Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma.
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ABSTRACT:
SUBMITTER: Rowland J
PROVIDER: S-EPMC7434235 | biostudies-literature | 2020 Aug
REPOSITORIES: biostudies-literature
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Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma.
Rowland Jonathan J Fouchia Dean D Favot Mark M
Clinical practice and cases in emergency medicine 20200801 3
<h4>Case presentation</h4>An eight-week-old infant presented to the emergency department in cardiac arrest. Return of spontaneous circulation was obtained and the patient subsequently began seizing. Point-of-care ultrasound of the anterior fontanelle revealed an extra-axial fluid collection consistent with subdural hematoma (SDH).<h4>Discussion</h4>Abusive head trauma is still frequently missed on initial presentation. In addition to validated screening clinical prediction rules, point-of-care c ...[more]
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Project description:Abusive head trauma (AHT) is the leading cause of morbidity and mortality among abused children, yet the neuroanatomical underpinnings of AHT outcome is incompletely understood. The aim of this study was to characterize white matter (WM) abnormalities in infants with AHT using diffusion tensor imaging (DTI) and determine which microstructural abnormalities are associated with poor outcome. Retrospective DTI data from 17 infants (>3 months) with a diagnosis of AHT and a comparison cohort of 34 term infants of similar post-conceptual age (PCA) were compared using a voxel-based DTI analysis of cerebral WM. AHT cases were dichotomously classified into mild/moderate versus severe outcome. Clinical variables and conventional imaging findings were also analyzed in relation to outcome. Outcomes were classified in accordance with the Pediatric Cerebral Performance Category Score (PCPCS). Reduced axial diffusivity (AD) was shown in widespread WM regions in the AHT infants compared with controls as well as in the AHT severe outcome group compared with the AHT mild/moderate outcome group. Reduced mean diffusivity (MD) was also associated with severe outcome. Radial diffusivity (RD), conventional magnetic resonance findings, brain metric measurements, and clinical/laboratory variables (with the exception of Glascow Coma Scale) did not differ among AHT outcome groups. Findings support the unique role of DTI techniques, beyond conventional imaging, in the evaluation of microstructural WM injury of AHT. Reduced AD (likely reflecting axonal damage) and MD were associated with poor clinical outcome. DTI abnormalities may uniquely reflect AHT patterns of axonal injury that are not characterized by conventional imaging, which may have both therapeutic and prognostic implications.
| S-EPMC4171035 | biostudies-literature
Project description:Background:The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods:This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results:Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities. Conclusions:Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.
| S-EPMC6296307 | biostudies-other
Project description:Importance:Studies suggest that a postnatal parental intervention may reduce the incidence of abusive head trauma (AHT) of infants and young children. Objective:To assess the effect of statewide universal AHT education for parents on AHT hospitalization rates in Pennsylvania and on parents' self-reported knowledge gains and parenting behaviors. Design, Setting, and Participants:Changes in AHT hospitalization rates in Pennsylvania before and during the intervention were compared with those in 5 other states lacking universal parental AHT education during the same period. Data were collected from maternity units and birthing centers throughout Pennsylvania from the parents of 1?593?834 infants born on these units from January 1, 2003, to December 31, 2013. Parental behavior and knowledge were assessed through immediate (n?=?16?111) and 7-month postintervention (n?=?146) parent surveys in a per protocol analysis of evaluable parents. Interventions:Parents read a brochure, viewed an 8-minute video about infant crying and AHT, asked questions of the nurse, and signed a commitment statement affirming their participation. Educational posters were displayed on each unit. Main Outcomes and Measures:Changes in AHT hospitalization rates before and during the intervention in Pennsylvania and 5 other states. Secondary outcomes included self-reported knowledge gains and changes in parenting practices. Results:A total of 1?180?291 parents (74.1%) of children ranging in age from 0 to 23 months signed a commitment statement. Incidence rate ratios for hospitalization for AHT increased in Pennsylvania from 24.1 (95% CI, 22.1-26.3) to 26.6 (95% CI, 24.9-28.4) per 100?000 children aged 0 to 23 months during the intervention period; changes in Pennsylvania were not significantly different from aggregate changes in the 5 other states, from 22.4 (95% CI, 21.2-23.6) to 22.0 (95% CI, 21.2-22.8) per 100?000 children aged 0 to 23 months. A total of 16?111 parents (21.5% men, 78.5% women) completed the postnatal survey. Despite an overall 74.1% adherence with the intervention, only 20.6% of parents saw the brochure and video and only 5.7% were exposed to the entire intervention. Among the respondents answering individual questions on the postnatal surveys, 10?958 mothers (91.0%) and 2950 fathers (88.6%) reported learning a lot about understanding infant crying as normal; 11?023 mothers (92.2%) and 2923 fathers (88.9%), calming their infant, 11?396 mothers (94.6%) and 3035 fathers (91.9%), calming themselves; 10?060 mothers (85.1%) and 2688 fathers (83.4%), selecting other infant caregivers; and 11?435 mothers (94.8%) and 3201 fathers (95.8%), that the information would decrease the likelihood of shaking an infant. Among the 143 respondents completing the 7-month survey, 109 (76.2%) reported remembering the information while their child was crying. Conclusions and Relevance:This intervention was not associated with a reduction in pediatric AHT hospitalization rates but was associated with self-reported gains in parental knowledge that were retained for 7 months.
