Retinal hemorrhage variation in inertial versus contact head injuries.

BACKGROUND: Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. OBJECTIVE: The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. PARTICIPANTS AND SETTING: This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. METHODS: Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. RESULTS: PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91-170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004-0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09-67.01) vs 0.5 % (2/339), OR = 0.04 (0.01-0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. CONCLUSIONS: cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries.

Subdural hemorrhage, macrocephaly, rash, and developmental delay in an infant: A pathogenic variant in NLRP3 causes CINCA/NOMID.

Subdural hemorrhages (SDHs) in children are most often observed in abusive head trauma (AHT), a distinct form of traumatic brain injury, but they may occur in other conditions as well, typically with clear signs and symptoms of an alternative diagnosis. We present a case of an infant whose SDH initially raised the question of AHT, but multidisciplinary evaluation identified multiple abnormalities, including rash, macrocephaly, growth failure, and elevated inflammatory markers, which were all atypical for trauma. These, along with significant cerebral atrophy, ventriculomegaly, and an absence of other injuries, raised concerns for a genetic disorder, prompting genetic consultation. Clinical trio exome sequencing identified a de novo likely pathogenic variant in NLRP3, which is associated with chronic infantile neurological, cutaneous, and articular (CINCA) syndrome, also known as neonatal-onset multisystem inflammatory disease (NOMID). He was successfully treated with interleukin-1 blockade, highlighting the importance of prompt treatment in CINCA/NOMID patients. This case also illustrates how atraumatic cases of SDH can be readily distinguished from AHT with multidisciplinary collaboration and careful consideration of the clinical history and exam findings.

Short Falls in Childhood Occasionally Cause Major Brain Injuries Because of Unusual Circumstances.

METHODS: Records and imaging were reviewed for children younger than 6 years, hospitalized between 2015 and 2020 for major closed head injuries following less than 4-ft falls. Major injury was defined as intensive care admission more than 2 days, neurosurgical intervention, death, or disability at hospital discharge. Subjects were identified through Seattle and Spokane, Washington abuse consultations. Harborview Medical Center's trauma registry and Seattle Children's Hospital's Hemophilia Treatment Program and Radiology were searched for subjects. RESULTS: We identified 12 young children who sustained major closed head injury due to short falls. Seven developed major space-occupying epidural hemorrhages. One child developed internal hydrocephalus after intraventricular hemorrhage. One child with prior meningomyelocele, Chiari 2 malformation, and ventriculoperitoneal shunt developed shunt decompensation after an acute-on-chronic subdural hemorrhage. One child developed an internal capsule stroke because of a previously undiagnosed calcifying angiopathy. Another child developed space-occupying subdural hemorrhage associated with previously unrecognized platelet pool disorder. Only this child had abuse concerns, which were resolved with his coagulopathy diagnosis. One child had a diastatic skull fracture leading to pseudomeningocele.At Harborview Medical Center, 140 children were seen for short falls in the emergency department or inpatient service. Among the 40 needing intensive care, 4 (12.5%) had major injuries after short falls. Our hemophilia treatment program did not see any children who had sustained major injury following a short fall in a 5½ year period. CONCLUSIONS: Although young children rarely sustain major head injury following short falls, serious head injuries do occasionally occur because of unusual injury mechanisms or preexisting conditions. It is important to fully evaluate these patients to differentiate these unintentional falls from abusive head injury.

Pediatric abusive head trauma: visual outcomes, evoked potentials, diffusion tensor imaging, and relationships to retinal hemorrhages.

PURPOSE: Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures. METHODS: Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR). RESULTS: Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping. DISCUSSION: Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics.

Accidental and Abusive Mandible Fractures in Infants and Toddlers.

OBJECTIVE: Mandible fractures are uncommon injuries in infants and young children and may raise concern for nonaccidental trauma. Our study describes several children with mandible fractures to identify features that might differentiate abuse from accident. METHODS: Records and imaging were reviewed for children aged 24 months and younger who were diagnosed with mandible fractures at 2 tertiary pediatric care centers. Twenty-one cases were included, 8 of whom had formal child abuse consultations. Cases were reviewed for mechanisms of injury, physical examination findings, and occult injuries identified, as well as the final abuse determination. RESULTS: Among children with child abuse consultations, 5 injuries (62.5%) were determined to be accidental, 1 (12.5%) was abusive, and 2 were indeterminate for abuse or accident (25%). In each accidentally injured child, the reported mechanism of injury was a short fall with evidence of facial impact. No accidentally injured child had unexpected occult injuries or noncraniofacial cutaneous injuries. CONCLUSIONS: Infants and young children can sometimes sustain mandible fractures accidentally after well-described short falls with evidence of facial impact. Abuse remains in the differential diagnosis, and children should be evaluated accordingly. We propose that accidental injury be considered when a well-evaluated child with an isolated mandible fracture has a history of a short fall.

