Which clinical features distinguish inflicted from noninflicted brain injury? A systematic review

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1 An additional appendix is published online only at ad.bmj.om/ontent/vol94/ issue11 1 Child Health, Shool of Mediine, Cardiff University, Cardiff, UK; 2 Department of Primary Care and Publi Health, Shool of Mediine, Cardiff University, Cardiff, UK; 3 Support Unit for Researh Evidene, Cardiff University, Cardiff, UK Correspondene to: S Maguire, Child Health, Shool of Mediine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK; sabinemaguire@yahoo.o. uk Aepted 12 May 2009 Published Online First 15 June 2009 Whih linial features distinguish inflited from noninflited brain injury? A systemati review S Maguire, 1 N Pikerd, 1 D Farewell, 2 M Mann, 3 V Tempest, 1 A M Kemp 1 ABSTRACT Aim: A systemati review of the sientifi literature to define linial indiators distinguishing inflited (ibi) from non-inflited brain injury (nibi). Methods: An all language literature searh of 20 eletroni databases, websites, referenes and bibliographies from was arried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inlusion riteria inluded primary omparative studies of ibi and nibi in hildren aged,18 years, with high surety of diagnosis desribing key linial features. Multilevel logisti regression analysis was onduted, determining the positive preditive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fratures, apnoea, seizures and bruising to head/nek. Results: 8151 studies were identified, 320 were reviewed and 14 inluded, representing 1655 hildren, 779 with ibi. Gender was not a disriminatory feature. In a hild with intraranial injury, apnoea (PPV 93%, OR 17.06, p,0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most preditive of ibi. Rib fratures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fratures were not disriminatory, and skull frature and head/nek bruising were more assoiated with nibi, although not signifiantly so. Conlusions: This systemati review shows that apnoea and retinal haemorrhage have a high odds ratio for assoiation with ibi. This review identifies key features that should be reorded in the assessment of hildren where ibi is suspeted and may help liniians to define the likelihood of ibi. In 1974, radiologist John Caffey published his paper The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash indued intraranial and intraoular bleedings, linked with residual permanent brain damage and mental retardation. 1 The title aptured a proposed mehanism for the most serious form of physial hild abuse and referred to the assoiation of intraranial and retinal haemorrhages. The artile desribed the diagnosti hallenges of identifying a ondition where there are often no external signs of trauma to the head, skull fratures or a history of trauma of any kind, and assoiated injuries may be subtle or oult, partiularly in the ase of oexisting fratures. Caffey reognised that these hildren were often subjeted to repeated traumati episodes. Despite advanes in investigative neurology and widespread awareness of this ondition, inflited brain injury (ibi) is ommonly What is already known on this topi Considerable septiism is being expressed as to how to distinguish inflited (ibi) from noninflited brain injury (nibi). Varying weight has been given to speifi linial features of ibi in previous publiations. Apnoea, retinal haemorrhages and rib fratures are felt to be important but there is no omprehensive statistial estimate of preditive power regarding ibi. What this study adds The finding of apnoea and/or retinal haemorrhage in a hild with a brain injury is more strongly assoiated with ibi than nibi. Children where ibi may be a differential diagnosis should undergo fundosopy by an ophthalmologist and if,2 years old should have a skeletal survey. Infants less than 6 months of age with a brain injury are more likely to have sustained an ibi than older infants. under-reognised 2 3 and remains a diagnosti hallenge. Children with ibi often present with signifiant intraranial injury in the ontext of a history of a minor fall, trivial injury or no reported trauma. Clinial symptoms and signs vary from the most non-speifi, for example vomiting or irritability, to those that learly point to a entral neurologial insult suh as redued onsiousness. 