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Predictors for Nonaccidental Trauma in a Child With a Fracture-A National Inpatient Database Study
Caixia Zhao1, Matthew Starke, Jeffrey D Tompson
1From the Rutgers-New Jersey Medical School, Newark, NJ (Dr. Zhao, Dr. Starke, and Dr. Tompson), and the Department of Clinical Orthopedics, University of California, San Francisco, Benioff Children's Hospital of Oakland, Oakland, CA (Dr. Sabharwal).
Insights
A new predictive model helps clinicians assess the likelihood of nonaccidental trauma (NAT) in children with fractures. Key predictors include younger age, black race, intracranial injury, rib fractures, and burns, aiding in early identification and intervention.
Area of Science:
- Pediatric Traumatology
- Forensic Medicine
- Public Health
Background:
- Nonaccidental trauma (NAT) in children remains a significant concern, yet a validated predictive model for clinicians to assess its likelihood in fracture cases is lacking.
- Existing efforts have heightened awareness but not provided quantitative tools for risk assessment in pediatric fracture patients.
Purpose of the Study:
- To develop an evidence-based predictive model for estimating the likelihood of nonaccidental trauma (NAT) in pediatric patients presenting with fractures.
- To identify key clinical factors associated with NAT in this population.
Main Methods:
- Utilized the 2012 Kids' Inpatient Database to identify pediatric inpatients with extremity or spine fractures.
- Employed multivariate logistic regression analysis to identify predictors and generate a predictive model for NAT probability.
- Classified children with fractures into NAT and non-NAT groups for comparative analysis.
Main Results:
- Identified a 1.54% prevalence of NAT among 57,183 pediatric fracture cases; multiple fractures showed the highest NAT rate (2.8%).
- Key predictors for NAT included younger age, black race, intracranial injury, concomitant rib fracture, and burns, with significant odds ratios.
- Developed a weighted predictive equation with excellent discriminative ability (area under the curve = 0.962).
Conclusions:
- Established the prevalence of NAT in hospitalized children with fractures at 1.54% using a national database.
- Generated a validated, evidence-based algorithm incorporating five independent predictors to estimate NAT probability in clinical settings.
- Highlighted the need for clinical validation of this predictive tool for improved child abuse detection.
Background:
Despite heightened awareness and multidisciplinary efforts, a predictive model to help the clinician quantify the likelihood of nonaccidental trauma (NAT) in a child presenting with a fracture does not exist. The purpose of this study was to develop an evidence-based likelihood of NAT in a child presenting with a fracture.
Methods:
Using the 2012 Kids' Inpatient Database, we identified all available pediatric inpatients admitted with an extremity or spine fracture. Children with a fracture were subcategorized based on the diagnosis of NAT. Multivariate analysis using multiple logistic regression was used to generate odds ratios and create a predictive model for the probability of NAT in a child with a fracture.
Results:
Of the 57,183 pediatric fracture cases, 881 (1.54%) had a concurrent diagnosis of NAT. Of these children, those presenting with multiple fractures had the highest rate of NAT (2.8%). The overall mortality rate in patients presenting with fractures and abuse was 1.8%, which was twice as high as patients without abuse (odds ratio [OR] = 2.0). Based on multivariate analysis, younger age (OR = 0.5), black race (OR = 1.7), intracranial injury (OR = 3.7), concomitant rib fracture (OR = 7.2), and burns (OR = 8.3) were positive predictors of NAT in a child with a fracture. A weighted equation using regression coefficients was generated and plotted on a receiver operative characteristic curve, demonstrating excellent correlation and probability of NAT (area under curve = 0.962). (Equation - ln (P/(1 - P)) = -1.79 - 0.65 (age in years) + 0.51 (black race) + 1.97 (rib fracture) + 1.31 (intracranial injury) + 2.12 (burn)).
Conclusion:
Using a large, national inpatient database, we identified an overall prevalence of 1.54% of NAT in children admitted to the hospital with a fracture. Based on five independent predictors of NAT, we generated an estimated probability chart that can be used in the clinical workup of a child with a fracture and possible NAT. This evidence-based algorithm needs to be validated in clinical practice.
Level Of Evidence:
Prognostic study, Level III (case-control study).
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