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Loos MLHJ, Bakx R, Duijst WLJM, Aarts F, de Blaauw I, Bloemers FW, Ten Bosch JA, Evers M, Greeven APA, Hondius MJ, van Hooren RLJH, Huisman E, Hulscher JBF, Keyzer-Dekker CMG, Krug E, Menke J, Naujocks T, Reijnders UJL, de Ridder VA, Spanjersberg WR, Teeuw AH, Theeuwes HP, Vervoort-Steenbakkers W, de Vries S, de Wit R, van Rijn RR. High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands. Forensic Sci Med Pathol 2021; 17:621-633. [PMID: 34773580 PMCID: PMC8629892 DOI: 10.1007/s12024-021-00416-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
Purpose Between 0.1—3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. Methods This is a retrospective study that included children (0–18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. Results The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66–12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. Conclusion One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children. Supplementary information The online version contains supplementary material available at 10.1007/s12024-021-00416-7.
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Affiliation(s)
- Marie-Louise H J Loos
- Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Roel Bakx
- Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wilma L J M Duijst
- Department of Forensic Medicine, GGD IJsselland, Zwolle, the Netherlands
- Criminal Law and Criminology, Faculty of Law, Maastricht University, Maastricht, the Netherlands
| | - Francee Aarts
- Department of Forensic Medicine, GGD Nijmegen, Nijmegen, the Netherlands
| | - Ivo de Blaauw
- Department of Paediatric Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jan A Ten Bosch
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martina Evers
- Department of Forensic Medicine, GGD Euregio, Enschede, the Netherlands
- Department of Surgery, Haga Teaching Hospital & Juliana Children's Hospital, The Hague, the Netherlands
| | | | | | | | - Erik Huisman
- Department of Forensic Medicine, GGD Haaglanden, The Hague, the Netherlands
- GGD Hollands-Midden, Department of Forensic Medicine, Leiden, the Netherlands
| | - Jan B F Hulscher
- Department of Surgery, Division of Paediatric Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Claudia M G Keyzer-Dekker
- Erasmus Medical Centre, Department of Paediatric Surgery, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Egbert Krug
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jack Menke
- Forensisch Artsen Rotterdam-Rijnmond' (FARR), Rotterdam, the Netherlands
| | - Tatjana Naujocks
- GGD Groningen, Department of Forensic Medicine, Groningen, the Netherlands
| | - Udo J L Reijnders
- Department of Forensic Medicine, GGD Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Victor A de Ridder
- Department of Paediatric Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Arianne H Teeuw
- Amsterdam UMC, Department of Social Paediatrics, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Hilco P Theeuwes
- Department of Trauma Surgery, Elizabeth TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Selena de Vries
- Department of Forensic Medicine, Section On Forensic Paediatrics, Netherlands Forensic Institute, The Hague, The Netherlands
| | - Ralph de Wit
- Department of Trauma Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Rick R van Rijn
- Department of Forensic Medicine, Section On Forensic Paediatrics, Netherlands Forensic Institute, The Hague, The Netherlands
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Center for Forensic Science and Medicine, Amsterdam, The Netherlands
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Goh B, Soundappan SSV. Traumatic duodenal injuries in children: a single-centre study. ANZ J Surg 2020; 91:95-99. [PMID: 33369841 DOI: 10.1111/ans.16502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/07/2020] [Accepted: 11/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. METHODS Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. RESULTS Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. CONCLUSION In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.