4 Some may present with other inflited injuries, suh as bruising or fratures, as the primary indiator. For some hildren with a non-speifi linial presentation, the possibility of an ibi may not be onsidered. 3 5 As in most ases of physial hild abuse there is no diagnosti test for ibi, the diagnosis is made on a balane of probability and after areful exlusion of other possible auses of the linial presentation whih inlude aidental injury and medial onditions suh as rare metaboli onditions (glutari aiduria 6 ), oagulation disorders, 7 9 infetive enephalopathies, et. It has been reognised that up to 50% of hildren with ibi had presented previously with signs of physial abuse that were missed. 2 3 Although well reognised as a ondition that is prevalent in infants and babies, the estimated 860 Arh Dis Child 2009;94: doi: /ad

2 Box 1 Databases and websites searhed Databases All EBM Reviews ACP Journal Club (ACP), Cohrane Database of Systemati Reviews (COCH), Database of Abstrats of Reviews of Effets (DARE), Cohrane Central Register of Controlled Trials, Health Tehnology Assessment, National Health Servie Eonomi Evaluation, Cohrane Methodology Register ASSIA (Applied Soial Sienes Index and Abstrats) ChildData CINAHL (Cumulative Index to Nursing and Allied Health Literature) EMBASE MEDLINE MEDLINE In-Proess & Other Non-Indexed Citations SCOPUS Open SIGLE (System for Information on Grey Literature in Europe)* Soial Care Online TRIP Plus Web of Knowledge ISI Proeedings Web of Knowledge ISI Siene Citation Index Web of Knowledge ISI Soial Siene Citation Index Websites The Child Brain Injury Trust (CBIT), Child Welfare Information Gateway (formerly National Clearing House on Child Abuse and Neglet), gov/ International Soiety for Prevention of Child Abuse and Neglet (ISPCAN), The National Center on Shaken Baby Syndrome, dontshake.om/ *Up to 2005 when the database eased indexing. inidene of inflited head injury is per infants under the age of 1 year. Cases may present regularly to speialist neurology units but present infrequently to general paediatri units. Cliniians in all settings need to be aware of the linial indiators for this ondition to make evidene based deisions as to when they should onsider investigating an infant where ibi is a possible ause and to inform a final diagnosis. Many are asked to present their professional or expert opinion in the family or riminal ourts as part of the hild protetion proess and they must be able to ite relevant evidene to bak up their statements. Although there is a onsiderable amount of published sientifi literature in this field, there have been few attempts to systematially review and ritially appraise the world literature. We have attempted to repair this defiit and have addressed the question: What are the linial features that distinguish inflited from non-inflited brain injury?. The neuro-radiologial features of ibi/nibi are the subjet of a separate review. METHODS We onduted an all language literature searh from , searhing 20 databases, websites, referenes and bibliographies, using over 100 keyword ombinations (box 1, table 1). This yielded 320 studies for review by reviewers, drawn from paediatriians, paediatri neurologists, neuro-radiologists and ophthalmologists, designated and named dotors/nurses in hild protetion. All reviewers underwent standardised ritial appraisal training, based on the NHS Centre for Reviews and Dissemination ritial appraisal standards, 12 supported by a dediated eletroni ritial appraisal module. All studies underwent two independent reviews and a third if there was disagreement (fig 1). Inlusion/exlusion riteria and quality standards We defined the term brain injury as extra-axial haemorrhage (subdural, extradural, subarahnoid) and/or injury to the brain (hypoxi ishaemi injury, parenhymal injury, ontusion, diffuse axonal injury, erebral oedema). Inlusion/exlusion riteria are listed in box 2. Inflited brain injury (ibi), the item of interest, refers to hildren who had sustained brain injury from physial hild abuse. Those