AHT diagnoses: The influences of clinical presentation and evidence of impact

Background: The frequency of abusive head trauma (AHT) diagnoses by child abuse pediatricians (CAPs), especially regarding external evidence of head impact, has been questioned. Objectives: To compare CAP diagnoses in subjects with subdural hemorrhage (SDH) across clinical presentations, including subgroups with and without external evidence of head impact. Additionally, we aimed to describe subjects with SDH and concomitant suspicious injuries (CSI) without evidence of head impact. Participants and setting: Multicenter retrospective study including subjects <24 months old with SDH. Methods: Subjects were divided into groups based on clinical presentations: Ill SDH only, Non-ill SDH only, and SDH + CSI. Groups were subcategorized based on presence/absence of external evidence of head impact. AHT diagnoses were compared across groups. Results: Of the 492 study subjects, 386 (78%) were diagnosed with abuse. Of the 266 subjects without evidence of head impact, 206 (77%) were diagnosed with abuse. In both the total group and the subgroup without evidence of head impact, SDH + CSI subjects were significantly more likely to be diagnosed with abuse than Ill-SDH only and Non-ill SDH only subjects, with odds ratios ranging from 2.6 (95% CI 1.2–5.6) to 10.4 (95% CI 5.0–21.8). Of the 147 SDH + CSI subjects without evidence of head impact, 33% had severe non-retinal injury, such as high specificity and/or multiple fractures or abdominal injury. Conclusions: In young children with SDH, many of whom are ill and/or have other concerning injuries, CAPs often do not diagnose abuse. Lack of evidence of head impact does not eliminate trauma as a cause of SDH.