Immunizations, retinal and subdural hemorrhages: are they related?

The "New Science" of Abusive Head Trauma

Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.

Evaluation of a Temporal Association between Vaccination and Subdural Hematoma in Infants

OBJECTIVE

To investigate a temporal association between vaccination and subdural hematoma, the main feature of abusive head trauma.

STUDY DESIGN

From a prospective population-based survey carried out in 1 administrative district in France between January 2015 and April 2017, including all infants between 11 and 52 weeks old who underwent a first cerebral imaging (computerized tomography scan or magnetic resonance imaging), we conducted a nested case-control study. Vaccine exposure was compared between cases (infants with subdural hematoma) and 2-3 paired controls, without subdural hematoma or any other imaging findings compatible with abusive head trauma. Cases and controls were matched on chronological (±7 days) and gestational (≤33 vs >33 weeks) ages, respectively. Vaccination status was collected in the personal national pediatric health booklet.

RESULTS

Among the 228 prospectively surveyed infants, 28 had subdural hematoma including 22 with abusive head trauma. The mean chronological age at imaging was 5.3 months among the 28 cases and the 62 controls, who did not differ significantly in median time since last vaccination (1.4 vs 1.3 months, P = .62) or frequency of at least 1 vaccination since birth (86% vs 89%; matched-pairs OR 0.77, 95% CI 0.17-3.86) or within 7 days (0.94, 0.08-6.96), 14 days (0.70, 0.12-2.92), or 21 days (0.48, 0.08-1.98) before cerebral imaging.

CONCLUSIONS

We found no significant temporal association between vaccination and subdural hematoma diagnosis, which must continue to be considered a red flag for abusive head trauma and child abuse.

Evaluation of Temporal Association Between Vaccinations and Retinal Hemorrhage in Children

IMPORTANCE

Vaccinations have been proposed as a cause of retinal hemorrhage in children, primarily as part of a defense strategy in high-stakes abusive head trauma cases. If vaccination injections cause retinal hemorrhage, this consideration would affect the evaluation of children for suspected child abuse.

OBJECTIVES

To describe the prevalence and causes of retinal hemorrhage among infants and young children in an outpatient ophthalmology clinic and to test the hypothesis that, if vaccination injections cause retinal hemorrhage, then retinal hemorrhage would be seen frequently and be temporally associated with immunization.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study between June 1, 2009, and August 30, 2012, at The Children's Hospital of Philadelphia pediatric ophthalmology clinics among 5177 children 1 to 23 months old undergoing a dilated fundus examination as an outpatient for any reason. Children with intraocular surgery or active retinal neovascularization were excluded from the study.

MAIN OUTCOMES AND MEASURES

The prevalence and causes of retinal hemorrhage, as well as the temporal association between vaccination injection within 7, 14, or 21 days preceding examination and retinal hemorrhage.

RESULTS

Among 7675 outpatient fundus examinations, 9 of 5177 children had retinal hemorrhage for a prevalence of 0.17% (95% CI, 0.09%-0.33%). All 9 had abusive head trauma diagnosable with nonocular findings. Among a subset of 2210 children who had complete immunization records and underwent 3425 fundoscopic examinations, 163 children had an eye examination within 7 days of vaccination, 323 within 14 days, and 494 within 21 days. No children had retinal hemorrhage within 7 days of vaccination, 1 child had hemorrhage within 14 days, and no additional child had hemorrhage within 21 days. There was no temporal association between vaccination injection and retinal hemorrhage in the prior 7 days (P > .99), 14 days (P = .33), or 21 days (P = .46).

CONCLUSIONS AND RELEVANCE

Retinal hemorrhage was rare among outpatients younger than 2 years. Considering both immediate and delayed effects, no temporal association existed between vaccination injection and retinal hemorrhage. Vaccination injections should not be considered a potential cause of retinal hemorrhage in children, and this unsupported theory should not be accepted clinically or in legal proceedings. Ophthalmologists noting incidental retinal hemorrhage on an outpatient examination should consider a child abuse evaluation in the absence of other known ocular or medical disease.

Evaluating for suspected child abuse: conditions that predispose to bleeding

Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding/bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, the pediatrician must consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising/bleeding and should be considered when evaluating for abusive injury.