The AHT Clinical Prediction Rule Helps to Rule Out Abusive Head Trauma in Children < 3 Years Old Admitted to the Pediatric Intensive Care Unit with Acute Head Injury

EBM Focus - Volume 9, Issue 49

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Reference: Pediatrics 2014 Dec;134(6):e1537 (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 suffer 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 Mar;117(3):722, Clin Orthop Relat Res 2007 Aug;461:219, Pediatrics 2010 Sep;126(3):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 Feb;14(2):210), which was recently validated in 291 children < 3 years old admitted to 1 of 14 pediatric intensive care units (PICUs) with acute head injury.

The study excluded all children injured in a car accident as well as those with radiologic evidence of preexisting 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 4 variables that can be assessed at or near the time of PICU admission including: i) clinically significant respiratory compromise at scene of injury, during transport, in the emergency department, or before admission; ii) bruising involving the childÂ’s ears, neck, or torso; iii) bilateral or interhemispheric subdural hemorrhage or fluid collection; iv) and skull fracture other than isolated, unilateral, nondiastatic, linear, parietal fracture. The presence of 1 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%).

The performance of the AHT clinical prediction rule in this validation cohort matched or exceeded its performance in the original derivation study (Pediatr Crit Care Med 2013 Feb;14(2):210) and suggests this prediction rule may help rule out abuse in children presenting with acute head injury. The negative predictive value was not 100%, however, and a small number of children ultimately diagnosed with abusive head trauma were categorized as low risk. Furthermore, both the original derivation study and this validation study were conducted in children admitted to the PICU and the performance of this rule is as of yet untested in non-PICU populations. The AHT clinical prediction rule may help increase physician confidence when ruling out abuse, but a low risk score should not deter further investigation if abuse is suspected.

For more information, see the Moderate to severe traumatic brain injury and Concussion and mild traumatic brain injury topics in DynaMed.