Ophthalmologic findings in suspected child abuse victims with subdural hematomas

Odds of abuse associated with retinal hemorrhages in children suspected of child abuse

PURPOSE

To describe the prevalence of retinal hemorrhages in children being evaluated for abusive head trauma and quantify the association between the likelihood of abuse and the presence and severity of retinal hemorrhages.

METHODS

Retrospective cross-sectional study of 110 children aged 15 months or younger who were evaluated for abusive head trauma and received an ophthalmological examination. The child abuse specialist's diagnosis was categorized as definite accident, probable accident, probable abuse, or definite abuse, according to an algorithm that excluded eye findings. Retinal hemorrhage severity was scored on a 12-point scale (6 points per eye) based on type, size, location, and extent. Higher scores indicated greater severity of eye findings.

RESULTS

Seventy-four percent of children were younger than 6 months old. Forty-five percent of cases were definite abuse and 37% were definite accident. The prevalence of retinal hemorrhages was 32%. Across all subjects, the presence of retinal hemorrhage was highly associated with definite or probable abuse versus definite or probable accident (age-adjusted odds ratio 5.4 [95% CI, 2.1-13.6]). The odds ratio in children younger than 6 months (n = 81) was 11.7 (95% CI, 2.9-66.8). Retinal hemorrhage severity was higher in abuse versus accident (p < 0.0001) and correlated positively with abuse (Spearman r = 0.406, p < 0.0001). Scores above 8 (n = 13) were only present in abused children.

CONCLUSIONS

Retinal hemorrhages are highly associated with abusive head trauma, particularly in children younger than 6 months of age. Increasing retinal hemorrhage severity is correlated with increasing likelihood of abuse.

Abusive head trauma

Child physical abuse that results in injury to the head or brain has been described using many terms, including battered child syndrome, whiplash injuries, shaken infant or shaken impact syndrome, and nonmechanistic terms such as abusive head trauma or nonaccidental trauma. These injuries sustained by child abuse victims are discussed in detail in this article, including information about diagnosis, management and outcomes. The use of forensics, the use imaging studies, and associated injuries are also detailed.

Retinal hemorrhages: advances in understanding

Retinal hemorrhage is a cardinal manifestation of abusive head injury characterized by repetitive acceleration-deceleration with or without blunt head impact. Detailed description of the hemorrhages and documentation are critical to diagnosis. Vitreoretinal traction appears to be the major causative factor. Outcome is largely dependent on brain and optic nerve injury.

Shaken baby syndrome: a common variant of non-accidental head injury in infants

BACKGROUND

Recent cases of child abuse reported in the media have underlined the importance of unambiguous diagnosis and appropriate action. Failure to recognize abuse may have severe consequences. Abuse of infants often leaves few external signs of injury and therefore merits special diligence, especially in the case of non-accidental head injury, which has high morbidity and mortality.

METHODS

Selective literature review including an overview over national and international recommendations.

RESULTS

Shaken baby syndrome is a common manifestation of non-accidental head injury in infancy. In Germany, there are an estimated 100 to 200 cases annually. The characteristic findings are diffuse encephalopathy and subdural and retinal hemorrhage in the absence of an adequate explanation. The mortality can be as high as 30%, and up to 70% of survivors suffer long-term impairment. Assessment of suspected child abuse requires meticulous documentation in order to preserve evidence as well as radiological, ophthalmological, laboratory, and forensic investigations.

CONCLUSIONS

The correct diagnosis of shaken baby syndrome requires understanding of the underlying pathophysiology. Assessment of suspected child abuse necessitates painstaking clinical examination with careful documentation of the findings. A multidisciplinary approach is indicated. Continuation, expansion, and evaluation of existing preventive measures in Germany is required.

Shaken baby syndrome: intending to harm or attempting to help?

PURPOSE

To describe the role of ophthalmologists in shaken baby syndrome evaluation.

METHODS

Case report.

RESULTS

A 3.5-month-old girl was admitted to the Pediatrics Clinic with lethargy. The mother, who brought in the baby, claimed that the baby had fallen from her cradle 6 hours ago. Clinical examination showed signs of head injury. Ophthalmologic examination was requested and revealed extensive retinal hemorrhages bilaterally covering the whole fundus, and retrohyaloid hematoma in the right eye. Computerized tomography neuroimaging documented large subdural hematomas exerting force on the brain parenchyma. The sum of the results of the clinical and neuroimaging examination-retinal hemorrhages and subdural hematomas-was indicative of violent shaking of the baby. Coronal evaluation was unable to determine whether the baby was abused by her parents or whether she was accidentally hurt.

CONCLUSIONS

Ophthalmologic examination is necessary to document shaken baby syndrome since it reveals the retinal hemorrhages which together with the neuroimaging findings are almost always present in such cases. However, even when all the signs of shaken baby syndrome are present, it is difficult and sometimes destructive for a parent to be falsely accused of abusing his or her own child.

Ischemic retinopathy and neovascular proliferation secondary to shaken baby syndrome

BACKGROUND

Ocular lesions known to occur after shaken baby syndrome (SBS) are epiretinal, intraretinal, and subretinal hemorrhages, which are present in up to 100% of patients. Retinoschisis and retinal folds have also been described. We describe three patients with SBS who presented with tractional retinal detachments secondary to neovascular proliferation and discuss the role of ischemia at the retinal level.

PATIENTS

Three patients (two 4-month-old babies and one 4-year-old child) with a history of SBS in the first year of life presented with tractional retinal detachment due to severe preretinal fibrovascular proliferation. Peripheral retinal ischemia and vascular disorganization were noted during clinical examination.

