Abusive head trauma (AHT) is a leading cause of traumatic death in infants and young children.1 Children who suffer AHT are often subjected to repeated and sustained episodes of abuse; thus, timely identification is crucial and can be lifesaving.2 However, there are numerous challenges associated with the identification of AHT. Because the clinical signs and symptoms can vary and be subtle, AHT can be missed by practitioners.3
The coronavirus disease 2019 (COVID-19) pandemic has had a profound adverse impact on families and households. As a result, concerns have been raised that children may be at increased risk for physical abuse and that some cases may go undiagnosed.4 In this issue of Pediatrics, Maassel et al5 report findings from a national study conducted in the United States that examined changes in the frequency of AHT hospitalizations during the COVID-19 pandemic. Using data from the Pediatric Health Information System database, the authors compared mean hospital admission rates for AHT and key demographic and admission characteristics at 49 children’s hospitals during March to September 2020 with those across the same months of the preceding 3 years. There was a statistically significant decrease in hospital admissions for AHT during the COVID-19 pandemic compared with each previous year. In addition, there were no statistically significant differences in the proportion of children who were admitted to an ICU, required a ventilator, presented with subdural or retinal hemorrhage, or died of their injuries.5 The study findings echo those of a recent similar US study that used the Pediatric Health Information System database to investigate emergency visits and hospitalizations for all types of physical child abuse during the COVID-19 pandemic.6
As Maassel et al5 note, their findings differ from earlier single-center studies documenting an increase in the number7 or proportion8 of children presenting with abuse-related injuries during the COVID-19 pandemic. Although the authors of one UK study reported an alarming 1493% rise in the incidence of AHT during the pandemic compared with equivalent time periods in the 3 previous years, the data represented only 1 institution over the first month of the national lockdown.7 In contrast, Sanford et al9 reported a decrease in the number of emergency department visits for blunt trauma at 1 US tertiary pediatric hospital during the first 2 months of the pandemic and no corresponding increase in the proportion of suspected abuse cases. A major strength of the studies conducted by Maassel et al5 and Kaiser et al6 is the inclusion of 6 months of data from multiple children’s hospitals across the United States. These studies highlight the value of national administrative data in facilitating rapid, population-wide child abuse surveillance studies that will ultimately help to inform public health policy and practice.
Maassel et al5 hypothesized that because of the severity of AHT, it is difficult for caregivers to forgo seeking medical care for the child, implying that the decrease in hospitalizations represents a true decrease in AHT incidence. However, the brief acknowledgment that “mild cases of AHT may be able to forgo care”5 necessitates discussion. Evidence suggests that even when medical care is sought, many AHT cases go unrecognized by medical professionals, even without the additional challenges posed by the pandemic.2,3,10,11 Existing challenges in the identification of AHT have been exacerbated by COVID-19-associated physical-distancing measures. For example, national US data reveal that patterns in child abuse–related emergency department presentations changed during the pandemic.12 Although the number of presentations decreased, the percentage requiring hospital admission increased in children aged 0 to 4 years, suggesting that less severe cases are not being brought for care. Such changes in health care use can be attributed in part to anxieties around contracting COVID-19.7
If milder AHT is being missed, we might expect more severe hospitalizations for AHT and/or physical abuse in the COVID-19 period compared with earlier time periods, which is not the case.5,6 However, although hospital admission data are undeniably useful for assessing the scope of AHT and trends in incidence and case composition, they represent only 1 piece of the puzzle. A recent study examining the accuracy of International Classification of Diseases, 10th Revision, Clinical Modification coding for physical child abuse revealed that AHT hospitalization data alone are likely to significantly underestimate the incidence of AHT and only represent the “tip of the iceberg” of likely cases.13 Meanwhile, there is evidence that the incidence of AHT increases during and after an economic recession14–16 and after a natural disaster.17 For these reasons, the observed decrease in hospitalizations for AHT is indeed surprising. Although Maassel et al5 conjecture that this decrease may be explained by more caregivers in the home, there may also be some underrecognition of cases. Kaiser et al6 postulate that either (1) the true occurrence of abuse decreased similarly across the whole spectrum of severity or (2) presentation of abuse cases to medical care and/or missed cases decreased similarly across the whole spectrum of severity. Regardless, we agree with Maassel et al5 that it is paramount to consider all possible explanations in these unprecedented times and that emerging hypotheses must be explored going forward.
Important questions remain regarding implications for the identification and prevention of AHT. What are the factors that are driving the changes in frequency of AHT hospital admissions, and how do we best study them? What does this mean for prevention interventions during and after the pandemic? If children are not being brought in for care, how can we ensure that risk factors of abuse and sentinel injuries are recognized? It is likely that a strengthened community approach is required.18 Future research should be focused on untangling the factors driving changes in health care use and designing and implementing interventions to better understand and mitigate the short- and long-term effects of COVID-19 on violence and abuse in children.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-050361.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.