van Gemert Martin J C, Zwinderman Aeilko H, Koppen Peter J van, Neumann H A Martino, Vlaming Marianne
Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Department of Clinical Epidemiology & Bio-Statistics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
Children (Basel). 2023 May 6;10(5):843. doi: 10.3390/children10050843.
A newborn girl had, from two weeks on, small bruises on varying body locations, but not on her chest. Her Armenian grandmother easily bruised, too. Her mother was diagnosed with hypermobility-type Ehlers-Danlos-Syndrome (hEDS), an autosomal dominant connective tissue disorder, with a 50% inheritance probability. Referral to a University Medical Center located "" resulted (prior to consultation) in physical abuse suspicion. Protocol-based skeletal X-rays showed three healed, asymptomatic rib fractures. A protocol-based Bayesian likelihood ratio guesstimation gave 10-100, erroneously used to suggest a 10-100 times likelier non-accidental-than-accidental cause. Foster care placement followed, even in a secret home, where she also bruised, suggesting hEDS inheritance. Correct non-accidental/accidental Bayes' probability of symptoms is (likelihood ratio) × (physical abuse incidence). From the literature, we derived an infant abuse incidence between about ≈0.0009 and ≈0.0026 and a likelihood ratio of <5 for bruises. For rib fractures, we used a zero likelihood ratio, arguing their cause was birth trauma from the extra delivery pressure on the chest, combined with fragile bones as the daughter of an hEDS-mother. We thus derived a negligible abuse/accidental probability between <5 × 0.0009 <0.005 and <5 × 0.0026 <0.013. The small abuse incidence implies that correctly using Bayes' theorem will also miss true infant physical abuse cases. Curiously, because likelihood ratios assess how more often symptoms develop if abuse did occur versus non-abuse, Bayes' theorem then implies a 100% infant abuse incidence (unwittingly) used by LECK. In conclusion, probabilities should never replace differential diagnostic procedures, the accepted medical method of care. Well-known from literature, supported by the present case, is that (child abuse pediatrics) physicians, child protection workers, and judges were unlikely to understand Bayesian statistics. Its use without statistics consultation should therefore not have occurred. Thus, Bayesian statistics, and certainly (misused) likelihood ratios, should never be applied in cases of physical child abuse suspicion. Finally, parental innocence follows from clarifying what could have caused the girl's bruises (inherited hEDS), and rib fractures (birth trauma from fragile bones).
一名新生女婴自两周大起,身体不同部位出现小瘀伤,但胸部没有。她的亚美尼亚祖母也很容易出现瘀伤。她的母亲被诊断患有高活动型埃勒斯-当洛综合征(hEDS),这是一种常染色体显性遗传性结缔组织疾病,遗传概率为50%。转诊至位于“”的大学医学中心(在咨询之前)引发了对虐待儿童的怀疑。基于协议的骨骼X线检查显示有三处愈合的、无症状的肋骨骨折。基于协议的贝叶斯似然比估计得出的结果为10 - 100,但被错误地用来表明非意外原因比意外原因的可能性高10 - 100倍。随后女婴被安置到寄养家庭,甚至是一个秘密住所,在那里她也出现了瘀伤,这表明是hEDS遗传所致。正确的非意外/意外症状的贝叶斯概率是(似然比)×(虐待儿童的发生率)。从文献中,我们得出婴儿受虐发生率约在0.0009至0.0026之间,瘀伤的似然比<5。对于肋骨骨折,我们使用了零似然比,认为其原因是分娩时胸部受到额外压力导致的出生创伤,再加上作为hEDS母亲的女儿骨骼脆弱。因此,我们得出虐待/意外的概率可以忽略不计,在<5×0.0009<0.005和<5×0.0026<0.013之间。低虐待发生率意味着正确使用贝叶斯定理也会漏诊真正的婴儿身体虐待案例。奇怪的是,因为似然比评估的是如果发生虐待与未发生虐待时症状出现的频率差异,贝叶斯定理进而意味着LECK(无意中)使用了100%的婴儿虐待发生率。总之,概率绝不应取代鉴别诊断程序,即公认的医疗护理方法。从文献中可知,并由本案例支持的是,(儿童虐待儿科)医生、儿童保护工作者和法官不太可能理解贝叶斯统计学。因此,在没有统计学咨询的情况下不应使用它。所以,贝叶斯统计学,尤其是(被滥用的)似然比,绝不应用于怀疑儿童身体虐待的案例。最后,通过明确导致女孩瘀伤(遗传性hEDS)和肋骨骨折(脆弱骨骼导致的出生创伤)的原因,可以证明父母是无辜的。