Mild Traumatic Brain Injury Characteristics and Symptoms in Preschool Children: How Do They Differ to School Age Children? A Multicenter Prospective Observational Study.

OBJECTIVE: To investigate if preschool children differ to school age children with mild traumatic brain injury (TBI) with respect to injury causes, clinical presentation, and medical management. DESIGN: A secondary analysis of a dataset from a large, prospective and multisite cohort study on TBI in children aged 0-18 years, the Australian Paediatric Head Injury Rules Study. SETTING: Nine pediatric emergency departments (ED) and 1 combined adult and pediatric ED located across Australia and New Zealand. PARTICIPANTS: 7080 preschool aged children (2-5 years) were compared with 5251 school-age children (6-12 years) with mild TBI (N= (N=12,331) MAIN OUTCOME MEASURES: Clinical report form on medical symptoms, injury causes, and management. RESULTS: Preschool children were less likely to be injured with a projectile than school age children (P<.001). Preschool children presented with less: loss of consciousness (P<.001), vomiting (P<.001), drowsiness (P=.002), and headache (P<.001), and more irritability and agitation (P=.003), than school-age children in the acute period after mild TBI. Preschool children were less likely to have neuroimaging of any kind (P<.001) or to be admitted for observation than school age children (P<.001). CONCLUSIONS: Our large prospective study has demonstrated that preschool children with mild TBI experience a different acute symptom profile to older children. There are significant clinical implications with symptoms post-TBI used in medical management to aid decisions on neuroimaging and post-acute intervention.

The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Demographic, Injury Event, and Social Characteristics on Outcomes for People With Moderate-Severe Traumatic Brain Injury.

The objective of the Australian Traumatic Brain Injury (AUS-TBI) Initiative is to develop a data dictionary to inform data collection and facilitate prediction of outcomes of people who experience moderate-severe TBI in Australia. The aim of this systematic review was to summarize the evidence of the association between demographic, injury event, and social characteristics with outcomes, in people with moderate-severe TBI, to identify potentially predictive indicators. Standardized searches were implemented across bibliographic databases to March 31, 2022. English-language reports, excluding case series, which evaluated the association between demographic, injury event, and social characteristics, and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Abstracts and full text records were independently screened by at least two reviewers in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association. The review findings were discussed with an expert panel to determine the feasibility of incorporation of routine measurement into standard care. The search strategy retrieved 16,685 records; 867 full-length records were screened, and 111 studies included. Twenty-two predictors of 32 different outcomes were identified; 7 were classified as high-level (age, sex, ethnicity, employment, insurance, education, and living situation at the time of injury). After discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous predictors capable of enabling early identification of those at risk for poor outcomes and improved personalization of care through inclusion in routine data collection.

Hypercapnia alters mitochondrial gene expression and acylcarnitine production in monocytes.

CO2 is produced during aerobic respiration. Normally, levels of CO2 in the blood are tightly regulated but pCO2 can rise (hypercapnia, pCO2 > 45 mmHg) in patients with lung diseases, for example, chronic obstructive pulmonary disease (COPD). Hypercapnia is a risk factor in COPD but may be of benefit in the context of destructive inflammation. The effects of CO2 per se, on transcription, independent of pH change are poorly understood and warrant further investigation. Here we elucidate the influence of hypercapnia on monocytes and macrophages through integration of state-of-the-art RNA-sequencing, metabolic and metabolomic approaches. THP-1 monocytes and interleukin 4-polarized primary murine macrophages were exposed to 5% CO2 versus 10% CO2 for up to 24 h in pH-buffered conditions. In hypercapnia, we identified around 370 differentially expressed genes (DEGs) under basal and about 1889 DEGs under lipopolysaccharide-stimulated conditions in monocytes. Transcripts relating to both mitochondrial and nuclear-encoded gene expression were enhanced in hypercapnia in basal and lipopolysaccharide-stimulated cells. Mitochondrial DNA content was not enhanced, but acylcarnitine species and genes associated with fatty acid metabolism were increased in hypercapnia. Primary macrophages exposed to hypercapnia also increased activation of genes associated with fatty acid metabolism and reduced activation of genes associated with glycolysis. Thus, hypercapnia elicits metabolic shifts in lipid metabolism in monocytes and macrophages under pH-buffered conditions. These data indicate that CO2 is an important modulator of monocyte transcription that can influence immunometabolic signaling in immune cells in hypercapnia. These immunometabolic insights may be of benefit in the treatment of patients experiencing hypercapnia.

