Abusive head trauma in young children: characteristics and medical charges in a hospitalized population

Ettaro, Lorraine; Berger, Rachel P.; Songer, Thomas J.

doi:10.1016/j.chiabu.2004.06.006

Cited by 84 publications

(64 citation statements)

References 24 publications

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“…Proper diagnosis of ITBI is often difficult even for experienced, astute physicians because caretakers rarely provide a history of trauma (4,5), children present with nonspecific symptoms, such as vomiting or fussiness (6) and physical examination can be normal (7,8). As a result, misdiagnosis is common and can have catastrophic medical consequences (9,10).…”

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confidence: 99%

Multiplex Assessment of Serum Biomarker Concentrations in Well-Appearing Children With Inflicted Traumatic Brain Injury

et al. 2009

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Proper diagnosis of mild inflicted traumatic brain injury (ITBI) is difficult; children often present without a history of trauma and with nonspecific symptoms, such as vomiting. Previous studies suggest that biomarkers may be able to screen for brain injury in this population, but these studies focused on only a few biomarkers. We hypothesized that using multiplex bead technology we would be able to identify multiple differences in the serum biomarker profile between in children with ITBI and those without brain injury. We compared the concentrations of 44 serum biomarkers in 16 infants with mild ITBI and 20 infants without brain injury. There were significant group differences in the concentrations of nine of the 44 markers. Vascular cellular adhesion molecule (VCAM) (p Ͻ 0.00) and IL-6 (IL-6) (p Ͻ 0.00) had the most significant group differences; IL-6 was higher after ITBI, whereas VCAM was lower. Using VCAM and IL-6 in classification algorithms, we could discriminate the groups with a sensitivity and specificity of 87% and 90%, respectively. The results suggest significant changes in the serum biomarker profile after mild ITBI. Future research is needed to determine whether these biomarkers can screen for brain injury in infants with nonspecific symptoms. Proper diagnosis of ITBI is often difficult even for experienced, astute physicians because caretakers rarely provide a history of trauma (4,5), children present with nonspecific symptoms, such as vomiting or fussiness (6) and physical examination can be normal (7,8). As a result, misdiagnosis is common and can have catastrophic medical consequences (9,10). The importance of timely diagnosis of ITBI cannot be overemphasized: if not recognized, child abuse is an escalating form of trauma that often ends in death or disability (11).The frequency with which ITBI is misdiagnosed and the resulting morbidity and mortality are compounded by the lack of a well-established screening test to help physicians identify children who might benefit from evaluation with cranial computed tomography (CT). We previously reported on the possible use of serum biomarkers as screening tools for infants at increased risk of missed ITBI-infants without a history of trauma and with nonspecific symptoms (12-15). We focused on three well-established and relatively brain-specific markers: neuron-specific enolase, S100B, and myelin-basic protein.Our study evaluating these markers as screening tools for ITBI in high-risk infants showed that a combination of neuronspecific enolase and myelin-basic protein was 79% sensitive and 70% specific for brain injury (14). Contrary to previous literature in adults and older children, S100B was not specific for brain injury in infants.Biomarker concentrations in our previous studies have been measured using ELISA. ELISA allows for measurement of only one biomarker at a time and requires up to 100 L of serum for each biomarker. In young children, it is difficult to collect large sample volumes and 100 L may be the entire sample.Multiplex bead...

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confidence: 99%

Multiplex Assessment of Serum Biomarker Concentrations in Well-Appearing Children With Inflicted Traumatic Brain Injury

et al. 2009

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“…Our original tool was derived from a rigorous systematic review of world literature. 18 Thanks to the generous sharing of original data on 6 key clinical features from the highestquality publications, [24][25][26][27][28][29] we developed a tool to predict AHT, using a data set of 1053 cases of children with intracranial injury (ICI). 30 We refer to this as the PredAHT tool.…”

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confidence: 99%

Validation of a Prediction Tool for Abusive Head Trauma

et al. 2015

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BACKGROUND AND OBJECTIVES: Abusive head trauma (AHT) may be missed in the clinical setting. Clinical prediction tools are used to reduce variability in practice and inform decision-making. From a systematic review and individual patient data analysis we derived the Predicting Abusive Head Trauma (PredAHT) tool, using multilevel logistic regression to predict likelihood of AHT. This study aims to externally validate the PredAHT tool.METHODS: Consecutive children aged ,36 months admitted with an intracranial injury, confirmed as abusive or nonabusive, to 2 sites used in the original model were ascertained. Details of 6 influential features were recorded (retinal hemorrhage, rib and long -bone fractures, apnea, seizures, and head or neck bruising). We estimated the likelihood of an unrecorded feature being present with multiple imputation; analysis included sensitivity, specificity, and area under the curve, with 95% confidence intervals (CIs).RESULTS: Data included 133 non-AHT cases and 65 AHT cases, 97% of children were ,24 months old. Consistent with original predictions, when $3 features were present in a child ,36 months old with intracranial injury, the estimated probability of AHT was .81.5% (95% CI, 63.3-91.8). The sensitivity of the tool was 72.3% (95% CI, 60.4-81.7), the specificity was 85.7% (95% CI, 78.8-90.7), area under the curve 0.88 (95% CI, 0.823-0.926).CONCLUSIONS: When tested on novel data, the PredAHT tool performed well. This tool has the potential to contribute to decision-making in these challenging cases. An implementation study is needed to explore its performance and utility within the child protection process. WHAT'S KNOWN ON THIS SUBJECT:A previous multivariable statistical model, using individual patient data, estimated the probability of abusive head trauma based on the presence or absence of 6 clinical features: rib fracture, long-bone fracture, apnea, seizures, retinal hemorrhage, and head or neck bruising. WHAT THIS STUDY ADDS:The model performed well in this validation, with a sensitivity of 72.3%, specificity of 85.7%, and area under the curve of 0.88. In children ,3 years old with intracranial injury plus $3 features, the estimated probability of abuse is .81.5%. Ms Cowley drafted the Methods section, produced the tables, revised the article, formatted the article, and contributed to overall editing; Dr Morris collected the data in data set 1 and entered all anonymized data into the database; Dr. Maguire had the initial study idea, drafted and revised the article, and contributed to the study design and overall editing; Dr Farewell designed and conducted all statistical analyses, drafted the statistical components of the article, produced the figures, and contributed to overall editing; Prof Kemp revised the article and contributed to overall study design and editing; and all authors approved the final manuscript as submitted. Clinicians who undertake child protection investigations of children presenting with head injury can meet resistance and face a barrage of critici...

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“…Our decision to subcategorize in this way was based on data from a previous study by our group that evaluated the cost of child maltreatment. 19 In this study, children with possible abuse were most similar to subjects with no abuse, whereas subjects with probable abuse were most similar to subjects with definite abuse.…”

Section: Data Collectedmentioning

confidence: 70%

Use of Skeletal Surveys to Evaluate for Physical Abuse: Analysis of 703 Consecutive Skeletal Surveys

2010

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Abusive head trauma in young children: characteristics and medical charges in a hospitalized population

Cited by 84 publications

References 24 publications

Multiplex Assessment of Serum Biomarker Concentrations in Well-Appearing Children With Inflicted Traumatic Brain Injury

Multiplex Assessment of Serum Biomarker Concentrations in Well-Appearing Children With Inflicted Traumatic Brain Injury

Validation of a Prediction Tool for Abusive Head Trauma

Use of Skeletal Surveys to Evaluate for Physical Abuse: Analysis of 703 Consecutive Skeletal Surveys

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