Pediatric Trauma and Critical Illness Branch (PTCIB)

Female doctor listening to young girl's heart with stethoscope while mother looks on.Overview/Mission

PTCIB supports research and training aimed at preventing, treating, and reducing all forms of childhood traumatic injury and critical illness across the continuum of care.

This includes research to understand the biobehavioral, psychosocial, and pathophysiologic aspects of trauma; to improve prevention, diagnosis, and treatment of traumatic injury and critical illness in infants, children, adolescents, and young adults; and to reduce secondary injury and comorbidities. 

We are interested in applications that align with the following research priorities. For more information about NICHD’s research themes, cross-cutting topics, and aspirational goals, visit the plan’s Scientific Research Themes and Objectives.

Optimal Time Periods for the Prevention and Treatment of Traumatic Injuries

Strategic Plan Theme 4: Improving Child and Adolescent Health and the Transition to Adulthood
Strategic Plan Cross-Cutting Topic: Disease Prevention

Gap: Injury is the leading cause of morbidity and mortality in children and adolescents, yet it is an understudied public health problem in the United States and around the world with serious effects on health, well-being, and developmental transitions. Research is needed to prevent adverse health outcomes and developmental sequelae by improving early detection and treatment and by identifying optimal time periods for prevention and intervention efforts. 

Priority: Research to develop the most effective prevention, diagnostic, and treatment strategies for the leading causes of traumatic injury in children and adolescents, including all forms of violence against children; unintentional injury, including motor vehicle crashes; critical illness and life-threatening injury; and self-injurious behavior.

Gap: Little is known about multiple forms of trauma in children or about the independent and combined effects of multiple forms of physical and psychological trauma or traumatic stress in children. More research is needed to understand how these forms of trauma affect children’s short- and long-term recovery, as well as overall health and well-being, through key developmental transition points.

Priority: Multidisciplinary research that examines the distinctive aspects of psychological and physical trauma, the complex interplay of those traumas, and the implications for trauma-informed systems of care and treatment of diverse pediatric populations in primary care, community, humanitarian, emergency medical, or critical care contexts.

Collaborative Multidisciplinary Research Across the Continuum of Care

Strategic Plan Theme 4: Improving Child and Adolescent Health and the Transition to Adulthood
Strategic Plan Aspirational Goal: Facilitate application of precision medicine approaches in children

Gap: The current approach to studying pediatric trauma, injury prevention, and critical illness is often compartmentalized, with each discipline operating independently. This approach is insufficient to advance the science, accelerate discovery, inform clinical practice, and establish the scientific evidence needed for effective treatment of critically ill, injured, or traumatized children. 

Priority: Research involving multidisciplinary and interdisciplinary teams to develop, test, and evaluate effective therapeutic agents and modalities, medical devices, precision medicine interventions, behavioral interventions, and large-scale datasets to optimize outcomes for traumatized, injured, and critically ill children.

Care and Treatment of Critical Illness in Pediatric Populations

Strategic Plan Theme 4: Improving Child and Adolescent Health and the Transition to Adulthood
Strategic Plan Cross-Cutting Topic: Infectious Disease

Gap: Critical illness in children is an under-recognized major public health problem that accounts for more quality of life years lost than any other medical condition. Critical illness may occur with a wide variety of medical conditions, rare diseases, and life-threatening injuries, making the completion of generalizable studies quite difficult. The impact of these illnesses on the developmental trajectory is poorly understood. Additionally, therapies for these illnesses and rare conditions are most often based on extrapolated adult data. Given that a child’s physiological responses to critical illness differ substantially from those of an adult, there exists a large gap in knowledge regarding optimal therapy for these conditions among children.

Priority: Research that optimizes recovery for children who experience critical illness and/or traumatic injury. This includes research that examines the epidemiology, pathophysiology, diagnosis, prevention, and treatment of all forms of critical illness and life-threatening injury among non-neonatal pediatric populations, as well as identifying sensitive time periods when prevention and treatment strategies are most optimal for children.

Gap: Children with complex medical conditions or rare diseases are frequently dependent upon technology and highly specialized care to survive and thrive, especially during periods of life-threatening illness, such as infections or respiratory distress or failure. Balancing the unique needs of these patients due to their underlying condition or disease with the life-saving measures and technology required can be challenging, at best, yet little research exists to substantiate and direct care. Empirical efforts are needed to develop, test, and evaluate safe and effective solutions that meet the unique needs of critically ill children with complex medical conditions.

