Insurance status and pediatric mortality in nonaccidental trauma.

BACKGROUND: Nonaccidental trauma (NAT) is a leading cause of injury and death in early childhood. We sought to understand the association between insurance status and mortality in a national sample of pediatric NAT patients. MATERIALS AND METHODS: We performed a retrospective cohort study using the 2012-2014 National Trauma Databank. We included children ≤18 y hospitalized with NAT (The International Classification of Diseases, Ninth Revision codes: E967-968). The primary exposure was insurance status (categorized as public, private, and uninsured). The primary outcome was emergency department or inpatient mortality from NAT. RESULTS: We identified 6389 children with NAT. Mean age was 1.6 y (standard deviation 3.7), with 41% female and 42% of an ethnic or racial minority. Most were publicly insured (77%), with 17% privately insured and 6% uninsured. Mean injury severity score (ISS) was 13.9 (standard deviation 10.3). Overall, 516 (8%) patients died following NAT. Compared to patients who survived, those who died were more likely to be younger (mean age 1.0 y versus 1.6 y; P < 0.001), uninsured (13% versus 6%; P < 0.001), transferred to a higher-care facility (57% versus 49%; P < 0.001), and more severely injured (mean ISS 25.9 versus 12.8; P < 0.001). After adjusting for age, race, transfer status, and ISS, uninsured patients had 3.3-fold (95% CI = 2.4-4.6) greater odds of death compared to those with public insurance. For every 1 point increase in ISS, children had 12% (95% CI = 11%-13%) increased adjusted odds of death. CONCLUSIONS: Pediatric patients without insurance had significantly greater odds of death following NAT, compared to children with public insurance. Knowledge that uninsured children comprise an especially vulnerable population is important for targeting potential interventions.

National study shows that abusive head trauma mortality in Sweden was at least 10 times lower than in other Western countries.

AIM: The validity of the diagnostic criteria for abusive head trauma (AHT) and its attributes has been widely debated. This national study investigated the possibility of false-positive and false-negative cases of fatal AHT in Sweden. METHOD: This was a retrospective evaluation of the records of 733 deceased infants up to the age of 365 days who were examined during 1994-2013 at the six forensic medicine departments. All the records were scrutinised for possible cases of AHT. RESULTS: We included 12 cases, of which eight had been diagnosed as AHT. Of these 12 infants, eight had a concomitant disease or perinatal illness, five were born prematurely and three were twins. Figures from other Western countries would suggest 6-7 deaths per 100,000 per year in Sweden, but in reality, there was a maximum possible incidence of 0.6 per 100,000 infants per year. CONCLUSION: The risk of unreported fatal AHT in Sweden was low, and there may have been cases misdiagnosed as AHT. The at least 10 times lower incidence than has been reported from other Western countries, raises the question if previously reported higher incidences of fatal AHT have been exaggerated.

Muertes por agresión infantil en Costa Rica entre los años 2003 y 2011 / Deaths from childhood aggression in Costa Rica between 2003 and 2011

Se revisaron 26551 autopsias efectuadas en el Departamento de Medicina Legal de Costa Rica entre el 01 enero de 2003 y el 31 de diciembre de 2011 y se seleccionaron los homicidios en menores de 13 años cometidos por sus propios familiares, en un contexto de agresión infantil. Se obtuvieron 56 casos, que representan un pequeño porcentaje de las muertes violentas para ese periodo (0,35 por ciento), pero que por lo aberrante de este tipo de comportamientos y el hecho de que son muertes totalmente prevenibles, deben llamar la atención de la sociedad, pues representan el extremo m s violento del espectro de la agresión infantil, cuya mayor parte de casos permanece desconocido. El perfil de las víctimas que se obtuvo fue: predominio de lactantes y menores de cuatro años que fallecen en la casa, con predominio en los meses de febrero y agosto, con mayor frecuencia los lunes. Dentro de las provincias más afectadas proporcionalmente a su población destaca San José, Puntarenas y Limón. Los traumas letales fueron en su mayoría contusos, en la cabeza y cuello del menor. El responsable de la muerte fue, en una importante proporción, su padre biológico. La tasa de mortalidad por esta causa entre se ha cuadruplicado entre el año 2009 y el 2011...

