Brief CommunicationHow useful is the presence of petechiae in distinguishing non-accidental from accidental injury?
Introduction
Petechiae are non-specific cutaneous lesions occurring in a wide spectrum of disorders (Jaffe, 1994). These lesions have been reported to have corroborative if not diagnostic value in conditions of forensic interest such as infanticide and sudden infant death syndrome (Oehmichen, Gerling, & Meissner, 2000). However, the degree of usefulness of unexplained petechiae as a diagnostic aid in suspected non-accidental injury (NAI) has yet to be established. Distinguishing non-accidental injury from accidental injury can be problematic, and the presence of unexplained petechiae may increase the likelihood that the injury is non-accidental. We have been unable to find any literature specifically addressing unexplained petechiae in non-accidental injury other than that related to suffocation. However, clinical anecdote suggests that petechiae with or without other bruising may indicate an increased likelihood of non-accidental injury. A legal challenge to the clinical opinion of one of the authors (N.S.) provided an additional impetus to contribute to an evidence-base in this under-researched clinical area.
The aim of this study, therefore, was to ascertain the prevalence of petechiae in children with accidental and non-accidental injury and the value of the presence or absence of petechiae as a diagnostic test for non-accidental injury.
Section snippets
Methods
A retrospective group of all 190 children aged less than 17 years examined between November 1998 and October 2000 in a community pediatric referral clinic for children suspected of suffering non-accidental injury and a prospective group of all 263 children aged less than 17 years attending Accident and Emergency (A&E) with minor trauma, defined as ambulatory cases not requiring hospital admission, over a 2-week period in January 2001 were compared for the reported prevalence of petechiae. The
Results
Of 453 children included in the study, 190 children were referred to the community pediatric clinic for suspected non-accidental injury and 263 children attended the Accident and Emergency Department. The characteristics of the children in the two groups are shown in Table 1. Similar proportions of children in the two groups sustained head and neck injuries and limb injuries, although more children referred for possible non-accidental injuries had combined head, neck, and trunk injuries. A
Discussion
In this study, the presence of petechiae was considerably more common among those believed to have had a non-accidental cause for their injuries. The finding of a likelihood ratio for a positive result of 6 implies that the presence of petechiae on examination increases sixfold the likelihood that the injuries were non-accidental. However, the absence of petechiae does not assist in excluding non-accidental injury as the likelihood ratio for a negative result was close to unity.
An alternative
Acknowledgements
We thank the community pediatricians who completed the standard proformas in the non-accidental injury referral clinic and the doctors in A&E who completed the proformas in the prospective cohort of children attending A&E. We also thank Dr Karen McLachlan, Consultant Pediatrician at the University Hospitals of Coventry and Warwickshire, who classified the 10% sample of proformas.
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