| S-EPMC5863059 | biostudies-literature
Project description:AimTo report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT).MethodsA systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT.ResultsOf the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined.ConclusionsOur systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.
| S-EPMC3545381 | biostudies-literature
Project description:BACKGROUND:Evidence-based, patient-specific estimates of abusive head trauma probability can inform physicians' decisions to evaluate, confirm, exclude, and/or report suspected child abuse. OBJECTIVE:To derive a clinical prediction rule for pediatric abusive head trauma that incorporates the (positive or negative) predictive contributions of patients' completed skeletal surveys and retinal exams. PARTICIPANTS AND SETTING:500 acutely head-injured children under three years of age hospitalized for intensive care at one of 18 sites between 2010 and 2013. METHODS:Secondary analysis of an existing, cross-sectional, prospective dataset, including (1) multivariable logistic regression to impute the results of abuse evaluations never ordered or completed, (2) regularized logistic regression to derive a novel clinical prediction rule that incorporates the results of completed abuse evaluations, and (3) application of the new prediction rule to calculate patient-specific estimates of abusive head trauma probability for observed combinations of its predictor variables. RESULTS:Applying a mean probability threshold of >0.5 to classify patients as abused, the 7-variable clinical prediction rule derived in this study demonstrated sensitivity 0.73 (95% CI: 0.66-0.79) and specificity 0.87 (95% CI: 0.82-0.90). The area under the receiver operating characteristics curve was 0.88 (95% CI: 0.85-0.92). Patient-specific estimates of abusive head trauma probability for 72 observed combinations of its seven predictor variables ranged from 0.04 (95% CI: 0.02-0.08) to 0.98 (95% CI: 0.96-0.99). CONCLUSIONS:Seven variables facilitate patient-specific estimation of abusive head trauma probability after abuse evaluation in intensive care settings.
| S-EPMC6333504 | biostudies-literature
Project description:PurposeThe purpose of the study was to audit the use of non-contact ultra-widefield retinal imaging in infants with suspected abusive head trauma (AHT) using the Optos P200MA Scanning Laser Ophthalmoscope.Patients and methodsA retrospective, observational case series. Ten eyes of five consecutive infants (aged 1-15 months) with suspected (or in 1 case, known) AHT referred for an ophthalmological opinion were included. Each infant underwent non-contact ultra-widefield retinal imaging using the Optos P200MA scanning laser ophthalmoscope. Optos fundus fluorescein angiography (FFA) was performed in one infant with oral sedation. The other four infants did not require sedation. The main outcome measure was the acquisition of a single, definitive ultra-widefield retinal image in each eye. Safety was audited by determining adverse changes in heart rate and oxygen saturations that required cessation of imaging.ResultsThe Optos P200MA ultra-widefield scanning laser ophthalmoscope acquired good quality retinal images in all infants. Documentation of acute, widespread retinal haemorrhages contributed to a diagnosis of AHT in three infants. Chronic pre-macular haemorrhage and macular schisis were documented by FFA in a fourth infant. The absence of retinal haemorrhages was documented in a fifth infant contributing to the exclusion of a diagnosis of AHT. There were no adverse safety signals in any infant in this series.ConclusionThe Optos P200MA ultra-widefield scanning laser ophthalmoscope appears safe to use in infants with suspected AHT, providing high-quality retinal images in a single frame without ocular contact. Optos P200MA may be used as alternative to RetCam to document retinal haemorrhages in stable infants with suspected AHT.
