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Curcoy AI, Serra A, Morales M, Luaces C, Trenchs V. Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse? CHILD ABUSE & NEGLECT 2023; 144:106387. [PMID: 37549636 DOI: 10.1016/j.chiabu.2023.106387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse. OBJECTIVE To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children. PARTICIPANTS AND METHODS Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT. RESULTS Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH2O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1. CONCLUSIONS RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted.
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Affiliation(s)
- Ana I Curcoy
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Alicia Serra
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marta Morales
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Carles Luaces
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Victoria Trenchs
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain.
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Christian CW, Levin AV, Flaherty EG, Sirotnak AP, Budzak AE, Gavril AR, Haney SB, Idzerda SM, Laskey A, Legano LA, Messner SA, Moles RL, Palusci VJ, Karr DJ, Bradford GE, Nischal K, Roarty JD, Rubin SE, Suh DW. The Eye Examination in the Evaluation of Child Abuse. Pediatrics 2018; 142:peds.2018-1411. [PMID: 30037976 DOI: 10.1542/peds.2018-1411] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
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Affiliation(s)
- Cindy W. Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Alex V. Levin
- Departments of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital and Departments of Ophthalmology and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Küppers L, Hartung B, Karenfort M, Ritz-Timme S. Schütteltrauma vs. Impfkomplikation. Rechtsmedizin (Berl) 2017. [DOI: 10.1007/s00194-017-0170-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bais B, Karst WA, Kubat B, Verdijk RM. Persistent Retinal Iron in Abusive Head Trauma. J Forensic Sci 2016; 61:1693-1696. [DOI: 10.1111/1556-4029.13215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 02/02/2016] [Accepted: 02/13/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Babette Bais
- Department of Forensic Medicine; Netherlands Forensic Institute; The Hague The Netherlands
| | - Wouter A. Karst
- Department of Forensic Medicine; Netherlands Forensic Institute; The Hague The Netherlands
| | - Bela Kubat
- Department of Forensic Medicine; Netherlands Forensic Institute; The Hague The Netherlands
| | - Robert M. Verdijk
- Department of Pathology; Section Ophthalmic Pathology; Erasmus MC University Medical Center; Rotterdam The Netherlands
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Abstract
Abusive head trauma has a robust and interesting scientific history. Recently, the American Academy of Pediatrics has endorsed a change in terminology to a term that is more general in describing the vast array of abusive mechanisms that can result in pediatric head injury. Simply defined, abusive head trauma is "child physical abuse that results in injury to the head or brain." Abusive head trauma is a relatively common cause of childhood neurotrauma, with an estimated incidence of 16 to 33 cases per 100,000 children per year in the first 2 years of life. Clinical findings are variable; AHT should be considered in all children with neurologic signs and symptoms, especially if no or only mild trauma is described. Subdural and retinal hemorrhages are the most common findings. The current best evidence-based literature has identified some features--apnea and severe retinal hemorrhages--that reliably discriminate abusive from accidental injury. Longitudinal studies of outcomes in abusive head trauma patients demonstrate that approximately one-third of the children are severely disabled, one third of them are moderately disabled, and one third have no or only mild symptoms. Abusive head trauma cases are complex cases that require a rigorous, multidisciplinary team approach. The clinician can establish this diagnosis with confidence if he/she maintains a high index of suspicion for the diagnosis, has knowledge of the signs, symptoms, and risk factors of abusive head trauma, and reasonably excludes other etiologies on the differential diagnosis.
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Affiliation(s)
| | - Jennifer Clarke
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
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The eye in child abuse: key points on retinal hemorrhages and abusive head trauma. Pediatr Radiol 2014; 44 Suppl 4:S571-7. [PMID: 25501729 DOI: 10.1007/s00247-014-3107-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
This review presents an up-to-date overview of ocular injuries resulting from child abuse, with a spotlight on abusive head trauma. Retinal hemorrhage is a principle finding of inflicted head trauma. The specific pattern of hemorrhages holds valuable diagnostic information, which can help to guide multidisciplinary assessments of the likelihood of abuse. Indirect ophthalmoscopy through dilated pupils by an ophthalmologist is necessary for adequate examination and documentation of retinal findings. Initial pediatrician evaluation of the eye and indications for ophthalmological consultation are reviewed. Focus is then placed upon understanding retinal hemorrhage patterns, their diagnostic significance and likely pathophysiological mechanisms. The differential diagnosis of retinal hemorrhage in young children is discussed, highlighting key distinctions among retinal hemorrhage patterns, severity and frequencies, as well as other ocular findings. The most common cause of retinal hemorrhage in an infant is trauma, and most other causes can be identified by considering the hemorrhage pattern, ocular or systemic signs and the results of laboratory and imaging tests, when indicated.
