Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review

• Published in: Archives of disease in childhood Vol. 94; no. 11; pp. 860 - 867
• Main Authors: Maguire, S, Pickerd, N, Farewell, D, Mann, M, Tempest, V, Kemp, A M
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health 01.11.2009; BMJ Publishing Group; BMJ Publishing Group Ltd; BMJ Publishing Group LTD
• Subjects: Adolescent; Apnea; Apnea - diagnosis; Apnea - etiology; Babies; Biological and medical sciences; Bones of Lower Extremity - injuries; Bones of Upper Extremity - injuries; Brain; Brain damage; Brain injuries; Brain Injuries - diagnosis; Brain Injuries - etiology; Child; Child Abuse; Child abuse & neglect; Child Abuse - diagnosis; Child Neglect; Child, Preschool; Children & youth; Citation indexes; Comparative studies; Contusions - diagnosis; Craniocerebral Trauma - diagnosis; Criminal investigations; Demographic aspects; Diagnosis; Diagnosis, Differential; Evidence; Female; Fractures; Fractures, Bone - diagnosis; Fractures, Bone - etiology; General aspects; Head injuries; Humans; Infant; Infant, Newborn; Injuries; Male; Medical sciences; Miscellaneous; Neck Injuries - diagnosis; Prevention and actions; Public health. Hygiene; Public health. Hygiene-occupational medicine; Regression analysis; Retinal hemorrhage; Retinal Hemorrhage - diagnosis; Retinal Hemorrhage - etiology; Rib Fractures - diagnosis; Seizures - diagnosis; Skull Fractures - diagnosis; Trauma; Traumatic brain injury; Websites; Young Children; United Kingdom; Human; Pediatrics; Symptomatology; Nervous system diseases; Central nervous system disease; Clinical form; Systematic review; Child; Public health; Cerebral disorder
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/adc.2008.150110

Aim: A systematic review of the scientific literature to define clinical indicators distinguishing inflicted (iBI) from non-inflicted brain injury (niBI). Methods: An all language literature search of 20 electronic databases, websites, references and bibliographies from 1970–2008 was carried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inclusion criteria included primary comparative studies of iBI and niBI in children aged <18 years, with high surety of diagnosis describing key clinical features. Multilevel logistic regression analysis was conducted, determining the positive predictive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fractures, apnoea, seizures and bruising to head/neck. Results: 8151 studies were identified, 320 were reviewed and 14 included, representing 1655 children, 779 with iBI. Gender was not a discriminatory feature. In a child with intracranial injury, apnoea (PPV 93%, OR 17.06, p<0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most predictive of iBI. Rib fractures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI, although not significantly so. Conclusions: This systematic review shows that apnoea and retinal haemorrhage have a high odds ratio for association with iBI. This review identifies key features that should be recorded in the assessment of children where iBI is suspected and may help clinicians to define the likelihood of iBI.