Elsevier

The Journal of Pediatrics

Volume 161, Issue 4, October 2012, Pages 716-722.e1
The Journal of Pediatrics

Original Article
Risk Factors for Mortality in Children with Abusive Head Trauma

https://doi.org/10.1016/j.jpeds.2012.03.046Get rights and content

Objective

We sought to identify risk factors for mortality in a large clinical cohort of children with abusive head trauma.

Study design

Bivariate analysis and multivariable logistic regression models identified demographic, physical examination, and radiologic findings associated with in-hospital mortality of children with abusive head trauma at 4 pediatric centers. An initial Glasgow Coma Scale (GCS) ≤8 defined severe abusive head trauma. Data are shown as OR (95% CI).

Results

Analysis included 386 children with abusive head trauma. Multivariable analysis showed children with initial GCS either 3 or 4-5 had increased mortality vs children with GCS 12-15 (OR = 57.8; 95% CI, 12.1-277.6 and OR = 15.6; 95% CI, 2.6-95.1, respectively, P < .001). Additionally, retinal hemorrhage (RH), intraparenchymal hemorrhage, and cerebral edema were independently associated with mortality. In the subgroup with severe abusive head trauma and RH (n = 117), cerebral edema and initial GCS of 3 or 4-5 were independently associated with mortality. Chronic subdural hematoma was independently associated with survival.

Conclusions

Low initial GCS score, RH, intraparenchymal hemorrhage, and cerebral edema are independently associated with mortality in abusive head trauma. Knowledge of these risk factors may enable researchers and clinicians to improve the care of these vulnerable children.

Section snippets

Methods

All procedures were approved by the Institutional Review Boards of the institutions involved. A database of children who had been diagnosed with unequivocal abusive head trauma by the Child Protection Team at 1 of 4 pediatric institutions (Nationwide Children's Medical Center [Columbus, Ohio], Seattle Children's Hospital/Harborview Medical Center [Seattle, Washington], Cincinnati Children's Hospital Medical Center [Cincinnati, Ohio], and Children's Hospital of Pittsburgh of UPMC [Pittsburgh,

Results

The inclusion and exclusion of children into this study is described in the Figure. The overall database contained 460 children. Exclusion of 74 children with no GCS score reported yielded a total of 386 children for bivariate analysis. An additional 28 children were excluded from the multivariable analysis because of individual missing data points. The mean age of all 386 included children was 9.6 ± 0.6 months and the mean initial GCS score was 10.6 ± 0.3 (Table I). Overall, 69 children died

Discussion

We found that incrementally decreased GCS scores, RH, intraparenchymal hemorrhage, and cerebral edema are independently associated with death in the hospital in children with abusive head trauma. In the subgroup of children with severe abusive head trauma and RH, mortality was associated with decreased initial GCS score and cerebral edema. Interestingly, chronic SDH was significantly associated with decreased mortality in this subgroup.

Knowledge of risk factors for mortality can aid clinicians

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    Supported by the Matty Eappen Foundation, which had no role in study design, collection, analysis, and interpretation of data, the writing of the report, and the decision to submit for publication. The authors declare no conflicts of interest.

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