Most of the children who sustained injury in our study were school-going children (6–12 years). It is similar to the study according to Hegde et al. and Bhatti et al.[23] In the present study, 76% (n = 52) of the injured children were males while females accounts for 24% (n = 16). It may be due to social factors like more freedom, opportunities and facilities given to males in our society in India and environmental factors such as playing on roads, trees, rooftop and near construction sites makes them more vulnerable to get injured. All these factors were mentioned in the study of Kundal et al.,[1] it is similar to the previous studies according to Kulshrestha et al., Verma et al. and Sharma et al.[456]

The most common mode of injury in our study was FFH (n = 42, 62%) while road traffic accidents account for 35% (n = 24), miscellaneous causes like hit by animal and fall of heavy object on the abdomen were seen in 3%. Similar results were noted in the previous study by Sharma et al. and Bangdiwala et al.[67] In our study fall from roof, fall from stairs, fall from bed and fall on the ground while playing were more common which signifies the need for proper supervision at home and play areas.

In the present study, majority (53%, n = 36) of patients presented within 24 h after injury and 28% (n = 19) of them presented between 24 and 72 h after injury; according to the study of Hegde et al., 80% of patients presented within 24 h.[3] Usually retroperitoneal injuries presents late because the signs and symptoms will be subtle and associated intra-abdominal and multisystem involvement further delays the diagnosis.[8] In our study, late presentation is observed in children with Grade I or II injuries and retroperitoneal injuries.

At the time of presentation majority of the patients (90%, n = 61) were hemodynamically stable. Fifty-one out of 68 patients (75%) had abnormal abdominal examination (AAE) which includes abdominal distension, abdominal wall contusion/seat belt sign, tenderness on palpation and other signs of peritonitis. This is statistically significant (z = 8.29, P < 0.001). Increase in abdominal girth (AG) was observed in 11 patients (16%) on serial measurement and all of them underwent laparotomy. Streck et al. proposed a clinical prediction rule to identify IAI, thus reducing unnecessary CT scans of abdomen.[9] It includes six high risk clinical factors which can predict IAI and those are hypotension, AAE, haematocrit < 30, aspartate amino transferase (AST) >200, serum amylase > 100 U/L and haematuria (>5 Red Blood Cells (RBC)/hpf). These clinical predictors taken into consideration in our study are enumerated in Table 2, all our patients had at least one parameter positive among the six, confirming the IAI, but CECT was done to know the exact grading of injury after stablilising the patient. According to Holmes et al., the six variables which can predict IAI are systolic blood pressure, AAE, haematocrit, liver function tests, urine analysis and femur fracture and application of this prediction rule helped in reducing abdominal CT scans by 33% in patients with low risk for IAI in their study.[10] These clinical predictors were not taken into consideration in our study.

About 59% (n = 40) of patients had Hb < 10 gm% and 62% (n = 42) of children had haematocrit packed cell volume (PCV) <30 at admission, both indicating the requirement for blood transfusion. In our study, 68% (n = 46) of patients received blood transfusion. Both clinical assessment and response to fluid resuscitation were taken into consideration before transfusing blood. Considerations for blood transfusion in our study include low Hb (<10 gm%) and PCV (<35) at the time of admission (intra-abdominal bleed) and a decreasing trend of Hb on serial monitoring (@>1 gm% fall/24 h), preexisting anaemia in most of the children in Indian scenario, signs of hypovolemia like tachycardia and hypotension appear late as children can tolerate up to 20% loss of blood volume.

FAST plays an important role in the initial evaluation of trauma child. Holmes et al.’s study on the role of ultrasonography (USG) (FAST) in trauma concluded that a hemodynamically stable child with positive USG should undergo CT.[11] CT is readily available nowadays and is highly sensitive in detecting IAI, hence it became the procedure of choice in evaluating injured children.[12] Ellison et al. concluded in their study that routine use of oral contrast is not necessary and it delays the time taken for CT scans and angiographic studies and only intravenous contrast is adequate.[13] In the current study, CT scans were done with intravenous contrast.

Most of the patients in our study (n = 36, 53%) sustained Grade IV injury, lower grade injuries (Grade I, II, III) might be under-reported in the present study because some of the asymptomatic patients might have not reported or referred to our hospital.

