Abstract
Background
Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent
injury and death. This study assesses the clinical and social risks associated with
fatal and non-fatal AHT.
Methods
A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry
data yielded demographic, clinical, family, psycho-social and other follow-up information.
Descriptive statistics were used to look for differences between patients with AHT
and accidental head trauma. Logistic regression estimated the adjusted odds ratios
(AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate
model sensitivity and specificity.
Results
Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR]
age 23[4.5–39.0] months. Of 758 non-fatal patients, age was 7[3.0–11.0] months; 59.5%
male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial
hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental,
181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included
multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural
blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness
(Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown
mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of
AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police
involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown
number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence
(Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86–0.93]
p = .001) provides 73% sensitivity; 91% specificity.
Conclusions
To improve surveillance of AHT, interviews should include and consider social factors
including caregiver/household substance abuse, intimate partner violence, prior police
involvement and household size. An unknown number of adults in home is associated
with an increased risk of AHT.
Study Type/Level of Evidence
Prognostic, Level III.
Abbreviations:
AHT (Abusive head trauma), AOR (Adjusted odds ratio), CI (Confidence interval), CPS (Child Protective Service), CPT (Child Protective Team), CT (Computed tomography), DCS (Department of Child Safety), IPV (Domestic violence), ED (Emergency Department), GCS (Glasgow Coma Scale), LOS (Length of stay), MOI (Method of injury), PCH (Phoenix Children's Hospital), TBI (Traumatic brain injury)Key words
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Article info
Publication history
Published online: October 24, 2020
Accepted:
October 20,
2020
Received:
October 13,
2020
Footnotes
☆Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
☆☆Conflict of Interest Statement: Nothing to declare
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