Initial predictive factors of outcome in severe non-accidental head trauma in children.

OBJECT: The aim of this study is to evaluate the outcome of young children hospitalized for non-accidental head trauma in our PICU, to evaluate PRISM II score in this sub-population of pediatric trauma and to identify factors that might influence the short-term outcome. MATERIALS AND METHODS: Files of all children less than 2 years old with the diagnosis of non-accidental head trauma over a 10-years period were systematically reviewed. We collected data on demographic information, medical history, clinical status, and management in the PICU. Three severity scores were then calculated: PRISM II, Glasgow Coma Scale (GCS), and Pediatric Trauma Score (PTS). Prognosis value of qualitative variables was tested with a univariate procedure analysis (anemia, diabetes insipidus...). Then, quantitative variables were tested with univariate procedure too (age, weight, PRISM II, GCS, Platelet count, fibrin, prothrombin time (PT)...). Potential association between variables and death was tested using univariate procedure. Variables identified by univariate analysis were then analyzed with multivariate analysis through a forward-stepping logistic regression. RESULTS: Thirty-six children were included. Mean age was 5.5 months (8 days-21.5 months). Mortality rate was 27.8%. At admission, PTS, PRISM II, GCS, PT, PTT, and diabetes insipidus were significantly altered or more frequent in non survivors. Cutoff value for PRISM II at which risk of mortality increased was 17.5 (sensitivity = 0.8; specificity = 0.88). CONCLUSION: PRISM II is a reliable and easy performing tool for assessing the prognosis of non-accidental cranial traumatism in young children. GCS and PTS, scores even simpler than PRISM II, showed good accuracy regarding survival prediction.

Child abuse-related homicides in New Mexico: a 6-year retrospective review.

We retrospectively reviewed autopsy records at a statewide medical examiner's office in order to identify and characterize deaths due to child abuse. In a 6-year period in New Mexico, the medical examiner investigated 45 deaths determined to be child abuse-related. Decedents were predominantly male (68.9%), Hispanic White (53.3%), and all were 5 years of age or younger, with a median age of 1 year. Head injuries were the most common cause of death (44.4%), followed by battered baby syndrome (15.6%). Relatives were involved as alleged perpetrators in 80% of the cases, with the father most often implicated (36.1% of cases), and 88.9% of child abuse injuries resulting in death occurred in the family's residence. Toxicology was positive in 26.7% of cases, but only two cases had substances of abuse present. Information on risk factors such as prematurity, parental age, and history of abuse was also collected.

Nonaccidental head trauma as a cause of childhood death.

OBJECT: The authors present the demographic and clinical information in 36 children who died as a result of abusive head trauma at a Level 1 pediatric trauma center between January 1, 1997, and January 1, 2004. METHODS: Abusive head trauma was defined as radiographic evidence of intracranial injury and documentation from a multidisciplinary child protection team that the injury was nonaccidental. There was no sex bias for the children in the 1st year of life (nine girls, nine boys). In children older than 1 year of age, boys were much more likely to be victims (14 boys, four girls). At the time of admission, every child exhibited a seriously impaired level of consciousness and 81% had retinal hemorrhages. Injuries to other organ systems were rare (17%). The most common abnormality found on neuroimaging studies was subdural hematoma. Six children underwent craniotomy for extraaxial hematomas. Death occurred within 24 hours after hospital admission in one half of the cases. CONCLUSIONS: Abusive head trauma was the cause of death in 36 (86%) of the 42 children whose deaths were classified as nonaccidental at the Children's Hospital in Denver between 1997 and 2003. The authors were unable to identify anything that could have been done from a medical or neurosurgical viewpoint to prevent the deaths of these children after they came to medical attention.

Shaking-impact syndrome of infancy.

