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Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of Missed Cases of Abusive Head Trauma. JAMA. 1999;281(7):621–626. doi:10.1001/jama.281.7.621
Author Affiliations: Department of Pediatrics, Brown University School of Medicine (Dr Jenny), and Lifespan Medical Computing (Mr Reinert), Providence, RI; Department of Pediatrics, National Naval Medical Center, Bethesda, Md (Dr Hymel); Department of Pediatrics, University of Oregon Health Sciences Center, Portland (Dr Ritzen); and the Department of Radiology, University of Colorado School of Medicine, Denver (Dr Hay).
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
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
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