The Australian and New Zealand brain injury lifespan cohort protocol: Leveraging common data elements to characterise longitudinal outcome and recovery.

INTRODUCTION: Cognitive, behavioural, academic, mental health and social impairments are common following paediatric traumatic brain injury (TBI). However, studies are often reliant on small samples of children drawn from narrow age bands, and employ highly variable methodologies, which make it challenging to generalise existing research findings and understand the lifetime history of TBI. METHOD AND ANALYSIS: This study will synthesise common data sets from national (Victoria, New South Wales, Queensland) and international (New Zealand) collaborators, such that common data elements from multiple cohorts recruited from these four sites will be extracted and harmonised. Participant-level harmonised data will then be pooled to create a single integrated data set of participants including common cognitive, social, academic and mental health outcome variables. The large sample size (n=1816), consisting of participants with mild, moderate and severe TBI, will provide statistical power to answer important questions that cannot be addressed by small, individual cohorts. Complex statistical modelling, such as generalised estimation equation, multilevel and latent growth models, will be conducted. ETHICS AND DISSEMINATION: Ethics approval was granted by the Human Research Ethics Committee (HREC) of the Royal Children's Hospital (RCH), Melbourne (HREC Reference Number 2019.168). The approved study protocol will be used for all study-related procedures. Findings will be translated into clinical practice, inform policy decisions, guide the appropriate allocation of limited healthcare resources and support the implementation of individualised care.

Psychological and Peer Difficulties of Children with Cleft Lip and/or Palate: A Systematic Review and Meta-Analysis.

OBJECTIVES: A systematic review and meta-analysis were conducted to determine if children born with cleft lip and/or palate are at increased risk of psychological and peer difficulties, and if so, which difficulties they develop. METHODS: EMBASE, MEDLINE, and PsycINFO were searched for English language studies published between January 2005 and January 2022 which investigated the psychological outcomes and peer function of children with nonsyndromic cleft lip and palate. Outcomes included internalizing problems, such as anxiety and depression, externalizing problems, such as hyperactivity, conduct disorders, self-concept including self-image and self-esteem, peer problems, resilience, coping, and overall psychological function. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. Random effects models were used in the meta-analysis to compare the outcomes for children born with a cleft and those without. RESULTS: In total 41 studies met inclusion criteria, with 9 included in the meta-analysis. Children born with a cleft appear to have similar psychological outcomes compared to normative controls when using the strengths and difficulties questionnaire. There are some minor differences between self-report and parent report, with parents generally reporting that their child with a cleft has increased emotional, conduct, and hyperactivity problems. The small differences between the study cohort and control cohorts are unlikely to imply any differences on a clinical level. CONCLUSIONS: Overall psychological outcomes appear to be similar between children born with a cleft and the nonaffected population, however, some symptoms such as anxiety and depression appear higher in children with cleft lip and/or palate.

Self-perception and behavioural outcomes of early acquired brain injury.

Acquired brain injury (ABI) occurs commonly in young children. Despite this, the psychosocial implications of ABI in young children are not established, with little understood about the impacts on self-perception and self-esteem. In this study we investigated self-perception, self-esteem and behaviour of children with early ABI. Children with an ABI (n = 47) before six years were compared to 17 typically developing controls (TDCs) matched on demographics. Children were aged 6-12 years and completed the Harter Self-Perception Profile. One parent completed the Child Behavior Checklist. No differences for self-perception and self-esteem were found between the groups. Parents of children with an early ABI reported more internalizing and externalizing behaviours. Children with more externalizing behaviour and social skill problems had more negative self-perceptions. Interaction effects were seen between socioeconomic status (SES) and child self-perception and behaviour. Specifically, children from families of higher SES had a more positive perception of their appearance and children from lower SES backgrounds had more externalizing behaviours and social problems. The study suggests that the relationship between ABI and self-perception and self-esteem is complicated and that children with behavioural problems have lowered feelings of competence. SES has an important role in self-perception and behavioural outcomes.

