Hi, my name is Kate McNamara, and I'm a third-year PICU and T32 fellow at Children's Hospital of Pittsburgh. And today, I'll be presenting research on the long-term outcomes in abusive head trauma and compared to accidental traumatic brain injury. As for disclosures, I receive funding through the NIH with the T32. To start, let's set the scene. Child abuse is horrifyingly common. In 2020, there were 3.9 million Child Protective Service reports of suspected child abuse. It is a leading cause of death in children under 5 years old, and there were 2,250 deaths from abusive head trauma from 2009 to 2014. Prior studies comparing abusive head trauma and accidental TBI have shown that patients who experience abusive head trauma have lower GCS at admission and have higher frequency of subdural hemorrhages. The ADAPT trial, which was a comparative effectiveness trial in pediatric severe TBI, had 190 patients in their study who had experienced abusive head trauma. They showed that these patients had more frequent apnea and seizures in the pre-hospital phase and more frequent seizures in the resuscitation phase. It is well known that secondary insults, like hypoxemia and seizures, contribute to worse outcomes. There have been several studies looking at outcomes in abusive head trauma. In 2006, a qualitative study where they interviewed caregivers of children with TBI one year after discharge found that more abusive head trauma patients had poor POPC scores than accidental TBI patients. In 2021, Jackson et al. utilized a large IBM database to look at ICD-10 codes to ascertain outcomes at 5 years and 11 years old in patients with abusive head trauma. They showed that these patients had more incidence over time of developmental delays and epilepsy. What's unknown from the literature and what we hope to add with this research is a direct comparison of abusive head trauma and accidental TBI patients while looking at the changes over time. Our objective then was to explore differences in longitudinal outcomes between abusive head trauma and accidental TBI and then to analyze the factors associated with new impairment. We hypothesized that abusive head trauma would have worse outcomes than accidental TBI patients. Data collection started with the Benidorm database, our trauma center research database, and we then did chart review to collect imaging results, PLOD 2 scores at days 1, 3, and 7, as well as functional status score at pre-injury, hospital discharge, short-term, which was a median of one year, and long-term, which was a median of four years. We took a retrospective cohort of patients under 3 years old admitted to the Pittsburgh PICU between 2014 and 2019 with TBI. The cohort had 476 patients. We then excluded gunshot wounds, drownings, and suffocations, leaving 460 patients. 170 were diagnosed with abusive head trauma by a child abuse pediatrician, and 290 patients were diagnosed with accidental TBI. To look at outcomes, the functional status score, or FSS, was calculated. There are six domains included, mental status, sensory, communication, motor, feeding, and respiratory, with a maximum score of 30. A score of 30 is also utilized for death. We defined new impairment as a change of two or more in the FSS score from pre-injury. For statistical analysis, we conducted nonparametric tests and a multivariate logistic regression in RStudio to compare characteristics and outcomes between abusive head trauma and accidental TBI. Here is our first table, which describes the patient characteristics. Abusive head trauma patients were younger than accidental TBI patients, but there were no differences across sex, race, and health status pre-injury. Here we continue to explore with the hospital course. Abusive head trauma patients had lower GCS and higher injury severity scores on admission. They also had positive PLAD2 scores during admission. Positive PLAD2 scores indicate presence of multi-organ dysfunction. They also were more frequently mechanically ventilated, had subdural hemorrhages, and seizures, in addition to needing neurosurgical intervention more frequently. All of these indicate abusive head trauma patients were more critically ill than the accidental TBI group. Interestingly, there were more skull fractures in the accidental TBI group. In this table, we start to explore the differences in outcomes. Abusive head trauma patients had longer length of stay in the hospital and ICU. When looking at disposition, there were 13 deaths, or 7.6% in the abusive head trauma cohort, and four deaths, or 1.4% in the accidental TBI group. Most accidental TBI patients, 92%, went home at discharge. In the abusive head trauma cohort, 14, or 8.2% of patients went to rehab. Looking at our follow-up data, we had 90% follow-up in the short-term, and 63% in the long-term. The median time to short-term follow-up was 10 months for the accidental TBI patients, and 11 months in the abusive head trauma patients, which was significantly different. The median time for long-term follow-up was 49 months, or four years, and there was no difference between the two cohorts. Here's a graph of the total FSS change over time, with abusive head trauma patients represented by the orange line, and accidental TBI patients represented by the blue line. As you can see, abusive head trauma patients had more impairment at each time point. Impairment consistently improved over time in the accidental TBI group, but if you remove the deaths from the discharge time point, there was no improvement in the abusive head trauma patients over time. Now we start to look at the different domains in the FSS score. In terms of mental status, abusive head trauma patients had significantly more impairment at discharge, but no difference at short and long-term. When looking at the sensory domain, abusive head trauma patients had more impairment at all time points, with improvement only seen between discharge and short-term. The communication and motor domains are examined here, with abusive head trauma patients having more impairment than accidental TBI at all time points. The communication domain showed no improvement in both abusive head trauma and accidental TBI, while the motor domain revealed steady improvement over time. This most likely indicates correlation with fractures after initial injury. When looking at the feed domains, abusive head trauma patients had more impairment at discharge and short-term, while in terms of the respiratory domain, abusive head trauma patients only had more impairment at discharge, likely indicating the patients who died. Both domains demonstrated steady improvement over time. We performed a multivariate logistic regression, and abusive head trauma had the largest odds ratio associated with impairment at discharge, short, and long-term follow-up. Multi-organ dysfunction, calculated by PLOD2 scoring to assess level of illness, was also significantly associated with impairment at all time points. To summarize, abusive head trauma patients had higher severity of illness, more seizures, more neurosurgical interventions, higher mortality, and impairment at all time points compared to accidental TBI. Impairments in sensory, communication, and motor domains persisted in abusive head trauma patients. When thinking about why outcomes are worse in abusive head trauma, it could be the higher severity of illness, which could be related to delayed presentation post-injury, secondary hits from seizures and hypoxia, or multiple injuries prior to admission. The persistence of impairment over time could be related to possible limited access to rehab resources. The strengths of our study is that we had relatively large comparative groups for the level of data that we have, and our longitudinal outcomes are unique compared to other studies. We also had several limitations. This was a retrospective single-center study, and we had about 40% loss of documentation for the FSS at long-term follow-up. We were calculating FSS from documentation, which can be inadequate, and prospective detailed neuropsych outcomes are needed. There are also challenges inherent to the diagnosis of child abuse in that it is never 100% certain. However, our findings supported several other studies showing that abusive head trauma patients have increased longitudinal multi-domain impairment. Sensory and communication domains are the most significantly impacted and did not improve over time. This demonstrates an opportunity to improve outcomes with assessments and rehab. It also demonstrates that we need focused research on patients who experience child abuse who are often excluded from research. Future directions include looking at factors associated with multi-domain impairment, like social determinants of health, multi-organ dysfunction, and then perhaps doing a prospective study on outcomes and resources available to this patient population. I just want to quickly thank my mentors in the Benedim Center. Thank you all for this opportunity. Thank you so much.

abusive head trauma

long-term outcomes

Glasgow Coma Scale

mortality rates

rehabilitation