Hospital Admissions for Abusive Head Trauma at Children's Hospitals During COVID-19
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Prepublication Release
Hospital Admissions for Abusive Head Trauma at
Children’s Hospitals During COVID-19
Nathan L. Maassel, MD, Andrea G. Asnes, MSW, MD, John M. Leventhal, MD, Daniel G.
Solomon, MD
DOI: 10.1542/peds.2021-050361
Journal: Pediatrics
Article Type: Research Brief
Citation: Maassel NL, Asnes AG, Leventhal JM, Solomon DG. Hospital admissions for abusive
head trauma at children’s hospitals during COVID-19. Pediatrics. 2021; doi: 10.1542/peds.2021-
050361
This is a prepublication version of an article that has undergone peer review and been accepted
for publication but is not the final version of record. This paper may be cited using the DOI and
date of access. This paper may contain information that has errors in facts, figures, and
statements, and will be corrected in the final published version. The journal is providing an early
version of this article to expedite access to this information. The American Academy of
Pediatrics, the editors, and authors are not responsible for inaccurate information and data
described in this version.
©2021 American Academy of Pediatrics
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Hospital Admissions for Abusive Head Trauma at
Children’s Hospitals During COVID-19
Nathan L. Maassel, MD1, Andrea G. Asnes, MSW, MD2, John M. Leventhal, MD2, Daniel G.
Solomon, MD3
Affiliation: 1Yale University School of Medicine, Department of Surgery, New Haven, CT;
2
Yale University School of Medicine, Department of Pediatrics, New Haven, CT; 3Yale
University School of Medicine, Department of Surgery, Division of Pediatric Surgery New
Haven, CT
Address correspondence to: Nathan Maassel, Department of Surgery, 333 Cedar Street, New
Haven, CT 06510, Nathan.maassel@yale.edu, (203) 909-7840
Conflict of Interest Disclosures: The Department of Pediatrics at the Yale School of Medicine
receives grants from the State of Connecticut to support its child abuse programs and bills for the
expert child abuse consultation and testimony in court of Dr. Asnes and Dr. Leventhal. The
remaining authors have nothing to disclose.
Funding/Support: No funding was secured for this study
Abbreviations: abusive head trauma (AHT), international classification of disease (ICD),
Centers for Disease Control (CDC),
Contributors’ Statement Page
Dr. Maassel collected data, carried out the initial analyses, drafted the initial manuscript and
reviewed and revised the manuscript
Drs Asnes, Leventhal conceptualized and designed the study, and critically reviewed the
manuscript.
Dr. Solomon conceptualized and designed the study, coordinated and supervised data collection,
and reviewed and revised the manuscript
All authors approved the final manuscript as submitted and agree to be accountable for all
aspects of the work.
©2021 American Academy of Pediatrics
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INTRODUCTION
Evidence that reports to child protective services (CPS)1 and emergency department (ED) visits2
for maltreatment have decreased during the COVID-19 pandemic has led to concerns that
children are being maltreated but not being brought to care. We hypothesized that in the case of
potentially life-threatening abuse, such as abusive head trauma (AHT), it is more difficult for
caregivers to forgo medical care. A standard approach to estimating the occurrence of AHT has
been counting hospitalizatons.3 Therefore, comparing AHT hospitalizations during COVID-19 to
years prior would provide useful insight into how the pandemic is influencing this type of abuse.
METHODS
The Pediatric Health Information System (PHIS), a database of 51 children’s hospitals in the
United States (U.S.), was used to identify hospitalizations for AHT from 1/1/17 to 9/30/20 in
children < 5 years of age. This study was limited to 49 hospitals with consistent contributions to
the PHIS since 2017. Inclusion as hospitalizations for AHT required International Classification
of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for both confirmed child
abuse and head trauma (Centers for Disease Control’s broad definition for AHT 4) (Appendix 1).
