Occult head injury is common in children with concern for physical abuse

  • Mitchell Boehnke
  • David Mirsky
  • Nicholas Stence
  • Rachel M. Stanley
  • Daniel M. Lindberg
  • for the ExSTRA investigators
Original Article

Abstract

Background

Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients.

Objectives

Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury.

Materials and methods

This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury.

Results

One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8–6.8), macrocephaly (OR 8.5, 95% CI 3.7–20.2), and loss of consciousness (OR 5.1, 95% CI 1.2–22.9) had higher odds of occult head injury.

Conclusion

Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.

Keywords

Abusive head trauma Children Computed tomography Magnetic resonance imaging Neuroimaging Non-accidental trauma 

Notes

Acknowledgments

A portion of Dr. Lindberg’s work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The funder played no role in the research design, data analysis, manuscript preparation or decision to publish. The other authors report no funding.

The Examining Siblings To Recognize Abuse (ExSTRA) investigators are: Jayme Coffman, MD (Cook Children’s Hospital, Ft. Worth, TX); Deb Bretl, APNP (Children’s Hospital Wisconsin, Wauwatosa, WI); Nancy Harper, MD (Driscoll Children’s Hospital, Corpus Christi, TX); Katherine Deye, MD (Children’s National Medical Center, Washington, DC); Antoinette L. Laskey, MD, and Tara Harris, MD (Riley Hospital for Children, Indianapolis, IN); Yolanda Duralde, MD (Mary Bridge Children’s Health Center, Tacoma, WA); Marcella Donaruma-Kwoh, MD (Texas Children’s Hospital, Houston, TX); Daryl Steiner, DO (Akron Children’s Hospital, Akron, OH); Kenneth Feldman, MD (Seattle Children’s Hospital, Seattle, WA); Kimberly Schwartz, MD (University of Massachusetts Medical Center, Worcester, MA); Robert A. Shapiro, MD, and Mary Greiner, MD (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH); Alice Newton, MD (Boston Children’s Hospital, Boston, MA); Rachel Berger, MD, MPH, and Ivone Kim, MD (Children’s Hospital Pittsburgh of University of Pittsburgh Medical Center); Kent Hymel, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH); Suzanne Haney, MD (Children’s Hospital & Medical Center, Omaha, NE); Alicia Pekarsky, MD (SUNY Upstate Medical University, Syracuse, NY); Andrea Asnes, MD (Yale-New Haven Children’s Hospital, New Haven, CT); Paul McPherson, MD (Akron Children’s Hospital, Youngstown, OH); Neha Mehta, MD (Sunrise Children’s Hospital, Las Vegas, NV), and Gwendolyn Gladstone, MD (Exeter Pediatric Associates, Exeter, NH).

Compliance with ethical standards

Conflicts of interest

Dr. Lindberg has received payment for expert witness record review and testimony related to children with concern for physical abuse. None of the other authors has potential conflicts of interest.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Diagnostic RadiologyChildren’s Hospital ColoradoAuroraUSA
  2. 2.University of Colorado School of MedicineAuroraUSA
  3. 3.Department of Emergency MedicineNationwide Children’s HospitalColumbusUSA
  4. 4.The Ohio State University School of MedicineColumbusUSA
  5. 5.The Kempe Center for the Prevention & Treatment of Child Abuse & NeglectAuroraUSA

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