with non-inflited brain injury (nibi) had other ausative mehanisms inluding aidental trauma, and medial auses of intraranial lesions. Given the nature of this researh field, our optimal study type was population based studies that ompared the linial features of ibi and nibi with onseutive ase asertainment. As only studies with both nibi and ibi ases ould be used for any analysis of preditive power of the features identified, many oft ited (non-omparative) studies were not eligible for inlusion. The inluded studies detailed the linial features of interest but did not rely solely on these for the determination of diagnosis (ibi vs nibi). Only studies after 1970 were onsidered for inlusion, as radiologial tehniques prior to this would not be relevant to urrent pratie. Inluded studies had a high surety of diagnosis of ibi 13 and onfirmation of ause in nibi. To determine a high surety of abuse, we implemented our previously published ranking of abuse, that is, hildren stated as abused in the study had had that outome onfirmed by multi-ageny hild protetion teams, legal deision, witnessed abuse or perpetrator admission (rank 1 2) 13 (table 2). Studies where the deision of abuse had relied solely on linial features were exluded to minimise seletion bias and irularity. Where studies inluded a ategory aetiology indeterminate, these ases were exluded from the final analysis. Statistial analysis The analysis was limited by the items that the authors hose to report and we were able to analyse the following features: apnoea retinal haemorrhages rib fratures long bone fratures bruising to the head and/or nek seizures skull fratures. We were dependent on the primary authors definitions of the above terms. Apnoea reflets either reorded or reported apnoea in the two studies that reorded this item Seizures were not always defined, but some authors did reord that some hildren presented in status epileptius. 16 Long bone fratures inluded any frature to the femur, tibia, fibula, radius, ulna or humerus. Likewise, skull or rib fratures inluded any type or loation of frature, respetively. We inluded only data from studies where a key feature was expliitly mentioned by the authors. Further, even when a feature was inluded in the study, not all hildren in eah group were examined for the feature in question. For example, not all hildren in the nibi group had a fundosopy examination to look for retinal haemorrhages. We have eleted to adopt an Arh Dis Child 2009;94: doi: /ad

3 Table 1 Keywords Keywords and searh strategy Set 1 battered hild hild protetion non-aidental injury shaken baby hildren non-aidental trauma battered baby inflited brain injury physial abuse battered infant or shaken infant inflited erebral injury shaking baby syndrome hild inflited traumati head injury shaking impat syndrome hild abuse inflited traumati brain soft tissue injury hild maltreatment intentional abuse Set 2 abusive head trauma growing skull frature intraventriular hematoma bleeding into brain haematoma laeration blow to the head haemorrhagi retinopathy laminar nerosis brain head injuries leptomeningeal yst brain damage head trauma multiple skull frature brain haemorrhages hematoma neurologi injury in hild abuse brain hemorrhages hemorrhagi retinopathy.af. neuropathology brain injuries hydroephalus non-aidental head injury brain swelling hygroma parafaline brainstem hypoxi-ishaemi injury parenhymal ontusion, laeration entral nervous system hypoxi-ishemi injury retinal haemorrhage erebral impat injury retinal hemorrhage erebral atrophy infartion siwora erebral edema inflited brain injury shaking impat syndrome erebral injuries inflited erebral injury shearing injury ervial lumbar inflited traumati brain injury skull fratures ervial spine injury inflited traumati head injury spinal ord injury ervial spine interhemispheri subarahnoid hematoma neuropathology intraerebral bleeding subdural hematoma ontusion intraerebral haemorrhage subdural haematoma ontusional tear intraerebral hemorrhage subdural hygroma ranial injury intraranial haemorrhage thorai lumbar saral ranioerebral trauma intraranial hemorrhage traumati effusions ranioervial intraranial injuries ventriular