Analysis of missed cases of abusive head trauma

JAMA. 1999 Feb 17;281(7):621-6. doi: 10.1001/jama.281.7.621.

Abstract

Context: Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children.

Objectives: To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis.

Design: Retrospective chart review of cases of head trauma presenting between January 1, 1990, and December 31, 1995.

Setting: Academic children's hospital.

Patients: One hundred seventy-three children younger than 3 years with head injuries caused by abuse.

Main outcome measures: Characteristics of head-injured children in whom diagnosis of AHT was unrecognized and the consequences of the missed diagnoses.

Results: Fifty-four (31.2%) of 173 abused children with head injuries had been seen by physicians after AHT and the diagnosis was not recognized. The mean time to correct diagnosis among these children was 7 days (range, 0-189 days). Abusive head trauma was more likely to be unrecognized in very young white children from intact families and in children without respiratory compromise or seizures. In 7 of the children with unrecognized AHT, misinterpretation of radiological studies contributed to the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%) experienced medical complications related to the missed diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been prevented by earlier recognition of abuse.

Conclusion: Although diagnosing head trauma can be difficult in the absence of a history, it is important to consider inflicted head trauma in infants and young children presenting with nonspecific clinical signs.

MeSH terms

  • Child Abuse / diagnosis*
  • Child Abuse / statistics & numerical data
  • Child, Preschool
  • Craniocerebral Trauma / epidemiology
  • Craniocerebral Trauma / etiology*
  • Diagnostic Errors
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Retrospective Studies