Predictors for Nonaccidental Trauma in a Child With a Fracture—A National Inpatient Database Study

Abstract

Background: Despite heightened awareness and multidisciplinary efforts, a predictive model to help the clinician quantify the likelihood of nonaccidental trauma (NAT) in a child presenting with a fracture does not exist. The purpose of this study was to develop an evidence-based likelihood of NAT in a child presenting with a fracture. Methods: Using the 2012 Kids' Inpatient Database, we identified all available pediatric inpatients admitted with an extremity or spine fracture. Children with a fracture were subcategorized based on the diagnosis of NAT. Multivariate analysis using multiple logistic regression was used to generate odds ratios and create a predictive model for the probability of NAT in a child with a fracture. Results: Of the 57,183 pediatric fracture cases, 881 (1.54%) had a concurrent diagnosis of NAT. Of these children, those presenting with multiple fractures had the highest rate of NAT (2.8%). The overall mortality rate in patients presenting with fractures and abuse was 1.8%, which was twice as high as patients without abuse (odds ratio [OR] = 2.0). Based on multivariate analysis, younger age (OR = 0.5), black race (OR = 1.7), intracranial injury (OR = 3.7), concomitant rib fracture (OR = 7.2), and burns (OR = 8.3) were positive predictors of NAT in a child with a fracture. A weighted equation using regression coefficients was generated and plotted on a receiver operative characteristic curve, demonstrating excellent correlation and probability of NAT (area under curve = 0.962). (Equationln (P/(1 2 P)) = 21.79 to 0.65 (age in years) 1 0.51 (black race) 1 1.97 (rib fracture) 1 1.31 (intracranial injury) 1 2.12 (burn)). Conclusion: Using a large, national inpatient database, we identified an overall prevalence of 1.54% of NAT in children admitted to the hospital with a fracture. Based on five independent predictors of NAT, we generated an estimated probability chart that can be used in the clinical workup of a child with a fracture and possible NAT. This evidence-based algorithm needs to be validated in clinical practice. Level of Evidence: Prognostic study, Level III (case-control study). C hild abuse or nonaccidental trauma (NAT) is a growing problem facing society and represents a substantial burden on the healthcare system in the United States. 1,2 In 2012, there were over 3.4 million referrals for child abuse in the United States, and Child Protective Services estimates

Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried

“…This publication provides an overview of the key “red flags” when evaluating a child for suspected abuse, and a comprehensive overview of the recommended clinical workflow. Complementing this work, a recent large-scale study assessing predictors of NAT in children with fractures recorded as part of the national inpatient database, reported that younger age, the presence of intracranial injury, concomitant rib fracture, and concomitant burns were all positive predictors of NAT in children with fractures 29. Similarly, work by Baldwin and colleagues found that in children with femur fractures, risk factors that aided in predicting NAT included age below 18 months, physical or radiographic evidence of a prior injury, or an inconsistent or suspicious history from the caregivers.…”

¿Convulsive Crisis Or Child Abuse?

“…En un centro de emergencia coreano reportan que las fracturas más comunes suelen situarse en el cráneo seguido de los miembros superiores e inferiores (11) . Inclusive, solo una minoría presentan múltiples fracturas (11,12) . Las hemorragias retinianas forman parte de la triada del SBS (1) , en la cual la prevalencia, en un estudio norteamericano, fue de 63% de niños con TCA (10) .…”

A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children

“…A study conducted by Zhao et al, using the Kids’ Inpatient Database (KID), demonstrates that children belonging to black ethnic groups and the female gender had a higher probability of being diagnosed with abuse when presenting with fractures [ 13 ]. Patients presenting with spinal cord injuries and fractures of the skull were less frequently associated with nonaccidental circumstances as compared to the children presenting with rib fractures [ 13 ]. Ultimately, their analysis revealed five predictor variables for the presence of abuse; age, race, burns, fractures of the rib, and intracranial injuries.…”