Validation of the PediBIRN-7 clinical prediction rule for pediatric abusive head trauma.

BACKGROUND: The PediBIRN-7 clinical prediction rule incorporates the (positive or negative) predictive contributions of completed abuse evaluations to estimate abusive head trauma (AHT) probability after abuse evaluation. Applying definitional criteria as proxies for AHT and non-AHT ground truth, it performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.88 (95 % CI: 0.85-0.92) in its derivation study. OBJECTIVE: To validate the PediBIRN-7's AHT prediction performance in a novel, equivalent, patient population. PARTICIPANTS AND SETTINGS: Consecutive, acutely head-injured children <3 years hospitalized for intensive care across eight sites between 2017 and 2020 with completed skeletal surveys and retinal exams (N = 342). METHODS: Secondary analysis of an existing, cross-sectional, prospective dataset, including assignment of patient-specific estimates of AHT probability, calculation of AHT prediction performance measures (ROC-AUC, sensitivity, specificity, predictive values), and completion of sensitivity analyses to estimate best- and worst-case prediction performances. RESULTS: Applying the same definitional criteria, the PediBIRN-7 performed with sensitivity 0.74 (95 % CI: 0.66-0.81), specificity 0.77 (95 % CI: 0.70-0.83), and ROC-AUC 0.83 (95 % CI: 0.78-0.88). The reduction in ROC-AUC was statistically insignificant (p = .07). Applying physicians' final consensus diagnoses as proxies for AHT and non-AHT ground truth, the PediBIRN-7 performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.90 (95 % CI: 0.87-0.94). Sensitivity analyses demonstrated minimal changes in rule performance. CONCLUSION: The PediBIRN-7's overall AHT prediction performance has been validated in a novel, equivalent, patient population. Its patient-specific estimates of AHT probability can inform physicians' AHT-related diagnostic reasoning after abuse evaluation.

An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma.

BACKGROUND: Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms. OBJECTIVES: To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT. PARTICIPANTS AND SETTING: Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021. METHODS: Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values. RESULTS: Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96. CONCLUSIONS: The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."

Extra-axial haemorrhages in young children with skull fractures: abuse or accident?

OBJECTIVE: Infant and toddler subdural haemorrhages (SDH) are often considered indicative of abuse or major trauma. However, accidental impact events, such as falls, cause contact extra-axial haemorrhages (EAHs). The current study sought to determine frequency and clinical behaviour of EAHs with infant and toddler accidental and abusive skull fractures. PATIENTS AND METHODS: Children aged <4 years with accidental skull fractures and abusive fractures identified by CT at two paediatric tertiary care centres. Clinical data were abstracted by child abuse paediatricians and images were reviewed by paediatric radiologists. Data were analysed using univariate and multivariate logistic regression as well as descriptive statistics. RESULTS: Among 227 subjects, 86 (37.9%) had EAHs. EAH was present in 73 (34.8%) accidental and 13 (76.5%) of the abusive injuries. Intracranial haemorrhage rates were not different for children with major or minor accidents but were fewer than abused. EAH was equally common with falls <4 and >4 ft. EAH depths did not differ by mechanism, but 69% of accidental EAHs were localised solely at fracture sites vs 38% abuse. Widespread and multifocal EAHs were more common with abuse. Children with abuse or major accidental injuries presented with lower initial Glasgow Coma Scales than those with minor accidents. Abused children had initial loss of consciousness more often than those with either minor or major accidents. CONCLUSIONS: Simple contact EAHs were common among children with minor and major accidental skull fractures. Accidental EAHs were more localised with less neurological dysfunction than abusive.

Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis.