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Affiliation(s)
- Barnabas Goh
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Inferior mesenteric artery laceration associated with blunt abdominal trauma with Casper's sign in a physically abused child: An autopsy case and literature review. J Forensic Leg Med 2020; 74:102001. [PMID: 33012316 DOI: 10.1016/j.jflm.2020.102001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/21/2022]
Abstract
There have been few studies of the death of children secondary to child abuse-related abdominal compression, and the detailed pathophysiology of such deaths is therefore unknown. The autopsy findings of a 3-year-old boy who died of hemorrhagic shock due to non-accidental severe blunt abdominal trauma were compared to those of children who died of other non-accidental abdominal injuries. Old and acute subcutaneous hemorrhages, abrasions, and scars were present all over the subject's body. No superficial injuries were found on the ventral midline, but a minor hemorrhage was found in the subcutaneous fat tissue, as well as in the rectus abdominis muscle. The intraperitoneal space contained 450 mL of blood, including coagulated blood. There was a tear in the transverse mesocolon and a crush injury in the small bowel mesentery. The inferior mesenteric artery was transected 0.5 cm from the aortic root. The transverse colon was necrotic, with hemorrhages in the mucosa. Since various organs were ischemic, the cause of death was determined to be blood loss from the inferior mesenteric artery injuries. Blunt abdominal trauma in children usually causes organ damage and intestinal injury, but because it is caused on the posterior surface of the mesentery, vascular injury should also be considered, and an autopsy should be performed. In the case of child abuse-related deaths, damage to the skin surface may not always be present; therefore, imaging tests, histopathological examinations, and biochemical tests should be performed with a focus on the gross anatomy to determine the cause of death and pathology.
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Maguire SA, Upadhyaya M, Evans A, Mann MK, Haroon MM, Tempest V, Lumb RC, Kemp AM. A systematic review of abusive visceral injuries in childhood--their range and recognition. CHILD ABUSE & NEGLECT 2013; 37:430-445. [PMID: 23306146 DOI: 10.1016/j.chiabu.2012.10.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 10/28/2012] [Accepted: 10/31/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. METHODS We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome. RESULTS Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated. CONCLUSIONS Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.
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Affiliation(s)
- S A Maguire
- Child Health Department, School of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
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The importance of surgeon involvement in the evaluation of non-accidental trauma patients. J Pediatr Surg 2013; 48:1357-62. [PMID: 23845630 DOI: 10.1016/j.jpedsurg.2013.03.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Non-Accidental Trauma (NAT) is a significant cause of childhood morbidity and mortality, causing 50% of trauma-related deaths at our institution. Our purpose was to evaluate the necessity of primary surgical evaluation and admission to the trauma service for children presenting with NAT. METHODS We reviewed all NAT patients from 2007-2011. Injury types, demographic data, and hospitalization information were collected. Comparisons to accidental trauma (AT) patients were made using Wilcoxon rank sum and Student's t tests. RESULTS We identified 267 NAT patients presenting with 473 acute injuries. Injuries in NAT patients were more severe than in AT patients, and Injury Severity Scores, ICU admission rates, and mortality were all significantly (p<0.001) higher. The majority suffered from polytrauma. Multiple areas of injury were seen in patients with closed head injuries (72%), extremity fractures (51%), rib fractures (82%), and abdominal/thoracic trauma (80%). Despite these complex injury patterns, only 56% received surgical consults, resulting in potential delays in diagnosis, as 24% of abdominal CT scans were obtained >12 hours after hospitalization. CONCLUSION Given the high incidence of polytrauma in NAT patients, prompt surgical evaluation is necessary to determine the scope of injury. Admission to the trauma service and a thorough tertiary survey should be considered for all patients.
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Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? Pediatr Radiol 2011; 41:92-8. [PMID: 20936274 DOI: 10.1007/s00247-010-1847-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 08/19/2010] [Accepted: 09/01/2010] [Indexed: 12/01/2022]
Abstract
BACKGROUND Incomplete history and concern for occult injury in suspected child abuse occasionally results in CT screenings of the abdomen and pelvis. At our institution, we noted that these exams were infrequently positive. OBJECTIVE To identify clinical or laboratory criteria that may predict intra-abdominal injury and guide the use of abdominal and pelvic CT in this population. MATERIALS AND METHODS This retrospective review involved 68 children older than 36 months who had a CT of the abdomen/pelvis for suspected abuse. CT results and patient charts were reviewed for physical exam and historical and laboratory variables. RESULTS CTs were positive in 16% of patients (11/68). Hypoactive/absent bowel sounds (P = 0.01, specificity = 94.7%) and AST and ALT values greater than twice normal (P = 0.004 and P = 0.003 respectively, NPV = 93.6%) were significantly associated with positive CTs. Multiple abnormal physical exam or laboratory findings were also significantly associated with positive CTs (P = 0.03 and P = 0.002 respectively, specificity = 91.3% and NPV = 93.6% respectively). CONCLUSION CTs of the abdomen and pelvis are infrequently positive in cases of suspected abuse. To reduce radiation exposure, CTs should only be ordered if there are findings indicating that they may be positive. In our population, these findings include absent/hypoactive bowel sounds, LFTs greater than twice normal and ≥2 abnormal labs or physical exam findings.
