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Beyond Injury Severity: Comparing Outcomes of Isolated Traumatic Brain Injury between Non-Accidental and Accidental Pediatric Trauma Patients
Nada Fadl, Robert Levis, Rosa Hwang, Chris Penney, Camryn Krumbhaar, April Gianotti, Gary Nace, Michael Nance, Myron Allukian
Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
Background: Non-accidental trauma (NAT) is a significant contributor to pediatric morbidity and mortality, with traumatic brain injury (TBI) representing one of the most common and devastating manifestations. While prior studies suggest worse outcomes in NAT compared to accidental trauma (AT), it remains unclear whether these differences are driven by greater injury severity or by factors inherent to NAT. This study investigates and compares the associated demographic and outcome differences of isolated traumatic brain injuries in pediatric NAT and AT patients.
Method: A retrospective cohort study of the Trauma Quality Improvement Program (TQIP) (2016-2023) was performed. Patients 18 years old and younger with an isolated traumatic brain injury were included. 258,330 pediatric patients were analyzed, of whom 3,354 (1.3%) sustained NAT. Outcomes were analyzed using Chi-Squared, Wilcoxon Rank Sum and Fisher's Exact test. Propensity score matching (3:1) was performed based on age, SIPA score, max AIS and GCS. The cohort was then further filtered for additional analyses based on a head AIS score >3, indicating an isolated severe TBI, and the same descriptive and statistical test pipelines were performed.
Results: NAT patients with isolated TBI were significantly younger (median 2 vs. 13 years) and more likely to be treated at pediatric trauma centers (39% vs. 20%) (p<0.001). Patients who were Black (28% vs. 16%) and publicly insured (71% vs. 38%) were overrepresented in the NAT cohort (p<0.001). In general, patients in the NAT cohort had a significantly worse GCS, higher max AIS and ISS (p<0.001). In the propensity matched cohort, NAT was associated with higher mortality (14% vs. 9.3%, p<0.001). Among patients with severe isolated traumatic brain injuries (AIS >3), NAT remained associated with higher mortality (29% vs. 20%, p<0.001), longer hospital and ICU length of stay, and persistent racial and insurance status differences (p<0.001).
Conclusions: Pediatric patients with NAT experience worse outcomes than those with AT, even after controlling for injury severity. Isolated NAT TBI disproportionately affects younger, Black, and publicly insured patients, highlighting significant disparities. These findings suggest that factors beyond injury burden may contribute to increased morbidity and mortality. Future studies should investigate racial and socioeconomic differences related to NAT head trauma risk and reporting practices.
Table 1. Comparison of clinical outcomes between Accidental Trauma and Non-Accidental Trauma patients (< 19 years old) with an isolated traumatic brain injury queried from TQIP (2016-2023) after a 3:1 propensity matching based on age, SIPA**, maximum AIS, and GCS.
| | Total Cohort
N= 10,871 | Accidental Trauma
N=8,109
| Non-Accidental Trauma
N=2,762 | p-value* |
| Total Hospital LOS | 3 (2,6) | 3 (2,5) | 4 (2,9) | <0.001 |
| Total ICU LOS | 3 (2,6) | 3 (2,6) | 3 (2,7) | <0.001 |
| Blood Transfusion Within 4 Hours | 6,196 (57%) | 4,766 (59%) | 1,430 (52%) | <0.001 |
| Mortality | 1,157 (11%) | 758 (9.3%) | 399 (14%) | <0.001 |
N (%); Median (IQR)
*Pearson's Chi-squared test, Wilcoxon rank sum test, Fisher's exact test
**Positive Shock Index, pediatric age adjusted for pediatric patients <6 years old SI >1.22, 7-12 years old SI >1.0, >13 years old SI >0.9
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