Symptomatic Cervical Spinal Cord Injury Without Accompanying Intracranial Injury Because of Child Abuse.

ABSTRACT: Although spinal ligamentous injuries and extra-axial hemorrhages are known to commonly accompany abusive head trauma (AHT), symptomatic and radiological apparent cervical spinal cord injuries are rare. Of the 16 previously reported cases, 3 such cord injuries lacked the accompanying intracranial injuries of AHT. We report an additional child who developed symptomatic central cervical cord syndrome, with accompanying cervical imaging findings, but no intracranial AHT injuries. The mechanism of trauma for this child and the other children without intracranial injury remains unclear. However, 1 additional reported child sustained similar injuries when she was held by her head and shaken. It is likely that as cervical magnetic resonance imaging becomes more common in AHT, more cases will be recognized.

Optical Coherence Tomography and Visual Outcomes in Pediatric Abusive Head Trauma.

PURPOSE: Compare follow-up optical coherence tomography (OCT) with visual function in children with abusive head trauma (shaken baby syndrome). METHODS: Retrospective follow-up studies of 3 children who were victims of abusive head trauma (AHT) within the first year of life. RESULTS: OCTs showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in 3 out of 4 eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage. DISCUSSION: Significant abnormalities of retinal anatomy can be detected on OCT years after AHT. OCTs and assessment of visual pathways help to elucidate causes of visual dysfunction in children with AHT.

The overlap of medical child abuse and central sensitization in adolescents: An exploratory qualitative study.

BACKGROUND: Both medical child abuse (MCA) and central sensitization (CS) may present in adolescents with chronic pain, disability, high healthcare utilization, and unremarkable medical evaluations. OBJECTIVE: This study aimed to identify themes in the clinical narratives of adolescents with chronic pain that may help differentiate MCA from CS. PARTICIPANTS AND SETTING: Participants were 28 adolescents (ages 13-18 years) with chronic pain referred to either the Child Abuse Pediatrics team or the Pediatric Pain Medicine team at a tertiary children's hospital between 2011 and 2019, and diagnosed with MCA or CS, respectively. METHODS: This was a qualitative, retrospective study. Qualitative themes were derived through a process of inductive content analysis utilizing open coding, grouping, and secondary review by an interdisciplinary panel of experts. The relative prevalence of each code, theme, and overarching category was examined between groups to identify areas of convergence and divergence. RESULTS: Several themes appeared to be more prevalent in the MCA group (n = 9) compared to the CS group (n = 19). These included sick identity, homeschooling, caregiver with mental health disorder, maternal catastrophizing, maternal misrepresentation, persistence in healthcare-seeking, mandated reports made, medical neglect, and unnecessary and harmful medical care. CONCLUSIONS: This exploratory work identified themes from the clinical narratives of adolescents with chronic pain that may help differentiate MCA from CS. A visual reference, two illness scripts, and management recommendations are presented to aid pediatric providers in facilitating appropriate referrals for adolescents with chronic pain and disability out of proportion to diagnostic workup.

Extra-axial haemorrhages in young children with skull fractures: abuse or accident?

OBJECTIVE: Infant and toddler subdural haemorrhages (SDH) are often considered indicative of abuse or major trauma. However, accidental impact events, such as falls, cause contact extra-axial haemorrhages (EAHs). The current study sought to determine frequency and clinical behaviour of EAHs with infant and toddler accidental and abusive skull fractures. PATIENTS AND METHODS: Children aged <4 years with accidental skull fractures and abusive fractures identified by CT at two paediatric tertiary care centres. Clinical data were abstracted by child abuse paediatricians and images were reviewed by paediatric radiologists. Data were analysed using univariate and multivariate logistic regression as well as descriptive statistics. RESULTS: Among 227 subjects, 86 (37.9%) had EAHs. EAH was present in 73 (34.8%) accidental and 13 (76.5%) of the abusive injuries. Intracranial haemorrhage rates were not different for children with major or minor accidents but were fewer than abused. EAH was equally common with falls <4 and >4 ft. EAH depths did not differ by mechanism, but 69% of accidental EAHs were localised solely at fracture sites vs 38% abuse. Widespread and multifocal EAHs were more common with abuse. Children with abuse or major accidental injuries presented with lower initial Glasgow Coma Scales than those with minor accidents. Abused children had initial loss of consciousness more often than those with either minor or major accidents. CONCLUSIONS: Simple contact EAHs were common among children with minor and major accidental skull fractures. Accidental EAHs were more localised with less neurological dysfunction than abusive.

Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed Tomography Imaging?

OBJECTIVE: The aim of the study was to determine whether complex skull fractures are more indicative of child abuse or major trauma than simple skull fractures. DESIGN: This is a retrospective chart and imaging review of children diagnosed with a skull fracture. Subjects were from 2 pediatric tertiary care centers. Children younger than 4 years who underwent a head computed tomography with 3-dimensional rendering were included. We reviewed the medical records and imaging for type of skull fracture, abuse findings, and reported mechanism of injury. A complex skull fracture was defined as multiple fractures of a single skull bone, fractures of more than 1 skull bone, a nonlinear fracture, or diastasis of greater than 3 mm. Abuse versus accident was determined at the time of the initial evaluation with child abuse physician team confirmation. RESULTS: From 2011 to 2012, 287 subjects were identified by International Classification of Diseases, Ninth Revision, code. The 147 subjects with a cranial vault fracture and available 3-dimensional computed tomography composed this study's subjects. The average age was 12.3 months. Seventy four (50.3%) had complex and 73 (49.7%) had simple fractures. Abuse was determined in 6 subjects (4.1%), and a determination could not be made for 5 subjects. Adding abused children from 2013 to 2014 yielded 15 abused subjects. Twelve of the abused children (80%) had complex fractures; more than the 66 (48.5%) of 136 accidentally injured children (P = 0.001; relative risk = 1.65 [1.21-2.24]). However, among children with a complex fracture, the positive predictive value for abuse was only 7%. CONCLUSIONS: Complex skull fractures frequently occur from accidental injuries. This study suggests that the presence of complex skull fractures should not be used alone when making a determination of abuse.

Child Abuse Pediatricians Assess a Low Likelihood of Abuse in Half of 2890 Physical Abuse Consults.

The aim of this study was to examine the frequency with which child abuse pediatricians (CAPs) assess consultations as low versus high likelihood of abuse. In this retrospective secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) study, the likelihood of abuse score for 2890 consultations at 20 medical centers was collected. Descriptive statistics were used to examine the percentage of cases representing low versus high likelihood of abuse (i.e., score of 1-4 vs. 5-7 on a 7-point scale). Linear and logistic regression analyses were used to examine score variability between medical centers. Overall, fifty-three percent of cases were assessed as low likelihood of abuse, suggesting that CAPs were equally as likely to assess a high versus low likelihood of abuse. The percentage of cases representing low likelihood of abuse differed significantly (P < .001) between medical centers after controlling for patient age, sex, race/ethnicity, twin/triplet status, injury types, and injury severity. The variability between CAP assessments at different medical centers is discussed, along with potential contributors to this variability and directions for future work.

Evaluation of an Emergency Department High-risk Bruising Screening Protocol.

OBJECTIVES: The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). METHODS: A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed. RESULTS: Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. CONCLUSIONS: High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.

3 Cases of Inflicted Skull Crush Injuries in Infants.

ABSTRACT: We describe 3 infants with skull fractures that involved more than 1 skull bone. On further evaluation, 2 of the 3 infants had additional fractures at other sites of the body and the third infant had concerning bruising of the face. Although an accidental mechanism of injury was initially given as the history in each case, law enforcement investigations led all 3 fathers to confess to crushing their infants' skulls out of frustration. These crushes were caused by their arms or hands. Bilateral skull fractures or those involving more than 1 skull bone can be seen in falls as well as in crush injuries. A crush-like pattern of injury, in the absence of a clear and plausible accidental mechanism, should raise concerns for possible physical abuse especially in nonambulatory infants.

Atraumatic Spinal Epidural Hematoma as Initial Presentation of Hemophilia A in an Infant.

ABSTRACT: Hemophilia A is characterized by deficiency of factor VIII. We present a unique, illustrative case of an infant with a short history of neck pain and irritability without neurological deficits who was found to have a spinal epidural hematoma. The subsequent investigation for the etiology, including workup for nonaccidental trauma, led to a diagnosis of severe hemophilia A.

Multiple Abusive Fractures in an Infant With a Concurrent Parathyroid Hormone-Related Peptide-Secreting Renal Tumor: Abusive Fractures Accompanying a Parathyroid Hormone-Related Peptide-Secreting Tumor.

