Janet Fromkin

Abusive Head Trauma During a Time of Increased Unemployment: A Multicenter Analysis

OBJECTIVE: To evaluate the rate of abusive head trauma (AHT) in 3 regions of the United States before and during an economic recession and assess whether there is a relationship between the rate of AHT and county-level unemployment rates. METHODS: Clinical data were collected for AHT cases diagnosed in children younger than 5 years from January 1, 2004 until June 30, 2009, by hospital-based child protection teams within 3 geographic regions. The recession was defined as December 1, 2007 through June 30, 2009. Quarterly unemployment rates were collected for every county in which an AHT case occurred. RESULTS: During the 5½-year study period, a total of 422 children were diagnosed with AHT in a 74-county region. The overall rate of AHT increased from 8.9 in 100 000 (95% confidence interval [CI]: 7.8–10.0) before the recession to 14.7 in 100 000 (95% CI: 12.5–16.9) during the recession (P < .001). There was no difference in the clinical characteristics of subjects in the prerecession versus recession period. There was no relationship between the rate of AHT and county-level unemployment rates. CONCLUSIONS: The rate of AHT increased significantly in 3 distinct geographic regions during the 19 months of an economic recession compared with the 47 months before the recession. This finding is consistent with our understanding of the effect of stress on violence. Given the high morbidity and mortality rates for children with AHT, these results are concerning and suggest that prevention efforts might need to be increased significantly during times of economic hardship.

Use of Skeletal Surveys to Evaluate for Physical Abuse: Analysis of 703 Consecutive Skeletal Surveys

OBJECTIVES: The goals were to assess the use of the skeletal survey (SS) to evaluate for physical abuse in a large consecutive sample, to identify characteristics of children most likely to have unsuspected fractures, and to determine how often SS results influenced directly the decision to make a diagnosis of abuse. METHODS: A retrospective, descriptive study of a consecutive sample of children who underwent an SS at a single childrens hospital over 4 years was performed. Data on demographic characteristics, clinical presentation, SS results, and effects of SS results on clinical diagnoses were collected. A positive SS result was defined as a SS which identified a previously unsuspected fracture(s). RESULTS: Of the 703 SSs, 10.8% yielded positive results. Children <6 months of age, children with an apparent life-threatening event or seizure, and children with suspected abusive head trauma had the highest rates of positive SS results. Of children with positive SS results, 79% had ≥1 healing fracture. CONCLUSIONS: This is the largest study to date to describe the use of the SS. Almost 11% of SS results were positive. The SS results influenced directly the decision to make a diagnosis of abuse for 50% of children with positive SS results. These data, combined with the high morbidity rates for missed abuse and the large proportion of children with healing fractures detected through SS, suggest that broader use of SS, particularly for high-risk populations, may be warranted.

Validation of the Pittsburgh Infant Brain Injury Score for abusive head trauma

BACKGROUND: Abusive head trauma is the leading cause of death from physical abuse. Misdiagnosis of abusive head trauma as well as other types of brain abnormalities in infants is common and contributes to increased morbidity and mortality. We previously derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction rule to assist physicians deciding which high-risk infants should undergo computed tomography of the head. METHODS: Well-appearing infants 30 to 364 days of age with temperature <38.3°C, no history of trauma, and a symptom associated with an increased risk of having a brain abnormality were eligible for enrollment in this prospective, multicenter clinical prediction rule validation. By using a predefined neuroimaging paradigm, subjects were classified as cases or controls. The sensitivity, specificity, and negative and positive predictive values of the rule for prediction of brain injury were calculated. RESULTS: A total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0 months (1 point), head circumference >85th percentile (1 point), and serum hemoglobin <11.2g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%–96.3%) and 53% (95% confidence interval 49.3%–57.1%), respectively. CONCLUSIONS: Our data suggest that the PIBIS accurately identifies infants who would benefit from neuroimaging to evaluate for brain injury. An implementation analysis is needed before the PIBIS can be integrated into clinical practice.

ASSESSING THE USE OF FOLLOW-UP SKELETAL SURVEYS IN CHILDREN WITH SUSPECTED PHYSICAL ABUSE

BACKGROUND Child physical abuse is an important cause of morbidity and mortality in young children. The skeletal survey (SS) is considered a mandatory part of the evaluation for suspected physical abuse in young children. Literature suggests that a follow-up SS performed 10 to 21 days after the initial SS can provide important additional information, but previous studies evaluating the follow-up SS have been small and included very selective patient populations. METHODS A retrospective descriptive study of a consecutive sample of children who underwent an initial SS and a follow-up SS at a single children’s hospital during a 7-year period. Data on demographics, clinical presentation, results, and effect of the follow-up SS on clinical diagnosis were collected. RESULTS Of the 1470 children who underwent an initial SS, 11% (169 of 1470 children) also underwent a follow-up SS. The mean age of the children who underwent both an initial SS and a follow-up SS was 5.8 months. Fourteen percent of the follow-up SS identified previously unrecognized fractures; all of which were healing. There were eight children in whom the information obtained from the follow-up SS resulted in a diagnosis of definite physical abuse; all eight children were younger than 12 months, and in six of these cases, the initial SS did not demonstrate any fractures. CONCLUSION Only a small proportion of children who undergo an initial SS also undergo a follow-up SS. The relatively high proportion of follow-up SS that demonstrated previously unrecognized fracture(s), the young age of children undergoing the follow-up SS, and the high morbidity and mortality of unrecognized/missed child physical abuse in this age group suggest that the follow-up SS should be a routine part of the evaluation of child physical abuse. LEVEL OF EVIDENCE III, observational study.