Priority: Research designed to determine the optimal use of—and identify patient populations most likely to benefit from—innovative critical care interventions (e.g., extracorporeal membrane oxygenation [ECMO], renal replacement therapy [RRT], etc.), including research that assesses morbidities and functional outcomes related to those treatment modalities.

Psychosocial Issues Related to the Care of Critically Ill and Injured Children and Their Families

Strategic Plan Theme 4: Improving Child and Adolescent Health and the Transition to Adulthood

Gap: Stress related to critical care illness and injury, as well as the inherent ethical concerns and conflicts that contribute to that stress, create a myriad of psychosocial concerns for the child, family, and healthcare providers, yet these concerns and how they might affect clinical outcomes remain grossly understudied. Similarly, both the short-term and long-term psychological consequences of critical illness and injury on these populations are largely unknown. 

Priority: Research aimed at understanding psychosocial issues in critically ill children and their families, as well as ethical and communication issues that arise in the Pediatric Intensive Care Unit, and approaches to reducing the negative sequelae of these issues. Also prioritized is research aimed at understanding the effect of environmental and palliative care interventions in critically ill or injured children on functional outcomes and the psychological consequences of critical stress.

  • Valerie Maholmes, Branch Chief
    Main Research Areas: Pediatric trauma (diagnosis, treatment, prevention); childhood adversity, child traumatic stress, violence and violence-related injury, abuse, neglect, and maltreatment; training (child maltreatment, violence); emergency medical and psychological response/services to children
  • Cinnamon Dixon, Medical Officer
    Main Research Areas: Emergency medical services for children (EMSC) (prevention, diagnostics, interventions, treatment, utilization, quality); disaster management for children (preparedness, mitigation, response, and acute recovery); pediatric unintentional injury prevention and trauma care; global health advancements in EMSC; unintentional injury prevention, trauma care, and disaster management; education and training (unintentional injury prevention, pediatric emergency medical and trauma care, disaster management)
  • Tammara Jenkins, Program Official/Nurse Consultant
    Main Research Areas: Pediatric critical care and injury (general, diagnosis, treatment, prevention, ethics, end-of-life issues, palliative care, environment of care, and psychosocial aspects of critical care); palliative care in the hospitalized child; acute care in the hospitalized child; training and career development (pediatric critical care, acute care, and palliative care)
  • Zsuzsanna Kocsis, Program Analyst
  • Tessie October, Medical Officer
    Main Research Areas: Pediatric critical care and injury (general, diagnosis, treatment, prevention, healthcare communication, decision-making, and small business innovation); training (pediatric critical care, trauma, and palliative care)
  • Lynne Haverkos, Special Research Volunteer
    Main Research Areas: Pediatric injury prevention and epidemiology; emergency care; emergency medical response/services to children
  • Tiffany Ferguson, Extramural Staff Assistant

