BACKGROUND: Intracranial birth-related subdural hemorrhage frequently occurs in asymptomatic newborns and has no adverse long-term sequelae. It is medically and medicolegally important to differentiate birth-related subdural hemorrhage from other pathological causes of intracranial hemorrhage. There is limited literature available on the incidence of birth-related subdural hemorrhage, its imaging features, and evolution over time, mainly because asymptomatic infants do not routinely undergo cranial MRI.
OBJECTIVE: To establish the incidence and distribution of birth-related subdural hemorrhage and evaluate their association with various modes of delivery, identify associated features, and evaluate the sequential evolution of signal changes of the birth-related hemorrhages on MRI.
METHODS: A total of 200 healthy term neonates and young infants were included in this retrospective review study. All infants underwent MRI of the brain and cervical spine at postnatal age of 0-2 months with acquisition of a 3D T1-weighted (T1W), 3D or 2D T2-weighted (T2W), and axial diffusion-weighted imaging (DWI) sequences. The scans were evaluated for the presence and distribution of subdural hemorrhages, other intracranial hemorrhages, and associated injuries. Prevalence of intracranial hemorrhage in various modes of delivery was analyzed. Relationship between the signal intensities of the bleeds on T1W, T2W, and DWI scans and the age of the infants was analyzed. Appropriate tests were applied to test for statistical significance of the data.
RESULTS: Out of 200 neonates, 66 (33%) had detectable intracranial hemorrhage on MRI with an age range of 11-25 days, including 31 (47%) males and 35 (53%) females. All of them had subdural hemorrhages, 54 (81.8%) of which were in the posterior fossa. Additional parenchymal hemorrhages were present in a few, but no subarachnoid hemorrhages, cervical spinal canal hemorrhages, cortical bridging vein injury, or cervical spinal ligamentous injury were identified within the limitations of the study. No detectable intracranial hemorrhage was found in subjects above 25 days of age. Overall incidence of subdural hemorrhage by mode of delivery was 8/68 (11.8%) in babies born by cesarean section and 58/132 (43.9%) in babies born by vaginal delivery. Among the vaginal deliveries, the highest incidence was observed in assisted vaginal delivery (19/30, 63.3%). Subjects with birth-related subdural hemorrhage were categorized into three age groups: <13 days, 13-21 days, and >21 days. All detected hemorrhages were T1W hyperintense. In the <13 days group, all bleeds were T2W hypointense. In the 13-21 days group, 73.1% were T2W hypointense, while 26.9% were T2W mixed. All bleeds in the >21 days group were T2W hypointense. All DWI hyperintense bleeds were found in the 13-21 days group.
CONCLUSIONS: Birth-related subdural hemorrhage occurs in over a third of normal deliveries and has a characteristic distribution, predominantly in the posterior fossa. Associated cervical spinal subdural hemorrhages, cervical spinal ligamentous injury, or cortical bridging vein injury, which are concerning for traumatic etiology, were not identified. Birth-related subdural hemorrhages follow a characteristic pattern of signal changes on MRI. Although not completely reliable, this can help in differentiating them from traumatic intracranial hemorrhages which usually occur postnatally. No birth-related subdural hemorrhages were seen after 25 days of age in our cohort.

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient\'s symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.

BACKGROUND: Outcomes after non-accidental trauma (NAT) have been shown to be impacted by social determinants of health. Our study aims to investigate the association between NAT, patient demographics, neighborhood disadvantage as measured by the Area Deprivation Index (ADI), and patient disposition.
METHODS: An 8-year retrospective chart review was conducted in pediatric patients presenting to our level I trauma center with suspected NAT. Patient demographics, ADI, injury severity score (ISS), Glasgow coma scale (GCS), length of stay, and discharge disposition were analyzed using univariate and multivariate techniques to evaluate associations between patient demographics, injury severity, and patient outcomes.
RESULTS: A total of 84 patients were admitted with suspected NAT. Of our study population, 45% of patients were White and 26% were Black. Black children were overrepresented in this cohort compared to general population means, while White children were underrepresented (p < 0.05). Median ADI was 6.5 (IQR 4.0-8.0). Of our cohort, 65 patients were discharged home, and 18 patients to foster care. One patient in our cohort died. An ADI >6 was the only factor significantly associated with discharge to foster care. This association held on both univariate (OR 1.4; 95% CI 1.07-1.84, p = 0.02) and multivariate (OR 1.4; 95% CI 1.05-1.86, p = 0.02) analyses.
CONCLUSIONS: Our study found that neighborhood disadvantage, as measured by ADI, is an independent predictor of discharge to foster care. Additionally, Black children remain over-represented in the NAT population referred to our institution, including those discharged to foster care. Efforts to address healthcare disparities and community-based NAT prevention and reunification programs are necessary.
METHODS: Prognosis Study (Retrospective Case-Control Study).
METHODS: Level III.

