Estimating the probability of abusive head trauma after abuse evaluation

Hymel, Kent P.; Wang, Ming; Chinchilli, Vernon M.; Karst, Wouter A.; Willson, Douglas F.; Dias, Mark S.; Herman, Bruce; Carroll, Christopher L.; Haney, Suzanne B.; Isaac, Reena

doi:10.1016/j.chiabu.2018.11.015

Cited by 29 publications

(17 citation statements)

References 19 publications

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“…1). From this set of results, 93 full-text articles were reviewed for inclusion, of which 19 new articles (representing 18 studies) were included [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42]. In addition, the 13 studies evaluated in the Bailhache et al review [43][44][45][46][47][48][49][50][51][52][53][54][55] were included in this review update, for a total of 32 articles (31 studies).…”

Section: Resultsmentioning

confidence: 99%

“…Hymel et al evaluated a five-variable clinical prediction rule (derivation study) [34] and a four-variable clinical prediction rule (validation study) [33] in identifying potential abusive head trauma in children less than 3 years of age who were admitted to the post-intensive care unit for management of intracranial injuries. An additional article by Hymel et al [38] combined the study populations in the derivation and validation studies in order to evaluate a seven-variable clinical prediction rule in identifying potential abusive head trauma. The seven-variable clinical prediction rule used seven indicators to predict potential abusive head trauma (e.g., any clinically significant respiratory compromise at the scene of injury, during transport, in the emergency department, or prior to admission).…”

Section: Clinical Predication Rules and Predictive Symptomsmentioning

confidence: 99%

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Identifying children exposed to maltreatment: a systematic review update

et al. 2020

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Background: Child maltreatment affects a significant number of children globally. Strategies have been developed to identify children suspected of having been exposed to maltreatment with the aim of reducing further maltreatment and impairment. This systematic review evaluates the accuracy of strategies for identifying children exposed to maltreatment. Methods: We conducted a systematic search of seven databases: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Cochrane Libraries, Sociological Abstracts and the Education Resources Information Center. We included studies published from 1961 to July 2, 2019 estimating the accuracy of instruments for identifying potential maltreatment of children, including neglect, physical abuse, emotional abuse, and sexual abuse. We extracted data about accuracy and narratively synthesised the evidence. For five studies-where the population and setting matched known prevalence estimates in an emergency department setting-we calculated false positives and negatives. We assessed risk of bias using QUADAS-2. Results: We included 32 articles (representing 31 studies) that evaluated various identification strategies, including three screening tools (SPUTOVAMO checklist, Escape instrument, and a 6-item screening questionnaire for child sex trafficking). No studies evaluated the effects of identification strategies on important outcomes for children. All studies were rated as having serious risk of bias (often because of verification bias). The findings suggest that use of the SPUTOVAMO and Escape screening tools at the population level (per 100,000) would result in hundreds of children being missed and thousands of children being over identified. Conclusions: There is low to very low certainty evidence that the use of screening tools may result in high numbers of children being falsely suspected or missed. These harms may outweigh the potential benefits of using such tools in practice (PROSPERO 2016:CRD42016039659).

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Section: Resultsmentioning

confidence: 99%

Section: Clinical Predication Rules and Predictive Symptomsmentioning

confidence: 99%

Identifying children exposed to maltreatment: a systematic review update

et al. 2020

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“…Although not yet externally validated, an update to the PediBIRN in 2019 saw the creation of the PediBIRN-7, which includes results of the AHT workup (imaging-skeletal survey and neuroimaging; retinal exam) to predict probability of AHT in order to further inform a clinician's diagnosis (76). The Predicting Abusive Head Trauma (PredAHT) CPR used 6 clinical indicators and found that when ≥3 of these are present, the estimated probability for AHT is >81.5% (77,78).…”

Section: Clinical Prediction Rulesmentioning

confidence: 99%

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

2020

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Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10-30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as "Never Shake a Baby." This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.

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“…10 Indeed, there is no gold standard for the diagnosis of SBS or AHT, but many efforts have been made to develop tools that can accurately identify when abuse has occurred based on the pattern of injuries. 11 The need for such a tool stems from the fact that these events are seldom witnessed and the perpetrator does not confess to the crime in most cases. 12 Adding further to the confusion, unsubstantiated theories, such as dysphagic choking, 13 have been developed for use in the courtroom as alternative explanations for these injuries, with minimal scientific or medical merit.…”

Section: A History Of Controversymentioning

confidence: 99%

“…24 Specifically, bilateral subdural hematomas, interhemispheric subdural hematomas, retinal hemorrhages, seizures, apnea, impaired consciousness, diffuse cerebral edema, hydrocephalus, complex skull fractures, and bruising of the torso, ears, and neck are more common in cases of AHT, while simple parietal skull fractures and epidural hematomas are more common in cases of accidental trauma. 1,11,24 There are special examples of accidental trauma, such as falling down stairs, that can present with severe injuries in patterns similar to AHT, but these are typically associated with external signs of trauma. 1 A traumatic birth can cause bilateral subdural hematomas and retinal hemorrhages, but these injuries tend to be asymptomatic and resolve after 4 weeks.…”

Section: Medical Obligations Of the Neurosurgeon In Cases Of Suspected Ahtmentioning

confidence: 99%

Medicolegal issues in abusive head trauma for the pediatric neurosurgeon

Bass

Lee

Browd

et al. 2020

Neurosurgical Focus

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The purpose of this article is to serve as a rational guide for the pediatric neurosurgeon in navigating common medicolegal issues that arise in the management of abusive head trauma (AHT). Many of these issues may be unfamiliar or unpleasant to surgeons focused on addressing disease. The authors begin with a brief history on the origins of the diagnosis of AHT and the controversy surrounding it, highlighting some of the facets of the diagnosis that make it particularly unique in pediatric neurosurgery. They then review some special medical considerations in these patients through the perspective of the neurosurgeon and provide several examples as illustration. The authors discuss how to appropriately document these cases in the medical record for expected legal review, and last, they provide an overview of the legal process through which the neurosurgeon may be called to provide testimony.

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Estimating the probability of abusive head trauma after abuse evaluation

Cited by 29 publications

References 19 publications

Identifying children exposed to maltreatment: a systematic review update

Identifying children exposed to maltreatment: a systematic review update

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

Medicolegal issues in abusive head trauma for the pediatric neurosurgeon

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