haemorrhage diagnosti triad intraparenhymal tear ventriular hemorrhage diffuse axonal injury intraparenhymal haemorrhage whiplash impat syndrome eggshell frature intraparenhymal hemorrhage whiplash injury enephalomalaia whiplash shaken infant enephalopathy extraranial CNS injury extradural haemorrhage extradural hemorrhage Searh strategy 1. Child/ 54. (retinal hemorrhage or retinal haemorrhage).af. 2. (hild: or infant: or toddler:).af. 55. skull frature:.af or (spinal ord injury adj3 radiologi abnormality).af. 4. non-aidental injur:.af. 57. spinal ord injur:.af. 5. non-aidental trauma.af. 58. (subdural haematoma or hemotoma).af. 6. (non-aidental: and injur:).af. 59. (subarahnoid hematoma or subarahnoid haematoma).af. 7. soft tissue injur:.af. 60. (subdural haemorrhage or subdural hemorrhage).af. 8. physial abuse.af. 61. (ventriular haemorrhage or ventriular hemorrhage).af. 9. (inflited brain injur: or inflited erebral injur:).af. 62. whiplash impat syndrome.af. 10. (inflited traumati head injur: or inflited traumati brain 63. whiplash injur:.af. injur:).af. 11. (or/4-10) and whiplash shaken infant.af. 12. (hild abuse or hild maltreatment or hild protetion).af. 65. infartion.af. 13. (battered hild or shaken baby or battered baby).af. 66. (hypoxi-ishemi injur: or hypoxi-ishaemi injur:).af. 14. (battered infant or shaken infant).af. 67. (ontusion: or ontusional tear).af. 15. Shak: Baby Syndrome.af. 68. (hematoma or haematoma).af. 16. shak: impat syndrome.af. 69. laeration:.af. 17. Caffey-Kempe syndrome.af. 70. shearing injur:.af. 18. battered hild syndrome.af. 71. traumati effusion:.af. Continued 862 Arh Dis Child 2009;94: doi: /ad

4 APPENDIX Table 1 Continued A 1 Continued Searh strategy 19. * Child Abuse /di [Diagnosis] 72. subdural hygroma.af. 20. infant traumati stress syndrome.af. 73. hygroma.af. 21. parent-infant traumati stress syndrome.af. 74. interhemispheri.af. 22. or/ parafaline.af or (brain or brainstem).af. 24. abusive head trauma.af. 77. erebral.af. 25. bleeding into brain.af. 78. intraparenhymal.af. 26. blow to the head.af. 79. siwora.mp. 27. brain damage.af. 80. spinal ord injury without radiologi abnormality.af. 28. (brain haemorrhage: or brain hemorrhage:).af. 81. ervial lumbar.af. 29. (brain swelling or erebral edema).af. 82. thorai lumbar saral.af. 30. erebral injur:.af. 83. leptomeningeal yst.af. 31. ervial spine injur:.af. 84. growing skull frature.af. 32. ervial spine neuropathology.af. 85. hydroephalus.af. 33. ranial injur:.af. 86. laminar nerosis.af. 34. ranioerebral trauma.af. 87. enephalomalaia.af. 35. diffuse axonal injur:.af. 88. erebral atrophy.af. 36. extraranial CNS injur:.af. 89. ranioervial.af. 37. extraranial Central Nervous System injur:.af. 90. enephalopathy.af. 38. entral nervous system injur:.af. 91. (intraparenhymal hemorrhag: or intraparenhymal haemorrhag:).af. 39. (extradural haematoma or hematoma).af. 92. Haemorrhagi retinopathy.af. 40. extradural haemorrhage.af. 93. hemorrhagi retinopathy.af. 41. haemorrhagi retinopathy.af. 94. (Haemorrhagi retinopathy adj3 retinal haemorrhages).af. 42. (head inur: or head trauma).af. 95. Extradural haemorrhage.mp. or Extradural hemorrhage.af. 43. impat injur:.af. 96. (extradural haemorrhag: or extradural hemorrhag:).af. 44. intraerebral bleeding.af. 97. (extradural spinal haemorrhag: or extradural spinal hemorrhag:).af. 45. (intraerebral haemorrhage or intraerebral hemorrhage).af. 98. (Haemorrhagi retinopathy adj3 retinal haemorrhag:).af. 46. (intraranial haemorrhage or intraranial hemorrhage).af. 99. (Hemorrhagi retinopathy adj3 retinal hemorrhag:).af. 47. intraranial injur:.af (retinal hemorrhag: or retinal haemorrhag:).af. 48. (intraventriular hematoma or intraventriular 101. or/ haematoma).af. 49. (multiple skull fratur: or eggshell fratur:).af and (neurologial injur: adj3 hild abuse).af 51. neuropathology.af. 52. non-aidental head injur:.af. 53. (parenhymal ontusion or laeration).af. extremely onservative imputation approah to aount for this missing information. 