Abusive head trauma: an epidemiological and cost analysis

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Research on pediatric abusive head trauma (AHT) has largely focused on clinical presentation and management. The authors sought to review a single-institution experience from a public health perspective to gain a better understanding of the local population affected, determine overall incidence and seasonal trends, and provide details on the initial hospitalization, including extent of injuries, neurosurgical interventions, and hospital charges.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>All cases of AHT involving patients who presented to Le Bonheur Children's Hospital (LBCH) from 2009 through 2014 were identified. AHT was defined as skull fracture or intracranial hemorrhage in a child under the age of 5 years with a suspicious mechanism or evidence of other intentional injuries, such as retinal hemorrhages, old or new fractures, or soft-tissue bruising. Injuries were categorized as Grade I (skull fracture only), Grade II (intracranial hemorrhage or edema not requiring surgical intervention), or Grade III (intracranial hemorrhage requiring intervention or death due to brain injury).</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Two hundred thirteen AHT cases were identified. The demographics of the study population are similar to those reported in the literature: the majority of the patients involved were 6 months of age or younger (55%), male (61%), African American (47%), and publicly insured (82%). One hundred one neurosurgical procedures were performed in 58 children, with the most common being bur hole placement for treatment of subdural collections (25%) and decompressive hemicraniectomy (22%). The annual incidence rate rose from 2009 (19.6 cases per 100,000 in the population under 5 years of age) to 2014 (47.4 cases per 100,000) and showed seasonal peaks in January, July, and October (6-year average single-month incidence, respectively, 24.7, 21.7, and 24.7 per 100,000). The total hospital charges were $13,014,584, with a median cost of $27,939. Treatment costs for children who required surgical intervention (i.e., those with Grade III) were up to 10 times those of children with less severe injuries.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>In the authors' local population, victims of AHT are overwhelmingly infants, are more often male than female, and are disproportionately from lower socioeconomic ranks. The incidence is increasing and initial hospitalization charges are substantial and variable. The authors introduce a simple 3-tiered injury classification scheme that adequately stratifies length of hospital stay and cost.</jats:p></jats:sec>

Pediatric abusive head trauma and stroke

“…38 In fact, within the population served by our medical center, the incidence appears to be increasing. 8 Of the numerous intentional injuries described in children-cranial and extracranial-stroke is well recognized, with the most catastrophic example being the holohemispheric infarct. 21,24 Areas of infarction in survivors, in turn, can lead to what is termed "multicystic encephalopathy."…”

“…Hospital "charges" were considered a surrogate for "cost," although technically "charges" are always greater than "costs," typically by a fixed factor (professional fees are not included). 18 Injury severity was graded as follows 8 : Grade I, skull fracture alone with or without associated craniofacial soft-tissue injury; Grade II, intracranial hemorrhage or cerebral edema not requiring neurosurgical intervention or bedside procedure; and Grade III, intracranial hemorrhage requiring neurosurgical intervention or resulting in death as a direct result of AHT.…”

“…2,5,7,22,39,41,44,45 We recently published our 6-year experience with AHT and introduced a novel injury grading scale. 8 Using our AHT database, we sought to identify all patients who sustained a CVA, either using CT or MRI to and combine a detailed radiological analysis with demographic, clinical, cost, and readmission data. We postulate that an AHT-related CVA predicts a more severe injury, which translates to a greater likelihood of needing surgical intervention, longer hospital stay, and greater cost.…”

Emergency Department Visits Owing to Intentional and Unintentional Traumatic Brain Injury among Infants in the United States: A Population-Based Assessment

“…11 Studies have also reported that infants are more likely to have long-term sequelae and greater financial costs resulting from AHT than older children. [12][13][14][15] Because an increase in TBI has been reported in children and because infants are an especially vulnerable subpopulation, it would be informative to conduct a national assessment of TBI rates and trends for infants, who have been otherwise studied in aggregate with older children. This study examined national trends in ED visits owing to TBI by infants with the specific aim of attempting to differentiate these injuries based on intentional and unintentional mechanisms.…”

Initial response of the European Society of Paediatric Radiology and Society for Pediatric Radiology to the Swedish Agency for Health Technology Assessment and Assessment of Social Services’ document on the triad of shaken baby syndrome

“…We patiently await the translated report and, in the meantime, end this commentary much as we began: we cannot ignore the concept of abusive neurotrauma in children. It not only exists, but may be increasing in incidence, with associated increases in patient and societal costs [6]. What clinical and imaging features support inflicted head trauma?…”