Post-concussive Signs and Symptoms in Preschool Children: A Systematic Review.

Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery.

Characteristics of concussion based on patient age and sex: a multicenter prospective observational study.

OBJECTIVE: Children with concussion frequently present to emergency departments (EDs). There is limited understanding of the differences in signs, symptoms, and epidemiology of concussion based on patient age. Here, the authors set out to assess the association between age and acute concussion presentations. METHODS: The authors conducted a multicenter prospective observational study of head injuries at 10 EDs in Australia and New Zealand. They identified children aged 5 to < 18 years, presenting with a Glasgow Coma Scale score of 13-15, presenting < 24 hours postinjury, with no abnormalities on CT if performed, and one or more signs or symptoms of concussion. They extracted demographic, injury-related, and signs and symptoms information and stratified it by age group (5-8, 9-12, 13 to < 18 years). RESULTS: Of 8857 children aged 5 to < 18 years, 4709 patients met the defined concussion criteria (5-8 years, n = 1546; 9-12 years, n = 1617; 13 to < 18 years, n = 1546). The mean age of the cohort was 10.9 years, and approximately 70% of the patients were male. Sport-related concussion accounted for 43.7% of concussions overall, increasing from 19.1% to 48.9% to 63.0% in the 5-8, 9-12, and 13 to < 18 years age groups. The most common acute symptoms postinjury were headache (64.6%), disorientation (36.2%), amnesia (30.0%), and vomiting (27.2%). Vomiting decreased with increasing age and was observed in 41.7% of the 5-8 years group, 24.7% of the 9-12 years group, and 15.4% of the 13 to < 18 years group, whereas reported loss of consciousness (LOC) increased with increasing age, occurring in 9.6% in the 5-8 years group, 21.0% in the 9-12 years group, 36.7% in the 13 to < 18 years group, and 22.4% in the entire study cohort. Headache, amnesia, and disorientation followed the latter trajectory. Symptom profiles were broadly similar between males and females. CONCLUSIONS: Concussions presenting to EDs were more sports-related as age increased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with increasing age.

Social Cognitive Dysfunction Following Pediatric Arterial Ischemic Stroke: Evidence From a Prospective Cohort Study.

Background and Purpose: Childhood and adolescence coincide with rapid maturation of distributed brain networks supporting social cognition; however, little is known about the impact of early ischemic brain insult on the acquisition of these skills. This study aimed to examine the influence of arterial ischemic stroke (AIS) on facial emotion recognition and theory of mind (ToM) abilities of children and adolescents initially recruited to a single-center, prospective longitudinal study of recovery following AIS. Methods: The study involved 67 participants, including 30 children with AIS (mean time since stroke=5 years) and 37 age-matched typically developing controls who were assessed on measures of cognitive ToM, facial emotion recognition, and affective ToM. Acute clinical magnetic resonance imaging, including diffusion-weighted imaging sequences, were used to evaluate prospective structure-function relationships between acute lesion characteristics (size, location, and arterial territories affected) and long-term social cognitive abilities. Results: Relative to age-matched typically developing controls, children with AIS showed significantly worse performance on measures of basic facial emotion processing, cognitive ToM, and affective ToM. In univariate models, poorer ToM was associated with larger infarcts, combined cortical-subcortical pathology, and involvement of multiple arterial territories. In multivariate analyses, larger lesions and multiterritory infants were predictive of ToM processing but not facial emotion recognition. Poorer cognitive ToM predicted less frequent prosocial behavior and increased peer problems. Conclusions: Social cognitive skills appear vulnerable to disruption from early ischemic brain insult. In the first study to examine social cognition in a prospective cohort of children with AIS, our findings suggest that acute magnetic resonance imaging-based lesion characteristics may have predictive value for long-term social cognitive outcomes and may assist to identify children at elevated risk for social cognitive dysfunction.