17 For example, if we are analysing a feature that we suspet may be assoiated with ibi, for instane, retinal haemorrhages: in the group of hildren with ibi, if only 6/10 ibi hildren underwent fundosopy, we made the assumption that the four hildren who were not examined would not have had the feature. By ontrast, in the group of hildren with nibi, if an investigation for this feature was not performed, for example, if only 2/10 nibi hildren underwent fundosopy, we made the assumption that the eight hildren who were not examined would have had the feature. Only in the ase of skull fratures, a feature whose presene we suspet to be assoiated with nibi, was the opposite imputation performed. We believe that by approahing the missing data in this way, we err on the side of aution, and risk underestimating, rather than overestimating, the strength of the disrimination provided by this feature. We have speifially employed this tehnique to avoid reinforing any prior assumptions, but rather to determine a valid estimate of the signifiane of eah of the features under analysis. These imputations being given, we then onduted a multilevel logisti regression analysis, 18 allowing not only the prevalene of abuse to vary between studies, but also the odds ratios (OR) for the features in question. By allowing the odds ratio to differ between studies, we again aim to minimise the risk of irularity, where an individual study may have overly relied upon a partiular feature in order to arrive at the diagnosis of abuse. For eah feature, we report the estimated odds ratio for the feature in disriminating between ibi and nibi, together with a 95% onfidene interval (95% CI). We also provide a p value to determine if this odds ratio is signifiantly different from 1, and a positive preditive value (PPV), the estimated probability of abuse given the presene of this feature in a hild with brain injury, together with a 95% CI. RESULTS Of 320 reviewed studies, 14 met the inlusion riteria. All were published after Six were ross-setional studies, five ase series, two ase ontrol studies and one a longitudinal ohort study. 21 Eight studies involved prospetive enrolment of ases. The six retrospetive studies ahieved full ase asertainment from hospital inpatient oding and/or radiology databases. Full study details are given in online appendix A. Of the 306 studies exluded, the most ommon reasons for exlusion were the lak of omparative data or a rank of abuse of less than 1 or 2. A small number (11 studies) were exluded Arh Dis Child 2009;94: doi: /ad

5 Figure 1 Main phases and number of studies identified at eah stage. Box 2 Inlusion and exlusion riteria Inlusion riteria hildren aged 0 to,18 years observational omparative study (ross-setional/ase ontrol/ase series/longitudinal ohort) hildren with inflited brain injury diagnosed on CT/MR: intraranial haemorrhage (extra-axial with or without additional brain injury intra-parenhymal haemorrhage, diffuse axonal injury hypoxi ishaemi injury erebral ontusion erebral oedema) ranking of abuse 1 or 2 for inflited brain injury (ibi) non-inflited brain injury (nibi): non-inflited aetiology onfirmed hildren who were alive at presentation all language studies relevant linial details given for eah group Exlusion riteria studies about ompliations, management or prognosis of ibi/ nibi onsensus statements or personal pratie studies non-omparative studies studies addressing exlusively post mortem neuropathologial findings studies with mixed adult and hild data, where the hildren s data annot be extrated methodologially flawed studies (eg, signifiant bias, where ibi was not adequately onfirmed or where inadequate linial details were given) studies that only addressed head injury where there was no intraranial abnormality studies with a low surety of diagnosis of inflited injury (rank 3 5 abuse) due to study design (expert opinion/review artile, et) and a further 10 inluded mixed adult and hild data. Many studies were exluded on more than one basis (eg, rank of abuse/nonomparative/lak of detail on features for analysis). Studies represented ombined data on 1655 hildren, 779 of whom had suffered ibi and 876 nibi. Eleven of 14 studies inluded hildren less than 3 years of age Seven studies asertained all hildren who were hospitalised with traumati head injuries, six studies inluded all hildren with subdural haemorrhage of any aetiology (trauma, oagulopathy, metaboli disorder or post infetion, et) and one study inluded hildren with subdural or extradural haemorrhage. 