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Injury (ciTBI)
Stephen Rohl, DOa, James Burns, MD, MPHa, and Raid Amin, PhDb
a University of Florida Pediatric Residency Program, Pensacola, Florida
b University of West Florida, Pensacola, Florida
Abstract:
Head injury in children is a major cause of morbidity and mortality. The goal of this study is to
compare the outcomes of traumatic brain injury (TBI) by mechanism of injury.
Methods:
A retrospective study of 89 infants, 0-6 months old who presented with TBI was conducted.
Mechanisms of injury that had a degree of uncertainty such as falls, no explanation, struck by
object were included whereas motor vehicle, bicycle related accidents or penetrating injury were
excluded. Data was further stratified based whether an explanation of head injury was present vs.
no explanation. Chi-square was used to analyze categorical relationships.
Results:
16 of 89 infants (81.3%) with no explanation vs. 19/73 (26.0%) with explanation were found to
have ciTBI (p <0.001). For no explanation there were higher rates vs. explanation of having:
GCS ≤ 8 (18.7% vs. 2.7%; p = 0.039), seizures (56.3% vs. 11%; p <0.001) and admission to ICU
(81.2% vs. 50.7%; p = 0.029). Suspicion for abuse was found in 100% for no explanation vs.
69.6% with explanation (p = 0.009). Also, outcomes at discharge were favorable in 56.3% with
no explanation vs. 91.3% with explanation (p = 0.002).
Conclusion:
When no explanation is given in cases of suspected ciTBI, our study revealed increased
incidence of ciTBI, increased markers of clinical acuity, higher suspicion for abuse, and poorer
outcomes compared to cases with any explanation. Lack of history should serve as a strong
indicator to evaluate for ciTBI, especially in the infant population.
Introduction:
For the pediatric population, head trauma is one of the most common reasons for presentation
to the emergency department. As such, several guidelines have been developed in order to stratify risk
for severe injury such as the PECARN trial (Kuppermann et al., 2009) in order to reduce radiation
exposure from unnecessary imaging and limit further workup. A number of these commonly used
guidelines, however, have limited effectiveness when there is a questionable mechanism or abusive
head trauma is suspected (Kuppermann et al., 2009; Osmond et al., 2010). Clinically important
traumatic brain injury (ciTBI) within the first year of life can have estimated mortality above 20% with
morbidity seen for two-thirds of the survivors (Parks, Annest, Hill, & Karch, 2019). When mechanisms of
head trauma are compared, abusive head trauma (AHT) represents a significant risk for ciTBI in the
infant population and developing methods of identifying such cases are of great importance to first
ciTBI can be difficult to screen for in the infant population, as historical information can
sometimes be either sparse, exaggerated, or in some cases withheld completely. Studies such as Babl et
al. (2018) have called into question the validity of screenings such as PECARN, CATCH, and CHALICE as
limited potential to increase accuracy of detecting ciTBI was demonstrated. A similarity that each of
these tools share is that criteria is based on mostly symptoms and physical exam findings. Our
institution has set out to investigate cases of ciTBI with respect to reported mechanism of injury (Burns
et al. 2016) and markers of abuse and their prevalence in association with ciTBI (Proctor et al., 2018).
Falls with a suspected minor mechanism had a negative correlation with ciTBI while cases concerning for
suspected AHT strongly correlated with ciTBI and death in the Burns et al. study. Proctor et. al found
that cases with ciTBI had a statistically significant higher prevalence of markers for abuse (presence of
non-accidental trauma workup, sheltering by child protective services at discharge, and presence of
retinal hemorrhages).
Suspicion for abusive mechanisms within both of the prior investigations was associated with
higher incidence of ciTBI which was in keeping with several other publications (Miller Ferguson et al.,
2017; Robertson, Abbe, Pelletier, & Hennes, 2018; Yu et al., 2018). Even with the possibility of
inaccurate history, does the absence of history portend a higher incidence of ciTBI?