Hospitalizations associated with ICD-10-CM codes for suspected abuse, motor vehicle accidents,
or falls were excluded (Appendix 2). Patient characteristics and mean monthly AHT admissions
in 2020 were compared to those from 2017-2019 using the time period March 11 (World Health
Organization declaration of COVID-19 as a pandemic in 20205) to September 30 for each year to
account for seasonality. This study was considered exempt from review by the institutional
review board of the Yale School of Medicine.
©2021 American Academy of Pediatrics
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Statistical comparison of patient characteristics was performed using Wilcoxon and chi-square
tests. Mean monthly admissions during COVID-19 were compared across all years using a
Kruskal Wallis test, followed by pair-wise testing. Analyses were performed using JMP Version
15.0.0 (SAS Institute Inc., Cary, NC, 1989-2019).
RESULTS
Of the 1,216,336 hospitalizations for children < age 5, 1317 (0.1%) were for AHT. Of these, 750
occurred between March 11 and September 30, 127 (16%) of which were in 2020. Compared to
2017-2019, children hospitalized with AHT during 2020 had a shorter length of stay but were
otherwise similar regarding the percentage of ICU stay, ventilator utilization, subdural
hemorrhage, retinal hemorrhage, and mortality. There was a significant difference in mean
monthly admissions when comparing all years together (P = 0.003). On pair-wise comparisons,
mean monthly admissions were lower in 2020 compared to 2019 (P =0.002), 2018 (P = 0.004),
and 2017 (P = 0.007) (Figure). There were no statistical differences in monthly admissions
among 2017-2019.
DISCUSSION
This study demonstrates a significant decrease in AHT admissions in children < 5 years of age
across 49 children’s hospitals within the U.S. during the COVID-19 pandemic. The expectation
was that child maltreatment would increase due to the emotional and economic stressors of the
pandemic.6 Some early studies supported this expectation but were limited to single institutions
with short study periods during the pandemic.7, 8 In contrast, decreased CPS reporting and
national ED visits related to child abuse have generated concern that maltreatment may be
occurring without subsequent evaluation. 1, 2 Mild cases of AHT may be able to forego care;
©2021 American Academy of Pediatrics
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however, the overall severity of this type of abuse necessitates consideration of alternative
hypotheses given our findings. One possible explanation could be that with the marked increase
in job losses for women9 and many adults working from home, young children were more likely
than pre-pandemic to be cared for by two or more caregivers, potentially reducing the likelihood
of sole male caregivers who are the most common perpetrators of AHT.10
The study’s major limitation is its reliance on diagnostic coding, which may be erroneous.
Additionally, admission criteria may have been more restricted during COVID-19; however, this
effect may be minimal given a similar percentage of ICU admissions compared to previous
years. Furthermore, PHIS data are available for patients discharged through 9/30/2020; therefore,
a few admissions during COVID-19 may not have been counted, but this is unlikely to
substantially affect our results. Given the severity of AHT, the observed decrease in
hospitalizations likely represents a true decrease in the occurrence of AHT. As more data
become available, continued surveillance of AHT trends will clarify our findings.
References
1. Rapoport E, Reisert H, Schoeman E, Adesman A. Reporting of child maltreatment during
the SARS-CoV-2 pandemic in New York City from March to May 2020. Child Abuse
Negl. 2020:104719.
2. Swedo E, Idaikkadar N, Leemis R, Dias T, Radhakrishnan L, Stein Z, et al. Trends in
U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and
Neglect Among Children and Adolescents AgedPrepublication Release
5. WHO Director-General's opening remarks at the media briefing on COVID-19. World
Health Organization.
6. Griffith AK. Parental Burnout and Child Maltreatment During the COVID-19 Pandemic.
J Fam Violence. 2020:1-7.
7. Sidpra J, Abomeli D, Hameed B, Baker J, Mankad K. Rise in the incidence of abusive
head trauma during the COVID-19 pandemic. Archives of disease in childhood. 2020.
