Rural versus urban pediatric non-accidental trauma: different patients, similar outcomes

Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse

OBJECTIVES

Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury.

METHODS

Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity.

RESULTS

A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27).

CONCLUSIONS

Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

Clinical Patterns and Treatment of Pediatric Facial Fractures: A 10-Year Retrospective Romanian Study

Pediatric facial fractures have different clinical patterns and require different therapeutic approaches in comparison with those of facial fractures that occur among adults. The aim of this study was to describe the main clinical characteristics of pediatric facial fractures (such as fracture location, fracture pattern, treatment, complications and evolution) in a group of pediatric patients from NW Romania. This research was a retrospective study that was conducted for 10 years in a tertiary hospital for oral and maxillofacial surgery from NW Romania. A total of 142 pediatric patients were included in this study, with ages between 0 and 18 years. Mandibular (66.2%), midface (25.4%) and combined fractures (8.5%) were identified, and patients from the 13-18 years age group were more frequently affected by facial fractures (78.9%). Most of the diagnosed fractures among all three types of fractures were total fractures, and most mandibular (92.6%) and midface (80.6%) fractures were without displacement. Hematomas, lacerations and abrasions were identified as associated lesions. Patients with associated lesions were more frequently associated with combined fractures or midface fractures than mandibular fractures. The instituted treatment was, in general, orthopedic, for all three types of fractures (mandibular-86.2%; midface-91.7%; combined-66.7%). Most fractures, mandibular (96.8%), midface (100%) and combined (91.7%) fractures, had a favorable evolution. Most fractures did not present any complications at the follow-up. Pediatric facial fractures have unique patterns and must be treated with caution, considering the particularities of pediatric facial anatomy.

Recidivism following childhood maltreatment necessitating inpatient care in the United States

INTRODUCTION

Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population.

METHODS

The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries.

RESULTS

NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers.

CONCLUSION

Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children.

LEVEL OF EVIDENCE

III.

TYPE OF EVIDENCE

Case Control Study.

Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic

BACKGROUND AND OBJECTIVES

The Covid-19 pandemic has forced mass closures of childcare facilities and schools. While these measures are necessary to slow virus transmission, little is known regarding the secondary health consequences of social distancing. The purpose of this study is to assess the proportion of injuries secondary to physical child abuse (PCA) at a level I pediatric trauma center during the Covid-19 pandemic.

METHODS

A retrospective review of patients at our center was conducted to identify injuries caused by PCA in the month following the statewide closure of childcare facilities in Maryland. The proportion of PCA patients treated during the Covid-19 era were compared to the corresponding period in the preceding two years by Fisher's exact test. Demographics, injury profiles, and outcomes were described for each period.

RESULTS

Eight patients with PCA injuries were treated during the Covid-19 period (13 % of total trauma patients), compared to four in 2019 (4 %, p < 0.05) and three in 2018 (3 %, p < 0.05). The median age of patients in the Covid-19 period was 11.5 months (IQR 6.8-24.5). Most patients were black (75 %) with public health insurance (75 %). All injuries were caused by blunt trauma, resulting in scalp/face contusions (63 %), skull fractures (50 %), intracranial hemorrhage (38 %), and long bone fractures (25 %).

CONCLUSIONS

There was an increase in the proportion of traumatic injuries caused by physical child abuse at our center during the Covid-19 pandemic. Strategies to mitigate this secondary effect of social distancing should be thoughtfully implemented.

Comparing orthopaedic paediatric trauma in a rural district general hospital and an urban major trauma centre: A retrospective cohort study

Background

Studies from countries such as Australia and South Africa have demonstrated a difference in the types of injury managed in rural hospitals compared to larger, urban hospitals and so conclude staff require a different skill-set to work in these environments. There is some evidence this attitude may be prevalent amongst UK surgical trainees, resulting in difficulty recruiting to rural settings. In addition, studies have compared mortality in paediatric trauma patients in rural and urban hospitals, but none have described types of injury or orthopaedic operations required.We hypothesise the distribution of operative, orthopaedic paediatric trauma in a rural district general and an urban major trauma centre will not differ significantly in terms of patterns and mechanism of injury, orthopaedic intervention or time to theatre.

Materials/methods

All operative paediatric patients (0-15yrs) seen during an acute orthopaedic take at a rural district general and an urban major trauma centre were included. Non-operative admissions were excluded. Patients were identified using daily trauma work lists from each site. Outcomes were age, injury type, operation, time to theatre, seasonality and mechanism.

Results

183 patients from the urban hospital and 103 from the rural were identified. There were no significant differences found in age of patient, seasonality or time to theatre between cohorts (p > 0.05). There were also broadly similar patterns of injury and operations performed in both groups, although k-wiring was more often employed in the rural cohort than the urban (27% vs 17% of total operations). There were more bicycle and shinty related injuries in the rural cohort, and equine related in the urban.

Conclusions

Paediatric trauma admissions do not vary significantly between rural and urban trauma centres, although the types of procedure performed may be less conservative in a rural hospital. This may be due to geography or differences in ED practice.

Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center

Introduction

Pediatric nonaccidental trauma (NAT) is difficult to diagnose. Several isolated injuries in NAT could happen in the setting of accidental trauma (AT), and having a high index of suspicion is important to correctly identify abuse. NAT has a significant mortality rate if the sentinel event is not adequately diagnosed, and the infant is not separated from the perpetrator. Level 1 pediatric trauma centers (PTC) see a significant number of NAT. We evaluated the injury patterns of NAT admissions at our level 1 PTC.

Methods

Retrospective analysis of all cases of NAT for children under the age of two admitted at an ACS level 1 pediatric trauma center between the years of 2016 and 2018. Charts were queried for demographic data, injury patterns, mortality, and disposition. Correlation between disposition status and injury patterns was performed. The Fisher Exact test and student t-test were used to study the significance of differences in categorical and continuous data, respectively.

Results

32/91 (35%) trauma patients under the age of two years were diagnosed as NAT in the three-year study period. 21/32 (39%) male and 11/26 (42%) female admissions were confirmed NAT (p = NS). 20 were under 1 year of age, and 12 were aged between 1 and 2 years (p = NS). 13 (41%) were Caucasian, 6 (19%) were Hispanic/Latino, 11 (34%) were Black, and 2(6%) were of unknown ethnicity (p = NS). Facial, torso, lower extremity, retinal, and internal organ injury were significantly more common with NAT. Medicaid coverage was noted in 31/32 (97%) NAT patients. 20/32 (62.5%) patients were legally displaced as a result of the NAT.

Conclusion

1/3^rd of all admissions at a pediatric level 1 trauma center were identified as NAT. A high index of suspicion is necessary to not miss NAT, as injury patterns are variable. Nearly 1/3^rd of all victims go back to the same environment where they sustained NAT increasing their susceptibility to future NAT.

Investigating the Six-Month Incidence Rate of Burn Disease in Children in Greece

Introduction

Burns in children are painful, can be fatal, and involve a significant risk of complications, along with physical and psychological consequences. This study aimed to investigate the incidence of burns in children, for six months, and the most common causative factors, along with the existing correlations between demographic data and the characteristics of burn injuries.

Methods

The study was descriptive and prospective, and the sample consisted of minors up to 14 years old with burns in any areas of the body. The research was carried out in the Attica pediatric hospitals’ selected departments for six months (from July to December 2018). Sources for completing the created database were the patients, their guardians, and their medical-nursing documentation and records.

Results

The cumulative six-month incidence rate of childhood burn disease was 4.9%. The most affected age group appeared to be younger than two years (60%), while liquid heat appeared to be the primary form of the burn factor (76%). The average duration of hospitalization for children with a deep partial-thickness to a total-thickness burn degree was 16.5 days. The correlations that emerged related to the extent of the burn were directly related to the accident’s site, and patients with an increased likelihood of future additional surgeries had an increased mean total body surface area that was burned.

Conclusion

Continuous surveillance and removal of hazardous materials from the home environment is of utmost need. Early education/understanding of correct behaviors and proper attention to outdoor activities or excursions can significantly reduce burns. Training courses on burn prevention for parents are needed, as the best form of treatment is prevention.

Child Abuse and Deformational Plagiocephaly in a West Texas Hospital System

Background  The aim of this study was to assess deformational plagiocephaly’s (DP) predictive value in neglect and physical abuse (nonaccidental trauma [NAT]) within the pediatric population. In addition, we sought to characterize the prevalence of DP and NAT for our hospital’s mostly rural catchment area.

Methods  Data on hospitalized patients diagnosed with NAT and/or neglect between 2012 and 2018 were collected via retrospective chart review. All enrolled children were younger than the age of 4 years at the time of diagnosis, and those without legible head computed tomographies or magnetic resonance images during their initial hospitalization were excluded. Utilizing neuroimaging, we calculated the cranial vault asymmetry index (CVAI) and cranial index for each patient to assess for DP. Differences between the two groups were assessed using Wilcoxon’s rank-sum test for continuous variables and Fisher’s exact test for categorical variables. A p -value of 0.05 or less was considered statistically significant. All analyses were conducted using SAS 9.4 (Cary, North Carolina, United States).

Results  The prevalence of DP within the combined cohort of NAT and neglect patients is 21%, similar to that reported in the literature for the general population (20–50%). There was no significance between the prevalence of DP and a history of NAT ( p > 0.1) or neglect ( p > 0.1). Furthermore, there was no correlation between CVAI and characteristics of initial presentation or history of trauma for either NAT ( p -values: 0.359 and 0.250, respectively) or neglect groups ( p -values: 0.116 and 0.770, respectively).

Conclusion  While there are many limitations to this study, our results suggest that abused children are no more likely to have history of DP than the general population, and the degree of DP is not associated with severity of trauma history or initial presentation. We hope the results of this study promote future investigations for unique and subtle predictive factors of child abuse/neglect.