Validation of a Clinical Prediction Rule for Pediatric Abusive Head Trauma

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Pediatric Brain Injury Research Network investigators recently derived a highly sensitive clinical prediction rule for pediatric abusive head trauma (AHT). WHAT THIS STUDY ADDS:The performance of this AHT screening tool has been validated. Four clinical variables, readily available at the time of admission, detect pediatric AHT with high sensitivity in intensive care settings. abstract BACKGROUND AND OBJECTIVE: To reduce missed cases of pediatric abusive head trauma (AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to validate the screening performance of this AHT CPR in a new, equivalent patient population. METHODS:We conducted a prospective, multicenter, observational, cross-sectional study. Applying the same inclusion criteria, definitional criteria for AHT, and methods used in the completed derivation study, Pediatric Brain Injury Research Network investigators captured complete clinical, historical, and radiologic data on 291 acutely headinjured children ,3 years of age admitted to PICUs at 14 participating sites, sorted them into comparison groups of abusive and nonabusive head trauma, and measured the screening performance of the AHT CPR. RESULTS:In this new patient population, the 4-variable AHT CPR demonstrated sensitivity of .96, specificity of .46, positive predictive value of .55, negative predictive value of .93, positive likelihood ratio of 1.67, and negative likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified 98% of study patients who were ultimately diagnosed with AHT.CONCLUSIONS: Four readily available variables (acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture) identify AHT with high sensitivity in young, acutely head-injured children admitted to the PICU. Pediatrics 2014;134:e1537-e1544

Clinical prediction rules for abusive head trauma: a systematic review

“…The search in PubMed and the Cochrane Database of Systematic Reviews and Cochrane Controlled Trials did not add any additional relevant studies. After removing duplicates, reviewing abstracts and excluding irrelevant articles, three recently published, externally validated CPredRs for AHT met the inclusion criteria: the Pediatric Brain Injury Research Network (PediBIRN) 4-Variable AHT CPredR,19 the Predicting Abusive Head Trauma (PredAHT) tool20 and the Pittsburgh Infant Brain Injury Score (PIBIS) for AHT21 (see figure 1 and table 1). …”

Validation of a Prediction Tool for Abusive Head Trauma

“…injury where one could use a CDR: to determine which children should undergo neuroimaging in the first instance, 35 to exclude abuse when the results of the tool are negative, 8,9 or to assist in determining the likelihood of abuse, once all the clinical information is known. The recently validated tool developed by the Pediatric Brain Injury Research Network investigators offers a high sensitivity (96%; 95% CI, 90-99) but at the expense of low specificity (43%; 95% CI, 35-50), 9 whereas the PredAHT tool performs as a clinical prediction tool with a sensitivity of 72.3% (95% CI, 60.4-81.7) and a specificity of 86.3% (95% CI, 78.8-90.7) with a 50% cutoff applied.…”

“…The recently validated tool developed by the Pediatric Brain Injury Research Network investigators offers a high sensitivity (96%; 95% CI, 90-99) but at the expense of low specificity (43%; 95% CI, 35-50), 9 whereas the PredAHT tool performs as a clinical prediction tool with a sensitivity of 72.3% (95% CI, 60.4-81.7) and a specificity of 86.3% (95% CI, 78.8-90.7) with a 50% cutoff applied. The sensitivity and specificity depend on the cutoff point applied to the probability scale.…”

“…A recently validated CDR with a high sensitivity of 96% (95% confidence interval [CI], 90%-99%) has been developed for the pediatric intensive care setting for nonvehicular traumatic brain injury to help exclude AHT. 8,9 This approach has been questioned by some, 10 on the grounds that the pretest probability of AHT was as high as 45%, in which case there is an argument that all children should be screened for the condition, and a CDR of this kind is not justified. Clearly, the optimal CDR in this setting would have high sensitivity and specificity without incurring extensive investigations that are not otherwise clinically warranted and may expose children to unnecessary doses of radiation.…”

Update on abusive head trauma

“…However, given that AHT often presents with nonspecific symptoms, without external sign of injury, and without a disclosed history of head trauma, researchers hope that certain serum biomarkers might help identify more subtle cases of AHT just as transaminases are used to screen for occult abdominal trauma [17]. Gao et al [18 && ] compared serum proteomic profiles of patients diagnosed with mild AHT [Glasgow Coma Scale (GCS) [13][14][15] who presented for the evaluation of head trauma or a neurologic symptom (e.g., vomiting, fussiness, or seizures) with those of matched controls presenting with similar symptoms but without a history of head trauma or diagnosis of brain injury. Serum amyloid A, an acute phase reactant previously identified as a potential marker of injury in hypoxic-ischemic encephalopathy and traumatic brain injury (TBI), had significantly higher mean expression among AHT cases versus controls, with impressive discriminating ability and an area under the receiver operator curve of 0.96.…”