8. Kovler ML, Ziegfeld S, Ryan LM, Goldstein MA, Gardner R, Garcia AV, et al. Increased
proportion of physical child abuse injuries at a level I pediatric trauma center during the
Covid-19 pandemic. Child Abuse Negl. 2020:104756.
9. Karageorge EX. COVID-19 recession is tougher on women. US Bureau of Labor and
Statistics - Monthly Labor Review. https://www.bls.gov/opub/mlr/2020/beyond-
bls/covid-19-recession-is-tougher-on-women.htm. Published September 2020. Accessed
2/20/2021.
10. Scribano PV, Makoroff KL, Feldman KW, Berger RP. Association of perpetrator
relationship to abusive head trauma clinical outcomes. Child Abuse Negl.
2013;37(10):771-777.
©2021 American Academy of Pediatrics
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Table: Comparison of Patient Demographics and Admission Characteristics of Abusive Head
Trauma Hospitalizations Occurring March 11 – September 30 Over Four Years
Patient and Admission All Years 2017-2019 2020
Characteristics N=750 N=623 N=127 P value
Age, median (IQR), days 137.5 (263.5) 132 (243) 148 (413) 0.19
Length of stay, median (IQR), days 6 (13) 7 (15) 5 (8) 0.004
Gender (male) 483 (64.4%) 401 (64.4%) 82 (64.6%) 0.97
AgePrepublication Release
Figure: Comparison of Mean Monthly Admissions for Abusive Head Trauma Between March
11 and September 30 Over Four Years
Data are reported as means with one standard deviation for monthly admissions for abusive head trauma.
Mean monthly admissions for 2020 (19.1±2.9), were lower than 2017 (29.1±4.2), 2018 (33.5±6.3), and
2019 (30.9±2.3). Numbers for total abusive head trauma admissions: 2017, 194; 2018, 223; 2019, 206;
2020, 127.
©2021 American Academy of Pediatrics
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Appendix 1: Abusive Head Trauma
Abuse Codes Head Trauma Codes
Unspecified child maltreatment, confirmed T7492XA Fracture of vault of skull S02.0
+
Child physical abuse, confirmed T7412XA Fracture of base of skull S02.1
Shaken infant syndrome T744XXA Multiple fractures involving skull and facial bones S02.7
Fractures of other specified skull and facial bones S02.8
Fracture of unspecified skull and facial bones S02.9
Injury of optic nerve and pathways S04.0
Concussion S06.0
Traumatic cerebral edema S06.1
Diffuse traumatic brain injury S06.2
Focal traumatic brain injury S06.3
Epidural hemorrhage S06.4
Traumatic subdural hemorrhage S06.5
Traumatic subarachnoid hemorrhage S06.6
Intracranial injury with prolonged coma S06.7
Other specified intracranial injuries S06.8
Unspecified intracranial injury S06.9
Crushing injury of skull S07.1
Crushing injury of other parts of head S07.8
Crushing injury of head, part unspecified S07.9
Multiple injuries of head S09.7
Other specified injuries of head S09.8
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©2021 American Academy of PediatricsPrepublication Release
Appendix 2: Exclusion Criteria
Description ICD-10 Codes
Suspected Abuse Codes
Unspecified child maltreatment, suspected T7692XA
Child physical abuse, suspected T7612XA
Fall Codes W00-W19
Motor Vehicle Accident V40-49, V89
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©2021 American Academy of PediatricsHospital Admissions for Abusive Head Trauma at Children's Hospitals During
COVID-19
Nathan L. Maassel, Andrea G. Asnes, John M. Leventhal and Daniel G. Solomon
Pediatrics originally published online April 20, 2021;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2021/04/18/peds.2021-05
0361.citation
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Downloaded from www.aappublications.org/news by guest on May 15, 2021Hospital Admissions for Abusive Head Trauma at Children's Hospitals During
COVID-19
Nathan L. Maassel, Andrea G. Asnes, John M. Leventhal and Daniel G. Solomon
Pediatrics originally published online April 20, 2021;
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2021/04/18/peds.2021-050361.citation
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
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American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2021 by the
American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
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