Abusive Versus Nonabusive Head Injury in Children: a Systematic Review

Abstract

Introduction: Abusive head injury is the leading cause of traumatic death in infancy. Studies have shown that up to one-third of abusive head injury is initially misdiagnosed as accidental by emergency department (ED) physicians. By identifying characteristic clinical and radiological features of abusive and nonabusive traumatic head injury we may be able to improve recognition of abuse by ED physicians. Methods: We searched electronic databases, Cochrane Library, conference proceedings, and reference lists to identify all comparative studies of children aged 6 years or younger with abusive or nonabusive head injury. Only studies in which children were admitted to hospital and that compared historical features, physical exam features or imaging findings were eligible. Results: A total of 485 citations were identified and 29 studies were included in the review. There was variability in the methods by which head injuries were deemed to be abusive - 1 study used determination by single MD, 1 required admission of abuse, 5 relied on multidisciplinary assessment, 6 relied on discharge diagnosis and 16 used a combination of criteria (e.g., witnessed abuse, history inconsistent with developmental stage). Inconsistency in the definition and reporting of clinical and imaging characteristics as well as high statistical heterogeneity presented challenges to meta-analysis. Notwithstanding these important limitations, there were 3 characteristics where odds ratios (ORs) for abusive versus nonabusive head injuries could be combined: subdural hemorrhage (pooled OR 10.5, 95% CI 7.2 to 15.2, 19 studies), metaphyseal fractures (12.7, 95% CI 2.9 to 55.3, 3 studies), and long bone fractures (3.7, 95% CI 1.8 to 7.7, 8 studies). Conclusion: This systematic review highlights the need within the child abuse research literature for greater consistency in the criteria used to identify head injuries as abusive or nonabusive and for greater consistency in examining and denning characteristics that may be associated with these injuries.