Sexual function, intimate relationships and Friedreich ataxia.

BACKGROUND: Sexual dysfunction (SD) is reported in neurological conditions similar to Friedreich ataxia (FRDA). Anecdotally individuals with FRDA report SD including erectile dysfunction and altered genital sensation. Understanding SD in FRDA assists health professionals identify SD issues and improve healthcare for individuals with FRDA. OBJECTIVE: To quantify if, and to what extent, people with FRDA experience challenges with sexual function and intimate relationships as a result of primary (genital function), secondary (physical) and tertiary (psychosocial) dysfunction. METHODS: An online purpose designed anonymous questionnaire explored SD and intimate relationships. Invitations to participate were sent to individuals with FRDA aged 18 years and over on the Ataxia UK and Friedreich Ataxia Research Alliance databases. Date collection occurred between January and July, 2017. RESULTS: One-hundred-and-seventy-nine adults with FRDA participated, of which 107 reported current or previous sexual activity. Erectile dysfunction was reported in 57% (20/35) of males, inadequate vaginal lubrication interfering with sexual responsiveness was reported in 57.7% (26/45) of females, and 47% (51/107) reported reduced genital sensation. In addition, 88% (94/107) reported problems moving their body during sexual activity and 73% (78/107) reported reduced confidence about their sexuality due to FRDA. A significant negative relationship was shown between younger age of disease onset and SD. CONCLUSION: This study confirmed FRDA impacts sexual functioning, sexual satisfaction and the capacity to form intimate relationships. Understanding the nature and extent of SD is critical to developing interventions and recommendations designed to enhance sexual function, sexuality, and intimate relationships for individuals with FRDA.

Long-Term Intellectual Function After Traumatic Brain Injury in Very Young Children.

OBJECTIVE: To investigate long-term intellectual function following a traumatic brain injury (TBI) in early childhood and to identify the contribution of injury and environment to outcome. PARTICIPANTS: Fifty children younger than 3 years with a diagnosis of accidental TBI were recruited through a pediatric hospital emergency department. Children with TBI were compared with a group (n = 33) of typically developing children (TDC) matched on demographics. DESIGN: Longitudinal, single-site, case-control study. MEASURES: Children completed intellectual assessments (IQ) at 4.5 to 5.5 years of age (average 3.5 years after TBI) and at 7.5 to 9 years of age (average 6.5 years after TBI). Information on injury and environmental predictors of outcome was collected. RESULTS: IQ scores for all groups were in the average range; however, children with TBI of any severity had lower scores than TDC at both time points. There was some suggestion of children with TBI achieving lower verbal IQ scores over time than TDC. IQ scores were predicted by family environment, not injury characteristics. CONCLUSIONS: A TBI in early childhood is associated with lower IQ scores that persist several years postinjury. Socioeconomic status is an influential factor on IQ at 6.5 years post-TBI.

Validation of the PredAHT-2 prediction tool for abusive head trauma.

OBJECTIVE: The validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool calculates the probability of abusive head trauma (AHT) in children <3 years of age who have sustained intracranial injuries (ICIs) identified on neuroimaging, based on combinations of six clinical features: head/neck bruising, seizures, apnoea, rib fracture, long bone fracture and retinal haemorrhages. PredAHT version 2 enables a probability calculation when information regarding any of the six features is absent. We aimed to externally validate PredAHT-2 in an Australian/New Zealand population. METHODS: This is a secondary analysis of a prospective multicentre study of paediatric head injuries conducted between April 2011 and November 2014. We extracted data on patients with possible AHT at five tertiary paediatric centres and included all children <3 years of age admitted to hospital who had sustained ICI identified on neuroimaging. We assigned cases as positive for AHT, negative for AHT or having indeterminate outcome following multidisciplinary review. The estimated probability of AHT for each case was calculated using PredAHT-2, blinded to outcome. Tool performance measures were calculated, with 95% CIs. RESULTS: Of 87 ICI cases, 27 (31%) were positive for AHT; 45 (52%) were negative for AHT and 15 (17%) had indeterminate outcome. Using a probability cut-off of 50%, excluding indeterminate cases, PredAHT-2 had a sensitivity of 74% (95% CI 54% t o89%) and a specificity of 87% (95% CI 73% to 95%) for AHT. Positive predictive value was 77% (95% CI 56% to 91%), negative predictive value was 85% (95% CI 71% to 94%) and the area under the curve was 0.80 (95% CI 0.68 to 0.92). CONCLUSION: PredAHT-2 demonstrated reasonably high point sensitivity and specificity when externally validated in an Australian/New Zealand population. Performance was similar to that in the original validation study. TRIAL REGISTRATION NUMBER: ACTRN12614000463673.

