Derivation of a clinical prediction rule for pediatric abusive head trauma

Kent P. Hymel, Douglas F. Willson, Stephen C. Boos, Deborah A. Pullin, Karen Homa, Douglas J. Lorenz, Bruce E. Herman, Jeanine M. Graf, Reena Isaac, Veronica Armijo-Garcia, Sandeep K. Narang

Research output: Contribution to journalArticle

31 Citations (Scopus)

Abstract

OBJECTIVES:: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that - if validated - can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse. DESIGN:: Prospective, multicenter, cross-sectional, observational. SETTING:: Fourteen PICUs. PATIENTS:: Acutely head-injured children less than 3 years old admitted for intensive care. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity - to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. CONCLUSIONS:: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform - not dictate - their early decisions to launch (or forego) an evaluation for abuse.

Original languageEnglish (US)
Pages (from-to)210-220
Number of pages11
JournalPediatric Critical Care Medicine
Volume14
Issue number2
DOIs
StatePublished - Feb 1 2013

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Decision Support Techniques
Craniocerebral Trauma
Pediatrics
Critical Care
Cause of Death
Head

All Science Journal Classification (ASJC) codes

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

Hymel, K. P., Willson, D. F., Boos, S. C., Pullin, D. A., Homa, K., Lorenz, D. J., ... Narang, S. K. (2013). Derivation of a clinical prediction rule for pediatric abusive head trauma. Pediatric Critical Care Medicine, 14(2), 210-220. https://doi.org/10.1097/PCC.0b013e3182712b09
Hymel, Kent P. ; Willson, Douglas F. ; Boos, Stephen C. ; Pullin, Deborah A. ; Homa, Karen ; Lorenz, Douglas J. ; Herman, Bruce E. ; Graf, Jeanine M. ; Isaac, Reena ; Armijo-Garcia, Veronica ; Narang, Sandeep K. / Derivation of a clinical prediction rule for pediatric abusive head trauma. In: Pediatric Critical Care Medicine. 2013 ; Vol. 14, No. 2. pp. 210-220.
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Hymel, KP, Willson, DF, Boos, SC, Pullin, DA, Homa, K, Lorenz, DJ, Herman, BE, Graf, JM, Isaac, R, Armijo-Garcia, V & Narang, SK 2013, 'Derivation of a clinical prediction rule for pediatric abusive head trauma', Pediatric Critical Care Medicine, vol. 14, no. 2, pp. 210-220. https://doi.org/10.1097/PCC.0b013e3182712b09

Derivation of a clinical prediction rule for pediatric abusive head trauma. / Hymel, Kent P.; Willson, Douglas F.; Boos, Stephen C.; Pullin, Deborah A.; Homa, Karen; Lorenz, Douglas J.; Herman, Bruce E.; Graf, Jeanine M.; Isaac, Reena; Armijo-Garcia, Veronica; Narang, Sandeep K.

In: Pediatric Critical Care Medicine, Vol. 14, No. 2, 01.02.2013, p. 210-220.

Research output: Contribution to journalArticle

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T1 - Derivation of a clinical prediction rule for pediatric abusive head trauma

AU - Hymel, Kent P.

AU - Willson, Douglas F.

AU - Boos, Stephen C.

AU - Pullin, Deborah A.

AU - Homa, Karen

AU - Lorenz, Douglas J.

AU - Herman, Bruce E.

AU - Graf, Jeanine M.

AU - Isaac, Reena

AU - Armijo-Garcia, Veronica

AU - Narang, Sandeep K.

PY - 2013/2/1

Y1 - 2013/2/1

N2 - OBJECTIVES:: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that - if validated - can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse. DESIGN:: Prospective, multicenter, cross-sectional, observational. SETTING:: Fourteen PICUs. PATIENTS:: Acutely head-injured children less than 3 years old admitted for intensive care. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity - to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. CONCLUSIONS:: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform - not dictate - their early decisions to launch (or forego) an evaluation for abuse.

AB - OBJECTIVES:: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that - if validated - can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse. DESIGN:: Prospective, multicenter, cross-sectional, observational. SETTING:: Fourteen PICUs. PATIENTS:: Acutely head-injured children less than 3 years old admitted for intensive care. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity - to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. CONCLUSIONS:: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform - not dictate - their early decisions to launch (or forego) an evaluation for abuse.

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