Implementation of a brain injury screen MRI for infants at risk for abusive head trauma.

BACKGROUND: Head computed tomography (CT) is the current standard of care for evaluating infants at high risk of abusive head trauma. OBJECTIVE: To both assess the feasibility of using a previously developed magnetic resonance imaging (MRI) brain injury screen (MRBRscreen) in the acute care setting in place of head CT to identify intracranial hemorrhage in high-risk infants and to compare the accuracy of a rapid imaging pulse sequence (single-shot T2 fast spin echo [ssT2FSE]) to a conventional pulse sequence (conventional T2 fast spin echo [conT2FSE]). MATERIALS AND METHODS: This was a quality improvement initiative to evaluate infants <12 months of age who were screened for intracranial hemorrhage using an MRBRscreen as part of clinical care. The MRBRscreen included axial conT2FSE, axial gradient recalled echo, coronal T1-weighted inversion recovery, axial diffusion-weighted image and an axial ssT2FSE. A comparison of ssT2FSE to conT2FSE with respect to lesion detection was also performed. RESULTS: Of 158 subjects, the MRBRscreen was able to be completed in 155 (98%); 9% (14/155) were abnormal. Ninety-four percent (137/145) of subjects underwent only an MRBRscreen and avoided both radiation from head CT and sedation from MRI. The axial ssT2FSE and conT2FSE results were congruent 99% of the time. CONCLUSION: An MRBRscreen in place of a head CT is feasible and potentially could decrease head CT use by more than 90% in this population. Using a rapid ssT2FSE in place of a conT2FSE can reduce total scan time without losing lesion detection. If an MRBRscreen is readily available, physicians' threshold to perform neuroimaging may be lowered and lead to earlier detection of abusive head trauma.

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.

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 children's 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.

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.