Evaluation of the Hypothesis That Choking/ALTE May Mimic Abusive Head Trauma

• Published in: Academic pediatrics Vol. 17; no. 4; pp. 362 - 367
• Main Authors: Hansen, Jennifer B., MD, Frazier, Terra, DO, Moffatt, Mary, MD, Zinkus, Timothy, MD, Anderst, James D., MD, MS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-05-2017
• Subjects: Abdominal Injuries - epidemiology; abusive head trauma; Airway Obstruction - complications; Airway Obstruction - diagnosis; Brain Injuries - diagnosis; Brain Injuries - etiology; Case-Control Studies; child abuse; Child Abuse - diagnosis; Child Abuse - statistics & numerical data; child maltreatment; Child, Preschool; Contusions - epidemiology; Craniocerebral Trauma - diagnosis; Craniocerebral Trauma - epidemiology; Diagnosis, Differential; Female; Hematoma, Subdural - diagnosis; Hematoma, Subdural - etiology; Humans; Infant; Infant, Newborn; Male; Mortality; Neonatal and Perinatal Medicine; Odds Ratio; Pediatrics; physical abuse; Retinal Hemorrhage - diagnosis; Retinal Hemorrhage - etiology; Retinoschisis - epidemiology; Retrospective Studies; shaken baby syndrome; child maltreatment; physical abuse; abusive head trauma; child abuse; shaken baby syndrome
• ISSN: 1876-2859; 1876-2867
• DOI: 10.1016/j.acap.2016.10.002

Abstract Objective Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH. Methods We performed a 5-year retrospective case–control study of children <2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries. Results Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9–12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6–10.2), high-specificity bruising (OR 2.6, 95% CI 1.3–4.9), and internal abdominal injury (3.5, 95% CI 1.2–9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury. Conclusions ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.