27 The majority (seven) were onduted in the USA, five were European (three UK ) and one eah was from Australia 28 and Hong Kong. 16 In nine studies, hildren were inluded solely on the basis of age and onfirmation of ause. However, five had speifi exlusion riteria (table 3). Gender was reorded in 980 ases and was not a distinguishing feature. More boys than girls sustained brain injuries, regardless of aetiology (PPV of ibi if the hild is a boy (95% CI to 0.530), OR 0.697, p.0.2). It was not possible to undertake a formal analysis of age as a disriminating feature as eah study reported it differently. Eight studies onfirmed that hildren with ibi were signifiantly younger than those who sustained nibi Of the Table 2 Ranking Abuse ranking Criteria used to define abuse 1 Abuse onfirmed at ase onferene or ivil, family or riminal ourt proeedings or admitted by the perpetrator, or independently witnessed 2 Abuse onfirmed by stated riteria inluding multi-disiplinary assessment 3 Diagnosis of abuse defined by stated riteria 4 Abuse stated as ourring, but no supporting detail given as to how it was determined 5 Abuse stated simply as suspeted, no details on whether it was onfirmed or not 864 Arh Dis Child 2009;94: doi: /ad

6 Table 3 Additional exlusion riteria of inluded studies Author/year Additional exlusion riteria Ewing-Cobbs L, Kramer L, Prasad M, et al (1998) 21 Prior traumati brain injury, metaboli abnormality, preterm (,32 weeks) Hettler J, Greenes DS (2003) 22 Coagulopathy, neonatal neurologial abnormality, strutural abnormality, surgery or previous intraranial haemorrhage Fung ELW, Sung RYT, Nelson EAS, et al (2002) 16 Subdural haemorrhage due to infetion or surgery Pierre-Kahn V, Rohe O, Dureau P, et al (2003) 25 Cardiopulmonary resusitation, oagulation abnormality, severe dehydration or delayed eye examination Ettaro L, Berger RP, Songer T (2004) 20 Conussion, erebral laerations or ontusions eight studies addressing hildren less than 3 years of age, where mean ages were available, three studies found no signifiant differene between ibi and nibi. Five studies stated that hildren with ibi were signifiantly younger than those with nibi. Four of these studies gave the mean ages of hildren with ibi as less than or equal to 6 months, while the nibi groups ranged between 7.5 and months. Combined feature analysis It was not possible to identify whih hildren had speifi ombinations of features, as this level of detail was not given. Apnoea Apnoea appeared to be a highly disriminatory finding, with a PPV of 93% (97.5% CI to 0.986) and an OR of (97.5% CI to , p,0.001). However, it was one of the least reorded linial items, only being analysed by two authors (405 hildren), perhaps refleting that its signifiane has only been reognised more reently. Retinal haemorrhage Although 1283 hildren were inluded in studies that onsidered this feature, only 998 had fundosopy (670 ibi and 328 nibi). Many hildren presenting with witnessed trauma did not have formal fundosopy, whereas the majority of hildren with ibi did. Therefore, to aount for studies where this was not expliit, we used the onservative approah desribed above. Retinal haemorrhages were strongly assoiated with ibi, with a PPV of 71% (97.5% CI to 0.868) and an OR of (97.5% CI to , p = 0.03). A hild with an intraranial injury who has o-existent retinal haemorrhages is signifiantly more likely to have ibi than nibi. Rib fratures Rib fratures were onsidered in studies representing 1002 hildren, and data were available on 903 hildren. Rib fratures were assoiated with inflited injury, with a PPV of 73% (97.5% CI to 0.882) and an OR of (97.5% CI to ). The wide onfidene interval reflets the fat that relatively few hildren had data reorded on this item. Our onservative analysis therefore results in lower signifiane. Seizures Seizures were onsidered in studies involving 760 ases, and results were doumented in 758. Seizures were more assoiated with ibi than nibi, but not signifiantly so, with a PPV of 66% (97.5% CI to 0.821) and an OR of (97.5% CI to , p = 0.13). Long bone fratures One of the diffiulties in analysing fratures as reorded in studies, is knowing whether the author is ounting individual fratures, or individual hildren who have sustained fratures. In studies where this was not expliit, 20 we made the assumption that the number of hildren with fratures was reorded, a onservative approah. Studies onsidering long bone fratures represent 1020 hildren, of whom 921 underwent skeletal imaging. Overall, the PPV of long bone fratures for ibi was 59% (97.5% CI 0.48 to 0.69), OR (97.5% CI to 3.601, p = 0.14). Therefore a long bone frature in assoiation with an intraranial injury was a weak preditor for ibi, but not signifiantly so. Skull fratures and bruising to the head and nek Skull fratures were onsidered in studies representing 1014 hildren, and doumented as present or absent in 916 hildren. Skull fratures were more strongly assoiated with nibi than ibi, with a PPV for ibi of 44% (97.5% CI to 0.678), OR (97.5% CI to 2.301, p.0.2). Likewise, bruising to the head and nek was more ommon in the nibi hildren, but it was the least reorded item, weakening its signifiane. Only 212 ases had this feature onsidered, and overall the PPV of head and/or nek bruising for ibi was 37% (97.5% CI to 0.906), OR 0.811(97.5% CI to 9.410, p.0.2). No speifi mention was made of the use of 3D reonstrution tehniques to define suh fratures; the authors simply reorded their presene or absene when looked for. DISCUSSION Making the linial distintion between ibi and nibi in hildren is always going to be hallenging. By produing a multilevel logisti regression of speifi linial features on over 1600 hildren, we have shown that there is sientifi evidene to support the distintion between ibi and nibi, and we are able to offer positive preditive values and odds ratios for individual linial indiators in hildren hospitalised with brain injury. The published literature does not allow an analysis of ombined features. This review is the largest of its kind, and offers for the first time a valid statistial probability of ibi when ertain key features are present (eg, retinal haemorrhages). Although in some instanes, for example, rib fratures, the sample size limits our statistial power to detet the full effet of this feature, as with any systemati review, we are of ourse limited by the amount of high quality data available in the published literature. However, even with this limited data set, the presene of rib fratures (PPV 73%, OR 3.027) is still indiates an assoiation with ibi rather than nibi, and emphasises how important it is to ondut appropriate imaging to determine if suh fratures are present. It appears that the younger the hild, the greater the likelihood that an intraranial injury is due to abuse. Arh Dis Child 2009;94: doi: /ad

7 However, hildren as old as 10 years with severe ibi have also been desribed in isolated ase reports Apnoea appears to be a ritial distinguishing feature (PPV for abuse 93%, OR 17.06, p,0.001). There is inreasing evidene that hypoxi ishaemi injury and its attendant ompliations are an integral part of the asade in ibi. 4 The presene or absene of apnoea must be reorded in all ases of head injury in hildren. Retinal haemorrhages are a valuable disriminator, reinforing the need for fundosopy on any hild with unexplained intraranial injury, or suspeted ibi. Indiret ophthalmosopy should be onduted by an ophthalmologist, as studies have shown that other liniians are either unable to ondut an aurate examination, or when they do, may miss up to 13% of retinal haemorrhages present. 35 Fratures in physial abuse are often oult Therefore, in line with the Royal College of Paediatris and Child Health/ Royal College of Radiologists standards for the radiologial investigation of suspeted physial abuse, any hild aged less than 2 years in whom an inflited injury is onsidered, should have a full skeletal survey, inluding oblique views of the ribs. 38 Seizures were not a valuable disriminatory finding. Perhaps an analysis of speifi patterns of seizures (eg, status epileptius, omplex, foal) would be more informative. It was not possible to analyse the value of history given as a preditor, as a number of studies had used absene of a history of trauma or inonsistent explanation as part of their definition of abuse Only one large study set out to estimate the value of the initial history in prediting whether the head injury was inflited or non-inflited. 