The goal of this study is to investigate historical explanation of trauma and if this presence or
Methods:
A retrospective surveillance study was performed on patient charts entered into the Sacred
Heart Trauma Registry. The design of the study was reviewed and approved by the Sacred Heart
Hospital Institutional Review Board. The Sacred Heart Trauma Registry is made up of all encounters for
which a trauma alert was called at the Studer Family Children’s Hospital at Sacred Heart. Such events
are initiated by either EMS or ER staff when there is a concern for severe injury by traumatic mechanism
which may require urgent/emergent evaluation by the hospital trauma team. A specific portion of this
registry was selected from dates between January 1st, 2010 and May 1st, 2017. Charts were included
with any diagnosis related to traumatic brain injury (TBI) in an age range between 0 to ≤ 6 months such
as “unspecified injury/mechanism”, “falls”, and/or “hit by object”. Exclusion criteria included any kind
of penetrating injury and motor-vehicle, pedestrian, bicycle or ATV accidents. Although those
mechanisms can also cause ciTBI, they are easily verifiable mechanisms and our aim is to isolate and
A team of 8 people were trained on the method of chart review to standardize data collection.
Patient information was reviewed from the charts in the Sacred Heart Trauma Registry by each of these
individuals. This included records from the emergency department, admission history and physical
exams, progress notes, radiology reports, order and medication histories, discharge planning notes, and
discharge summaries. Data from each chart was added to the prior collected information table. Forty-
six variables in total comprised the final data entry (per chart), however not all of these were used in
this study.
Data was stratified based on two main criterion – if an explanation of the head injury was
present vs. if no explanation was given at the time of presentation to the Sacred Heart Emergency
Department. Each of these encounters were reviewed for the presence of clinically important traumatic
brain injury (ciTBI) as per PECARN criteria (Kuppermann et al., 2009, Table 1). Based on childhood
traumatic brain injury literature, we selected the following variables as markers of clinical acuity often
seen with ciTBI: “GCS less than or equal to 8”, “Seizures documented”, “Apnea on presentation”, “ICU
admission needed”. Evaluation by Department of Children’s and Families (DCF) was charted as an
Chi-square (or when appropriate, Fischer’s exact test) was used to analyze the relationship of
presenting with explanation vs. presenting with no-explanation using Crosstab 2 x 2 for various clinical
features of the head trauma patients including ciTBI, “GCS less than or equal to 8”, “seizures
documented”, “apnea on presentation”, “ICU admission needed”, and “DCF evaluation (NAT
suspected)”. Medical outcomes for each case were estimated based on the Pediatric Outcome
Performance Category Scale (Pollack et al., 2014, Table 4). This scale was applied based on the
estimated needs of the child, physical exam, and other findings at hospital discharge. The outcomes
were combined into two outcomes: generally favorable (category 1 or 2) vs. moderately to severely
impaired (category 3, 4, 5 or 6). All statistical analysis was performed by Dr. James Burns. Analysis was
Results:
Of the total 89 infants ≤ 6 months of age, 73 fell into the category of “presented with an
explanation of mechanism of injury” with 16 being in the category of “no explanation for injury”.
With regards to mechanism of ciTBI, 19 of the 73 (26.0%) cases of those with an explanation
given were found to have ciTBI while 13 of the 16 cases (81.3%) without an explanation of injury were
A GCS score of less than or equal to 8 was found in only 2 of the 73 cases with explanation
(2.7%) compared to 3 of the 16 cases with no explanation (18.7%) (p = 0.039 Fischer’s exact test) (Table
2).
Seizures were documented 8 of the 73 cases where any explanation was given (11.0 %) whereas
seizures were found in in 9 of the 16 cases where no explanation was given (56.3%) (p<0.001; Fischer’s
Although apnea was seen in 8.2% of the cases (6 of 73) with an explanation, 25.0% (4 of 16) of
the cases with no explanation had apnea; however the p value exceeded 0.05 (p = 0.076, Fischer’s exact
test)(Table 2).
An ICU admission was needed in 37 of 73 patients that had an explanation given (50.7%) vs. 13
DCF evaluation was performed in 51 (69.9%) of cases with explanation, while in the no
explanation group it was performed on all 16 cases (100%, p = 0.009, Fischer’s exact test)(Table 3)
The Pediatric Outcome Performance Category Scale (POPCS) was also statistically related to
whether there was an explanation on presentation to the Emergency Department or not: 67 out of 73
(91.8%) of those with an explanation had favorable outcome in category 1 or 2, vs. 9/16 (56.3%) without
Discussion:
Amongst infants ≤ 6 months who presented to our emergency department under a trauma
alert, those lacking explanation had clinically important traumatic brain injury (ciTBI) 81.3% of the time.
