenty-three percent of the children died, although death rates for boys and girls did not vary significantly. Male perpetrators outnumbered females 2.2:1, with fathers, step-fathers, and mothers' boyfriends committing over 60% of the crimes. Fathers accounted for 37% of the abusers, followed by boyfriends at 20.5%. Female baby-sitters, at 17.3%, were a large, previously unrecognized group of perpetrators. Mothers were responsible for only 12.6% of our cases. All but one of the confessed abusers were with the child at the time of onset of symptoms.
Our data suggest male caretakers are at greater risk to abuse infants. Baby-sitters are a concerning risk group, because they represent a significant proportion of abusers, and they more easily escape prosecution. In addition, no prevention efforts have been directed at baby-sitters. These statistics could help change the focus of efforts to prevent abusive head trauma.
Previous case-control or cross-sectional studies have provided conflicting results about whether children of teenage mothers are at increased risk of maltreatment compared with children of older mothers. This study is the first to examine this question using a longitudinal, cohort design and the first to address important methodologic issues such as detection bias. Subjects were 219 consecutive index children born to inner-city women who were 18 years or younger and 219 sociodemographically similar comparison children born to women 19 years or older. Data were collected by reviewing the medical records of each child through the fifth birthday. Three outcomes were examined: maltreatment, poor growth, and a change in the child's primary caretaker. Maltreatment was ascertained by having two experts, one of whom was blind to the group status, review each injury documented in the records. Predefined criteria were used to distinguish unintentional injuries from maltreatment (abuse, neglect, or sexual abuse). Maltreatment occurred more frequently in the children of young mothers (12.8%) than in the comparison group (6.4%) (risk ratio [RR] = 2.00; 95% confidence interval [CI] = 1.17, 3.64). Poor growth, defined by growth criteria, occurred in 6.9% of the index group and in 4.1% of comparison children (RR = 1.67; 95% CI = 0.75, 3.73). A change in the child's primary caretaker, either because of placement in foster care or because the mother left the home, occurred in 12.8% of the index group and in 3.2% in comparison children (RR = 4.00; 95% CI = 1.80, 8.87).(ABSTRACT TRUNCATED AT 250 WORDS)
Nonaccidental injury accounts for nearly one quarter of all hospital admissions for head injury in infancy, and is associated with significant morbidity and mortality. Long-term outcome in survivors, however, has been incompletely studied. In this series, 84 infants 2 years of age and younger with the shaking-impact syndrome consecutively admitted to a single hospital between 1978 and 1988 were identified. A questionnaire detailing current medical, developmental, and behavioral status was developed, and attempts were made to locate the 62 children surviving the acute injury. Family instability and strict confidentiality restrictions precluded locating the majority of children, but 14 children with demographic and injury characteristics similar to those of the overall group were contacted at an average of 9 years after injury. Seven children were severely disabled or vegetative, 2 were moderately disabled, and 5 had a good outcome. Of the latter group, 3 had repeated grades and/or required tutoring. Acute factors associated with poor outcome included unresponsiveness on admission, need for intubation, age less than 6 months, and bilateral or unilateral diffuse hypodensity on CT scan. All children with bilateral diffuse hypodensity and loss of gray-white differentiation on CT scan remained blind, retarded, nonverbal, and nonambulatory in spite of aggressive medical and surgical management. This study suggests that the majority of children surviving the shaking-impact syndrome suffer major permanent morbidity, and that acute factors predicting long-term outcome may help guide aggressiveness of care.