Evidence for significant misdiagnosis of abusive head trauma in pediBIRN data

Abstract

Independently witnessed events are used as a reference standard to robustly categorize accidental or non-abusive head trauma (non-AHT) cases in the pediBIRN data set of acutely symptomatic infants with closed head injuries. Findings in such independently witnessed non-AHT cases are compared to findings in cases that were diagnosed as AHT but were not independently witnessed. The data shows that 14% of independently witnessed non-AHT cases are misdiagnosed as AHT, and that risk factors for misdiagnosis include acute encephalopathy, bilateral or interhemispheric SDH, and/or severe retinal hemorrhages, findings that are commonly associated with AHT. The data also shows that "dense retinal hemorrhages extending to the periphery" are not highly suggestive of AHT, as they also occur in independently witnessed non-AHT cases.

Keywords: Abusive head trauma; Evidence based medicine; Shaken baby syndrome.

Fig. 1

A Circular Reasoning: findings such as retinal hemorrhages (RH) are used as diagnostic criteria to diagnose AHT, so RH will have high prevalence in cases diagnosed with AHT, and will be “validated” as a diagnostic criterion for AHT. B Judicial Admissions: findings such as RH are used as diagnostic criteria to diagnose AHT, so RH will have high prevalence in cases diagnosed with AHT who enter the judicial process, some of whom make admissions. The findings in judicial admission cases are determined by the criteria used to diagnose abuse. The circle is the same as in A, with an added step. C Spontaneous Admissions: admissions made independently of diagnosis can have any findings, which have not been pre-determined by assumed diagnostic criteria. Alongside independently witnessed AHT and non-AHT, clinical data from spontaneous admissions has clinical value.