Several studies (Fujiwara, Okuyama, & Miyasaka, 2008; Hettler & Greenes, 2003) have also noted
increased incidence of ciTBI and concern for abusive mechanisms with no history given, but did not
provide comparison to cases with explanations given. This rate of ciTBI in the group with any
Our markers of clinical acuity included “GCS ≤ 8”, “Seizures documented”, “Apnea on
presentation”, and “ICU admission needed”. An increase in each of these markers of acuity was
expected when no explanation was given. When compared to cases with explanation, individuals with
no explanation presented with lower GCS scores (18.7%, p = 0.039), higher incidences of seizures
(56.3%, p < 0.001), and higher rates of ICU admission (81.2%, p = 0.029). Although there was also a
higher rate of apnea in the no explanation group at 25%, this result was not found to be statistically
significant (p = 0.076). This may be due the n of the no explanation group or the limits of data present in
patient charts. A review by Maguire et al. included apnea as a variable in their evaluation for ciTBI,
which not only was found to be positively correlated with ciTBI, but also an even stronger indicator for
ciTBI when compared to seizures. The stakes of accurately diagnosing ciTBI are high, especially when
abusive mechanisms are expected. One such study showed that when abusive head trauma was missed,
infants re-presented with more significant complications during initial stabilization and admission (Oral,
Yagmur, Nashelsky, Turkmen, & Kirby, 2008). As physicians are evaluating infants in this age range with
head trauma as a mechanism, these symptoms can provide an increased suspicion for ciTBI.
suspicion for abusive head trauma (AHT) during our chart review process. Both categories of patients
presenting via trauma alert trigger high levels of suspicion in this population. Although many cases with
any explanation were evaluated by DCF, an even greater proportion of the cases without explanation
was evaluated (100%, p = 0.0092). Unfortunately, the Florida Department of Children and Families and
Child Protection Team (CPT) in Pensacola have their own systems of charting that are mostly separate
from any charting system available in this study. Furthermore, the results of these workups often finish
far after hospital discharge. As such, the information available can only assume a concern for abuse.
Pediatric Overall Performance Category is the result of a retrospective cohort study across
multiple sites and children’s hospitals to assess the outcome of pediatric intensive care (Pollack et al.,
2014). When applied across our study population, a higher level of disability was seen in the no
explanation group. 43.8% suffered a degree of moderate to severe impairment compared to just 8.2%
in the explanation category (p = 0.002). ciTBI in these moderate to severe categories can have long
lasting effects. A study of 940 cases of ciTBI over a period from 2000 to 2015 found that 676 out of 940
(72%) had significant disability at 5 years post-injury (Nuño et al., 2018). A lack of mechanism of ciTBI is
There were several challenges and limitations to the data described above. One of the main
criticisms of the several prior studies related to this topic is the circularity bias that exists. Hӧgberg et al
found a significant overlap between diagnostic criteria of AHT and explanatory variables of AHT. As
there is no gold standard for AHT, abuse can be defined by the same variables that are subsequently
analyzed as variables of abuse. An example of this would be using retinal hemorrhages as an indicator
of AHT, then studying the incidence of AHT with retinal hemorrhages found. This logic is inherently
circular. Although this study is comparing one category of history to another, both sets of criteria can
carry a rejection of caregiver credibility. Further directions of this study could include a ranking system
suggested by Hӧgberg et al to reduce this level of bias. The main source of data, the Sacred Heart
Trauma Registry, also provides limitations. All the cases above presented as trauma alerts, which is
group that has already been selected for more severe concern and suspected mechanism. When
compared to emergency department and PCP visits, this population cannot be considered entirely
representative. The trauma registry is made of a hybrid electronic and paper charting system. As a
result, some relevant information was missing which limited the inclusion of additional variables into
this study. Examples of this include charts with missing data on skull fracture, bruising on exam, or
vomiting.
The most important area for further investigation would be the confirmation of AHT/NAT. Such
work is already underway at our institution in partnership with physicians and leaders from DCF and
CPT. There is a wealth of information in the literature about AHT, its correlation to types of explanation
(none vs any), and strong association with ciTBI in the infant population (Ettaro, Berger, & Songer, 2004;
Shein et al., 2012; Pfeiffer et al.,2018). Confirmed cases of abuse could also be screened against
demographics for potential outreach and insight into prevention within the Pensacola community.
Conclusion:
When no explanation is given in cases of suspected ciTBI, our study revealed increased incidence
of confirmed ciTBI, increased markers of clinical acuity, higher suspicion for abuse, and poorer outcomes
when compared to cases when any explanation was given. A lack of any history should serve as a
strong indicator to evaluate for ciTBI further, especially in the infant population.
