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Published on: January 20, 2023
Estimating the probability of abusive head trauma: a pooled analysis
Sabine Ann Maguire1, Alison Mary Kemp, Rebecca Caroline Lumb
1Department of Child Health, School of Medicine, Cardiff University, Cardiff, United Kingdom. sabinemaguire@yahoo.co.uk
Insights
Combinations of clinical features, including apnea, retinal hemorrhage, and rib fractures, significantly increase the likelihood of abusive head trauma (AHT) in children. Three or more features strongly indicate AHT, aiding diagnosis.
Area of Science:
- Pediatrics
- Forensic Medicine
- Child Abuse Research
Background:
- Distinguishing abusive head trauma (AHT) from nonabusive head trauma is critical for child protection.
- Clinical features alone can be ambiguous in diagnosing AHT.
Purpose of the Study:
- To identify combinations of clinical features that effectively differentiate AHT from nonabusive head trauma in young children.
- To establish the diagnostic value of specific clinical presentations in suspected AHT cases.
Main Methods:
- An aggregate analysis of individual patient data from six comparative studies involving children under three years old with intracranial injury.
- Utilized multiple imputation for combined clinical features, employing a bespoke hot-deck imputation strategy to manage missing data.
- Focused on features such as apnea, retinal hemorrhage, rib/skull/long-bone fractures, seizures, and head/neck bruising.
Main Results:
- Excluding non-significant variables (gender, age, skull fractures), the positive predictive value (PPV) for AHT ranged from 4% to 97% based on feature combinations.
- Apnea showed a significant association with AHT (OR: 6.89).
- The presence of rib fracture or retinal hemorrhage with any other feature, or any three or more significant features, yielded an odds ratio (OR) >100, indicating a PPV >85% for AHT.
Conclusions:
- Specific combinations of clinical findings can reliably estimate the probability of abusive head trauma (AHT).
- The developed model shows promise for refining diagnostic tools to aid clinical decision-making in suspected AHT cases.
- Further validation in large-scale prospective studies with expanded datasets is recommended.
Context And Objective:
To determine which combinations of clinical features assist in distinguishing abusive head trauma (AHT) from nonabusive head trauma.
Methods:
Individual patient data from 6 comparative studies of children younger than 3 years with intracranial injury were analyzed to determine the association between AHT and combinations of apnea; retinal hemorrhage; rib, skull, and long-bone fractures; seizures; and head and/or neck bruising. An aggregate analysis of data from these studies used multiple imputation of combined clinical features using a bespoke hotdeck imputation strategy, which accounted for uncertainty arising from missing information.
Results:
Analyzing 1053 children (348 had AHT), excluding nonsignificant variables (gender, age, skull fractures), for a child with an intracranial injury and 1 or 2 of the 6 features, the positive predictive value (PPV) of AHT varies from 4% to 97% according to the different combinations. Although rarely recorded, apnea is significantly associated with AHT (odds ratio [OR]: 6.89 [confidence interval: 2.08-22.86]). When rib fracture or retinal hemorrhage was present with any 1 of the other features, the OR for AHT is >100 (PPV > 85%). Any combination of 3 or more of the 6 significant features yielded an OR of >100 (PPV for AHT > 85%).
Conclusions:
Probabilities of AHT can be estimated on the basis of different combinations of clinical features. The model could be further developed in a prospective large-scale study, with an expanded clinical data set, to contribute to a more refined tool to inform clinical decisions about the likelihood of AHT.
