To determine which combinations of clinical features assist in distinguishing abusive head trauma (AHT) from nonabusive head trauma.


Individual patient data from 6 comparative studies of children younger than 3 years with intracranial injury were analyzed to determine the association between AHT and combinations of apnea; retinal hemorrhage; rib, skull, and long-bone fractures; seizures; and head and/or neck bruising. An aggregate analysis of data from these studies used multiple imputation of combined clinical features using a bespoke hotdeck imputation strategy, which accounted for uncertainty arising from missing information.


Analyzing 1053 children (348 had AHT), excluding nonsignificant variables (gender, age, skull fractures), for a child with an intracranial injury and 1 or 2 of the 6 features, the positive predictive value (PPV) of AHT varies from 4% to 97% according to the different combinations. Although rarely recorded, apnea is significantly associated with AHT (odds ratio [OR]: 6.89 [confidence interval: 2.08–22.86]). When rib fracture or retinal hemorrhage was present with any 1 of the other features, the OR for AHT is >100 (PPV > 85%). Any combination of 3 or more of the 6 significant features yielded an OR of >100 (PPV for AHT > 85%).


Probabilities of AHT can be estimated on the basis of different combinations of clinical features. The model could be further developed in a prospective large-scale study, with an expanded clinical data set, to contribute to a more refined tool to inform clinical decisions about the likelihood of AHT.

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