Table 1 – Lack of explanation associated with CiTBI (p value obtained via Chi-Square analysis)
Table 3 – DCF evaluation (NAT suspected; p value obtained via Fischer’s Exact Test)
Bibliography
1.) Amagasa, S., Matsui, H., Tsuji, S., Uematsu, S., Moriya, T., & Kinoshita, K. (2018). Characteristics
distinguishing abusive head trauma from accidental head trauma in infants with traumatic
intracranial hemorrhage in Japan. Acute Med Surg, 5(3), 265-271. doi:10.1002/ams2.341
2.) Antonietti, J., Resseguier, N., Dubus, J. C., Scavarda, D., Girard, N., Chabrol, B., & Bosdure, E. (2019).
The medical and social outcome in 2016 of infants who were victims of shaken baby syndrome
between 2005 and 2013. Arch Pediatr, 26(1), 21-29. doi:10.1016/j.arcped.2018.10.002
3.) Babl, F. E., Oakley, E., Dalziel, S. R., Borland, M. L., Phillips, N., Kochar, A., . . . Lyttle, M. D. (2018).
Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children:
A Prospective Cohort Study. Ann Emerg Med, 71(6), 703-710.
doi:10.1016/j.annemergmed.2018.01.015
4.) Boop, S., Axente, M., Weatherford, B., & Klimo, P. (2016). Abusive head trauma: an epidemiological
and cost analysis. J Neurosurg Pediatr, 18(5), 542-549. doi:10.3171/2016.1.PEDS15583
5.) Burns JJ, Chaudhary P, Proctor D, Amin R, Hobby L, Johnson C, et al. (2017) A Comparative Analysis
of Mechanisms of Traumatic Brain Injury to Mortality and Severity. Unpublished manuscript.
6.) Cowley, L. E., Morris, C. B., Maguire, S. A., Farewell, D. M., & Kemp, A. M. (2015). Validation of a
Prediction Tool for Abusive Head Trauma. Pediatrics, 136(2), 290-298. doi:10.1542/peds.2014-
3993
7.) Dunning, J., Daly, J. P., Lomas, J. P., Lecky, F., Batchelor, J., Mackway-Jones, K., & group, C. s. h. i. a. f.
t. p. o. i. c. e. s. (2006). Derivation of the children's head injury algorithm for the prediction of
important clinical events decision rule for head injury in children. Arch Dis Child, 91(11), 885-
891. doi:10.1136/adc.2005.083980
8.) Ettaro, L., Berger, R. P., & Songer, T. (2004). Abusive head trauma in young children: characteristics
and medical charges in a hospitalized population. Child Abuse Negl, 28(10), 1099-1111.
doi:10.1016/j.chiabu.2004.06.006
9.) Fujiwara, T., Okuyama, M., & Miyasaka, M. (2008a). Characteristics That Distinguish Abusive From
Nonabusive Head Trauma Among Young Children Who Underwent Head Computed
Tomography in Japan. doi:10.1542/peds.2008-0387
10.) Hettler, J., & Greenes, D. S. (2003). Can the initial history predict whether a child with a head injury
has been abused? Pediatrics, 111(3), 602-607.
11.) Hobbs, C., Childs, A.-M., Wynne, J., Livingston, J., & Seal, A. (2005). Subdural haematoma and
effusion in infancy: an epidemiological study. doi:10.1136/adc.2003.037739
12.) Hӧgberg, G., Colville-Ebeling, B., Hӧgberg, U., Aspelin, P. (2016). Circularity bias in abusive head
trauma studies could be diminished with a new ranking scale. Egyptian Journal of Forensic
Sciences, 6(1), 6-10. doi:10.1016/j.ejfs.2015.12.001
13.) Hymel, K. P., Armijo-Garcia, V., Foster, R., Frazier, T. N., Stoiko, M., Christie, L. M., . . . Wang, M.
(2014). Validation of a Clinical Prediction Rule for Pediatric Abusive Head Trauma.
doi:10.1542/peds.2014-1329
14.) Hymel, K. P., Wang, M., Chinchilli, V. M., Karst, W. A., Willson, D. F., Dias, M. S., . . . Investigators, P.