Shaking-impact syndrome (SIS) is a leading cause of traumatic brain injury in infants and young children. Evaluation of these children requires a detailed history and physical examination as well as documentation of intracranial injury with neuroimaging, a dilated fundoscopic examination, a skeletal survey and other laboratory studies. Debate still exists as to the exact mechanisms of brain injury in these patients. The various contributions of shaking alone, shaking with impact, and apnea are discussed. Differences of injury type and severity between accidental traumatic brain injury and SIS are delineated. The long-term neurodevelopmental outcome for survivors of SIS is generally poor. Because few treatment options are successful in reducing the morbidity and mortality of this syndrome, prevention may be the only reasonable solution.

Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age.

OBJECTIVE: Mortality and morbidity data on childhood injury are used to construct developmentally appropriate intervention strategies and to guide pediatric anticipatory counseling on injury prevention topics. Effective anticipatory guidance depends on detailed injury data showing how risks change as children develop. Conventional age groupings may be too broad to show the relationship between children's development and their risk of various causes of injury. Previous studies revealed differences in overall rates and specific causes of injury by year of age. However, single year of age rates for children younger than 4 years may not reflect the variations in risk as a result of rapid developmental changes. This study was designed to analyze injury rates for children younger than 4 years by quarter-year intervals to determine more specifically the age period of highest risk for injury and for specific causes. METHODS: We used data from 1996-1998 California hospital discharges and death certificates to identify day of age and external cause of injury (E-code) for children younger than 4 years. The number of California residents for each day of age was estimated from US Census of estimates of California's population by year of age for the midpoints (1996-1998). Rates were calculated by 3-month intervals. We grouped the E-codes into major categories that would be particularly relevant for developmentally related risks of injury specific to young children. The categorization took into account physical, motor, behavioral, and cognitive developmental milestones of children 0 to 3 years. RESULTS: There were a total of 23,173 injuries; 636 resulted in death. The overall annual rate for children aged 0 to 3 years was 371/100,000. Beginning at age 3 to 5 months, the overall rate of injury rapidly increased with increased age, peaking at 15 to 17 months. The mean injury rate calculated for each single year of age did not reflect the variation and the highest rate of injury by quarter year of age for children younger than 1 year, 1 year, and 2 years. The leading major causes of injury in descending order were falls, poisoning, transportation, foreign body, and fires/burns. The overall rate of the major category of falls exceeded poisoning, the second leading cause of injury, by a factor of 2. Age-related differences were detected within each major cause of injury. For children 0 to 12 months of age, there was a different leading cause of specific injury for each 3-month period: other falls from height (0-2 months), battering (3-5 months), falls from furniture (6-8 months), and nonairway foreign body (9-11 months). Hot liquid and vapor injuries were the leading specific causes for children 12 to 17 months. Poisoning by medication was the leading specific cause of injury for all age groups from 18 to 35 months and exceeded poisoning by other substances. Pedestrian injury was the leading specific cause of injury for all age groups from 36 to 47 months. Fall from furniture has the highest rates of specific causes of falls from age 3 to 47 months. Fall from stairs peaked at age 6 to 8 months and 9 to 11 months. Fall from buildings was highest at 24 to 26 months. Poisoning by medication peaked at age 21 to 23 months, but poisoning by other substances peaked at 15 to 17 months. The motor vehicle occupant injury rates were fairly stable over the age span of this study. The pedestrian injury rate increased beginning at age 12 to 14 months and by 15 to 17 months was double that of the motor vehicle occupant. Foreign body had a marked peak at age 9 to 11 months. Both battering and neglect rates were highest among infants 0 to 2 and 3 to 5 months. Bathtub submersions had a narrow peak at age 6 to 11 months. Other submersions peaked at 12 to 14 months and remained high until 33 to 35 months. CONCLUSIONS: We departed from usual groupings of E-codes and devised groupings that would be reflective of age-related developmental characteristics. Differences in rates by narrow age groups for young children can be related to developmental achievements, w can be related to developmental achievements, which place the child at risk for specific causes of injury. We found marked variability in both rates and leading causes of injury by 3-month interval age groupings that were masked by year of age analyses. Children aged 15 to 17 months had the highest overall injury rate before age 15 years. This coincides with developmental achievements such as independent mobility, exploratory behavior, and hand-to-mouth activity. The child is able to access hazards but has not yet developed cognitive hazard awareness and avoidance skills. A remarkable finding was the high rate of battering injury among infants 0 to 5 months, suggesting the need to address potential child maltreatment in the perinatal period. Poisoning was the second major leading cause of injury; more than two thirds were medication. Cultural factors may influence views of medications, storage practices, use of poison control system telephone advice, and risk of toddler poisoning. The pedestrian injury rate doubled between 12 and 14 months and 15 and 17 months and exceeded motor vehicle occupant injury rates for each 3-month interval from 15 to 47 months. Pedestrian injury has not received sufficient attention in general and certainly not in injury prevention counseling for children younger than 4 years. Anticipatory guidance for pedestrian injury should be incorporated before 1 year of age. Effective strategies must be based on the epidemiology of childhood injury. Pediatricians and other pediatric health care providers are in a unique position to render injury prevention services to their patients. Integrating injury prevention messages in the context of developmental assessments of the child is 1 strategy. These data can also be used for complementary childhood injury prevention strategies such as early intervention programs for high-risk families for child abuse and neglect, media and advocacy campaigns, public policies, and environmental and product design.

Shaken baby syndrome.

PURPOSE: To examine the comprehensive ophthalmologic experience with the shaken baby syndrome at one medical center, including clinical findings, autopsy findings, and the outcome of survivors. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: One hundred twenty-three children admitted from January 1987 through December 1998 for subdural hematomas of the brain secondary to abuse were included. METHODS: Clinical features of eye examinations of the patients during their admission and after discharge and histopathologic observations for patients who died were retrieved from medical records and statistically analyzed. MAIN OUTCOME MEASURES: Visual response and pupillary response on initial examination, fundus findings, final vision, neurologic outcome of survivors, and death. RESULTS: Ninety percent of the patients had ophthalmologic assessments. Retinal hemorrhages were detected in 83% of the examined children. The retinal hemorrhages were bilateral in 85% of affected children and varied in type and location. Nonophthalmologists missed the hemorrhages in 29% of affected patients. Poor visual response, poor pupillary response, and retinal hemorrhage correlated strongly with the demise of the child. One child who died had pigmented retinal scars from previous abuse, a condition not previously observed histopathologically to our knowledge. One fifth of the survivors had poor vision, largely the result of cerebral visual impairment. Severe neurologic impairment correlated highly with loss of vision. CONCLUSIONS: Shaken baby syndrome causes devastating injury to the brain and thus to vision. Retinal hemorrhages are extremely common, but vision loss is most often the result of brain injury. The patient's visual reaction and pupillary response on presentation showed a high correlation with survival. Good initial visual reaction was highly correlated with good final vision and neurologic outcome. According to the literature, when retinal hemorrhages are found in young children, the likelihood that abuse occurred is very high. Nonophthalmologists' difficulty in detecting retinal hemorrhages may be an important limiting factor in identifying shaken babies so they can be protected from further abuse.

Prognostic indicators for vision and mortality in shaken baby syndrome.

OBJECTIVE: To study ocular and nonocular signs of patients diagnosed as having "shaken baby syndrome" and determine prognostic indicators for vision and mortality. METHODS: Medical records of child abuse cases involving bilateral retinal hemorrhages were reviewed. Particular attention was paid to visual function and pupillary light reaction at the time of admission as well as the location of retinal hemorrhages, neuroimaging findings, ventilatory requirement, and associated skeletal injuries. These findings were correlated with visual prognosis and mortality. RESULTS: Thirty consecutive cases met the criteria for review. At the initial visit, mean age of the children was 9.3 months (range, 1-39 months) and 12 children (40%) had at least fix-and-follow vision. Preretinal and intraretinal hemorrhages (93% [n = 28] and 100% [n = 30]) were more common than vitreous hemorrhage (10% [n = 3]). Subdural hematomas were detected in 21 patients (70%). Twenty children (67%) had seizures and 16 (53%) required ventilatory support; bruises and long bone fractures were seen in 14 (47%) and 4 (13%) children, respectively. Eight patients died. All patients with nonreactive pupils on presentation died, while all patients with a pupillary light reaction lived (P<.001). Six (86%) of 7 patients with midline shift died, whereas 21 (91%) of 23 with no midline shift lived (P<.001). At follow-up, retinal hemorrhages had resolved in nearly all children by 4 months, and 16 children (73%) had at least fix-and-follow vision. Ventilatory requirement was associated with poorer vision (P<.01). CONCLUSIONS: Nonreactive pupils and midline shift of the brain structures correlate highly with mortality. Ventilatory requirement, but not visual acuity on presentation, predicts visual outcome.

The shaken baby syndrome.

Trauma is the most common cause of death in childhood and non-accidental injury is the leading cause of death in infants between one month and one year of life. This is a newly emerging entity in Saudi Arabia. However, there is little available literature on the extent of child maltreatment in Saudi Arabia and other Arab countries. In this review, we will discuss various aspects of the central nervous system insults resulting from the inflicted trauma of child abuse. We aim to raise awareness in the region as the tragic loss of life and function is unequalled in childhood beyond the perinatal period.

[Fatal child abuse (caused by physical violence) in Germany during 1 January 1985 to 2 October 1990. Results of a multicenter study]. / Tödliche Kindesmisshandlung (durch physische Gewalteinwirkung) in der Bundesrepublik Deutschland im Zeitraum 1.1.1985 bis 2.10.1990. Ergebnisse einer multizentrischen Studie.

UNLABELLED: No reliable data are available on cases of lethal child abuse (by active force) in the area of Federal Republic of Germany prior to reunification (the former West Germany). In a multicenter study we therefore examined the police and court records for such cases occurring in the period 1 January 1985 to 2 October 1990 in nearly the entire area of Federal Republic of Germany. RESULTS: The study center received information on 58 cases of lethal child abuse. Extrapolated to all institutes of legal medicine, this corresponds to 62 cases in all of West Germany in the period studied. An approximately equal number of unreported cases should be added to this figure. Including unreported cases, at least 20 cases of lethal child abuse occurred per year; thus only one in every two cases ever came to light. Almost two thirds of the victims were younger than one year old. At autopsy 59% exhibited signs of repeated abuse at autopsy. By far the most common cause of death was direct impact from a blunt object, usually to the head. Mostly, the male person to whom the victim relates most closely (father, stepfather, partner of the mother) has killed the child. Twenty-one of the 74 persons charged saw the charges against them dropped or were acquitted due to lack of evidence; 51 received sentences ranging from one year probation to life. In the remaining two cases the outcome of the trial was unknown. Signs of abuse were readily apparent at autopsy in almost all cases. The high number of unreported cases underscores the need to educate medical students and practicing physicians to be on the look-out for signs of abuse and argues for an increase in the rate of autopsy.

Shaken baby syndrome and the death of Matthew Eappen: a forensic pathologist's response.

Subdural hemorrhage, retinal hemorrhage, and cerebral edema have been considered diagnostic for a "shaken infant" since the syndrome was described almost 30 years ago. However, the specificity of these findings has been disputed by defense witnesses in recent U.S. criminal prosecutions. This review examines the scientific basis for the shaken baby syndrome.

[Fatal child abuse in Japan and Germany. Comparative retrospective study]. / Tödliche Kindesmisshandlung in Japan und Deutschland. Vergleichende, retrospektive Untersuchung.

In this study a record for comparative international epidemiological studies on autopsy cases of child abuse is introduced. The form was proved in a retrospective comparative survey of cases of fatal child abuse at the Department of Legal Medicine in Kanazawa (Japan) and Institute of Legal Medicine of Lübeck (Germany). A total of 33 cases were included. The following data were evaluated: age and gender of victims and assailants, relationship between victims and assailants, causes and methods of abuse, chief autopsy findings, and causes of death. The results were leading into two directions between Kanazawa and Lübeck: (1) In the years of 1981-1996 in Kanazawa 23 cases of fatal child abuse were autopsied while during the same period in Lübeck only 10 cases were registered. (2) While sexual abuse was not registered in Kanazawa, it was recorded twice in Lübeck.

Da denúncia à impunidade: um estudo sobre a morbi-mortalidade de crianças vítimas de violência / From complaints to impunity: a morbidity and mortality profile of children suffering violence

Analisa denúncias contra crianças, bem como o encaminhamento dado a essas denúncias. A metodologia do estudo, predominantemente qualitativa, leva em conta dois procedimentos: (1) análise de dados de 1990 de delegacias de polícia das áreas programáticas números 1 e 5 do Município do Rio de Janeiro, e (2) discussäo do encaminhamento dado às denúncias, após decorridos cinco anos dos acontecimentos. Conclui-se que, entre outros eventos, os acidentes de trânsito predominam no conjunto dos dados. Também observa-se que as ocorrências pouco informam sobre as circunstâncias dos eventos violentos e praticamente nada foi feito para se apurar as responsabilidades de quem comete violência contra a criança.

Trends in intentional injury deaths in children and teenagers (1980-1995).

BACKGROUND: The aim of the study was to describe patterns and trends in intentional injury death rates in children and teenagers. METHODS: Analyses were carried out on data from the Office of National Statistics on all intentional injury deaths in people aged 0 to 19 years, in England and Wales, from 1980 to 1995. Trends in death rates were examined using Poisson regression modelling, and class-specific death rates were estimated using the Registrar General's Standard Classification of Occupations. RESULTS: Between 1980 and 1995, there has been a substantial fall in the unintentional injury death rate, but no reduction in the intentional injury death rate. Intentional injuries made up 13 per cent of injury and poisoning deaths in 1980, and 25 per cent of such deaths in 1995. Each year in England and Wales an average of 335 children and teenagers die as a result of homicide, suicide and injuries of undetermined intent. Older teenagers (15-19 years) account for 70 per cent of intentional injury deaths, children 0-4 years account for 18 per cent, and children 5-15 years account for 12 per cent. Of the 5361 intentional injury deaths, 45 per cent were classified as injury undetermined whether accidentally or purposely inflicted, 35 per cent were classified as suicide, and 20 per cent were classified as homicide. With the exception of suicide, there are steep social class gradients for each category of intentional injury. The homicide rate for children in social class V is 17 times that for children in social class I. For all intentional injury, homicide, suicide and injuries of undetermined intent, the relative risk of death for manual vs. non-manual was higher for the four year period 1992-1995 than in the four year period 1980-1983. CONCLUSIONS: Intentional injury is responsible for an average of 335 deaths of children and teenagers each year in England and Wales. Unlike for unintentional injury, there has been no reduction in death rates from intentional injury, which now accounts for 25 per cent of all injury deaths. There is a steep social class gradient in intentional injury death rates, which has widened over the period 1980-1995.

Funduscopic lesions associated with mortality in shaken baby syndrome.

PURPOSE: The shaken baby syndrome (SBS) has been defined as a syndrome of intraocular and intracranial hemorrhage in young children, thought to be caused by violent shaking inflicted by an adult. In many cases SBS is fatal as a result of intracranial injury. Intraocular findings include hemorrhage, which may be accompanied by characteristic retinal folds or retinoschisis lesions. This study was performed to determine whether acute ophthalmologic findings might predict a fatal outcome. METHODS: A consecutive series of 10 patients meeting a strict definition of SBS was reviewed for ophthalmic findings at presentation and outcome. RESULTS: Seven patients survived, and three died. Of the six funduscopic characteristics identified in these patients, two were significantly associated with a fatal outcome: circular perimacular retinal folds found in four patients (p = 0.048) and peripheral retinoschisis lesions seen in three patients (p = 0.012). Lack of visual response at initial examination was also significantly associated with a fatal outcome (p = 0.033). CONCLUSIONS: Ophthalmic examination of children with suspected SBS is important for prognostic as well as diagnostic purposes. Circular perimacular retinal folds, peripheral retinoschisis lesions, and lack of visual response correlated with fatal neurologic trauma and may be useful in predicting severity of central nervous system injury in shaken baby syndrome.