Bleeding disorders and non-accidental injury

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 or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to 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 or bleeding and should be considered when evaluating for abusive injury.

Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE

Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)?

DESIGN

Prospective comparative longitudinal study.

SETTING

Community.

PATIENTS

Children <6 years old.

INTERVENTIONS

The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases.

MAIN OUTCOME MEASURES

Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD.

RESULTS

Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%.

CONCLUSIONS

These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

Retinal hemorrhage and bleeding disorders in children: A review

BACKGROUND

Retinal hemorrhages (RH) are a common manifestation of abusive head trauma (AHT) resulting from acceleration-deceleration injury with or without blunt impact. Evaluation of a child with RH requires careful consideration of these differential diagnoses. The extent to which coagulopathy alone can cause RH would be useful to understand as coagulopathy may accompany AHT.

OBJECTIVE

In this systematic review, we sought to identify whether coagulopathies have been reported with RH similar to those of AHT.

METHODS

We performed a literature search for ocular manifestations of bleeding disorders in children less than 18 years old. We included clotting factor deficiencies, vitamin K deficiency, platelet function abnormalities, thrombocytopenia, disseminated intravascular coagulation (DIC), and trauma induced coagulopathy (TIC). We included only pediatric reports of intraocular bleeding or documented eye examinations that indicated no hemorrhages. We then re-examined cases for ocular and systemic findings that could potentially mimic abuse.

RESULTS

Our initial search yielded 816 results. Sixty-one articles met our inclusion criteria. Of these, there were 32 children within the AHT age range (less than 5 years old) who had RH and concomitant coagulopathy. Only 5 cases might potentially be confused for abuse. Of these, no classic characteristics of RH from abuse such as retinoschisis or retinal folds were found. Systemic features were inconsistent with AHT.

CONCLUSIONS

The presence of coagulopathy alone does not rule out the possibility that the child has been abused. Coagulopathy alone has not been reported as an etiology of RH that are consistent with AHT, especially when other findings are present.

A Morphometric Analysis of Platelet Dense Granules of Patients with Unexplained Bleeding: A New Entity of Delta-Microgranular Storage Pool Deficiency

One thousand and eighty patients, having prolonged bleeding times, frequent epistaxis, menorrhagia or easy bruising or other bleeding manifestations, and excluding those with von Willebrand's disease, were evaluated for platelet dense granule deficiency. The mean diameter of platelet dense granules was determined for all patients using image analysis. Four hundred and ninety-nine had "classic" dense (delta) granule storage pool deficiency (δ-SPD). Five hundred and eighty-one individuals (53.8%) were found to have a normal mean number of dense granules, but for some of these patients, the dense granules were smaller than for the controls. Of the patients having a normal number of dense granules, 165 (28.4%) were found to have significantly smaller granules than the platelets obtained from the control subjects. Their average granule diameter was 123.35 ± 0.86 nm, that is more than three standard deviations below the mean of the control data. Total δ-granule storage pool volumes (TDGV)/platelet were calculated using these measurements. Individuals with δ-SPD had half the number of granules (2.25 ± 0.04 DG/PL) and storage pool volume (3.88 ± 1.06 × 106 nm3) when compared to our control data (4.64 ± 0.11 DG/PL; 10.79 × 106 nm3 ± 0.42). Individuals having a bleeding history but a normal average of small dense granules had a calculated storage pool volume statistically different than controls and essentially the same storage pool volume as patients with δ-SPD. We have identified a sub-classification of δ-SPD that we have defined as micro-granular storage pool deficiency (δ-MGSPD).

Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study

OBJECTIVE

The extent that inherited bleeding disorders affect; number, size and location of bruises in young children <6 years.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Community.

PATIENTS

105 children with bleeding disorders, were compared with 328 without a bleeding disorder and classified by mobility: premobile (non-rolling/rolling over/sitting), early mobile (crawling/cruising) and walking and by disease severity: severe bleeding disorder factor VIII/IX/XI <1 IU/dL or type 3 von Willebrand disease.

INTERVENTIONS

Number, size and location of bruises recorded in each child weekly for up to 12 weeks.

OUTCOMES

The interventions were compared between children with severe and mild/moderate bleeding disorders and those without bleeding disorders. Multiple collections for individual children were analysed by multilevel modelling.

RESULTS

Children with bleeding disorders had more and larger bruises, especially when premobile. Compared with premobile children without a bleeding disorder; the modelled ratio of means (95% CI) for number of bruises/collection was 31.82 (8.39 to 65.42) for severe bleeding disorders and 5.15 (1.23 to 11.17) for mild/moderate, and was 1.81 (1.13 to 2.23) for size of bruises. Children with bleeding disorders rarely had bruises on the ears, neck, cheeks, eyes or genitalia.

CONCLUSIONS

Children with bleeding disorder have more and larger bruises at all developmental stages. The differences were greatest in premobile children. In this age group for children with unexplained bruising, it is essential that coagulation studies are done early to avoid the erroneous diagnosis of physical abuse when the child actually has a serious bleeding disorder, however a blood test compatible with a mild/moderate bleeding disorder cannot be assumed to be the cause of bruising.