OBJECTIVES: Data guiding abusive head trauma (AHT) diagnosis rest on case-control studies that have been criticized for circularity. We wished to sort children with neurologic injury using mathematical algorithms, without reference to physicians' diagnoses or predetermined diagnostic criteria, and to compare the results to existing AHT data, physicians' diagnoses, and a proposed triad of findings. METHODS: Unsupervised cluster analysis of an existing data set regarding 500 young patients with acute head injury hospitalized for intensive care. Three cluster algorithms were used to sort (partition) patients into subpopulations (clusters) on the basis of 32 reliable (κ > 0.6) clinical and radiologic variables. P values and odds ratios (ORs) identified variables most predictive of partitioning. RESULTS: The full cohort partitioned into 2 clusters. Variables substantially (P < .001 and OR > 10 in all 3 cluster algorithms) more prevalent in cluster 1 were imaging indications of brain hypoxemia, ischemia, and/or swelling; acute encephalopathy, particularly when lasting >24 hours; respiratory compromise; subdural hemorrhage or fluid collection; and ophthalmologist-confirmed retinoschisis. Variables substantially (P < .001 and OR < 0.10 in any cluster algorithm) more prevalent in cluster 2 were linear parietal skull fracture and epidural hematoma. Postpartitioning analysis revealed that cluster 1 had a high prevalence of physician-diagnosed abuse. CONCLUSIONS: Three cluster algorithms partitioned the population into 2 clusters without reference to predetermined diagnostic criteria or clinical opinion about the nature of AHT. Clinical difference between clusters replicated differences previously described in comparisons of AHT with non-AHT. Algorithmic partition was predictive of physician diagnosis and of the triad of findings heavily discussed in AHT literature.

Binky Bites and Other Oronasal Pressure Injuries.

Initial examination and exploration of childhood injuries may not lead to an obvious explanation of abuse. Although abusive oronasal injuries have been described, ones including nasal destruction are rare. We describe 4 children abused using implements that ultimately were thought to have caused significant nasal tissue destruction. In 2 of the cases, a forced pacifier placement was implicated in causing pressure injuries. In the other 2 cases, gags were part of the children's injuries. All 4 children had other findings of abuse and neglect.

Potential Impact of a Validated Screening Tool for Pediatric Abusive Head Trauma.

OBJECTIVE: To conduct a retrospective, theoretical comparison of actual pediatric intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT screening guided by a previously validated 4-variable clinical prediction rule (CPR) in datasets used by the Pediatric Brain Injury Research Network to derive and validate the CPR. STUDY DESIGN: We calculated CPR-based estimates of abuse probability for all 500 patients in the datasets. Next, we demonstrated a positive and very strong correlation between these estimates of abuse probability and the overall diagnostic yields of our patients' completed skeletal surveys and retinal examinations. Having demonstrated this correlation, we applied mean estimates of abuse probability to predict additional, positive abuse evaluations among patients lacking skeletal survey and/or retinal examination. Finally, we used these predictions of additional, positive abuse evaluations to extrapolate and compare AHT detection (and 2 other measures of AHT screening accuracy) in actual PICU screening for AHT vs AHT screening guided by the CPR. RESULTS: Our results suggest that AHT screening guided by the CPR could theoretically increase AHT detection in PICU settings from 87%-96% (P < .001), and increase the overall diagnostic yield of completed abuse evaluations from 49%-56% (P = .058), while targeting slightly fewer, though not significantly less, children for abuse evaluation. CONCLUSIONS: Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.

Medical neglect.

Medical neglect occurs when children are harmed or placed at significant risk of harm by gaps in their medical care. This is most likely to occur and to be recognized when families lack resources, commonly due to poverty, and when medical demands are high, such as with complex, severe, and chronic illness. A systematic evaluation of the probabilities for harm from gaps in care versus benefits from improved care will define medical neglect. A broad consideration of child, family, community, and medical system contributions to identified gaps will guide management. Special circumstances, such as lapsed immunizations, unremitting obesity, and medically motivated alterations in care, are often challenging for medical providers. Guidance for these specific situations is available from the American Academy of Pediatrics, and from the medical literature.

Derivation of a clinical prediction rule for pediatric abusive head trauma.

OBJECTIVES: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that-if validated-can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse. DESIGN: Prospective, multicenter, cross-sectional, observational. SETTING: Fourteen PICUs. PATIENTS: Acutely head-injured children less than 3 years old admitted for intensive care. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity-to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. CONCLUSIONS: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform-not dictate-their early decisions to launch (or forego) an evaluation for abuse.

Transverse fracture of the distal femoral metadiaphysis: a plausible accidental mechanism.

