Evidence that reports to child protective services1 and emergency department visits2 for maltreatment have decreased during the coronavirus disease 2019 (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 hospitalizations.3 Therefore, comparing AHT hospitalizations during the COVID-19 pandemic in 2020 with those in previous years 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, was used to identify hospitalizations for AHT from January 1, 2017, to September 30, 2020, 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, 10th Revision, Clinical Modification (ICD-10-CM) codes for both confirmed child abuse and head trauma (the Centers for Disease Control and Prevention’s broad definition for AHT4 ; Supplemental Table 2). Hospitalizations associated with ICD-10-CM codes for suspected abuse, auto crashes, or falls were excluded (Supplemental Table 3). Patient characteristics and mean monthly AHT admissions in 2020 were compared with those in 2017–2019 by using the time period March 11 (the World Health Organization declaration of COVID-19 as a pandemic5 in 2020) to September 30 for each year to account for seasonality (Table 1). This study was considered exempt from review by the Institutional Review Board of the Yale School of Medicine.
Comparison of Patient Demographics and Admission Characteristics of AHT Hospitalizations Occurring From March 11 to September 30 Over 4 Years
| Patient and Admission Characteristics | All Years (N = 750) | 2017–2019 (n = 623) | 2020 (n = 127) | P |
|---|---|---|---|---|
| Age, d, median (IQR) | 137.5 (263.5) | 132 (243) | 148 (413) | .19 |
| Length of stay, d, median (IQR) | 6 (13) | 7 (15) | 5 (8) | .004 |
| Sex, male, n (%) | 483 (64.4) | 401 (64.4) | 82 (64.6) | .97 |
| Age <1 y, n (%) | 572 (76.3) | 483 (77.5) | 89 (70.1) | .08 |
| Payer, government, n (%) | 620 (82.7) | 517 (83) | 103 (81.1) | .61 |
| Race, n (%) | .71 | |||
| White | 448 (59.7) | 369 (59.2) | 79 (62.2) | |
| Black | 174 (23.2) | 151 (24.2) | 23 (18.1) | |
| Asian | 7 (0.9) | 5 (0.8) | 2 (1.6) | |
| American Indian | 5 (0.7) | 4 (0.6) | 1 (0.8) | |
| Pacific Islander | 6 (0.8) | 5 (0.8) | 1 (0.8) | |
| Other | 110 (14.7) | 89 (14.3) | 21 (16.5) | |
| ICU, n (%) | 451 (60.1) | 370 (59.4) | 81 (63.8) | .36 |
| Ventilator use, n (%) | 316 (42.1) | 266 (42.7) | 50 (39.4) | .49 |
| Subdural hemorrhage, n (%) | 599 (79.9) | 493 (79.1) | 106 (83.5) | .26 |
| Retinal hemorrhage, n (%) | 418 (55.7) | 344 (55.2) | 74 (58.3) | .53 |
| Mortality, n (%) | 78 (10.4) | 61 (9.8) | 17 (13.4) | .24 |
| Patient and Admission Characteristics | All Years (N = 750) | 2017–2019 (n = 623) | 2020 (n = 127) | P |
|---|---|---|---|---|
| Age, d, median (IQR) | 137.5 (263.5) | 132 (243) | 148 (413) | .19 |
| Length of stay, d, median (IQR) | 6 (13) | 7 (15) | 5 (8) | .004 |
| Sex, male, n (%) | 483 (64.4) | 401 (64.4) | 82 (64.6) | .97 |
| Age <1 y, n (%) | 572 (76.3) | 483 (77.5) | 89 (70.1) | .08 |
| Payer, government, n (%) | 620 (82.7) | 517 (83) | 103 (81.1) | .61 |
| Race, n (%) | .71 | |||
| White | 448 (59.7) | 369 (59.2) | 79 (62.2) | |
| Black | 174 (23.2) | 151 (24.2) | 23 (18.1) | |
| Asian | 7 (0.9) | 5 (0.8) | 2 (1.6) | |
| American Indian | 5 (0.7) | 4 (0.6) | 1 (0.8) | |
| Pacific Islander | 6 (0.8) | 5 (0.8) | 1 (0.8) | |
| Other | 110 (14.7) | 89 (14.3) | 21 (16.5) | |
| ICU, n (%) | 451 (60.1) | 370 (59.4) | 81 (63.8) | .36 |
| Ventilator use, n (%) | 316 (42.1) | 266 (42.7) | 50 (39.4) | .49 |
| Subdural hemorrhage, n (%) | 599 (79.9) | 493 (79.1) | 106 (83.5) | .26 |
| Retinal hemorrhage, n (%) | 418 (55.7) | 344 (55.2) | 74 (58.3) | .53 |
| Mortality, n (%) | 78 (10.4) | 61 (9.8) | 17 (13.4) | .24 |
IQR, interquartile range.
Statistical comparison of patient characteristics was performed by using Wilcoxon rank and χ2 tests. The mean monthly admissions during COVID-19 were compared across all years by using a Kruskal-Wallis test, followed by pairwise testing. Analyses were performed by using JMP, version 15.0.0 (SAS Institute, Inc, Cary, NC).
Results
Of the 1 216 336 hospitalizations for children <5 years of age, 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 use, subdural hemorrhage, retinal hemorrhage, and mortality. There was a significant difference in mean monthly admissions when comparing all years together (P = .003). On pairwise comparisons, mean monthly admissions were lower in 2020 compared to 2019 (P = .002), 2018 (P = .004), and 2017 (P = .007; Fig 1). There were no statistical differences in monthly admissions among 2017 to 2019.
