Stephen C. Boos

Derivation of a clinical prediction rule for pediatric abusive head trauma

Objectives: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that—if validated—can inform pediatric intensivists’ early decisions to launch (or forego) an evaluation for abuse. Design: Prospective, multicenter, cross-sectional, observational. Setting: Fourteen PICUs. Patients: Acutely head-injured children less than 3 years old admitted for intensive care. Interventions: None. Measurements and Main Results: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity—to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. Conclusions: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform—not dictate—their early decisions to launch (or forego) an evaluation for abuse.

Accidental Hymenal Injury Mimicking Sexual Trauma

Hymenal injury is considered to be nearly pathognomonic of child sexual abuse. Accidental injury of the hymen is felt to be a rare event. Child abuse experts often cite cases of picket-fence or bedpost impalements as the exception, and dismiss the likelihood of accidental injury to the hymen. Despite this sentiment, accidental injuries of the anogenital region, including the hymen, have been described in the literature. The following case documents such an accidental injury, and follows the injuries from the acute stage through initial healing. A 7-year-old white girl presented to the emergency department with the chief complaint of vaginal bleeding after a fall in the bathtub. The physician who examined her noted vaginal blood with no clear source and consulted a staff pediatrician experienced in evaluating child abuse. The patient was a comfortable, articulate child who readily agreed to being interviewed alone. She gave a history of “bowling” in the bathtub and hurting herself on the “horses shoes.” On a request for elaboration, she recounted a connected narrative in which she had completed a shower and was setting her toy horses up at the drain end of the tub and sliding down the wet porcelain into them, knocking them down. On the final repetition of this game, she lost her balance, her legs went up in the air, and she hit the horses hard, causing pain in her genital area. She stood up and cried, touching her genital area with her hand, and then noted blood on her hands. Her father came in and blotted her with a towel. Shortly thereafter, her mother came home and used a spray bottle to clean her further. This was painful to her. Her parents then decided to bring her to the emergency department. Besides the above narrative, the patient also provided a … Address correspondence and reprint requests to Stephen C. Boos, MD, University of California, Davis, Medical Center, Center for Child Protection, 2516 Stockton Blvd, Sacramento, CA 95817.

Core Content for Residency Training in Child Abuse and Neglect

Since the identification of child abuse as a medical diagnosis, physicians have become resources to children, families, and communities to assist in diagnosing abuse, consulting with community agencies, testifying in courts of law, administering abuse prevention programs, and participating on teams to investigate and manage child abuse. Because the distribution of pediatric specialists in child abuse is limited, primary care physicians often are asked to perform these functions. Even in the face of this increasing demand, the education of physicians in the field of child abuse is very limited. Primary care residency programs can provide a good initial base to prepare physicians for forensic evaluations. This document outlines the basic elements of residency education in child abuse and neglect.

Educational paper : Abusive Head Trauma Part II: Radiological aspects

Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis. Conclusion: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Transverse Fracture of the Distal Femoral Metadiaphysis A Plausible Accidental Mechanism

Objectives: This study describes the mechanism of injury of an impacted transverse fracture of the distal femoral metadiaphysis. Individual experience by child abuse pediatricians with this fracture type has suggested that it is less associated with inflicted trauma than was described in a prior case series. Methods: Case contributions were solicited from an international group of child abuse clinicians. Eighteen cases were accepted for analysis. Cases were categorized as abuse or nonabuse by a predefined categorization scheme. Differences in the 2 groups were analyzed by Fischer exact test. Results: Thirteen cases (72%) were determined to be nonabusive, and 5 (28%) were determined to be from abuse. Additional skeletal injuries on skeletal radiograph survey, absence of any explanatory history, and significant changes in repeated histories identified cases of abuse. A short fall was accepted as the explanation for the nonabuse cases, with some indication that direct impact on the knee explained the injury. Conclusions: Impacted transverse fracture of the distal femoral metadiaphysis may occur as a result of an accidental short fall of young children. A traditional abuse evaluation should be pursued in these cases, but with an absence of additional skeletal findings, and a history of a fall, it is likely that an accidental mechanism accounts for the injury.

Racial and Ethnic Disparities and Bias in the Evaluation and Reporting of Abusive Head Trauma

Objective To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. Study design Aggregate and site‐specific analysis of the cross‐sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non‐Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. Results In the PediBIRN study sample of 500 young, acutely head‐injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non‐Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non‐AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P < .001 [aOR, 4.1] and P < .001 [aOR, 2.8]). Similar site‐specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. Conclusion Significant race/ethnicity‐based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians’ implicit bias.