Abstract

Background: Abusive head trauma (AHT) is challenging to diagnose due to unreliable histories and unrecognized clinical features.

Objective: To synthesize evidence on the association between reported clinical features and the likelihood of AHT versus non-abusive head trauma (nAHT) in children under 2 years with head injury.

Methods: We searched Ovid Medline, Web of Science, and the Cochrane Library (18/12/2020; updated 17/9/2023). Two reviewers independently selected studies, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale. Random-effects meta-analyses with forest plots and sensitivity analyses were performed.

Results: Twenty variables were identified in 27 studies, mainly retrospective cohorts. Seven variables were associated with AHT: evidence of old injury (OR 40.42 [95 % CI 7.53; 216.93]), apnea or hypoventilation (OR 14.23 [95 % CI 5.26; 38.48]), history of upper respiratory tract infection/distress (OR 11.96 [95 % CI 1.56; 92.02]), external injury excluding head (OR 5.80 [95 % CI 2.20; 15.31]), seizures (OR 5.65 [95 % CI 2.95; 10.81]), abnormal mental status (OR 3.98 [95 % CI 1.20; 13.18]), and a higher Injury Severity Score (median difference 9.34 [95 % CI 6.41; 12.27]). External head injury (OR 0.24 [95 % CI 0.09; 0.63]) and asymptomatic presentation (OR 0.03 [95 % CI 0.01; 0.18]) were associated with nAHT. Sensitivity analysis identified associations of unconsciousness (OR 3.68 [95 % CI 1.50; 9.03]) and cardiopulmonary arrest (OR 10.53 [95 % CI 1.35; 82.05]) with AHT, and of bruising (OR 0.27 [95 % CI 0.10; 0.71]) with nAHT. Moderate or high risk of bias was observed in 62 % of the assessments.

Conclusions: Certain clinical features in children under 2 years with head injury may indicate AHT. Results should be interpreted cautiously given the moderate to high risk of bias in the majority of assessments.