Which clinical features distinguish inflicted from non-inflicted brain injury? A Systematic Review

sabine A Maguire ^1*, Nicole Pickerd ¹, Daniel Farewell ¹, Mala K Mann ¹, Vanessa Tempest ¹ and Alison Mary Kemp ²

¹ Cardiff University, United Kingdom
² Department of Child Health, Cardiff University, United Kingdom

^* To whom correspondence should be addressed. E-mail: sabinemaguire{at}yahoo.co.uk.

Accepted 12 May 2009

Abstract

Aim: A systematic review of the scientific literature to define the clinical indicators that distinguish 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. Relevant studies were independently reviewed by two trained reviewers, and third review where required. Inclusion criteria: primary comparative studies of iBI and niBI in children <18 years, with high surety of diagnosis describing key clinical features. A multilevel logistic regression analysis was conducted, determining 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 most predictive features of iBI. Rib fractures (PPV 73%, OR 3.03, p=0.13) had a similar PPV to retinal haemorrhages, but there was less data to analyse. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more strongly associated with niBI.

Conclusions: This unique systematic review shows that certain features, namely apnoea and retinal haemorrhage, have a high odds ratio for association with inflicted brain injury. 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.