Original Paper Pediatr Neurosurg 2014–15;50:179–186 DOI: 10.1159/000430846
Received: February 5, 2015 Accepted after revision: April 21, 2015 Published online: June 9, 2015
Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience Ashly C. Westrick a Marjorie Moore a Steve Monk a Amber Greeno b Chevis Shannon a a
Department of Neurological Surgery, Vanderbilt University Medical Center, and b Pediatric Trauma Service, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., USA
Abstract Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children’s Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children’s Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children’s Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 1016–2291/15/0504–0179$39.50/0 E-Mail [email protected] www.karger.com/pne
Introduction
Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. According to the most recent reports by the United States Centers for Disease Control and Prevention, AHT incidence ranges from 20 to 30 cases per 100,000 infants less than 1 year old. This translates to between 1,200 and 1,400 cases of AHT per year in the US [1–3]. The consequences of AHT can be severe. Traumatic brain injuries are the primary source of death and irreversible disability in children [4, 5]. It is estimated that the fatality rate as a result of AHT is between 25 and 30% [3, 4]. Children that survive an AHT diagnosis frequently present with illnesses such as slow development, autism spectrum disorders, behavioral problems, mental retardation, vision problems, speech impediments, and epilepsy [3]. Many studies have identified sociodemographic factors associated with a higher likelihood of pediatric AHT. Although classification of pediatric AHT is restricted by the Centers for Disease Control and Prevention to children under the age of 5, the distribution of AHT diagnoses is uneven, peaking at 4–6 months of age and declining with increased age [2–4]. More general implicating facAshly C. Westrick, MPH Monroe Carell Jr. Children’s Hospital 2200 Children’s Way, 9222 Doctors’ Office Tower (DOT) Nashville, TN 37232-9557 (USA) E-Mail ashly.westrick @ vanderbilt.edu
Downloaded by: University of Florida, Gainesville and Jacksonville 198.143.41.97 - 1/27/2016 2:58:20 AM
Key Words Abusive head trauma · Child abuse · Outcomes
Table 1. Variables of interest
Patient-specific
Radiographic characteristics
Social
Age, race, gender, zip code Glucose levels ISS GCS ICU days Transportation Hospital disposition Organ donor
Bilateral bleeds Subdural hematomas Subarachnoid hemorrhages Epidural hematomas Retinal hemorrhage Midline shift Hydrocephalus Edema
Maternal age Parental marital status Season Day of week Suspected perpetrator Numbers of adults in home Siblings Sibling order of patient
180
Pediatr Neurosurg 2014–15;50:179–186 DOI: 10.1159/000430846
ries are less abundant than in nonaccidental head injuries [6]. Pediatric AHT presents a unique problem because it can cause significant childhood mortality and morbidity, yet is largely preventable, particularly with targeted education programs. Knowledge of clinical and social signs may help clinicians identify these patients sooner and prevent or lessen the severity of outcomes. The purpose of this study was to identify patient trends, social and clinical predictors of outcome at our institution.
Materials and Methods We conducted a retrospective cohort study of 139 pediatric patients aged 0–17 years evaluated, treated and managed for traumatic brain injury as the result of abuse at Monroe Carell Jr. Children’s Hospital at Vanderbilt between January 2006 and March 2014. Data from the Vanderbilt Trauma Registry were collected and complemented with electronic medical record and radiographic data. Patient-specific, injury-specific, medical evaluations and social work documentation were obtained. These variables are summarized in table 1. Nonparametric statistics were used in the analysis since our data were tested and found to not be normally distributed; χ2 and Fisher’s exact tests were used as appropriate and medians and interquartile ranges were reported. Statistics and multiple logistic regression analyses were conducted using SAS software, version 9.4 (SAS Institute, Cary, N.C., USA) and statistical significance was set a priori at p < 0.05.
