An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma.
Document Type
Article
Publication Date
7-2022
Identifier
DOI: 10.1016/j.chiabu.2022.105666
Abstract
BACKGROUND: Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms.
OBJECTIVES: To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT.
PARTICIPANTS AND SETTING: Acutely head injured patients2021.
METHODS: Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values.
RESULTS: Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96.
CONCLUSIONS: The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."
Journal Title
Child abuse & neglect
Volume
129
First Page
105666
Last Page
105666
MeSH Keywords
Child; Child Abuse; Craniocerebral Trauma; Cross-Sectional Studies; Hematoma, Subdural; Humans; Physicians
Keywords
Abusive head trauma; Diagnosis.
Recommended Citation
Hymel KP, Boos SC, Armijo-Garcia V, et al. An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma. Child Abuse Negl. 2022;129:105666. doi:10.1016/j.chiabu.2022.105666
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