Performance of Two Head Injury Decision Rules Evaluated on an External Cohort of 18,913 Children.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) decision rule demonstrates high sensitivity for identifying children at low risk for clinically important traumatic brain injury (ciTBI). As with the PECARN rule, the Israeli Decision Algorithm for Identifying TBI in Children (IDITBIC) recommends proceeding directly to computed tomography (CT) in children with Glasgow Coma Score (GCS) <15. The aim was to assess the diagnostic accuracy of two clinical rules that assign children with GCS <15 at presentation directly to CT. MATERIALS AND METHODS: Accuracy analysis for detecting ciTBI was performed on a multicenter cohort of children used in the Australasian Pediatric Head Injury Rules Study. RESULTS: The external cohort included 18,913 children; 1691 (8.9%) had CT scan, 160 had ciTBI, and 24 (0.13%) had neurosurgery. Applying IDITBIC and PECARN rules would have missed 11 and 1 ciTBI patients; respectively. All patients with missed injuries were classified as such based on a hospital stay of >2 d. None of these patients died, needed neurosurgery, or required ventilatory support. In children aged <2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 95.2%, 79.5%, 3.8%, and 99.9% and 100.0%, 59.1%, 2.0%, and 100.0%, respectively. In children ≥2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 92.4%, 75.3%, 3.1%, and 99.9% and 99.2%, 52.9%, 1.7%, and 100.0%, respectively. CONCLUSIONS: The two decision rules demonstrated high accuracy in identifying ciTBI. As a screening tool, the PECARN rule outperformed IDITBIC. The findings suggest that clinicians should strongly consider directing children with GCS <15 at presentation to CT scan.

Paediatric abusive head trauma in the emergency department: A multicentre prospective cohort study.

AIM: Abusive head trauma (AHT) is associated with high morbidity and mortality. We aimed to describe characteristics of cases where clinicians suspected AHT and confirmed AHT cases and describe how they differed. METHODS: This was a planned secondary analysis of a prospective multicentre cohort study of head injured children aged <18 years across five centres in Australia and New Zealand. We identified cases of suspected AHT when emergency department clinicians raised suspicion on a clinical report form or based on research assistant-assigned epidemiology codes. Cases were categorised as AHT positive, negative and indeterminate after multidisciplinary review. Suspected and confirmed AHT and non-AHT cases were compared using odds ratios with 95% confidence intervals. RESULTS: AHT was suspected in 70 of 13 371 (0.5%) head-injured children. Of these, 23 (32.9%) were categorised AHT positive, 18 (25.7%) AHT indeterminate and 29 (27.1%) AHT negative. Median age was 0.8 years in suspected, 1.4 years in confirmed AHT and 4.1 years in non-AHT cases. Odds ratios (95% confidence interval) for presenting features and outcomes in confirmed AHT versus non-AHT were: loss of consciousness 2.8 (1.2-6.9), scalp haematoma 3.9 (1.7-9.0), seizures 12.0 (4.0-35.5), Glasgow coma scale ≤12 30.3 (11.8-78.0), abnormal neuroimaging 38.3 (16.8-87.5), intensive care admission 53.4 (21.6-132.5) and mortality 105.5 (22.2-500.4). CONCLUSIONS: Emergency department presentations of children with suspected and confirmed AHT had higher rates of loss of consciousness, scalp haematomas, seizures and low Glasgow coma scale. These cases were at increased risk of abnormal computed tomography scans, need for intensive care and death.

Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study.

AIM: To characterise the causes, clinical characteristics and short-term outcomes of neonates who presented to paediatric emergency departments with a head injury. METHODS: Secondary analysis of a prospective data set of paediatric head injuries at 10 emergency departments in Australia and New Zealand. Patients without neuroimaging were followed up by telephone call. We extracted epidemiological information, clinical findings and outcomes in neonates (≤28 days). RESULTS: Of 20 137 children with head injuries, 93 (0.5%) occurred in neonates. These were mostly fall-related (75.2%), commonly from a care giver's arms, or due to being accidentally struck by a person/object (20.4%). There were three cases of non-accidental head injuries (3.2%). Most neonates were asymptomatic (67.7%) and many had no findings on examination (47.3%). Most neonates had a Glasgow Coma Scale 15 (89.2%) or 14 (7.5%). A total of 15.1% presented with vomiting and 5.4% were abnormally drowsy. None had experienced a loss of consciousness. The most common findings on examination were scalp haematoma (28.0%) and possible palpable skull fracture (6.5%); 8.6% underwent computed tomography brain scan and 4.3% received an ultrasound. Five of eight computed tomography scan (5.4% of neonates overall) showed traumatic brain injury and two of four (2.2% overall) had traumatic brain injury on ultrasound. Thirty-seven percent were admitted, one patient was intubated and none had neurosurgery or died. CONCLUSIONS: Neonatal head injuries are rare with a mostly benign short-term outcome and are appropriate for observation. However, non-accidental injuries need to be considered.

Cognitive and Behavioural Outcomes of Paediatric Liver Transplantation for Ornithine Transcarbamylase Deficiency.

Ornithine Trans-Carbamylase (OTC) deficiency is the most common disorder of the urea cycle. Cognitive impairments in skills such as attention and executive function have been reported in individuals with OTC deficiency who are managed with medication. In some cases, children undergo liver transplantation (LTx) to correct the metabolic defect. The metabolic and medical outcomes of LTx are generally good. However, little is known about the impacts on cognition. In this study, four children (three female) completed detailed neuropsychological batteries prior to (n = 6) and following LTx (n = 8 assessments). Children's age at assessment ranged from 3 to 11 years. The battery included standardised, age-referenced measures of intellectual ability (IQ), attention, memory and educational ability. Additionally, parent measures of behaviour and executive function were administered. Generally, there was little change in overall IQ following LTx. Memory and academic skills were at expected levels for the three female patients and gains were made after LTx. Children showed ongoing impairments in attention and parent rated executive function. In conclusion, the immediate effect of LTx on cognition may not appear beneficial in the short-term and impairments in IQ, attention and behaviour persisted after the procedure. However, LTx seems to enable stabilisation to premorbid function in the longer term.

Paediatric intentional head injuries in the emergency department: A multicentre prospective cohort study.

OBJECTIVE: Although there is a large body of research on head injury (HI) inflicted by caregivers in young children, little is known about intentional HI in older children and inflicted HI by perpetrators other than carers. Therefore, we set out to describe epidemiology, demographics and severity of intentional HIs in childhood. METHODS: A planned secondary analysis of a prospective multicentre cohort study was conducted in 10 EDs in Australia and New Zealand, including children aged <18 years with HIs. Epidemiology codes were used to prospectively code the injuries. Demographic and clinical information including the rate of clinically important traumatic brain injury (ciTBI: HI leading to death, neurosurgery, intubation >1 day or admission ≥2 days with abnormal computed tomography [CT]) was descriptively analysed. RESULTS: Intentional injuries were identified in 372 of 20 137 (1.8%) head-injured children. Injuries were caused by caregivers (103, 27.7%), by peers (97, 26.1%), by siblings (47, 12.6%), by strangers (35, 9.4%), by persons with unknown relation to the patient (21, 5.6%), other intentional injuries (8, 2.2%) or undetermined intent (61, 16.4%). About 75.7% of victims of assault by caregivers were <2 years, whereas in other categories, only 4.9% were <2 years. Overall, 66.9% of victims were male. Rates of CT performance and abnormal CT varied: assault by caregivers 68.9%/47.6%, by peers 18.6%/27.8%, by strangers 37.1%/5.7%. ciTBI rate was 22.3% in assault by caregivers, 3.1% when caused by peers and 0.0% with other perpetrators. CONCLUSIONS: Intentional HI is infrequent in children. The most frequently identified perpetrators are caregivers and peers. Caregiver injuries are particularly severe.