Multisystem involvement is common in children. Two or more organ system involvement is called polytrauma. The most commonly associated injury in the current study was thoracic injury (28%). This is similar to other studies by Peres et al., Bhatti et al.[314] In our study, one male child who was 3-year-old had facial nerve palsy with a deviation of mouth along with head injury and it resolved after oral corticosteroid.

The current management of stable children with solid organ injuries is non-operative management (NOM) and it depends on haemodynamic status, not grade of injury.[1516] Success rate of NOM of liver injuries is 85%–90% and for splenic injuries it is 90%–98%.[17] Indications for emergency laparotomy include free air in peritoneal cavity, hemodynamic instability despite maximum resuscitation, evisceration of intra-abdominal contents, gunshot wounds of abdomen or any penetrating injury with breach in peritoneum.[18] All the patients who underwent laparotomy had AAE and increase in AG on serial examination with guarding and rigidity. Decision to proceed for surgical exploration was made on the basis of hemodynamic stability and serial clinical examination. According to Cohn et al. sensitivity of all grading systems is poor in predicting the necessity of intervention like surgery or angioembolisation in solid organ injuries.[19]

In our study, two patients had Grade III and Grade IV abdominal venous injuries (iliac vein and Inferior Vena Cava [IVC]) and were managed conservatively. Virgilio et al. Reported conservative management for patients with established venous thrombus.[20] Literature regarding the distribution and management of major abdominal venous injuries in children is not widely available. If there are no risk factors such as associated arterial injury, multiple injuries, seat belt injury and high energy mechanism of injury, trial of NOM should be considered for these injuries.[21]

APSA has given guidelines for hospital stay (grade of injury + 1 day) and activity restriction (grade of injury + 2 weeks) for solid organ injuries.[22] In the current study, only 25% (n = 17) were discharged from the hospital as per the APSA guidelines, remaining all other patients (75%, n = 51) stayed in the hospital more than the recommended stay. Reasons may be, treating surgeon being extra cautious for rebleed and poor compliance, patient factors like fear of taking the child home early and medicolegal nature of these cases.

In the current study, only four patients (6%) were treated in intensive care unit (ICU). Fremgen et al. described that ICU admission is not required in stable children and it should be based on haemodynamic status rather than imaging findings.[23] McVay et al. also suggested that the management should be based on haemodynamic status not on grade of injury.[24] Graziano et al. suggested that bed rest was not required in case of renal injuries.[25] In our study, we advised activity restriction because on resuming to normal activities early in renal injury patients caused haematuria.

In the current study, mortality rate was zero. Low mortality in our study may be because the patients with abdominal trauma were referred to us after initial stabilisation and FAST in the emergency department by the trauma team as our institute is a specialised trauma centre. Those who have expired in the emergency department were not reported to us. Most of the patients (88%, n = 60) had good outcome despite high grade of injury which suggest that grade of injury does not correlate with the outcome (χ² = 1.67; P = 0.79, statistically not significant). Good outcome in these patients may be because of early presentation in higher grade of injury, timely intervention and regular follow-up. Angiogenesis, revascularisation and transforming growth factor-β (TGF-β) kinetics controlling collagen deposition and extracellular remodelling were better in children leading to a better outcome.[26] During follow-up, morbidity is seen in three patients (4.4%), which include one child who underwent laparotomy for jejunal perforation re-admitted twice for gastritis and sub-acute adhesive intestinal obstruction which resolved with conservative management, CBD repair patient had stricture at the site of repair who was managed with endoscopic stenting and urinary bladder rupture patient planned for bladder neck reconstruction in view of incontinence. Other complications observed were pseudo aneurysm of hepatic artery in the patient who was operated for Grade III liver injury. Two patients of liver injury developed liver abscess which managed by pigtail catheter insertion for drainage of abscess. One child with complete pancreatic transaction developed pseudocyst of pancreas which was managed by endoscopic internal drainage. One more child with Grade IV kidney injury had scarred and nonfunctioning kidney on radionuclide scan (Dimercapto Succinic Acid [DMSA]) but there is no evidence of hypertension on regular follow-up. Fuchs et al. described that late hypertension and renal insufficiency are uncommon after renal injuries.[27] Giss et al. and Notrica et al. described in their studies that re-imaging is not needed in asymptomatic children.[2829] Even the current APSA guidelines recommend the same.[22] In our study also, reimaging was done only in symptomatic patients.