Delayed Recognition of Abusive Head Trauma: A Diagnostic Error

Missed cases of abusive head trauma have been described in the medical literature. A 1999 study found that abusive head trauma was more likely to be missed in young white children from two parent households. Diagnostic errors in the evaluation of abusive head trauma may have changed since that time. We aimed to identify rates of diagnostic error in the diagnosis of abusive head trauma at our institution and to evaluate characteristics associated with missed or delayed diagnoses of abusive head trauma.

We performed a case-control study of children 2 years and younger with an intracranial injury suspicious for abusive head trauma between January 2015 and May 2023. Demographics, social factors, clinical presentation, and the presence of high-risk bruising were also collected. Descriptive statistics, odds ratios, chi-squared tests, and Fisher's exact tests were used for statistical analysis.

One hundred eighteen children with abusive head trauma were identified. Our control group included 107 (90.7%) patients in which no diagnostic error was identified. Eleven (9.3%) had missed diagnosis or delayed diagnosis identified and 4 (3.4%) had possible missed diagnosis identified. High-risk bruising was identified in 4/11 (36.4%) cases of missed diagnosis/delayed diagnosis.

Abusive head trauma diagnosis continues to be missed or delayed in nearly 10% of cases. With greater than 30% of missed or delayed diagnoses having high-risk bruising on exam, increased attention to bruising may help decrease diagnostic error and help increase identification of abusive head trauma.