Evaluating abusive head trauma in children < 5 years old: Risk factors and the importance of the social history

David M. Notrica, Lisa Kirsch, Shivani Misra, Cara Kelly, Jodie Greenberg, J. Bryce Ortiz, Rachel K. Rowe, Jonathan Lifshitz, P. David Adelson, Rachael L. Stottlemyre, Aaron Cohen, Lois W. Sayrs

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background: Abusive head trauma (AHT) is the leading cause traumatic death in children ≤ 5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. Methods: A single-institution, retrospective review of suspected AHT patients ≤ 5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. Results: Forensic evaluations of 783 children age ≤ 5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5–39.0] months. Of 758 non-fatal patients, age was 7[3.0–11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86–0.93] p = .001) provides 73% sensitivity; 91% specificity. Conclusions: To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. Study Type/Level of Evidence: Prognostic, Level III.

Original languageEnglish (US)
Pages (from-to)390-396
Number of pages7
JournalJournal of Pediatric Surgery
Issue number2
StatePublished - Feb 2021


  • Abusive head trauma
  • Child abuse
  • Pediatrics
  • Traumatic brain injury

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Surgery


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