Highlights

  • PTCIB leads and participates in NICHD’s activities related to COVID-19.
  • Highlights from selected branch-funded research:
    • Community prevention of child maltreatment (CM). In the first phase of an ongoing study, Dr. Kenneth Dodge and his team evaluated the long-term population impact and mechanisms of Family Connects (FC), a program designed to prevent CM in communities via brief home visits by nurses during an infant’s first 2 years. Between July 1, 2009, and December 31, 2010, every infant in Durham County, North Carolina, born on an even birth date (n=2,329 births) received the FC Program, and all infants born on an odd birth date (n=2,450 births) received regular community services. Evaluation indicated high penetration (80.0% of all births consented to participate), high fidelity to the model (84% adherence), and high reliability of scoring risk factors (Κ=0.69). Further evaluation with a representative random sample from intervention (n=269) and control (n=280) groups indicated that FC families accessed more community resources and exhibited less anxiety and better parenting behavior. Hospital records indicated FC families also had fewer emergency medical care visits and overnights in the hospital through age 24 months; child protective service records indicated 39% lower investigation rates for CM in FC families through age 60 months. These investigations indicate that a modest economic investment in a short-term, postpartum, universal home-visiting program like FC ($700/birth) could produce positive, sustained returns for communities over time. Dr. Dodge and his team suggest that building a continuum of support for families, such as integrating FC in infancy with another family-centered intervention in toddlerhood, present a promising possibility for supporting sustained population impact throughout early childhood and into the transition to kindergarten. (PMID: 31477190)
    • A mixed-method study of neighborhood factors and child maltreatment (CM). CM affects one in five children nationwide and often leads to profound physical, psychological, and behavioral consequences that may persist throughout life. Interventions to prevent CM are critically needed. Besides the inestimable cost in human suffering, CM’s material costs to society total more than $100 billion per year. Though most prevention efforts focus on individuals or families, the neighborhood is a key environment that both influences maltreatment rates and might serve as a potential intervention location to reduce CM. This branch-funded mixed-methods study found that neighborhood structural factors (e.g., economic disadvantage, residential instability, childcare burden, immigrant concentration) are linked to greater maltreatment, even after accounting for the effects of family and individual factors. Dr. James Spilsbury and his team examined the perceptions of neighborhood residents (n=400) and neighborhood-based child-welfare workers (n=260) in 20 neighborhoods in Cleveland, Ohio, on two neighborhood process measures: social disorder (risk factor) and collective efficacy (protective factor). Child-welfare workers and residents needed to reach a common understanding of these factors to also agree on the safety of children in these neighborhoods. Multilevel modeling, taking into account individual and neighborhood characteristics, showed that child-welfare workers consistently perceived higher social disorder and lower collective efficacy compared to residents. Neighborhood characteristics were associated with residents' and child-welfare workers' perspectives on social disorder in different ways, and these differences have implications for better understanding the context and improving the effectiveness of neighborhood-based interventions to prevent CM. (PMID: 30035561)
    • Clinical decision rules to identify bruising caused by physical child abuse (PCA). Many cases of PCA are missed initially because early signs of abuse, such as bruising, go unrecognized. This lack of recognition leads to errors in decision-making, which leads to poor patient outcomes. When abuse is missed, repeat injury occurs in up to 80% of victims, with mortality rates as high as 30%. Bruising is one of the most common signs of PCA and is missed as an early warning sign in up to 44% of fatal and near-fatal cases. Although no evidence-based guidelines currently exist to aid clinicians in distinguishing between bruises caused by PCA versus accidental trauma, evidence from several studies indicates that discriminating characteristics do exist. The predictive accuracy of these findings has not yet been determined or incorporated into a practical decision-making model, such as a clinical decision rule, for the acute care setting. In this study, Dr. Mary Clyde Pierce and colleagues provide the first practical screening tool in the form of a Bruising Clinical Decision Rule (BCDR) for classifying bruises caused by PCA in children older than 4 years of age. This observational study builds on the team’s previous work in which they derived a BCDR with 97% sensitivity and 84% specificity for identifying bruises caused by PCA. findings suggest that once infants begin to cruise (i.e., walk while holding onto objects), they are more likely to bruise. Three studies of clinic patients ranging from 6 to 12 months of age yielded prevalence of 12%-13%, with increased mobility associated with increased bruising. The prevalence rate for this study also increased within age strata but was only half that reported for the 6- to 12-month-olds. The reason for the higher rate of infant bruising in a well-child clinic population compared to a pediatric emergency department (ED) population is not clear. However, the oldest patients in the study sample (11 and 12 months of age) exhibited a more comparable prevalence rate of 10%. Studies of high-risk and/or abuse populations yielded the highest bruising prevalence rates, ranging from 25.9% for children referred to child abuse teams to 72% for children who died from abusive head trauma. The relatively low prevalence of bruising in healthy well-child and ED visits in the first year of life compared to that among populations referred for or dying from abuse underscores the importance of this physical examination finding and indicates that even a seemingly simple finding can be ominous and requires clinical due diligence. (PMID: 26233923)
  • HHS's "Strong and Thriving Families" website and CDC's "Child Abuse and Neglect Prevention" website both offer ways to increase awareness and provide families with the resources and strategies needed to prevent child abuse and neglect.
  • Video: PTCIB Chief Dr. Valerie Maholmes Talks About TBI in Kids 
    View the text alternative.
  • Meeting: Multiple Organ Dysfunction Syndrome: A Challenge for the Pediatric Critical Care Community. This 2-day workshop organized by the branch included discussions of this syndrome, identified key knowledge gaps, and considered potential opportunities for future research. Pediatric Multiple Organ Dysfunction Syndrome Supplement to Pediatric Critical Care Medicine .
  • Workshop on Pulmonary Complications of Pediatric Hematopoietic Stem Cell Transplantation (HCT). Co-sponsored by NICHD, the National Heart, Lung, and Blood Institute, and the National Cancer Institute, this workshop was a multidisciplinary effort to describe the status of pulmonary complications occurring within a year after HCT in children, to identify critical gaps in existing knowledge and to explore avenues for research to address these knowledge gaps to advance care and optimize outcomes.  
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