| S-EPMC5350378 | biostudies-literature
Project description:ObjectiveTo replicate the previously published finding that the absence of a history of trauma in a child with obvious traumatic head injuries demonstrates high specificity and high positive predictive value (PPV) for abusive head trauma.Study designThis was a secondary analysis of a deidentified, cross-sectional dataset containing prospective data on 346 young children with acute head injury hospitalized for intensive care across 18 sites between 2010 and 2013, to estimate the diagnostic relevance of a caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma inconsistent with the child's gross motor skills. Cases were categorized as definite or not definite abusive head trauma based solely on patients' clinical and radiologic findings. For each presumptive historical "red flag," we calculated sensitivity, specificity, predictive values, and likelihood ratio (LR) with 95% CI for definite abusive head trauma in all patients and also in cohorts with normal, abnormal, or persistent abnormal neurologic status.ResultsA caregiver's specific denial of any trauma demonstrated a specificity of 0.90 (95% CI, 0.84-0.94), PPV of 0.81 (95% CI, 0.71-0.88), and a positive LR (LR+) of 4.83 (95% CI, 3.07-7.61) for definite abusive head trauma in all patients. Specificity and LR+ were lowest-not highest-in patients with persistent neurologic abnormalities. The 2 other historical red flags showed similar trends.ConclusionsA caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma that is developmentally inconsistent are each highly specific (>0.90) but may provide weaker support than previously reported for a diagnosis of abusive head trauma in patients with persistent neurologic abnormalities.
| S-EPMC7042052 | biostudies-literature
Project description:OBJECTIVE:To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN:Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS:In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n?=?229) were more frequently evaluated (P?<?.001; aOR, 2.2) and reported (P?=?.001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n?=?271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P?=?.001 [aOR, 2.4] and P?=?.003 [aOR, 2.1]) or with an estimated AHT probability of ?25% (P?<.001 [aOR, 4.1] and P?<.001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION:Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians' implicit bias.
| S-EPMC7243470 | biostudies-literature
Project description:Head trauma from abuse, including shaken baby syndrome, is a devastating and potentially lethal form of infant physical abuse first recognized in the early 1970s. What has been less recognized is the role of the early increase in crying in otherwise normal infants in the first few months of life as a trigger for the abuse. In part, this is because infant crying, especially prolonged unsoothable crying, has been interpreted clinically as something wrong with the infant, the infant's caregiver, or the interactions between them. Here, we review an alternative developmental interpretation, namely, that the early increase in crying is a typical behavioral development in normal infants and usually does not reflect anything wrong or abnormal. We also review evidence indicating that this normal crying pattern is the most common trigger for abusive head trauma (AHT). Together, these findings point to a conceptualization of AHT as the consequence of a failure in an otherwise common, iterative, and developmentally normal infant-caregiver interaction. They also imply that there is a window of opportunity for prevention of AHT, and potentially other forms of infant abuse, through a public health primary universal prevention strategy aimed at changing knowledge and behaviors of caregivers and society in general concerning normal development of infants and the significance of early increased infant crying. If effective, there may be important implications for prevention of infant abuse nationally and internationally.
| S-EPMC3477395 | biostudies-other
Project description:Young children with severe traumatic brain injury (TBI) have frequently been excluded from studies due to age and/or mechanism of injury. Magnetic resonance imaging (MRI) is now frequently being utilized to detect parenchymal injuries and early cerebral edema. We sought to assess MRI findings in infants with severe TBI, and to determine the association between specific MRI findings and mechanisms of injury, including abusive head trauma (AHT). MRI scans performed within the first 30 days after injury were collected and coded according to NIH/NINDS Common Data Elements (CDEs) for Neuroimaging in subjects age < 2 years old with severe TBI enrolled in the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial. Demographics and injury characteristics were analyzed. A total of 81 children were included from ADAPT sites with MRI scans. Median age was 0.77 years and 57% were male. Most common MRI finding was ischemia, present in 57/81 subjects (70%), in a median of 7 brain regions per subject. Contusion 46/81 (57%) and diffuse axonal injury (DAI) 36/81 (44.4%) subjects followed. Children were dichotomized based on likelihood of AHT with 43/81 subjects classified as AHT. Ischemia was found to be significantly associated with AHT (p = 0.001) and "inflicted" injury mechanism (p = 0.0003). In conclusion, the most common intracerebral injury seen on MRI of infants with severe TBI was ischemia, followed by contusion and DAI. Ischemia was associated with AHT, and ischemia affecting > 4 brain regions was predictive of AHT.
| S-EPMC9322188 | biostudies-literature