Utility of hepatic transaminases to recognize abuse in children.
OBJECTIVE
Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse.


METHODS
This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken.


RESULTS
Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity.


CONCLUSIONS
In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.
Lindberg
Daniel
D
Department of Emergency Medicine, Brigham and Women'sHospital, Boston, Massachusetts 02115, USA. dlindberg@partners.org
Makoroff
Kathi
K
Harper
Nancy
N
Laskey
Antoinette
A
Bechtel
Kirsten
K
Deye
Katherine
K
Shapiro
Robert
R
D000007:Abdominal Injuries / Q000175:diagnosis* / Q000201:enzymology; D000410:Alanine Transaminase / Q000097:blood*; D001219:Aspartate Aminotransferases / Q000097:blood*; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008111:Liver Function Tests / Q000706:statistics & numerical data; D008279:Magnetic Resonance Imaging; D008297:Male; D008403:Mass Screening; D010808:Physical Examination; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012016:Reference Values; D012017:Referral and Consultation; D014057:Tomography, X-Ray Computed
D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase