Last month, Dartmouth-Hitchcock Medical Center physician Kent Hymel created the Pediatric Brain Injury Research Network, a group of experts who conduct research and collect data on child abuse rates, as well as methods to determine whether injuries are caused by abuse. On the network's web site, Hymel plans to publish a clinical prediction rule that will provide a standard for physicians to follow with young head trauma patients, he said.
Hymel, the medical director of the Child Advocacy and Protection Program at DHMC, created the network after leading a research team that identified head injury depth as a useful indicator of head injury causes for children under three years of age. Having better knowledge of the causes can lead to more effective protection from abuse, according to Hymel.
"Right now there are no tools or clinical prediction rules that have been derived or validated for this specific purpose," Hymel said. "Physicians make decisions to suspect, evaluate and report abuse solely on personal experience and knowledge, and therefore there is great variation in reporting."
Abusive head trauma is the leading cause of traumatic death and disability among children in the first three years of life, according to the PediBIRN web site. A 1999 study shows that physicians missed or misdiagnosed abusive head trauma in 31 percent of symptomatic children, 28 percent of whom were re-injured after returning to their abusive environments, the web site reports.
Hymel began researching pediatric abusive head trauma because he was astounded by the rates of morbidity and mortality among victims of abuse, which he attributes to chronic misdiagnosis and a general lack of reporting of potentially abusive cases, he said.
When some physicians suspect abuse, they often do not report it because they do no want to "under- or over-diagnose the injury," Hymel said.
"Physicians misdiagnose this problem not infrequently," he said.
Hymel began conducting a study on pediatric head trauma a year and a half ago with eight other scientists and medical professionals across the country, who helped him collect relevant data and statistics, he said. The study was published in the journal Pediatrics on March 29.
In order to gather subjects for the study, Hymel and his team "recruited" children of less than three years of age who were hospitalized with acute head trauma in medical facilities across the country, according to the Pediatrics article. The researchers collected clinical and imaging data and thoroughly interviewed the children's caregivers, the article said.
Six months after the injuries were sustained, the researchers conducted neuro-developmental evaluations and compared subject groups with injuries of varying depths, according to the article.
The rules developed from the study will be particularly effective in situations in which clinical decision-making is complex or has high stakes, according to PediBIRN's web site. The guidelines will also allow medical care facilities to save costs without compromising individual care, the web site says.
"[The guidelines] will facilitate calculation of an evidence-based estimate of the probability of abuse for any hospitalized, acutely-head injured child" less than three years of age, according to the web site.
Subjective variation in abuse reporting is being debated aggressively in courtrooms and has been recognized as a significant issue by the medical community and national press, Hymel said. Physicians have become increasingly hesitant to investigate abuse because of the controversy caused by cases of overlooked abuse, according to Hymel.
"I hope to give physicians a tool that they can choose to use to guide them when they suspect or report abuse," Hymel said. "This is intended to be applied in emergency rooms, hospitals and clinics."
Hymel will expand PediBIRN by soliciting collaborators at presentations he will make throughout the country about the network's objectives, he said. Through continued research, Hymel said he hopes to determine more concrete, widely applicable data that will be used to substantiate his clinical prediction rule.
"So far I have three [medical facilities] that have firmly committed to participate [in the network] over the past two and a half weeks," Hymel said. "I need about 12 to 15 sites to get the research done expeditiously."