22 Study design ensured that the history did not ontribute to the deision as to whether the hild belonged to the ibi or nibi group. The study onluded that having no history of trauma had a high speifiity (0.97) and high PPV (0.92) for inflited injury. Although many studies addressed enephalopathi features, the differing lassifiations that were used (altered onsiousness, oma, irritability, Glasgow Coma Sore (GCS)) preluded any ombined analysis of this information. It is reognised that performing a GCS on young infants is impreise; a study 24 that noted an inreased relative risk of this item for ibi (RR 1.7, 95% CI ) did not attah weight to this feature. We did not address soial features whih are more ulturally speifi, and less suited to meta-analysis. There is also the risk of introduing bias by undue reliane on soial features, as shown by Jenny, 3 who noted that white infants from two parent families were more likely to have their ibi missed than ethni minority hildren or those living with one parent. This review did not address biomehanial features. It is reognised that ibi an our as a onsequene of shaking, impat, 41 shaking and impat, water intoxiation, suffoation 45 or strangulation. 46 In our review skull frature and bruising to the head/nek were more strongly assoiated with nibi than ibi, suggesting blunt trauma as a ommon mehanism of nibi. Clinial evidene of impat may only be found on post mortem, 42 so onlusions as to whether an impat injury has ourred or not in ibi annot reliably be drawn from the linial features alone. It is reognised that subdural haemorrhage (SDH) an our in infany from other auses, and onsideration must be given to possible organi disease, suh as metaboli disorders (eg, glutari aiduria), 6 albeit this has harateristi MRI findings. While oagulopathy may ause intraerebral haemorrhage, 7 9 it may also be seondary to an ibi, 47 highlighting the need for thorough investigations in this group. It is reognised that SDH in partiular, may our as a onsequene of birth, partiularly following instrumental delivery, although a neonatal SDH without skull frature has also been desribed where the mother was assaulted ante-natally. 51 While this review has highlighted ertain linial features that in assoiation with intraranial injury have a high positive preditive value and odds ratio for ibi, suh as retinal haemorrhage, apnoea or rib fratures, none of these features are exlusive to ibi. It is essential that the diagnosis of ibi is only made after taking into onsideration full details on history (birth, medial, family, developmental, soial, details of any reported trauma) and a detailed examination, and having atively exluded other relevant organi diseases. It is vital that future work should endeavour to ollet data on all the features above, with detailed reording of preise abnormalities found, for example, on ophthalmology, if we are to refine these statistial orrelations. Baroness Kennedy has made it abundantly lear that liniians must be able to ite sientifi evidene to support their linial opinions when providing evidene to the ourts, 52 and it is hallenging for any liniian to keep up to date with all the urrent evidene (in the year 2007 alone 242 studies relating to ibi were published). Therefore, we feel that this unique, rigorously onduted systemati review will be a valuable resoure for liniians and other professionals in the field, providing, as it does, odds ratios of abuse for seven easily doumented linial features. Aknowledgements: This work is based on reviews onduted by the Welsh Child Protetion Systemati Review Group: T Abdelnour, M Barber, R Brooks, L Cole, M Gawne-Cain, C Graham, T Jaspan, N John, R Jones, K Kontos, A Mott, A Naughton, M Northey, L Prie, I Prosser, S Rajaram, A Rawlinson, J Saunders, M Shmidt, J Sibert, D Slade, J dewaternaude, J Venables, P Watts, S Datta, A Liu, N Stoodley. 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