OBJECTIVES: This study describes the mechanism of injury of an impacted transverse fracture of the distal femoral metadiaphysis. Individual experience by child abuse pediatricians with this fracture type has suggested that it is less associated with inflicted trauma than was described in a prior case series. METHODS: Case contributions were solicited from an international group of child abuse clinicians. Eighteen cases were accepted for analysis. Cases were categorized as abuse or nonabuse by a predefined categorization scheme. Differences in the 2 groups were analyzed by Fischer exact test. RESULTS: Thirteen cases (72%) were determined to be nonabusive, and 5 (28%) were determined to be from abuse. Additional skeletal injuries on skeletal radiograph survey, absence of any explanatory history, and significant changes in repeated histories identified cases of abuse. A short fall was accepted as the explanation for the nonabuse cases, with some indication that direct impact on the knee explained the injury. CONCLUSIONS: Impacted transverse fracture of the distal femoral metadiaphysis may occur as a result of an accidental short fall of young children. A traditional abuse evaluation should be pursued in these cases, but with an absence of additional skeletal findings, and a history of a fall, it is likely that an accidental mechanism accounts for the injury.

Into hot water head first: distribution of intentional and unintentional immersion burns.

INTRODUCTION: Experience with several, previously unreported, intentional face-first immersion burns led us to evaluate the distribution of inflicted and unintentional immersion scald burns in a hospital series. SETTING: (1) Authors' clinical and legal practices; (2) Burn center at regional Level 1 trauma hospital. SUBJECTS: : (1) Case series of face-first, inflicted immersion burn victims; (2) Consecutive hospitalized scald burn victims younger than 5 years old, 1/3/1996 to 3/25/2000. METHODS: (1) Individual case reports; (2) Retrospective records review. Simple descriptive statistics, Fisher Exact test and t test. RESULTS: (1) Six cases of inflicted head and neck immersion injury are described. Four were tap water and 2 food/drink scalds. (2) 22/195 hospitalized victims had sustained immersion burns, 13 from tap water and 9 from other fluids. Six (46%) tap water immersions and no (0%) other immersions had inflicted injuries (P = 0.05). Two of the tap water immersions and one other source immersion included burning of the head and neck. Of these, one tap water immersion, but no other immersion, was inflicted. In no patients were head and neck injuries the sole or predominant site of scalding. In all, 9 children sustained inflicted scalds. Bilateral lower extremity tap water immersion scalds occurred in 100% (6/6) of abusive and 29% (2/7) of unintentional injuries (P = 0.02). Buttock and perineal injuries occurred in 67% (4/6) inflicted versus 29% (2/7) unintentional tap water immersion scalds (P = 0.28). Other fluids caused bilateral lower extremity immersion burns in 3/9 (33 %) unintentionally injured patients, but no abused children (NS). CONCLUSIONS: Craniofacial immersion injury, although seen by the authors in legal cases, is infrequent. It was present incidentally in one inflicted tap water burn in the consecutive hospital series. This series affirms the predominance of bilateral lower extremity burns in inflicted tap water immersions. Buttock/perineal immersions were more common with abuse than with unintentional injury.

Anogenital injuries in child pedestrians run over by low-speed motor vehicles: four cases with findings that mimic child sexual abuse.

OBJECTIVE: Differentiating between child sexual abuse and nonintentional causes of anogenital injury can be challenging, and a misdiagnosis can have a profound impact on the child and family. This case series documents an important nonintentional mechanism of anogenital injury that mimics the physical findings of child sexual abuse. METHODS: Four children were examined after being run over by a slow-moving motor vehicle. In each case, the wheel of the vehicle passed longitudinally over the child's torso. RESULTS: Two children had perianal lacerations, and 2 had hymenal lacerations. One child with hymen injuries was followed for 4 weeks and developed findings identical to those seen in healed sexual abuse. CONCLUSIONS: Children run over by motor vehicles should be evaluated for anogenital injury. If such injury is suspected, it should be fully delineated and documented with colposcopy and follow-up examination. Although the possibility of sexual abuse must be considered, awareness of the occurrence of anogenital injuries in children run over by motor vehicles may prevent the misdiagnosis of acute sexual abuse in children. Conversely, children presenting for evaluation of acute or past sexual abuse should be questioned as to whether they were ever run over by a motor vehicle.