Thesis: Doctor of Medicine, University of Auckland

This thesis contains eight published scientific papers concerning abusive head trauma (AHT) in New Zealand. Aim The aim was to describe children with head trauma referred to the Starship Hospital Child Protection Team for evaluation for suspected AHT (Chapter 2) including the diagnostic approach (Chapters 2 and 3); to test alternative hypotheses for AHT (Chapter 4); to examine whether risk factors could be recognised in perinatal health records (Chapter 5); to examine whether risk factors could be recognised in child protective service (CPS) or police records for whānau members prior to the time of birth (Chapter 6); to determine the economic cost (Chapter 7) and to evaluate a prevention programme in the Auckland District Health Board (Chapter 8). Methods The methods were a retrospective comparative cohort study (Chapter 2); a case report (Chapter 3); review of data from a prospective Australasian study of congenital heart disease (Chapter 4); a multi-centre retrospective case-control study (Chapter 5); a retrospective case-control study of CPS and police records (Chapter 6); a multi-agency cost audit and cost-utility analysis of economic cost and disability burden (Chapter 7); and a pilot AHT prevention programme with analysis of surveys of caregivers and health professionals (Chapter 8). Findings • 345 head injured children had findings consistent with the literature (Chapter 2); • Retinal haemorrhage was a rare complication of acute disseminated encephalomyelitis (Chapter 3); • 152 cases of congenital heart disease provided no support for alternative hypotheses of AHT (Chapter 4); • In the case-control study (142 cases and 550 controls), nine perinatal factors were associated with the risk of AHT (Chapter 5). Data from CPS or police records added little predictive value (Chapter 6); • The average lifetime cost for a single case of AHT was $11.7 million (Chapter 7); • A prevention programme was regarded positively, and key messages were remembered (Chapter 8). Conclusions The incidence of AHT in New Zealand is similar to the US and may be increasing, and the risk profile for AHT in New Zealand is consistent with international literature. Māori are over-represented in AHT and missing health information may indicate increased risk. Although prior notification to CPS or police is associated with increased risk, information from perinatal health records is at least as useful in its capacity to predict risk. The health outcomes of AHT are poor, most victims return to their whānau, most cases are not prosecuted, and many are renotified for other child protection concerns. There is a strong economic argument for prevention and a need to reconceptualise AHT in New Zealand as a health problem requiring a public health response. (Author's abstract). Record #6974