Accuracy of NEXUS II head injury decision rule in children: a prospective PREDICT cohort study.

OBJECTIVE: The National Emergency X-Radiography Utilisation Study II (NEXUS II) clinical decision rule (CDR) can be used to optimise the use of CT in children with head trauma. We set out to externally validate this CDR in a large cohort. METHODS: We performed a prospective observational study of patients aged <18 years presenting with head trauma of any severity to 10 Australian/New Zealand EDs. In a planned secondary analysis, we assessed the accuracy of the NEXUS II CDR (with 95% CI) to detect clinically important intracranial injury (ICI). We also assessed clinician accuracy without the rule. RESULTS: Of 20 137 total patients, we excluded 28 with suspected penetrating injury. Median age was 4.2 years. CTs were obtained in ED for 1962 (9.8%), of whom 377 (19.2%) had ICI as defined by NEXUS II. 74 (19.6% of ICI) patients underwent neurosurgery.Sensitivity for ICI based on the NEXUS II CDR was 379/383 (99.0 (95% CI 97.3% to 99.7%)) and specificity was 9320/19 726 (47.2% (95% CI 46.5% to 47.9%)) for the total cohort. Sensitivity in the CT-only cohort was similar. Of the 18 022 children without CT in ED, 49.4% had at least one NEXUS II risk criterion. Sensitivity for ICI by the clinicians without the rule was 377/377 (100.0% (95% CI 99.0% to 100.0%)) and specificity was 18 147/19 732 (92.0% (95% CI 91.6% to 92.3%)). CONCLUSIONS: NEXUS II had high sensitivity, similar to the derivation study. However, approximately half of unimaged patients were positive for NEXUS II risk criteria; this may result in an increased CT rate in a setting with high clinician accuracy.

External Validation of the PediBIRN Clinical Prediction Rule for Abusive Head Trauma.

BACKGROUND AND OBJECTIVES: A 4-variable abusive head trauma (AHT) clinical prediction rule (CPR) for use in the PICU was derived and validated for children <3 years of age by the Pediatric Brain Injury Research Network (PediBIRN). We aimed to externally validate PediBIRN as designed (PICU only) as well as using broader inclusion criteria (admitted children with head injuries). METHODS: This was a secondary analysis of a prospective multicenter study of pediatric head injuries at 5 Australian and New Zealand tertiary pediatric centers. Possible AHT was identified by clinician suspicion, epidemiology codes, or a high-risk group (<3 years of age, admitted, abnormal neuroimaging results). At 1 center, we additionally reviewed head injuries in the forensic database. We designated patients as positive for AHT, negative for AHT, or having indeterminate outcome after multidisciplinary review and applied the PediBIRN CPR, blinded to outcome, to PICU admissions only, and any head injury admissions. CPR accuracy was calculated by using 95% confidence intervals. RESULTS: One hundred and forty-one patients were admitted with abnormal neuroimaging results. Twenty-eight (20%) were positive for AHT, 94 (67%) were negative for AHT, and 19 (13%) had indeterminate outcome. Excluding indeterminate cases, in the PICU (n = 28), the CPR was 100% (75%-100%) sensitive and 11% (0%-48%) specific; in all admitted patients (n = 141), sensitivity was 96% (82%-100%) and specificity of 43% (32%-53%). CONCLUSIONS: This validation revealed high sensitivity and low specificity for PICU patients. Specificity was improved but moderate in a broader group of admitted head injury patients.