Infant Head Trauma Surged in Paris During Pandemic

Abusive head trauma in infants nearly doubled in the Paris metropolitan area during the second year of the COVID-19 pandemic, researchers reported.

While cases of abusive head trauma were stable in 2020 compared with years before the pandemic, averaging 1.4 cases per month, that number jumped to 2.7 cases per month in 2021 (adjusted incidence rate ratio [aIRR] 1.92, 95% CI 1.23-2.99, P=0.02), according to Flora Blangis, MPH, and colleagues at the Université Paris Cité, writing in JAMA Network Open.

And mortality rates from abusive head trauma in infants jumped nearly 10-fold in 2021 (odds ratio 9.39, 95% CI 1.88-47.00), the group found.

"These findings suggest that the marked increase in abusive head trauma incidence during the COVID-19 pandemic in the Paris metropolitan area should prompt clinical awareness and preventive actions," wrote Blangis and co-authors. "No national prevention campaign against AHT [abusive head trauma] was implemented in France until January 2022."

The researchers hypothesized that since the increase did not occur in the first year of the pandemic, when containment and mitigation measures were maximum, the cause may be more related to an "accumulation of psychosocial distress over time."

Paris is an area of particular interest to study the association between the COVID-19 pandemic and abusive head trauma incidence, the investigators noted. As a densely populated area, the city "faced strong COVID-19 pandemic waves," leading to prolonged lockdowns, curfews, remote work, and daycare closures.

Social isolation amplified already-known risk factors for child abuse and neglect (CAN), Blangis and co-authors said: "Economic loss and unemployment, mental disorders such as acute and posttraumatic stress disorders and depression or suicidal behaviors are known risk factors for CAN," the team wrote, adding, though, that the design of the study "did not allow deciphering the respective roles of the pandemic and these measures."

To study the incidence of abusive head trauma in infants 12 months and younger in the Paris metropolitan area, the researchers assessed cases that presented to hospital there from 2017 to 2021. The median age of the infants was 4 months, and 65% were male. Of the 99 cases studied, 87% had bridging vein thrombosis, 75% had retinal hemorrhages, 32% had fractures, 26% had status epilepticus, and 20% had skin injuries.

More than half of the children (54%) needed neurosurgical interventions, and 13% died.

Writing in an accompanying editorial, however, Emily C. B. Brown, MD, of Seattle Children's Hospital, said that while this study and others have highlighted child maltreatment during the pandemic, the exact nature of the relationship between abusive head trauma incidence and the pandemic remains unclear.

"There are reasons to suspect that the pandemic and its associated stressors might be to blame for the 2021 increase of AHT in Paris; however, that conclusion cannot be drawn from this study alone," argued Brown.

Studies on this topic have been inconsistent, she noted. Still the new study may provide some insights. In particular, if relief measures on financial stress reduced abusive head trauma in 2020, this might inform social policies in the future, in addition to targeting caregiver education.

Prevention of abusive head trauma "has long proven elusive," she said. Paid parental leave, and other policies have shown some reduction, Brown explained, but "why did the factors that worked in 2020 start to fail?"

"Because families' lives are often stressful even outside of a pandemic, once we determine which preventive measures were the most effective at reducing AHT and other forms of maltreatment during the last couple years, we may want to advocate to keep them permanently," Brown said.

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