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01-08-2018 | Original Article

Occult head injury is common in children with concern for physical abuse

Authors: Mitchell Boehnke, David Mirsky, Nicholas Stence, Rachel M. Stanley, Daniel M. Lindberg, for the ExSTRA investigators

Published in: Pediatric Radiology | Issue 8/2018

Abstract

Background

Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients.

Objectives

Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury.

Materials and methods

This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury.

Results

One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8–6.8), macrocephaly (OR 8.5, 95% CI 3.7–20.2), and loss of consciousness (OR 5.1, 95% CI 1.2–22.9) had higher odds of occult head injury.

Conclusion

Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.

Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics (2015) The evaluation of suspected child physical abuse. Pediatrics 135:e1337–e1354CrossRefPubMed

Jenny C, Hymel KP, Ritzen A et al (1999) Analysis of missed cases of abusive head trauma. JAMA 281:621–626CrossRefPubMed

Duhaime AC, Christian CW, Rorke LB et al (1998) Nonaccidental head injury in infants--the “shaken-baby syndrome.” N Engl J Med 338:1822–1829

Palusci VJ, Covington TM (2014) Child maltreatment deaths in the U.S. National Child Death Review Case Reporting System. Child Abuse Negl 38:25–36CrossRefPubMed

Rubin DM, Christian CW, Bilaniuk LT et al (2003) Occult head injury in high-risk abused children. Pediatrics 111:1382–1386CrossRefPubMed

Laskey AL, Holsti M, Runyan, DK Socolar RR et al (2004) Occult head trauma in young suspected victims of physical abuse. J Pediatr 144:719–722

Fickenscher KA, Dean JS, Mena DC et al (2010) Occult cranial injuries found with neuroimaging in clinically asymptomatic young children due to abusive compared to accidental head trauma. South Med J 103:121–125CrossRefPubMed

Wootton-Gorges SL, Soares BP, Alazraki AL et al (2017) ACR appropriateness criteria(R) suspected physical abuse-child. J Am Coll Radiol 14:S338–s349CrossRefPubMed

Wilson PM, Chua M, Care M et al (2014) Utility of head computed tomography in children with a single extremity fracture. J Pediatr 164:1274–1279CrossRefPubMed

10.

Lindberg DM, Blood EA, Campbell KA et al (2013) Predictors of screening and injury in contacts of physically abused children. J Pediatr 163:730–735.e1–3

11.

Wood JN, French B, Song L Feudtner C et al (2015) Evaluation for occult fractures in injured children. Pediatrics 136:232–240

12.

Trokel M, Waddimba A, Griffith J Sege R et al (2006) Variation in the diagnosis of child abuse in severely injured infants. Pediatrics 117:722–728

13.

Kuppermann N, Holmes JF, Dayan PS et al (2009) Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374:1160–1170CrossRefPubMed

14.

Bressan S, Romanato S, Mion T et al (2012) Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med 19:801–807CrossRefPubMed

15.

Schonfeld D, Bressan S, Da Dalt L et al (2014) Pediatric emergency care applied research network head injury clinical prediction rules are reliable in practice. Arch Dis Child 99:427–431CrossRefPubMed

16.

Magana JN, Kuppermann N (2017) The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med 24:382–384CrossRefPubMed

17.

Berger RP, Fromkin J, Herman B et al (2016) Validation of the Pittsburgh infant brain injury score for abusive head trauma. Pediatrics 138

18.

Pierce MC, Kaczor K, Aldridge S et al (2010) Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 125:67–74CrossRefPubMed

19.

Slovis TL, Strouse PJ, Strauss KJ (2015) Radiation exposure in imaging of suspected child abuse: benefits versus risks. J Pediatr 167:963–968

20.

Mathews JD, Forsythe AV, Brady Z et al (2013) Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 346:f2360CrossRefPubMedPubMedCentral

21.

Brenner DJ, Hall EJ (2007) Computed tomography--an increasing source of radiation exposure. N Engl J Med 357:2277–2284CrossRefPubMed

22.

Lindberg DM, Shapiro RA, Laskey AL et al (2012) Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 130:193–201

23.

Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefPubMed

24.

Starling SP, Patel S, Burke BL et al (2004) Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med 158:454–458CrossRefPubMed

25.

Stanley RM, Nigrovic LE (2017) Research priorities for a multi-center child abuse network: lessons learned from pediatric emergency medicine networks. Child Abuse Negl 70:414–416CrossRefPubMed

Title: Occult head injury is common in children with concern for physical abuse
Authors: Mitchell Boehnke
David Mirsky
Nicholas Stence
Rachel M. Stanley
Daniel M. Lindberg
for the ExSTRA investigators
Publication date: 01-08-2018
Publisher: Springer Berlin Heidelberg
Published in: Pediatric Radiology / Issue 8/2018
Print ISSN: 0301-0449
Electronic ISSN: 1432-1998
DOI: https://doi.org/10.1007/s00247-018-4128-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Occult head injury is common in children with concern for physical abuse

Abstract

Background

Objectives

Materials and methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Objectives

Materials and methods

Results

Conclusion

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