BACKGROUND: When evaluating an infant with unexplained fractures for child abuse, it is important to evaluate for possible causes of underlying bone fragility. CASE: A 7-month-old infant was found to have a parathyroid hormone (PTH)-related peptide-secreting mesoblastic nephroma. In spite of having an elevated serum calcium, depressed serum phosphate, and high levels of PTH-related peptide, he had no demineralization or other hyper parathyroid-related bone changes. Instead, he had multiple classic metaphyseal lesions, fractures of differing ages including a proximal clavicle fracture, and current and past bruising. No fractures typical of bone insufficiency were present. These findings are highly indicative of abuse in addition to his hormone-secreting tumor. CONCLUSIONS: In spite of this child's abuse findings, endogenous or tumor-related hyper PTH should be in the differential of underlying bone fragility. Children with disorders that could cause injury susceptibility can also be abused.

Fracture-Associated Bruising and Soft Tissue Swelling in Young Children With Skull Fractures: How Sensitive Are They to Fracture Presence?

OBJECTIVES: The aim of this study was to determine how reliable scalp bruising and soft tissue swelling/cephalohematomas (STS) are for underlying young child skull fractures. METHODS: This was a retrospective clinical and imaging review from 2011 to 2012 of children younger than 4 years with skull fractures from 2 tertiary care hospitals. Imaging was reread by 3 pediatric radiologists. Descriptive statistics were utilized. The retrospective review had institutional review board approval. RESULTS: We identified 218 subjects for review: 210 unintentional and 8 abusive. One hundred forty-three had available 3-dimensional computed tomography reconstructions: 136 unintentional and 7 abused. Two-thirds were younger than 1 year. Twelve subjects had visible scalp bruising, but 73% had clinically and 93% radiologically apparent fracture-associated STS. There was no difference in clinical STS with simple (79%) versus complex (68%) fractures. Nor was there difference in subjects with fractures from minor (77%) versus major (70%) trauma. Unintentionally injured infants did not differ from abused for detectable STS (74% vs 50%). Parietal and frontal bones most frequently sustained fractures and most consistently had associated STS. CONCLUSIONS: Clinically apparent STS is present in approximately three-fourths of children with skull fractures. It may not be important to consistently identify skull fractures in unintentionally injured children. Point-of-care ultrasound may be adequate. For abuse concerns, it is important to identify skull fractures as evidence of cranial impacts and intracranial hemorrhages. The most sensitive, widely available imaging technique, cranial computed tomography scan with 3-dimensional skull reconstruction, should be utilized. Scalp bruising is present in a minority of young children with skull fractures. Its absence does not exclude cranial impact injury.

Riga-Fede Disease: A Case of Sublingual Trauma Not Associated With Abuse.

OBJECTIVES: The following case presents a pediatric patient with Riga-Fede disease (RFD), a rare disorder in children under 2 years of age characterized by sublingual ulceration of the tongue due to trauma from repeated rubbing against the primary teeth. Riga-Fede disease is well reported in dental literature but is relatively unknown to the general pediatric community. It can be confused with nonaccidental trauma (NAT) from forced feeding or other abusive trauma because it presents with injury of oral structures including the sublingual frenulum and often results in problems with growth. This case highlights the importance for physicians to recognize RFD as a source of isolated oral injury that is distinct from NAT. Although approximately 35 cases of RFD have been reported in the literature, this is the first case to describe the process of distinguishing this disease from child abuse. METHODS: We present a case of an 8-month-old female infant who presented with extensive injury of her ventral tongue from RFD who underwent a full workup for NAT. We review the literature for guidance on diagnosing RFD and discuss how to distinguish it from abuse. RESULTS: Infants with characteristic ulceration of the ventral tongue opposing new teeth and with no other medical, social, or developmental concerns do not need to undergo further workup. Clinical examination and thorough history are sufficient to make the diagnosis. CONCLUSIONS: Traumatic intraoral injury in nonmobile children is highly concerning for child abuse. However, RFD is a well described cause of sublingual ulceration in infants that is not associated with abuse.

Delayed Subaponeurotic Fluid Collections: A Benign Cause of Scalp Swelling in Infancy.

ABSTRACT: Delayed subaponeurotic fluid collections (DSFCs) are a recently described cause of idiopathic scalp swelling in young infants. Associated with traumatic birth and the use of vacuum-assisted devices or fetal scalp electrodes, DSFCs can be differentiated from similar causes of neonatal scalp swelling based on characteristic history and physical examination findings. In this article, we highlight 2 cases of young infants presenting to a pediatric emergency department with large, fluctuant scalp swellings, which were appropriately diagnosed as DSFCs; clinical data on an additional eight cases are presented in table format. In cases of isolated DSFCs in otherwise well-appearing infants, further laboratory work, imaging, subspecialty consultation, and child abuse investigation is not necessary. Recommendations for the diagnosis and management of DSFCs presented reflect the clinical experience of the authors in conjunction with a review of the available medical literature on this topic.