Age-related mortality in abusive head trauma

J Trauma Acute Care Surg. 2019 Oct;87(4):827-835. doi: 10.1097/TA.0000000000002255.


Background: Abusive head trauma (AHT) peaks during early infancy and decreases in toddler years. Infants and toddlers experience different injuries, possibly impacting the risk of mortality. We aimed to evaluate the association of age with mortality.

Methods: We conducted a retrospective study of AHT hospitalizations in 2000, 2003, 2006, 2009, and 2012 from the Kid's Inpatient Claims Database. An accidental head trauma cohort was included to hypothesize that the association between age and mortality is unique to abuse. A nested multivariable logistic regression was used to perform the analysis.

Results: Children aged 2 years to 4 years experienced higher mortality than those younger than 2 years (22% vs. 10%, p < 0.0001; adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2). The presence of subarachnoid hemorrhage (OR, 1.9; 95% CI, 1.3-2.9), cerebral edema (OR, 4.0; 95% CI, 2.9-5.4), and retinal hemorrhage (OR, 1.9; 95% CI, 1.5-2.5) were associated with an increase risk in mortality. Children younger than 2 years experienced more fractures and hemorrhage (subdural, subarachnoid, retinal) while children aged 2 years to 4 years encountered more internal injuries and cerebral edema.In children with accidental head trauma, those aged 2 years to 4 years have a lower mortality compared with those younger than 2 years (OR, 0.4; 95% CI, 0.3-0.6). Among children younger than 2 years, AHT and accidental trauma had comparable risk of mortality (OR, 0.9; 95% CI, 0.6-1.3). However, among those aged 22 years to 4 years, AHT had a higher risk of mortality than accidental trauma (OR, 3.3; 95% CI, 2.1-5.1).

Conclusion: There is a considerable risk of mortality associated with age at diagnosis in children with AHT.Children younger than 2 years and those aged 2 years to 4 years present with different types of injuries. The high risk of mortality in the children aged 2 years to 4 years is unique to AHT. Efforts should be made to increase awareness about the risk of mortality and identify factors that can aide in a timely accurate diagnosis.

Level of evidence: Prognostic and epidemiological study, level III.

MeSH terms

  • Accidental Injuries / diagnosis*
  • Accidental Injuries / epidemiology
  • Age Factors
  • Brain Edema* / diagnosis
  • Brain Edema* / etiology
  • Child Abuse / diagnosis*
  • Child Abuse / statistics & numerical data
  • Child, Preschool
  • Craniocerebral Trauma* / etiology
  • Craniocerebral Trauma* / mortality
  • Craniocerebral Trauma* / therapy
  • Diagnosis, Differential
  • Early Diagnosis
  • Female
  • Hospitalization / statistics & numerical data
  • Humans
  • Infant
  • Male
  • Mortality
  • Prognosis
  • Retrospective Studies
  • Risk Factors
  • Subarachnoid Hemorrhage* / diagnosis
  • Subarachnoid Hemorrhage* / etiology