Pediatric Radiology

, Volume 48, Issue 8, pp 1123–1129 | Cite as

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

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



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.


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.


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.


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.


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



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.


  1. 1.
    Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics (2015) The evaluation of suspected child physical abuse. Pediatrics 135:e1337–e1354CrossRefPubMedGoogle Scholar
  2. 2.
    Jenny C, Hymel KP, Ritzen A et al (1999) Analysis of missed cases of abusive head trauma. JAMA 281:621–626CrossRefPubMedGoogle Scholar
  3. 3.
    Duhaime AC, Christian CW, Rorke LB et al (1998) Nonaccidental head injury in infants--the “shaken-baby syndrome.” N Engl J Med 338:1822–1829Google Scholar
  4. 4.
    Palusci VJ, Covington TM (2014) Child maltreatment deaths in the U.S. National Child Death Review Case Reporting System. Child Abuse Negl 38:25–36CrossRefPubMedGoogle Scholar
  5. 5.
    Rubin DM, Christian CW, Bilaniuk LT et al (2003) Occult head injury in high-risk abused children. Pediatrics 111:1382–1386CrossRefPubMedGoogle Scholar
  6. 6.
    Laskey AL, Holsti M, Runyan, DK Socolar RR et al (2004) Occult head trauma in young suspected victims of physical abuse. J Pediatr 144:719–722Google Scholar
  7. 7.
    Fickenscher KA, Dean JS, Mena DC et al (2010) Occult cranial injuries found with neuroimaging in clinically asymptomatic young children due to abusive compared to accidental head trauma. South Med J 103:121–125CrossRefPubMedGoogle Scholar
  8. 8.
    Wootton-Gorges SL, Soares BP, Alazraki AL et al (2017) ACR appropriateness criteria(R) suspected physical abuse-child. J Am Coll Radiol 14:S338–s349CrossRefPubMedGoogle Scholar
  9. 9.
    Wilson PM, Chua M, Care M et al (2014) Utility of head computed tomography in children with a single extremity fracture. J Pediatr 164:1274–1279CrossRefPubMedGoogle Scholar
  10. 10.
    Lindberg DM, Blood EA, Campbell KA et al (2013) Predictors of screening and injury in contacts of physically abused children. J Pediatr 163:730–735.e1–3Google Scholar
  11. 11.
    Wood JN, French B, Song L Feudtner C et al (2015) Evaluation for occult fractures in injured children. Pediatrics 136:232–240Google Scholar
  12. 12.
    Trokel M, Waddimba A, Griffith J Sege R et al (2006) Variation in the diagnosis of child abuse in severely injured infants. Pediatrics 117:722–728Google Scholar
  13. 13.
    Kuppermann N, Holmes JF, Dayan PS et al (2009) Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374:1160–1170CrossRefPubMedGoogle Scholar
  14. 14.
    Bressan S, Romanato S, Mion T et al (2012) Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med 19:801–807CrossRefPubMedGoogle Scholar
  15. 15.
    Schonfeld D, Bressan S, Da Dalt L et al (2014) Pediatric emergency care applied research network head injury clinical prediction rules are reliable in practice. Arch Dis Child 99:427–431CrossRefPubMedGoogle Scholar
  16. 16.
    Magana JN, Kuppermann N (2017) The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med 24:382–384CrossRefPubMedGoogle Scholar
  17. 17.
    Berger RP, Fromkin J, Herman B et al (2016) Validation of the Pittsburgh infant brain injury score for abusive head trauma. Pediatrics 138Google Scholar
  18. 18.
    Pierce MC, Kaczor K, Aldridge S et al (2010) Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 125:67–74CrossRefPubMedGoogle Scholar
  19. 19.
    Slovis TL, Strouse PJ, Strauss KJ (2015) Radiation exposure in imaging of suspected child abuse: benefits versus risks. J Pediatr 167:963–968Google Scholar
  20. 20.
    Mathews JD, Forsythe AV, Brady Z et al (2013) Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 346:f2360CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Brenner DJ, Hall EJ (2007) Computed tomography--an increasing source of radiation exposure. N Engl J Med 357:2277–2284CrossRefPubMedGoogle Scholar
  22. 22.
    Lindberg DM, Shapiro RA, Laskey AL et al (2012) Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 130:193–201Google Scholar
  23. 23.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefPubMedGoogle Scholar
  24. 24.
    Starling SP, Patel S, Burke BL et al (2004) Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med 158:454–458CrossRefPubMedGoogle Scholar
  25. 25.
    Stanley RM, Nigrovic LE (2017) Research priorities for a multi-center child abuse network: lessons learned from pediatric emergency medicine networks. Child Abuse Negl 70:414–416CrossRefPubMedGoogle Scholar

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

Personalised recommendations