Related Experiment Video
Updated: Jul 20, 2025
A Pediatric Concussion Model in Mice: Closed Head Injury with Long-Term Disorders (CHILD)
Published on: February 7, 2025
Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury
Angela Doswell1, Emily Killough2, Timothy P Zinkus3
1Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
Insights
Pediatric subspecialists show significant variability in diagnosing and timing abusive head trauma cases. Developing consensus guidelines could improve care for infant head injuries.
Area of Science:
- Pediatric Medicine
- Forensic Pathology
- Medical Diagnostics
Background:
- Existing research on abusive head trauma (AHT) diagnosis and timing has not eliminated practice variations among pediatric subspecialists.
- Variability in clinical practice can impact patient outcomes and diagnostic accuracy in suspected AHT cases.
Purpose of the Study:
- To assess diagnostic variability in abusive head trauma (AHT) among various pediatric subspecialists using simulated infant head injury cases.
- To investigate timing variability in AHT diagnosis among subspecialists and specifically among Child Abuse Pediatricians (CAPs).
Main Methods:
- A multi-institutional, mixed-methods study involving 288 pediatric subspecialists from diverse fields (Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, Neurosurgery).
- Participants evaluated four case examples of infant head injury, including retinal hemorrhages (RH) and subdural hemorrhage (SDH).
- Statistical analyses (Chi-square, Fisher's exact tests) were used to compare diagnostic and timing responses across specialties and within CAPs, with a Bonferroni correction applied.
Main Results:
- Significant diagnostic variability was found across all case examples, with notable differences in the interpretation of mass-effect subdural hemorrhage (SDH).
- Timing variability was statistically significant for all case examples, indicating inconsistencies in determining the timeline of injury.
- A subset of experienced Child Abuse Pediatricians (CAPs) showed variability in timing assessment for severe retinal hemorrhages (RH).
Conclusions:
- The findings highlight considerable diagnostic and timing variability in abusive head trauma (AHT) among pediatric subspecialists.
- Implementing additional peer review processes and developing consensus guidelines for complex AHT cases is recommended to standardize care.
Background:
Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists.
Objectives:
To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs).
Participants And Setting:
Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career.
Methods:
This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons.
Results:
There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example.
Conclusions:
Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.
