Do preterm bones still break? Incidence of rib fracture and osteopenia of prematurity in very low birth weight infants.

AIM: Extremely premature babies are at risk of osteopenia of prematurity (OOP) as bone mineralisation in utero increases exponentially after 24 weeks gestation. Our aim was to assess the bone health of very low birth weight (VLBW) infants. We wanted to establish the incidences of OOP and rib fracture. We also looked at which biochemical markers best predicted OOP. Bone health in this vulnerable population is an important aspect of management which should not be overlooked. METHODS: This was an observational study which included all VLBW infants, born in a national maternity hospital, over a 5-year period. All X-rays performed on these infants were reviewed. Data were also collected on biochemical markers associated with bone health. The medical records of infants with rib fractures were reviewed looking for causes of bone fragility. RESULTS: Of the 609 VLBW infants included in the study, only two cases of definitive rib fractures were found. This represents a rib fracture incidence of 3 per 1000. Thirty-nine percent of VLBW babies showed radiological evidence suggestive of OOP. CONCLUSION: Our findings show a lower rate of rib fracture in preterm infants compared to previous evidence. We also showed that these fractures were not evident on the final X-ray prior to discharge. This implies that when an ex-preterm infant presents to the emergency department with a rib fracture there should be an even higher suspicion for non-accidental injury than previously thought.

Characteristics of femur fractures in ambulatory young children.

OBJECTIVES: To determine and identify the characteristics and circumstances of femur fractures in ambulatory young children. DESIGN AND SETTING: Retrospective review of 203 ambulatory children, between 1 and 5 years old, presenting with femur fractures to an urban paediatric hospital over a 10-year period. χ(2) And Student's t test were employed for statistical analysis. RESULTS: The mean age was 36.6 months, with 155 (76.2%) being male. The most frequent mechanism of injury was fall from a height (n=62, 30.5%). The highest number of injuries occurred in 2-3-year-olds. The most common history in 1-2-year-olds was stumbling on/over something causing a fall. For 4-5 year olds it was road traffic accidents. Other additional physical findings were infrequent (14.3%) and not suspicious of inflicted injury. Child protective services concluded three of the cases to be likely non-accidental, and four cases were inconclusive but requiring close follow-up. Of these seven children, six occurred in 1-2-year-olds. No distinguishing feature was noted in fracture type or location. CONCLUSIONS: Femur fractures can occur with low velocity injury whether from a short fall or twisting/stumbling injury in young healthy ambulatory children.

Shaken baby syndrome without intracranial hemorrhage on initial computed tomography.

OBJECTIVE: We sought to describe the unique characteristics of children diagnosed with shaken baby syndrome (SBS) despite the absence of intracranial hemorrhage on cranial computerized tomography (CT) on hospital admission. METHODS: Using an international e-mail-based listserv for professionals with an interest in child abuse, we identified and reviewed the charts of children hospitalized in different medical centers who were diagnosed with SBS although CT disclosed no signs of intracranial bleeding. Children with normal imaging were not included. RESULTS: Eight cases were identified. All children had cerebral edema in CT, which was severe on 7/8 cases (88%). All of these children had extensive retinal hemorrhage. The prognosis was poor; 5/8 infants died (63% mortality), and the rest had permanent neurologic damage. CONCLUSION: The diagnosis of SBS can be established even when CT at presentation does not demonstrate intracranial hemorrhage. We hypothesize that rapidly developing cerebral edema may cause increased intracranial pressure and tamponade that prevents the accumulation of intracranial blood. The prognosis in these cases is grave.

Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome.

Nonophthalmologists did not attempt to (36%) or were "unable to" (19%) examine the fundus in 72 children with shaken baby syndrome. When the retina was examined, nonophthalmologists were accurate in recognizing the absence or presence of retinal hemorrhage in 87%. However, false-negative examinations occurred in 13%. Ophthalmology consultation should be an integral part of the evaluation of children with suspected abuse.