CONCLUSION

Although physiopathology of SBS remains disputed, ischemia has been accepted as the main feature of cerebral lesions. Ischemia could also be present at the retinal level as suggested by our patients' presentation. It could be induced by direct vitreous shearing of the capillary network or more probably by vascular leak due to brain edema and hypoxic damage of capillaries. Long-term ocular follow-up is necessary in SBS to treat these patients preventively.

Epilepsy associated with shaken baby syndrome

OBJECT

The shaken baby syndrome (SBS) is an important cause of developmental delay in infants. Epileptic seizures are a common feature of this syndrome. The aim if this study is to analyse the impact of the early and late seizures disorder.

MATERIALS AND METHODS

We have retrospectively reviewed the clinical and electrophysiological findings in a series of 404 children hospitalised with SBS.

RESULTS

In the acute phase, clinical epileptic seizures of various semiologies were found in 73% of the infants. Only 11% of the children had a normal EEG on admission. A poor outcome was found in 88% of the children in case of persisting EEG anomalies despite anti-epileptic treatment with 48% mortality in these patients. The development of refractory epilepsy was also associated with a poor outcome in this series. In fact 96% of the children with seizure recurrence had behavioural problems.

CONCLUSIONS

The early recognition and subsequent management of these seizures is vital to prevent further neurological injury. Delayed or recurrent epileptic seizures may occur with a different semiology to the seizures in the acute phase and are also associated with a poor prognosis.

Update on shaken baby syndrome: ophthalmology

PURPOSE OF REVIEW

Shaken baby syndrome is a common problem with a high morbidity and mortality. Ophthalmologists help manage this condition and therefore must keep abreast of current advances.

RECENT FINDINGS

Clinical updates include the discovery that retinal folds and traumatic retinoschisis can very rarely occur after crush head injury, but remain specific for shaken baby syndrome in other scenarios. Pathology updates include new studies on orbital histology and woodpecker anatomy that suggest the retinal and optic nerve hemorrhages in shaken baby syndrome are caused by shaking itself rather than secondary to intracranial pathology. Regarding this shaking injury, some primary prevention strategies have proven surprisingly effective. In the near future, serum biomarkers may be used as a screening tool for inflicted neurotrauma. Animal models such as the neonatal pig and computer models using finite element analysis are promising experimental techniques for studying shaken baby syndrome. Finally, child abuse recently became an accredited subspecialty of pediatrics, which will lead to further advances in patient care, education, research and prevention.

SUMMARY

Ophthalmologists play a key role in the diagnosis of shaken baby syndrome. In addition, they are in a unique position to study ophthalmic aspects of the syndrome, which in turn furthers the overall understanding of this devastating condition.

Ocular autopsy and histopathologic features of child abuse

PURPOSE

To study the ocular histopathologic features in eyes of children with fatal suspected child abuse.

DESIGN

Retrospective case series.

PARTICIPANTS

One hundred eighteen autopsy cases of known or suspected child abuse.

METHODS

The ocular autopsy and histopathologic features of a cohort of consecutive cases of known or presumed child abuse submitted by Maryland's Office of the Chief Medical Examiner or Johns Hopkins Hospital to the Wilmer Eye Pathology Laboratory were tabulated.

MAIN OUTCOME MEASURE

Ocular hemorrhage or structural abnormality.

RESULTS

Retinal hemorrhage was present in 44% of cases. Circumferential folds with macular schisis cavities were present in 23% of cases and were bilateral in half of those cases. Peripapillary scleral hemorrhage was present in 38% of cases, and subdural hemorrhage was present in the distal optic nerve in 46% of cases. Hemosiderin was present in 27% of cases.

CONCLUSIONS

Intraretinal hemorrhages, circumferential macular folds with schisis cavities, peripapillary scleral hemorrhages, and subdural hemorrhages are common pathologic findings in cases of fatal known or suspected child abuse. Their presence on autopsy should raise the suspicion of shaking or blunt nonaccidental trauma.

Outcome following subdural haemorrhages in infancy

Subdural haemorrhages (SDH) are associated with significant neurodisability in affected individuals. The incidence of SDH in infants is between 12 and 25 cases per 100,000 children and most detected SDH are due to physical abuse. In the infant brain, SDH are caused by tearing of the bridging veins in the subdural space and may result in significant brain injury. The challenge of assessing outcome in infants with SDH is evaluating whether SDH or other accompanying brain insults are instrumental in the neurodevelopmental outcome.

Findings in older children with abusive head injury: does shaken-child syndrome exist?

Shaken-baby syndrome (SBS) has been hypothesized to occur after shaking by an adult during the first 2 years of life. We wondered whether it is possible to achieve rotational forces sufficient to cause SBS-like injuries in children >2 years of age. The present study describes cases of child abuse in older children who presented with the classic ophthalmologic and intracranial findings of SBS. In this case series, 4 cases of older children (2.5-7 years old; 11.8-22 kg) who died from abusive head injuries and who had diffuse retinal hemorrhages identified antemortem were selected for review. The cases were abstracted from hospital charts, records from autopsies, coroners' and district attorneys' offices, and court transcripts. In all 4 cases the history provided by the primary caregiver did not match the severity of the injuries. Three case subjects presented with patterned bruises. Multilayered retinal hemorrhages and acute subdural hematoma were observed in all 4 cases. At autopsy, diffuse axonal injury was evident in 3 of the 4 cases; all 4 cases had optic nerve sheath hemorrhages. None of the victims had skeletal fractures on radiologic examination or at autopsy. This case series demonstrates that it is possible to observe SBS-like retinal and central nervous system findings in the older and heavier child. Our findings underscore the need for providers to consider intentional shaking as a mechanism of injury in the evaluation of abusive head injury in older children.