Level 1: Likely reliable evidence
When a young child presents to the hospital with acute head trauma, physicians must carefully consider the possibility of abuse. Misdiagnosing abuse can have tragic consequences, as children returned to abusive situations may experience additional abuse or even death.
Unfortunately, several studies have found physician judgment of when to screen for child abuse to be significantly biased, especially in children presenting with acute head injury (Pediatrics. 2006;117:722; Clin Orthop Relat Res. 2007;461:219; Pediatrics. 2010;126:408).
To help physicians decide when to investigate for abuse, the Pediatric Brain Injury Research Network developed an abusive head trauma (AHT) clinical prediction rule (Pediatr Crit Care Med. 2013;14:210), which was recently validated in 291 children younger than 3 years old admitted to one of 14 pediatric intensive care units (PICUs) with acute head injury (Pediatrics. 2014;134:e1537).
The study excluded all children injured in a car accident, as well as those with radiologic evidence of pre-existing brain malformation, disease, infection, or hypoxia-ischemia. Abusive head trauma was diagnosed by predefined criteria in 43% of children.
The AHT clinical prediction rule consists of four variables that can be assessed at or near the time of PICU admission including clinically significant respiratory compromise at scene of injury, during transport, in the emergency department, or before admission; bruising involving the child’s ears, neck, or torso; bilateral or interhemispheric subdural hemorrhage or fluid collection; skull fracture other than isolated, unilateral, nondiastatic, linear, parietal fracture.
The presence of one or more factors had high sensitivity, but low specificity for predicting abusive head trauma, with a positive predictive value of 55% (95% CI 48%-62%) and a negative predictive value of 93% (95% CI 85%-98%).