Abstract
BACKGROUND: Abusive head trauma is the leading cause of death from physical abuse. Misdiagnosis of abusive head trauma as well as other types of brain abnormalities in infants is common and contributes to increased morbidity and mortality. We previously derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction rule to assist physicians deciding which high-risk infants should undergo computed tomography of the head.
METHODS: Well-appearing infants 30 to 364 days of age with temperature <38.3°C, no history of trauma, and a symptom associated with an increased risk of having a brain abnormality were eligible for enrollment in this prospective, multicenter clinical prediction rule validation. By using a predefined neuroimaging paradigm, subjects were classified as cases or controls. The sensitivity, specificity, and negative and positive predictive values of the rule for prediction of brain injury were calculated.
RESULTS: A total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0 months (1 point), head circumference >85th percentile (1 point), and serum hemoglobin <11.2g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%–96.3%) and 53% (95% confidence interval 49.3%–57.1%), respectively.
CONCLUSIONS: Our data suggest that the PIBIS accurately identifies infants who would benefit from neuroimaging to evaluate for brain injury. An implementation analysis is needed before the PIBIS can be integrated into clinical practice.
- AHT —
- abusive head trauma
- ALTE —
- apparent life-threatening event
- AUC —
- area under the curve
- CHG —
- Ann & Robert H. Lurie Children’s Hospital in Chicago, IL
- CHP —
- Children’s Hospital of Pittsburgh of UPMC
- CI —
- confidence interval
- CPR —
- clinical prediction rule
- CPT —
- Child Protection Team
- CT —
- computed tomography
- ED —
- emergency department
- NPV —
- negative predictive value
- PIBIS —
- Pittsburgh Infant Brain Injury Score
- PPV —
- positive predictive value
- ROC —
- receiver operator characteristic curve
- SLC —
- Primary Children’s Hospital in Salt Lake City, Utah
What’s Known on This Subject:
Abusive head trauma (AHT) is the leading cause of death from physical abuse. Identification of AHT, particularly in its mild forms, is difficult; missing the diagnosis can result in increased morbidity and mortality.
What This Study Adds:
The Pittsburgh Infant Brain Injury Score may be able to assist physicians to decide whether an infant at increased risk for AHT would benefit from computed tomography of the head.
Abusive head trauma (AHT) is the leading cause of death from traumatic brain injury in infants1–3 and the leading cause of death from physical abuse in the United States.4
A retrospective study using the Centers for Disease Control and Prevention definition of AHT demonstrated a rate of ∼1 in 3000 infants.5 Studies in other countries suggest similar incidences.6,7
Proper diagnosis of mild AHT is difficult because caretakers rarely provide an accurate history,8 infants present with nonspecific symptoms, such as vomiting or fussiness, and physical examination is often normal.9–11 As a result, misdiagnosis is common and can have catastrophic medical consequences.11–13 In a landmark study,12 31% (54/173) of children diagnosed with AHT were evaluated previously by a physician for symptoms compatible with brain injury. A multicenter study 15 years later demonstrated a similar rate of missed diagnoses (M. Letson, MD, MEd, personal communication, 2016), suggesting that early, accurate diagnosis of AHT continues to be challenging.
Although AHT is the leading cause of morbidity and mortality from brain injury in infants, infants with atraumatic neurologic abnormalities, such as hydrocephalus or a brain tumor, and infants with traumatic injuries that are not due to abuse, can present with the same symptoms as infants with AHT. Timely diagnosis of these non-AHT–related brain abnormalities also can be difficult for the same reasons as early recognition of AHT can be difficult: physicians may not consider a brain abnormality as a cause of the infant’s symptoms.
Clinical prediction rules (CPR) are tools that quantify the contributions that components of the history, physical examination, and laboratory tests make toward a patient’s diagnosis.14 CPRs are particularly useful in diseases in which clinical stakes are high and clinical experience and intuition are insensitive.15
The Pittsburgh Infant Brain Injury Score (PIBIS) CPR was retrospectively derived based on data from 187 infants (150 without brain injury and 37 with mild AHT) who presented to a tertiary care children’s hospital for evaluation of nonspecific symptoms (R.P.B., unpublished data). A 5-step CPR derivation process was performed.16 Five predictor variables were identified: age ≥3 months, head circumference percentile >90%, serum hemoglobin <11.2 g/dL, abnormality on neurologic or dermatologic examination, and a previous emergency department (ED) visit for a high-risk symptom. The receiver operator characteristic (ROC) curve using these predictor variables showed an area under the curve (AUC) of 0.87 (95% confidence interval [CI] 0.80–0.95).
The current study was designed as a multicenter, prospective validation and refinement of the PIBIS CPR.
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