B. I. R. N. P. (2019). Estimating the probability of abusive head trauma after abuse
evaluation. Child Abuse Negl, 88, 266-274. doi:10.1016/j.chiabu.2018.11.015
15.) Joyce, T., & Huecker, M. R. (2019). Pediatric Abusive Head Trauma (Shaken Baby Syndrome).
In StatPearls. Treasure Island (FL): StatPearls PublishingStatPearls Publishing LLC.
16.) Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Atabaki, S. M., Holubkov, R., . . . (PECARN),
P. E. C. A. R. N. (2009). Identification of children at very low risk of clinically-important brain
injuries after head trauma: a prospective cohort study. Lancet, 374(9696), 1160-1170.
doi:10.1016/S0140-6736(09)61558-0
17.) Maguire, S. A., Kemp, A. M., Lumb, R. C., & Farewell, D. M. (2011). Estimating the probability of
abusive head trauma: a pooled analysis. Pediatrics, 128(3), e550-564. doi:10.1542/peds.2010-
2949
18.) Miller Ferguson, N., Sarnaik, A., Miles, D., Shafi, N., Peters, M. J., Truemper, E., . . . Trial, I. o. t. A. a.
D. i. A. P. T. B. I. A. (2017). Abusive Head Trauma and Mortality-An Analysis From an
International Comparative Effectiveness Study of Children With Severe Traumatic Brain
Injury. Crit Care Med, 45(8), 1398-1407. doi:10.1097/CCM.0000000000002378
19.) Nuño, M., Ugiliweneza, B., Zepeda, V., Anderson, J. E., Coulter, K., Magana, J. N., . . . Boakye, M.
(2018). Long-term impact of abusive head trauma in young children. Child Abuse Negl, 85, 39-
46. doi:10.1016/j.chiabu.2018.08.011
20.) Oral, R., Yagmur, F., Nashelsky, M., Turkmen, M., & Kirby, P. (2008). Fatal abusive head trauma
cases: consequence of medical staff missing milder forms of physical abuse. Pediatr Emerg
Care, 24(12), 816-821. doi:10.1097/PEC.0b013e31818e9f5d
21.) Osmond, M. H., Klassen, T. P., Wells, G. A., Correll, R., Jarvis, A., Joubert, G., . . . Group, P. E. R. C. P.
H. I. S. (2010). CATCH: a clinical decision rule for the use of computed tomography in children
with minor head injury. CMAJ, 182(4), 341-348. doi:10.1503/cmaj.091421
22.) Parks, S. E., Annest, J. L., Hill, H. A., & Karch, D. L. (2019). Pediatric abusive head trauma :
recommended definitions for public health surveillance and research.
23.) Pfeiffer, H., Crowe, L., Kemp, A. M., Cowley, L. E., Smith, A. S., Babl, F. E., & (PREDICT), P. R. i. E. D. I.
C. (2018). Clinical prediction rules for abusive head trauma: a systematic review. Arch Dis Child,
103(8), 776-783. doi:10.1136/archdischild-2017-313748
24.) Pollack, M. M., Holubkov, R., Funai, T., Clark, A., Moler, F., Shanley, T., . . . Jenkins, T. L. (2014).
Relationship between the functional status scale and the pediatric overall performance
category and pediatric cerebral performance category scales. JAMA Pediatr, 168(7), 671-676.
doi:10.1001/jamapediatrics.2013.5316
25.) Proctor D, Burns JJ, Amin R. (2018) Clinically-Important Traumatic Brain Injury Resulting from Mild-
Moderate Falls: Evidence of Hidden Abusive Head Trauma? Unpublished Manuscript.
26.) Robertson, B. D., Abbe, M., Pelletier, J., & Hennes, H. (2018). Abusive Injuries Are Worse Than
Vehicular Injuries: Should We Refocus Prevention? Pediatr Emerg Care, 34(10), 723-728.
doi:10.1097/PEC.0000000000001263
27.) Shein, S. L., Bell, M. J., Kochanek, P. M., Tyler-Kabara, E. C., Wisniewski, S. R., Feldman, K., . . .
Berger, R. P. (2012). Risk Factors for Mortality in Children with Abusive Head Trauma. J Pediatr,
161(4), 716-722 e711. doi:10.1016/j.jpeds.2012.03.046
28.) Yu, Y. R., DeMello, A. S., Greeley, C. S., Cox, C. S., Naik-Mathuria, B. J., & Wesson, D. E. (2018).
Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers. J Pediatr
Surg, 53(5), 1028-1032. doi:10.1016/j.jpedsurg.2018.02.043