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Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With
Nikki Miller Ferguson1, Ajit Sarnaik, Darryl Miles
11Department of Pediatrics, Virginia Commonwealth University, Richmond, VA.2Department of Pediatrics, Wayne State University, Detroit, MI.3Department of Pediatrics, University of Texas Southwestern, Dallas, TX.4Department of Pediatrics, University of Tennessee, Memphis, TN.5Department of Pediatrics, Great Ormond Street Hospital, London, UK.6Department of Pediatrics, University of Nebraska, Omaha, NE.7Department of Anesthesiology, University of Washington, Seattle, WA.8Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.9Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA.10Office of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD.
Insights
Abusive head trauma in children presents differently than other traumatic brain injuries, with younger victims and a higher female proportion. Despite distinct prehospital and in-hospital injuries, mortality rates remain similar, suggesting potential benefits from advanced therapies.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Child Abuse Pediatrics
Background:
- Abusive head trauma (AHT) outcomes are suggested to be less favorable than other injury mechanisms.
- Limited data exists on differentiating AHT from other traumatic brain injuries (TBI) in children.
Purpose of the Study:
- To determine the impact of AHT on mortality in children.
- To identify factors differentiating AHT from other TBI mechanisms.
Main Methods:
- Observational, comparative effectiveness study of 190 children with severe TBI (Glasgow Coma Scale ≤ 8).
- Data collected from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial.
- Children were analyzed based on the likelihood of AHT.
Main Results:
- AHT subjects were younger (1.87 vs 9.23 years) and more often female (54.3% vs 34.8%).
- AHT cases were more likely to originate from home and involve prehospital apnea and seizures.
- Mortality rates were similar between AHT (25.7%) and non-AHT (18.7%) groups, with comparable deaths from refractory intracranial hypertension.
Conclusions:
- Children with AHT exhibit distinct prehospital and in-hospital injury patterns compared to other TBI.
- Female predominance was observed in the AHT cohort, unlike other pediatric TBI populations.
- Similar mortality and refractory intracranial pressure deaths suggest AHT patients may benefit from advanced therapies and evidence-based guidelines.
Objectives:
Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms.
Design:
First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial-a comparative effectiveness study using an observational, cohort study design.
Setting:
PICUs in tertiary children's hospitals in United States and abroad.
Patients:
Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring).
Interventions:
None.
Measurements And Main Results:
Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%).
Conclusions:
In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.