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Affiliation(s)
- Andrew T Trout
- Department of Radiology, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI 48109-5030, USA.
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Abbas SM, Upadhyay V. Hollow viscus injury in children: Starship Hospital experience. World J Emerg Surg 2007; 2:14. [PMID: 17547770 PMCID: PMC1892548 DOI: 10.1186/1749-7922-2-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 06/04/2007] [Indexed: 11/25/2022] Open
Abstract
Starship Children's Hospital in Auckland, New Zealand, serves a population of 1.2 million people and is a tertiary institution for pediatric trauma. This study is designed to review all cases of abdominal injury (blunt and penetrating) that resulted in injury of a hollow abdominal viscus including the stomach, duodenum, small intestine, large intestine and urinary bladder. The mechanism of injury; diagnosis and outcome were studied. This was done by retrospective chart review of patients admitted from January 1995 to December 2001. Thirty two injuries were found in 29 children. The age ranged from 7 months to 15 years with boys represented more commonly. Small bowel was the most frequently injured hollow viscus. Computerized Tomography (CT scan) is an extremely useful tool for the diagnosis of HVI.
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Affiliation(s)
- Saleh M Abbas
- University of Auckland; Starship Children's Hospital, Auckland, New Zealand
| | - Vipul Upadhyay
- University of Auckland; Starship Children's Hospital, Auckland, New Zealand
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Abstract
PURPOSE It is frequently overlooked that child abuse may result in significant intraabdominal injury, particularly to the duodenum. The authors hypothesized that a significant number of duodenal injuries in young children would be the result of nonaccidental trauma. METHODS An 8-year (1995 through 2002) retrospective review of a pediatric level I trauma center database was performed after Institutional Review Board approval was obtained, and information regarding patients with duodenal injury was abstracted. Demographic variables, injury severity, length of stay, mortality rate, and mechanism of injury were examined. Statistical analysis was performed using descriptive statistics and Student's t test. Statistical significance was defined as P less than.05. RESULTS Over the 8-year study period, 8,968 patients were admitted, 2,179 (24%) were less than 3 years of age. Thirty children (0.3%) suffered injury to the duodenum, with 20 hematomas and 10 perforations. Patients were overwhelmingly boys (80%), with an average age of 7.6 +/- 4.4 years and Injury Severity Score (ISS) of 14 +/- 10. No patients died. Children were injured by a variety of mechanisms, including collisions involving motor vehicles (n = 9), bicycles (n = 4), and ATVs (n = 2). However, all children less than 4 years of age (n = 8) were victims of nonaccidental trauma, 2.8% of all child abuse admissions. Three of these children suffered perforations of the duodenum. Among the entire population, those children who suffered perforations had a significantly higher ISS (23.7 +/- 7.2 v 9.6 +/- 7.3; P <.0003) and longer length of stay (27.1 +/- 15.3 v 12.6 +/- 11.7; P <.007) than those with hematomas CONCLUSIONS Injury to the duodenum is unusual in the pediatric trauma patient but does result in significant injury severity and prolonged hospitalization. In the young child, one must maintain a high index of suspicion regarding the etiology of the injury, because a large percentage is potentially the result of child abuse.
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Affiliation(s)
- Barbara A Gaines
- Benedum Program in Trauma, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
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