Comparison of mean monthly admissions for AHT between March 11 and September 30 over 4 years. Data are reported as means with 1 SD for monthly admissions for AHT. The mean monthly admissions for 2020 (19.1 ± 2.9) were lower than those for 2017 (29.1 ± 4.2), 2018 (33.5 ± 6.3), and 2019 (30.9 ± 2.3). The numbers for total AHT admissions were as follows: 194 in 2017, 223 in 2018, 206 in 2019, and 127 in 2020.
Comparison of mean monthly admissions for AHT between March 11 and September 30 over 4 years. Data are reported as means with 1 SD for monthly admissions for AHT. The mean monthly admissions for 2020 (19.1 ± 2.9) were lower than those for 2017 (29.1 ± 4.2), 2018 (33.5 ± 6.3), and 2019 (30.9 ± 2.3). The numbers for total AHT admissions were as follows: 194 in 2017, 223 in 2018, 206 in 2019, and 127 in 2020.
Discussion
This study reveals a significant decrease in AHT admissions in children <5 years of age across 49 children’s hospitals within the United States during the COVID-19 pandemic. The expectation was that child maltreatment would increase because of the emotional and economic stressors of the pandemic.6 In some early studies, researchers supported this expectation but were limited to single institutions with short study periods during the pandemic.7,8 In contrast, decreased child protective services reporting and national emergency department 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 forgo care; 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 before the pandemic to be cared for by ≥2 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 September 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.
Dr Maassel collected data, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Asnes and 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; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-050612.
We read with interest the article "Hospital Admissions for Abusive Head Trauma at Children's Hospitals During COVID-19" by Maassel et. al.1 Several single-center studies reported an increase in the incidence of abusive head trauma (AHT) during the pandemic. Therefore, we were surprised by the finding of a 30% reduction in the incidence of AHT during 2020 in 49 hospitals that contribute to the Pediatric Health Information Systems database. However, we advise caution in the interpretation of these findings as there are aspects of both study design and the COVID-19 response that must be considered before the findings of Maassel et. al.1 can be used to guide child protection policies.
First, it has been previously reported that International Classification of Diseases (ICD) codes have poor sensitivity for the identification of child abuse, ranging from 54-100% dependent upon the hospital and the precise set of codes used.2,3 ICD codes for traumatic brain injury secondary to child abuse are estimated to have a sensitivity of 70-85%, but the number of children available in these analyses was very small.3 Given the poor sensitivity of these diagnostic codes, it is unclear whether the changes noted by Maassel et. al.1 reflect a true change in the incidence of AHT, or, for example, a change in coding practices caused by staffing disruptions during the COVID-19 pandemic.
Second, the COVID-19 pandemic disrupted many facets of pediatric care. Unexpected decreases in nearly every category of pediatric encounter from hyperbilirubinemia4 to coarctation of the aorta5 suggest that there were disruptions in screening for important occult diagnoses, such as AHT. Thus, another potential explanation for the apparent decrease in incidence of AHT is an increase in "missed" diagnoses. Maassel et. al.1 propose that the severity of AHT would preclude such changes, but the majority of traumatic brain injury is mild. If parents chose not to present to the emergency department with concerns, the impact of the trauma may not be detected on routine clinical follow up, especially when many such visits are virtual and preclude a thorough physical exam.
Finally, the pandemic has offered a variety of unique natural experiments in pediatrics, including the opportunity to study the effects of increased unemployment in two-parent households on family dynamics, but it must also be stated that an important aspect of this context is that the United States implemented a massive, bipartisan stimulus package that helped to curb the financial impact of pandemic-related job losses. The notion proposed by Maasel et. al.1 that increased parental presence may mitigate the likelihood of abuse is compelling; however, we suggest more rigorous analyses of the counterbalancing forces of increased parent availability and financial stress imposed by job loss are necessary to better understand the veracity of such findings and the potential underlying mechanisms. If the decline in AHT identified by Maasel et al.1 is a true, beneficial effect of pandemic-related circumstances, then a clear understanding of the underlying mechanisms at play is essential to design policies to help sustain this trend.
References:
1. Maassel NL, Asnes AG, Leventhal JM, Solomon DG. Hospital Admissions for Abusive Head Trauma at Children's Hospitals During COVID-19. Pediatrics. Published online April 20, 2021:e2021050361. doi:10.1542/peds.2021-050361
2. Hooft AM, Asnes AG, Livingston N, et al. The Accuracy of ICD Codes: Identifying Physical Abuse in 4 Children's Hospitals. Acad Pediatr. 2015;15(4):444-450. doi:10.1016/j.acap.2015.01.008
3. Schnitzer PG, Slusher PL, Kruse RL, Tarleton MM. Identification of ICD codes suggestive of child maltreatment. Child Abuse Negl. 2011;35(1):3-17. doi:10.1016/j.chiabu.2010.06.008
4. Ramgopal S, Pelletier JH, Rakkar J, Horvat CM. Forecast modeling to identify changes in pediatric emergency department utilization during the COVID-19 pandemic. Am J Emerg Med. 2021;49:142-147. doi:10.1016/j.ajem.2021.05.047
5. Pelletier JH, Rakkar J, Au AK, Fuhrman D, Clark RSB, Horvat CM. Trends in US Pediatric Hospital Admissions in 2020 Compared With the Decade Before the COVID-19 Pandemic. JAMA Netw Open. 2021;4(2):e2037227. doi:10.1001/jamanetworkopen.2020.37227