Characteristics distinguishing abusive head trauma from accidental head trauma in infants with traumatic intracranial hemorrhage in Japan

Abstract

AimTo identify markers for detecting abusive head trauma (AHT) and its characteristics in the Japanese population.MethodsWe retrospectively reviewed the clinical records of 166 infants with traumatic intracranial hemorrhage between 2002 and 2013 in three tertiary institutions in Japan. The infants were classified into AHT (57), suspected AHT (24), and accidental (85) group based on the defined criteria. We compared clinical presentations and computed tomography findings among these three groups and also compared age distribution of infants with AHT in our study to those in the USA.ResultsAge distribution of AHT cases is significantly higher in our study than in the USA (P < 0.001). The rates of male sex, bruising, retinal hemorrhage, subdural hematoma, cerebral edema, and neurological sequelae were significantly higher, and those of skull fracture and scalp finding were significantly lower, in the AHT group than in the accidental group (P < 0.05). In the multivariable analysis of the infants with subdural hematoma, absence of skull fracture (odds ratio = 42.1; 95% confidence interval, 3.5–507.7, P = 0.003) was associated with AHT.ConclusionsThe age range of AHT in Japan is significantly different from that of countries in Europe and North America because of familial and sociocultural situations. Absence of bruising, and rib or long bone fractures did not reduce the likelihood of AHT. Subdural hematoma without findings of an impact to the head strongly suggested AHT. Abusive head trauma is a global problem, however, diagnosis and defensive measures likely need to be tailored to accommodate cultural risk factors.

Epidemiology, Patterns of treatment, and Mortality of Pediatric Trauma Patients in Japan

“…A previous study reported that about 10% of burn cases were suspected abuse cases 16 . Concerning to abuse and/or neglect, one observational study from Japan reported that about half of the traumatic intracranial hemorrhage was caused by abuse 17 . Though abuse data was not registered in JTDB and the association between pediatric burns and abuse could not investigated, the high prevalence of pediatric burns in children <1 year clinicians suspected abuse and/or neglect.…”

Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis

“…And yet, mathematical partition based on objective, reliably determined clinical variables replicated the results of decades of literature on the characteristics of children with AHT. [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] By replicating the segregation of clinical findings in the case-control literature, the cluster analyses demonstrate that the division of cases from controls reflected natural latent divisions in the larger population of young children with neurotrauma. The fact that these differences extended beyond neurologic and eye findings to include skeletal fractures, skin injuries, and visceral injuries supports the inference that inflicted trauma was closely related to the latent variable responsible for partition.…”

“…The evidence base for diagnosing AHT in children with neurotrauma relies on a series of case-control studies and meta-analyses of those studies. [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] Cohorts of AHT cases have been separated from controls by various methods: physician diagnosis, 15,16,22 consensus opinion of a multidisciplinary team, 14,17,18,22,23,26,28,29 predefined criteria designed to avoid indicators under study, 14,[19][20][21]29 and confessed abuse versus a public non-AHT event. 22 Results of the various methods have been consistent, lending strength to the findings.…”

“…The scientific foundation for identifying AHT largely rests on a series of case-control studies that compare abused with nonabused children and on meta-analyses of those studies. [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] Some authors have suggested that much of this literature is invalid because of circularity. They find that potential indicators of abuse being studied are used in assigning children as cases or controls.…”

日本における虐待頭部外傷診療の問題点(The problem of care for abusive head trauma in Japan)

“…Characteristics associated with the accident (odds ratio) (Fig. 1) 31 Comparison of age distribution of abusive head trauma (AHT) cases between our study and a study carried out in the USA 45) . Two peaks in the number of patients were observed in the AHT group, one at approximately 1-2 months and the other at 6-8 months.…”