Screening for pediatric abusive head trauma: Are three variables enough?

Abstract

Background: The PediBIRN 4-variable clinical decision rule (CDR) detects abusive head trauma (AHT) with 96% sensitivity in pediatric intensive care (PICU) settings. Preliminary analysis of its performance in Pediatric Emergency Department settings found that elimination of its fourth predictor variable enhanced screening accuracy.

Objective: To compare the AHT screening performances of the "PediBIRN-4" CDR vs. the simplified 3-variable CDR in PICU settings.

Participants and settings: 973 acutely head-injured children <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021.

Methods: Retrospective, secondary analysis of the combined, prospective PediBIRN data sets. AHT definitional criteria and physicians' diagnoses were applied iteratively to sort patients into abusive vs. other head trauma cohorts. Outcome measures of CDR performance included sensitivity, specificity, predictive values, likelihood ratios, ROC AUC, and the correlation between each CDR's patient-specific estimates of AHT probability and the overall positive yield of patients' completed abuse evaluations.

Results: Applied accurately and consistently, both CDR's would have performed with sensitivity ≥93% and negative predictive value ≥91%. Eliminating the PediBIRN-4's fourth predictor variable resulted in significantly higher specificity (↑'d ≥19%), positive predictive value (↑'d ≥8%), and ROC AUC (↑'d ≥5%), but a 3% reduction in sensitivity. Both CDRs provided patient-specific estimates of abuse probability very strongly correlated with the positive yield of patients' completed abuse evaluations (Pearson's r = 0.95 and 0.91, p = .13).

Conclusion: The PediBIRN 3-variable CDR performed with greater AHT screening accuracy than the 4-variable CDR. Both are good predictors of the results of patients' subsequent completed abuse evaluations.

Keywords: Abusive head trauma; Child abuse; Clinical decision rule; Clinical prediction rule; Screening test.

Figure 1.

The two plots present the intersections of ‘estimated probabilities of abuse’ and ‘overall diagnostic yield’ across patient subpopulations presenting with different combinations of each clinical decision rule’s predictor variables. The estimated probabilities of abuse were calculated applying definitional criteria for abusive head trauma (see Table 2). The data used to create the plots can be found in Table 5. The two correlations did not differ significantly (p =.13). In the plot on the right, the cluster of three data points marked by the arrow presents data regarding the 4-variable decision rule’s “lower risk” patients, and its two “higher risk” patient subpopulations highlighted in large bold font in Table 5.