Approximately 80% of mortality caused by AHT may be survived with earlier interventions (10). Primary clinicians should be highly alert to recognize the possibility of child maltreatment. However, timely diagnosis of AHT is difficult because the initial presentations often involve nonspecific complaints, such as difficulty feeding and breathing, poor activity, apnea, convulsions, or drowsiness; this consequently causes confusion on the diagnostic process among doctors (11). Differentiating between AHT and accidental TBI may be equivocal; this is especially true, as histories provided are usually fictitious to conceal abuse.
This study is the first to analyze the risk factors associated with the clinical prognosis of maltreated children admitted to the ICU. Herein, we included and investigated up to 480 victims admitted to the ICU within a relatively long study period (19 years). The ICU admission rate was 19.3% in the total study population of 2,481 children, which indicates that 1 in every 5 cases required critical care owing to child maltreatment. The mortality rate was 12.8% in the physically abused group and 8.3% in the unintentionally injured group, which was both higher than previous rates (5,6). We think that this may be attributed to the rarely reported cases from the medical and social systems in the past. Only very critically ill victims were admitted to the ICU and reported in the past.
In our study, we identified that initial presentation with shock within 24 hours was the strongest predictor of poor prognosis in both groups. The major type of shock observed was neurogenic shock, mainly caused by TBI, which accounted for approximately 51% of the mortality herein. TBI is a leading cause of morbidity and mortality in child maltreatment cases worldwide, and previous studies have demonstrated several risk factors associated with poor outcomes in children with TBI, including low GCS score, post-traumatic seizure, retinal hemorrhage, young age, and SDH (12–17). However, in our study, we found that shock, head injury, convulsions, retinal hemorrhage, lower initial GCS score, and lower body temperature were all risk factors of poor neurologic outcomes. Severe brain swelling and mass effect caused by TBI may lead to neurogenic shock. Shock may cause ischemic injuries and reperfusion impairment, which may increase the rates of cell death and multi-organ failure, resulting in high mortality rates (18–21). In our study, the children with shock expired earlier and easily and had poor neurologic outcomes. Therefore, the occurrence of shock within 24 hours of ICU admission may indicate a high mortality and a poor neurologic outcome in physically abused or unintentionally injured children. Hence, closely monitoring the early signs of shock, such as tachycardia, poor perfusion, and low blood pressure, and emergent fluid resuscitation with vasopressors could be important for children with TBI.
The second strongest risk factor associated with mortality in our study was spontaneous hypothermia following injuries. Previous studies have demonstrated that spontaneous hypothermia was a risk factor for mortality in adult patients with severe trauma and hemorrhage and identified it as a new risk factor after cardiac arrest in adults (22–24). Under normal conditions, body temperature is regulated by the hypothalamus. Spontaneous hypothermia after severe injuries may indicate a harmful mechanism of thermoregulation by the cerebrum resulting from ischemia and reperfusion damage. Therefore, spontaneous hypothermia may be translated as a sign of cerebral injury (24). In addition, hypothermia may disrupt systemic homeostasis, deplete energy stores, and finally cause multi-organ failure (23). This is the first study to analyze the impact of body temperature changes on ICU admission in abused children. In physically abused and unintentionally injured children, critical conditions with spontaneous hypothermia may indicate a high mutability rate. Moreover, spontaneous hypothermia may also serve as a predictor of poor neurologic prognosis in children with unintentional injuries. When shock and spontaneous hypothermia occur in physically abused and unintentionally injured children, the harmful changes become additive, and a higher mortality rate is ensued.
Herein, we also found that convulsion was not only a common post-trauma complication but also a risk factor for poor neurologic outcomes in both the physically abused and unintentionally injured groups. The correlation between convulsion and poor neurologic outcomes may be attributed to the consequent increases in metabolic demands, intracranial pressure, and release of neurotransmitters arising from secondary brain injury (14,25). Therefore, early detection using continuous electroencephalographic monitoring and antiepileptic drug administration could be recommended for pediatric TBI to avoid progression of poor neurologic outcomes (26,27). Although traumatic causes may result in a pattern of retinal hemorrhage, this type of hemorrhage is still an important manifestation of AHT and frequently observed particularly during dilated eye examination in approximately 85% of children with AHT. In our study, retinal hemorrhage was found to be a risk factor for poor neurologic outcomes among the physically abused children but not among the unintentionally injured children. The presence of retinal hemorrhage may have a nonspecific pattern in children with AHT; however, once retinal hemorrhages are noted in children with AHT, poor neurologic outcomes may be expected. Therefore, primary clinicians should pay more attention to performing dilated eye examinations in children suspected to have experienced child maltreatment because the presence of retinal hemorrhage may not only identify the existence of child abuse but also indicate the possibility of poor neurologic outcomes.