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Agrawal S, Peters MJ, Adams GGW, Pierce CM. Prevalence of retinal hemorrhages in critically ill children. Pediatrics 2012; 129:e1388-96. [PMID: 22614777 DOI: 10.1542/peds.2011-2772] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Retinal hemorrhages (RHs) with encephalopathy and subdural bleeding are considered suggestive of abusive head trauma (AHT). Existing studies describing RH focus on AHT and have potential selection bias. We undertook a prospective observational study to define the prevalence, distribution, and extent of RH in critically ill children. METHODS From February 2008 to December 2009, emergency intensive care admissions ≥ 6 weeks of age underwent dilated retinal examination by either a pediatric ophthalmologist or RetCam (retinal photograph) imaging after written informed consent. Patients with suspected or proven AHT, penetrating eye trauma, and elective admissions were excluded. RESULTS The prevalence of RH was 15.1% (24/159; 95% confidence interval [CI]: 9.5%-21%); 16/24 (66%) mild, and 2/24 (8%) moderate. Severe multilayered RH were seen in only 6 patients (3.7%), 3 with myeloid leukemia and sepsis, 2 with severe accidental head injury, and 1 with severe coagulopathy secondary to late onset hemorrhagic disease of newborn. There was no detectable impact of age, gender, seizures, coagulopathy or cardiopulmonary resuscitation on prevalence of severe multilayered RH; however, sepsis (odds ratio: 3.2; 95% CI: 1.3-8.0, P = .018) and coagulopathy (odds ratio: 2.8; 95% CI: 1.2-7.0, P = .025) were significantly associated with any RH. Only admission diagnosis was independently associated with severe multilayered RH on logistic regression. CONCLUSIONS RHs were seen in critically ill children with a prevalence of 15.1% (24/159); however, most were mild. Severe multilayered RH resembling those described in AHT were rare (6/24) and were only seen in patients with fatal accidental trauma, severe coagulopathy, sepsis with myeloid leukemia, or a combination of these factors.
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Affiliation(s)
- Shruti Agrawal
- Paediatric and Neonatal Intensive Care Units, Great Ormond Street Hospital for Children, London, United Kingdom.
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Abstract
Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.
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Affiliation(s)
- Alex V Levin
- Pediatric Ophthalmology and Ocular Genetics, Wills Eye Institute, Suite 1210, 840 Walnut St, Philadelphia, PA 19107, USA.
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Vincent AL, Kelly P. Retinal haemorrhages in inflicted traumatic brain injury: the ophthalmologist in court. Clin Exp Ophthalmol 2010; 38:521-32. [DOI: 10.1111/j.1442-9071.2010.02324.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Forbes BJ, Rubin SE, Margolin E, Levin AV. Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma. J AAPOS 2010; 14:267-73. [PMID: 20603062 DOI: 10.1016/j.jaapos.2010.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/30/2010] [Accepted: 03/31/2010] [Indexed: 11/18/2022]
Abstract
Extensive intraocular hemorrhage in young infants in the setting of acute brain injury and in the absence of a history of severe accidental trauma or underlying medical cause must be considered to be nonaccidental injury until otherwise proven. In the absence of any obvious explanation, the presence of any retinal hemorrhage should raise the possibility of abusive head trauma in the differential diagnosis and perhaps lead to such testing as skeletal radiography and neuroimaging, consultation with a child abuse specialist, as well as workup for other relevant systemic conditions. Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that the proper steps are taken to protect their patients from the potential for further harm. Ascertainment of abusive head trauma is critical to prevent a potentially fatal recurrence.
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Affiliation(s)
- Brian J Forbes
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Abstract
PURPOSE OF REVIEW As knowledge about child abuse and neglect increases worldwide, so does the literature on abuse and neglect. The authors explore many studies published this year, with attention to the advances in understanding which are guiding prevention efforts as well as diagnosis and treatment of abuse and neglect. RECENT FINDINGS The evidence base for many forms of child abuse continues to grow. Controversy around the diagnosis of child abuse still continues, with current debate focused on the diagnosis of abusive head injury and whether children with vitamin D deficiency are misdiagnosed with abusive fractures. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented, and researchers are evaluating these efforts with an eye to whether or not they really contribute to prevention. SUMMARY The short-term and long-term impact of child maltreatment is significant not only for individuals but for families and communities in which abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children. However, it is clear that specialists in child abuse should also play a role in order for diagnosis and management of abuse to adhere to a high standard of care. This has been validated this year by the creation of Child Abuse Pediatrics as a board certified specialty in the United States. As knowledge about abuse and neglect grows, clinicians are focusing on prevention as well as diagnosis and treatment.
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Wygnanski-Jaffe T, Morad Y, Levin AV. Pathology of retinal hemorrhage in abusive head trauma. Forensic Sci Med Pathol 2009; 5:291-7. [PMID: 20024631 DOI: 10.1007/s12024-009-9134-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2009] [Indexed: 12/01/2022]
Abstract
Abusive head injury, characterized by repeated acceleration-deceleration forces, is associated with retinal hemorrhages as demonstrated in many clinical and postmortem studies. The theory that vitreoretinal traction is the major factor in the pathogenesis of retinal hemorrhages is presently the most widely accepted explanation based on different lines of research. Postmortem examination of the eye and orbital structures is essential for recognizing abusive head injury and also for identifying other possible medical conditions which can cause retinal hemorrhage.
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Millichap JG. Infantile Convulsions and Retinal Hemorrhages. Pediatr Neurol Briefs 2009. [DOI: 10.15844/pedneurbriefs-23-12-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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