To determine the incidence of enlarged extra-axial space (EES) and its association with subdural hemorrhage (SDH) in a regional cohort of preterm infants. As part of a prospective cohort study of 395 preterm infants, brain magnetic resonance imaging (MRI) was collected on each infant at term-equivalent age. Six preterm infants showed evidence of SDH. We reviewed the MRIs to identify the incidence of EES in these 6 infants and the cohort broadly. We then completed a retrospective chart review of the 6 infants to identify any concerns for non-accidental trauma (NAT) since the MRI was obtained. The incidence of SDH in the cohort was 1.6%. The incidence of EES was 48.1% including all 6 infants with SDH. The incidence of SDH in infants with EES was 3.2%. The retrospective chart review of the 6 infants did not yield any evidence of NAT. The incidence of EES and SDH in our cohort was significantly higher than similar cohorts of term infants, demonstrating an increased risk in preterm infants. The incidence of SDH in infants with EES was greater than in the total cohort, suggesting that it is a risk factor for asymptomatic SDH in preterm infants.

BACKGROUND: Although non-accidental trauma continues to be a leading cause of morbidity and mortality among children in the United States, the underlying factors leading to NAT are not well characterized. We aim to review reporting practices, clinical outcomes, and associated disparities among pediatric trauma patients experiencing NAT.
METHODS: A literature search utilizing PubMed, Google Scholar, EMBASE, ProQuest, and Cochrane was conducted from database inception until April 6, 2023. This review includes studies that assessed pediatric (age <18) trauma patients treated for NAT in the United States emergency departments. The evaluated outcome was in-hospital mortality rates stratified by race, age, sex, insurance status, and socioeconomic advantage.
RESULTS: The literature search yielded 2641 initial articles, and after screening and applying inclusion and exclusion criteria, 15 articles remained. African American pediatric trauma patients diagnosed with NAT had higher mortality odds than white patients, even when adjusting for comparable injury severity. Children older than 12 mo experienced higher mortality rates compared to those younger than 12 mo, although some studies did not find a significant association between age and mortality. Uninsured insurance status was associated with the highest mortality rate, followed by Medicaid and private insurance. No significant association between sex and mortality or socioeconomic advantage and mortality was observed.
CONCLUSIONS: Findings showed higher in-hospital mortality among African American pediatric trauma patients experiencing child abuse, and in patients 12 mo or older. Medicaid and uninsured pediatric patients faced higher mortality odds from their abuse compared to privately insured patients.

暂无摘要。

Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.

Fractures are a common presentation of non-accidental trauma (NAT) in the pediatric population. However, the presentation could be subtle, and a high degree of suspicion is needed not to miss NAT.
To analyze a comprehensive database, providing insights into the epidemiology of fractures associated with NAT.
The TriNetX Research Network was utilized for this study, containing medical records from 55 healthcare organizations. TriNetX was queried for all visits in children under the age of 6 years from 2015 to 2022, resulting in a cohort of over 32 million.
All accidental and non-accidental fractures were extracted and analyzed to determine the incidence, fracture location, and demographics of NAT. Statistical analysis was done on a combination of Python and Epipy.
Overall, 0.36 % of all pediatric patients had a diagnosis of NAT, and 4.93 % of fractures (34,038 out of 689,740 total fractures) were determined to be non-accidental. Skull and face fractures constituted 17.9 % of all NAT fractures, but rib/sternum fractures had an RR = 6.7 for NAT. Children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD) had a 9 times higher risk for non-accidental fractures. The number of non-accidental fractures significantly increased after 2019.
The study findings suggest that nearly 1 out of all 20 fractures in children under age 6 are caused by NAT, and that rib/sternum fractures are most predictive of an inflicted nature. The study also showed a significant increase in the incidence of NAT, during and after the pandemic.