Development of a screening MRI for infants at risk for abusive head trauma.

BackgroundAbusive head trauma (AHT) is an important cause of morbidity in infants. Identifying which well-appearing infants are at risk for AHT and need neuroimaging is challenging, and concern about radiation exposure limits the use of head CT. Availability of an MRI protocol that is highly sensitive for intracranial hemorrhage would allow for AHT screening of well-appearing infants without exposing them to radiation.ObjectiveTo develop a screening MRI protocol to identify intracranial hemorrhage in well-appearing infants at risk for AHT.Materials and methodsInfants enrolled in a parent study of well-appearing infants at increased risk for AHT were eligible for the current study if they underwent both head CT and conventional brain MRI. A derivation cohort of nine infants with AHT was used to identify sequences that provided the highest sensitivity for intracranial hemorrhage. A validation cohort of 78 infants including both controls with normal neuroimaging and cases with AHT was used to evaluate the accuracy of the selected sequences.ResultsThree pulse sequences — axial T2, axial gradient recalled echo (GRE) and coronal T1-W inversion recovery — were 100% sensitive for intracranial hemorrhage in the derivation cohort. The same sequences were 100% sensitive (25/25) and 83% specific (44/53) for intracranial hemorrhage in the validation cohort.ConclusionA screening MRI protocol including axial T2, axial GRE and coronal T1-W inversion recovery sequences is highly sensitive for intracranial hemorrhage and may be useful as a screening tool to differentiate well-appearing infants at risk for AHT who should undergo head CT from those who can safely be discharged without head CT. Additional research is needed to evaluate the feasibility of this approach in clinical practice.

Retinal Hemorrhages in Low-Risk Children Evaluated for Physical Abuse

OBJECTIVES To describe the prevalence of retinal hemorrhage (RH) in children without intracranial injury who are being evaluated for abusive head trauma and to validate previously derived criteria for identifying patients within this population who are at low risk of having RH on dilated eye examination. DESIGN Medical record review. SETTING Childrens Hospital of Pittsburgh of University of Pittsburgh Medical Center from January 1, 2006, to April 30, 2010. PARTICIPANTS One hundred ninety-four infants and children evaluated for physical abuse by the hospital Child Protection Team who did not have intracranial injury and who underwent a dilated eye examination to evaluate for RH. MAIN OUTCOME MEASURE Number of children with RH who met a set of low-risk criteria: no intracranial hemorrhage with or without a simple, nonoccipital skull fracture, normal mental status, and no bruising on the head or face. RESULTS Of the 194 patients without intracranial injury who underwent dilated eye examination, 141 children (72.7%) met low-risk criteria. None of these 141 patients had RH. Of the 53 participants who did not meet low-risk criteria, 2 children (3.8%) had RH. CONCLUSIONS In children evaluated for physical abuse who fulfill a set of low-risk criteria, the dilated eye examination should not be a necessary component of the abuse evaluation. Use of these criteria can significantly decrease the number of children who need to undergo a dilated eye examination as part of an evaluation for abusive head trauma.

Derivation and Validation of a Serum Biomarker Panel to Identify Infants With Acute Intracranial Hemorrhage

Importance Abusive head trauma is the leading cause of death from physical abuse. Missing the diagnosis of abusive head trauma, particularly in its mild form, is common and contributes to increased morbidity and mortality. Serum biomarkers may have potential as quantitative point-of-care screening tools to alert physicians to the possibility of intracranial hemorrhage. Objective To identify and validate a set of biomarkers that could be the basis of a multivariable model to identify intracranial hemorrhage in well-appearing infants using the Ziplex System. Design, Setting, and Participants Binary logistic regression was used to develop a multivariable model incorporating 3 serum biomarkers (matrix metallopeptidase-9, neuron-specific enolase, and vascular cellular adhesion molecule-1) and 1 clinical variable (total hemoglobin). The model was then prospectively validated. Multiplex biomarker measurements were performed using Flow-Thru microarray technology on the Ziplex System, which has potential as a point-of-care system. The model was tested at 3 pediatric emergency departments in level I pediatric trauma centers (Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Primary Children’s Hospital, Salt Lake City, Utah; and Lurie Children’s Hospital, Chicago, Illinois) among well-appearing infants who presented for care owing to symptoms that placed them at increased risk of abusive head trauma. The study took place from November 2006 to April 2014 at Children’s Hospital of Pittsburgh, June 2010 to August 2013 at Primary Children’s Hospital, and January 2011 to August 2013 at Lurie Children’s Hospital. Main Outcomes and Measures A mathematical model that can predict acute intracranial hemorrhage in infants at increased risk of abusive head trauma. Results The multivariable model, Biomarkers for Infant Brain Injury Score, was applied prospectively to 599 patients. The mean (SD) age was 4.7 (3.1) months. Fifty-two percent were boys, 78% were white, and 8% were Hispanic. At a cutoff of 0.182, the model was 89.3% sensitive (95% CI, 87.7-90.4) and 48.0% specific (95% CI, 47.3-48.9) for acute intracranial hemorrhage. Positive and negative predictive values were 21.3% and 95.6%, respectively. The model was neither sensitive nor specific for atraumatic brain abnormalities, isolated skull fractures, or chronic intracranial hemorrhage. Conclusion and Relevance The Biomarkers for Infant Brain Injury Score, a multivariable model using 3 serum biomarker concentrations and serum hemoglobin, can identify infants with acute intracranial hemorrhage. Accurate and timely identification of intracranial hemorrhage in infants without a history of trauma in whom trauma may not be part of the differential diagnosis has the potential to decrease morbidity and mortality from abusive head trauma.