Results
Study Cohort We identified 139 children from January 2006 to March 2014 who presented with a traumatic brain injury due to abuse with 57 (42%) suffering a severe traumatic brain injury defined as a Glasgow Coma Scale (GCS) of Westrick/Moore/Monk/Greeno/Shannon
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tors are low parental income, family life disrupted by a natural disaster, living in a single-parent household, and having parents who have poor social support systems [2, 4]. African American children are at a higher risk than Caucasian children and boys are at a higher risk than girls [2]. Adult men are more likely to confess and be convicted for perpetrating AHT and their victims generally have more severe injuries and poorer prognoses than victims of female perpetrators. A study by Esernio-Jenssen et al. [1] of 34 pediatric victims of AHT indicated that the most common perpetrators were, in order: the child’s father, the mother’s boyfriend, and the mother herself. Other factors common to the perpetrator were low education level, drug addiction, mental illness, illiteracy, and a history of domestic violence [1, 6]. In terms of clinical presentation, the two most common presenting diagnoses of pediatric AHT are subdural hematoma (present in 83–90% of all cases) and retinal hemorrhage (present in 74% of all cases) [2, 4, 6, 7]. Subdural hematoma in children and infants is most often caused by abuse. It is rare for children under the age of 10 months to experience an accidental head injury; furthermore, accidental brain injury generally presents with drastically different symptoms than nonaccidental brain injury [4, 8]. Patients who suffered from accidental head injury were more likely to present with epidural hematomas (3% for AHT vs. 11% for accidental head injury), whereas AHT patients were more likely to suffer from diffuse brain edema/diffuse axonal injury (14% for AHT vs. 8% for accidental head injury) [6]. Similarly, retinal hemorrhages are rare in pediatric accidental head trauma, which presents with eye injuries only 6–8% of the time, yet common in AHT occurring up to 75% of the time. Retinal hemorrhages are also correlated with higher mortality rates and are present in 82% of fatal cases of AHT [4, 7]. Retinal hemorrhages in accidental head inju-
Table 2. Patient demographics and clinical characteristics
Table 3. Patient social and radiographic characteristics
Variable
Variable
5 (2.5 – 10.8) 80 (57.6) 59 (42.4) 88 (63.3) 33 (23.7) 12 (8.63) 6 (4.31) 66 (47.5) 73 (52.5) 6 (4.33) 133 (95.7) 50 (36.0) 12 (8.63) 49 (35.3) 3 (2.15) 25 (18.0) 9 (7.4) 67 (55) 27 (22) 14 (11) 5 (4.1) 138 (99.2) 1 (0.08) 44 (31.7) 49 (35.3) 4 (2.9) 42 (30.2)
a
Median and interquartile range. b Patients admitted to location other than ICU.
less than 8. Our cohort was 57.6% male and 63% Caucasian with the majority coming from urban counties (72%) and having public insurance (86%; table 2). Approximately 78% of our cohort was under the age of 1 year with the median age being 5 months (Q1: 2.5, Q3: 10.8). Sixtyeight percent of our cohort arrived from a referring hospital and 44.9% were transported by ground ambulance. Approximately 40.0% of our cohort was transported by helicopter. The median distance from the patient’s place of residence to Vanderbilt Children’s Hospital was 46 miles [Q1: 13 miles, Q3: 71 miles]. Fifty-two percent preIdentifying Characteristics in Abusive Head Trauma
Siblings Yes No Unknown Birth order Youngest Middle Oldest Only Unknown Season Winter (Dec–Feb) Spring (Mar–May) Summer (Jun–Aug) Fall (Sep–Nov) Weekend Yes No Parental marital status Married/cohabitating Single Unknown Suspected perpetrator Mother Father Parenta Mother’s boyfriend Other family Other nonfamily Bilateral bleeding Yes No Subdural hematomas Yes No Subarachnoid hemorrhages Yes No Epidural hematomas Yes No Midline shift Yes No Retinal hemorrhages Yes No Unknown
n (%) 80 (57.6) 28 (20.1) 31 (22.3) 69 (50.0) 4 (2.90) 5 (3.6) 27 (19.4) 34 (24.5) 28 (20.0) 32 (23.0) 44 (32.0) 35 (25.0) 51 (37.0) 88 (63.0) 39 (28.1) 80 (57.6) 20 (6.95) 13 (9.4) 41 (30.0) 25 (18.0) 31 (22.0) 10 (7.2) 19 (14.0) 55 (40) 84 (60) 110 (79) 29 (21) 17 (12) 122 (88) 8 (5.8) 131 (94) 15 (11) 124 (89) 79 (56.8) 52 (37.4) 8 (5.8)
a Medical record did not differentiate between whether the parent was the mother or the father.
