Published online July 20, 2009
PEDIATRICS Vol. 124 No. 2 August 2009, pp. 509-516 (doi:10.1542/peds.2008-2348)

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ARTICLE

Utility of Hepatic Transaminases to Recognize Abuse in Children

Daniel Lindberg, MD^a, Kathi Makoroff, MD^b, Nancy Harper, MD^c, Antoinette Laskey, MD, MPH^d, Kirsten Bechtel, MD^e, Katherine Deye, MD^f, Robert Shapiro, MD^b for the ULTRA Investigators

^a Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
^b Mayerson Center for Safe & Healthy Children, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
^c CARE Team, Driscoll Children's Hospital, Corpus Cristi, Texas
^d Division of Children's Health Services Research, Riley Hospital for Children, Indianapolis, Indiana
^e Department of Pediatrics, Section of Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, Connecticut
^f Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, Virginia

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.

PATIENTS AND 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.

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Key Words: abdominal injuries • child abuse • liver function tests • sensitivity • specificity

Abbreviations: CT—computed tomography • GCS—Glasgow coma scale • ROC—receiver operating characteristics • AST—aspartate aminotransferase • ALT—alanine aminotransferase • CI—confidence interval • AUC—area under the curve

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Accepted Feb 2, 2009.

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