Pediatr Neurosurg 2014–15;50:179–186 DOI: 10.1159/000430846
181
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Age, monthsa Sex Male Female Race/ethnicity Caucasian African American Hispanic Asian Presentation Alert Nonalert Care Single subspecialty Multiple subspecialty Hospital disposition Home with parents Home with other family State/foster care Rehabilitation Death Median ICU stay, days 0b ≤3 4–7 8 – 14 ≥15 Neurosurgery consultation Yes No Trauma level I II III Unknown
n (%)
Table 4. Patient characteristics associated with hospital disposition
Hospital disposition, n (%) home with parents Gender Male Female Presentation Alert Nonalert Suspected perpetrator Mother Father Parentsa Mother’s boyfriend Other family Other nonfamily Midline shift Yes No Transportation Helicopter Ground ambulance Private vehicle Fixed wing
rehabilitation
death
Received: February 5, 2015 Accepted after revision: April 21, 2015 Published online: June 9, 2015
Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience Ashly C. Westrick a Marjorie Moore a Steve Monk a Amber Greeno b Chevis Shannon a a
Department of Neurological Surgery, Vanderbilt University Medical Center, and b Pediatric Trauma Service, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., USA
Abstract Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children’s Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children’s Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children’s Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 1016–2291/15/0504–0179$39.50/0 E-Mail [email protected] www.karger.com/pne
Introduction
Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. According to the most recent reports by the United States Centers for Disease Control and Prevention, AHT incidence ranges from 20 to 30 cases per 100,000 infants less than 1 year old. This translates to between 1,200 and 1,400 cases of AHT per year in the US [1–3]. The consequences of AHT can be severe. Traumatic brain injuries are the primary source of death and irreversible disability in children [4, 5]. It is estimated that the fatality rate as a result of AHT is between 25 and 30% [3, 4]. Children that survive an AHT diagnosis frequently present with illnesses such as slow development, autism spectrum disorders, behavioral problems, mental retardation, vision problems, speech impediments, and epilepsy [3]. Many studies have identified sociodemographic factors associated with a higher likelihood of pediatric AHT. Although classification of pediatric AHT is restricted by the Centers for Disease Control and Prevention to children under the age of 5, the distribution of AHT diagnoses is uneven, peaking at 4–6 months of age and declining with increased age [2–4]. More general implicating facAshly C. Westrick, MPH Monroe Carell Jr. Children’s Hospital 2200 Children’s Way, 9222 Doctors’ Office Tower (DOT) Nashville, TN 37232-9557 (USA) E-Mail ashly.westrick @ vanderbilt.edu
Downloaded by: University of Florida, Gainesville and Jacksonville 198.143.41.97 - 1/27/2016 2:58:20 AM
Key Words Abusive head trauma · Child abuse · Outcomes
Table 1. Variables of interest
Patient-specific
Radiographic characteristics
Social
Age, race, gender, zip code Glucose levels ISS GCS ICU days Transportation Hospital disposition Organ donor
Bilateral bleeds Subdural hematomas Subarachnoid hemorrhages Epidural hematomas Retinal hemorrhage Midline shift Hydrocephalus Edema
Maternal age Parental marital status Season Day of week Suspected perpetrator Numbers of adults in home Siblings Sibling order of patient
180
Pediatr Neurosurg 2014–15;50:179–186 DOI: 10.1159/000430846
ries are less abundant than in nonaccidental head injuries [6]. Pediatric AHT presents a unique problem because it can cause significant childhood mortality and morbidity, yet is largely preventable, particularly with targeted education programs. Knowledge of clinical and social signs may help clinicians identify these patients sooner and prevent or lessen the severity of outcomes. The purpose of this study was to identify patient trends, social and clinical predictors of outcome at our institution.
Materials and Methods We conducted a retrospective cohort study of 139 pediatric patients aged 0–17 years evaluated, treated and managed for traumatic brain injury as the result of abuse at Monroe Carell Jr. Children’s Hospital at Vanderbilt between January 2006 and March 2014. Data from the Vanderbilt Trauma Registry were collected and complemented with electronic medical record and radiographic data. Patient-specific, injury-specific, medical evaluations and social work documentation were obtained. These variables are summarized in table 1. Nonparametric statistics were used in the analysis since our data were tested and found to not be normally distributed; χ2 and Fisher’s exact tests were used as appropriate and medians and interquartile ranges were reported. Statistics and multiple logistic regression analyses were conducted using SAS software, version 9.4 (SAS Institute, Cary, N.C., USA) and statistical significance was set a priori at p < 0.05.
Results
Study Cohort We identified 139 children from January 2006 to March 2014 who presented with a traumatic brain injury due to abuse with 57 (42%) suffering a severe traumatic brain injury defined as a Glasgow Coma Scale (GCS) of Westrick/Moore/Monk/Greeno/Shannon
Downloaded by: University of Florida, Gainesville and Jacksonville 198.143.41.97 - 1/27/2016 2:58:20 AM
tors are low parental income, family life disrupted by a natural disaster, living in a single-parent household, and having parents who have poor social support systems [2, 4]. African American children are at a higher risk than Caucasian children and boys are at a higher risk than girls [2]. Adult men are more likely to confess and be convicted for perpetrating AHT and their victims generally have more severe injuries and poorer prognoses than victims of female perpetrators. A study by Esernio-Jenssen et al. [1] of 34 pediatric victims of AHT indicated that the most common perpetrators were, in order: the child’s father, the mother’s boyfriend, and the mother herself. Other factors common to the perpetrator were low education level, drug addiction, mental illness, illiteracy, and a history of domestic violence [1, 6]. In terms of clinical presentation, the two most common presenting diagnoses of pediatric AHT are subdural hematoma (present in 83–90% of all cases) and retinal hemorrhage (present in 74% of all cases) [2, 4, 6, 7]. Subdural hematoma in children and infants is most often caused by abuse. It is rare for children under the age of 10 months to experience an accidental head injury; furthermore, accidental brain injury generally presents with drastically different symptoms than nonaccidental brain injury [4, 8]. Patients who suffered from accidental head injury were more likely to present with epidural hematomas (3% for AHT vs. 11% for accidental head injury), whereas AHT patients were more likely to suffer from diffuse brain edema/diffuse axonal injury (14% for AHT vs. 8% for accidental head injury) [6]. Similarly, retinal hemorrhages are rare in pediatric accidental head trauma, which presents with eye injuries only 6–8% of the time, yet common in AHT occurring up to 75% of the time. Retinal hemorrhages are also correlated with higher mortality rates and are present in 82% of fatal cases of AHT [4, 7]. Retinal hemorrhages in accidental head inju-
Table 2. Patient demographics and clinical characteristics
Table 3. Patient social and radiographic characteristics
Variable
Variable
5 (2.5 – 10.8) 80 (57.6) 59 (42.4) 88 (63.3) 33 (23.7) 12 (8.63) 6 (4.31) 66 (47.5) 73 (52.5) 6 (4.33) 133 (95.7) 50 (36.0) 12 (8.63) 49 (35.3) 3 (2.15) 25 (18.0) 9 (7.4) 67 (55) 27 (22) 14 (11) 5 (4.1) 138 (99.2) 1 (0.08) 44 (31.7) 49 (35.3) 4 (2.9) 42 (30.2)
a
Median and interquartile range. b Patients admitted to location other than ICU.
less than 8. Our cohort was 57.6% male and 63% Caucasian with the majority coming from urban counties (72%) and having public insurance (86%; table 2). Approximately 78% of our cohort was under the age of 1 year with the median age being 5 months (Q1: 2.5, Q3: 10.8). Sixtyeight percent of our cohort arrived from a referring hospital and 44.9% were transported by ground ambulance. Approximately 40.0% of our cohort was transported by helicopter. The median distance from the patient’s place of residence to Vanderbilt Children’s Hospital was 46 miles [Q1: 13 miles, Q3: 71 miles]. Fifty-two percent preIdentifying Characteristics in Abusive Head Trauma
Siblings Yes No Unknown Birth order Youngest Middle Oldest Only Unknown Season Winter (Dec–Feb) Spring (Mar–May) Summer (Jun–Aug) Fall (Sep–Nov) Weekend Yes No Parental marital status Married/cohabitating Single Unknown Suspected perpetrator Mother Father Parenta Mother’s boyfriend Other family Other nonfamily Bilateral bleeding Yes No Subdural hematomas Yes No Subarachnoid hemorrhages Yes No Epidural hematomas Yes No Midline shift Yes No Retinal hemorrhages Yes No Unknown
n (%) 80 (57.6) 28 (20.1) 31 (22.3) 69 (50.0) 4 (2.90) 5 (3.6) 27 (19.4) 34 (24.5) 28 (20.0) 32 (23.0) 44 (32.0) 35 (25.0) 51 (37.0) 88 (63.0) 39 (28.1) 80 (57.6) 20 (6.95) 13 (9.4) 41 (30.0) 25 (18.0) 31 (22.0) 10 (7.2) 19 (14.0) 55 (40) 84 (60) 110 (79) 29 (21) 17 (12) 122 (88) 8 (5.8) 131 (94) 15 (11) 124 (89) 79 (56.8) 52 (37.4) 8 (5.8)
a Medical record did not differentiate between whether the parent was the mother or the father.
Pediatr Neurosurg 2014–15;50:179–186 DOI: 10.1159/000430846
181
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Age, monthsa Sex Male Female Race/ethnicity Caucasian African American Hispanic Asian Presentation Alert Nonalert Care Single subspecialty Multiple subspecialty Hospital disposition Home with parents Home with other family State/foster care Rehabilitation Death Median ICU stay, days 0b ≤3 4–7 8 – 14 ≥15 Neurosurgery consultation Yes No Trauma level I II III Unknown
n (%)
Table 4. Patient characteristics associated with hospital disposition
Hospital disposition, n (%) home with parents Gender Male Female Presentation Alert Nonalert Suspected perpetrator Mother Father Parentsa Mother’s boyfriend Other family Other nonfamily Midline shift Yes No Transportation Helicopter Ground ambulance Private vehicle Fixed wing
rehabilitation
death