The importance of laboratory re-evaluation in cases of suspected child abuse - A case report

In order to accurately diagnose child abuse or neglect, a physician needs to be familiar with diseases and medical conditions that can simulate maltreatment. Unrecognized cases of abuse may lead to insufficient child protection, whereas, on the other hand, over-diagnosis could be the cause of various problems for the family and their potentially accused members. Regarding child abuse, numerous cases of false diagnoses with undetected causes of bleeding are described in the scientific literature, but, specifically concerning leukemia in childhood, only very few case reports exist. Here, for the first time, we report a case of a 2-year-old boy who got hospitalized twice because of suspicious injuries and psychosocial conspicuities, in a family situation known for repeated endangerment of the child's well-being. After his first hospitalization with injuries typical for child abuse, but without paraclinical abnormalities, medical inspections were arranged periodically. The child was hospitalized with signs of repeated child abuse again five months later. During second admission, an acute lymphoblastic leukemia was revealed by intermittent laboratory examination, ordered due to new bruises with changes in morphology, identifiable as petechial hemorrhages. This case elucidates the discussion of known cases of leukemia in childhood associated with suspected child abuse in order to provide an overview of possible diseases mimicking maltreatment. To arrange necessary supportive examinations, a skillful interaction between pediatrician and forensic pathologist is crucial in the differentiation between accidental and non-accidental injury.

Improving practice in safeguarding at the interface between hospital services and children’s social care: a mixed-methods case study

Background

Hospital settings have an important impact on children harmed by parents and carers. Concern arises from the capacity of these settings to respond effectively to individual needs despite increased NHS policy awareness and actions on safeguarding. Patient safety initiatives have rarely modelled in detail the social and cultural dynamics of child health settings and children’s safeguarding. This study is focused on supporting and evaluating clinician-led service design in an acute trust. A suite of initiatives and artefacts has been designed, based on sociotechnical principles, on the premise that only a thorough understanding of human, social and organisational challenges will afford effective solutions.

Objectives

The study addresses the following primary question: ‘Can a safeguarding culture be designed within the hospital environment that will provide the conditions for the detection of children at risk of abuse and support protective actions before discharge, including collaboration with external agencies?’ Objectives include the development of a sociologically rich understanding of why diagnostic failures and communication breakdowns occur; the design of a suite of integrated interventions for promoting a positive safety culture, following a user-centred approach; and the evaluation of the effectiveness of this package, including its generalisability across sites.

Design

The study took place in two sites: the primary site where the initiatives were developed and a further site with the original intention of transferring developments. The investigation follows a broaddesign scienceapproach. The evaluation of a design intervention relies on a rigorous understanding of the realities of everyday practice, and the study thus draws on mixed methods to examine the impact of service redesign on cultures and practices.

Findings

The data suggest that safeguarding children can become mainstream patient safety business. Board support is vital. In our primary site, there has been a steady integration of learning from serious case reviews and other child protection-related processes with ‘patient safety’-related incidents, with growing recognition that similar systemic issues impact on both domains. Making use of a familiar vocabulary to redescribesafeguardingas asafetyissue, and thus as something fundamental to the functions of an acute hospital, has been part of the success. The data suggest that persistence, resilience and vigilance from the safeguarding leadership and executive teams are crucial. Current policy includes the development of the Child Protection Information Sharing project, which is intended to improve information flow between the NHS, particularly hospitals and children’s social care. The findings from this study suggest the importance of good design, piloting, incrementalism and a thorough empirical engagement with everyday practices during implementation of this and any future information systems based reform.

Conclusions

Safeguarding takes place in a complex system and even minor changes within any part of that system can impact on the rest in unpredictable ways. It is important that managers adopt a ‘design attitude’ and seek to mitigate unintended consequences through careful experimentation. The findings suggest the need for the design of systems to enhance communication and not simply to ‘share information’. Technological solutions impact on everyday decision-making and can have unintended consequences. Attention to forces of change and stasis in health settings, the factors affecting technology transfer and the impact of the configuration of local authority services are suggested as a key priorities for future research.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A two-center retrospective review of the hematologic evaluation and laboratory abnormalities in suspected victims of non-accidental injury

Investigation for bleeding disorders in the context of suspected non-accidental injury (NAI) is inconsistent. We reviewed the hematologic evaluation of children who presented with symptoms of bleeding and/or bruising suspicious for NAI to determine the frequency of hematologic tests, abnormal hematologic laboratory results, and hematologic diagnoses. A retrospective cohort study design was employed at two freestanding academic children's hospitals. ICD-9 codes for NAI were used to identify 427 evaluable patients. Medical records were queried for the details of clinical and laboratory evaluations at the initial presentation concerning for NAI. The median age for the population was 326 days (range 1 day-14 years), 58% were male. Primary bleeding symptoms included intracranial hemorrhage (31.8%) and bruising (68.2%). Hematologic laboratory tests performed included complete blood cell count in 62.3%, prothrombin time (PT) in 55.0%, and activated partial thromboplastin time (aPTT) in 53.6%; fibrinogen in 27.6%; factor activity in 17.1%; von Willebrand disease evaluation in 14.5%; and platelet function analyzer in 11.7%. Prolonged laboratory values were seen in 22.5% of PT and 17.4% of aPTT assays; 66.0% of abnormal PTs and 87.5% of abnormal aPTTs were repeated. In our cohort, 0.7% (3 of 427) of the population was diagnosed with a condition predisposing to bleeding. In children with bleeding symptoms concerning for NAI, hemostatic evaluation is inconsistent. Abnormal tests are not routinely repeated, and investigation for the most common bleeding disorder, von Willebrand disease, is rare. Further research into the extent and appropriate timing of the evaluation is warranted.

Prekallikrein deficiency

Nurses often encounter abnormal laboratory assays that require them to investigate further to ensure that appropriate patient care is provided. A prolonged activated partial thromboplastin time (PTT) with a normal prothrombin time (PT) assay demand further examination, to rule out laboratory error or bleeding disorders. Prekallikrein deficiency is a rare coagulation deficiency that presents itself with a prolonged PTT and a normal PT. It was first identified in 4 of the 11 Fletcher family children in 1965, coincidentally when one of the Fletcher children was undergoing a workup for an adenoidectomy. Both the Fletcher parents had normal coagulation laboratory assays with no history of bleeding tendencies. The term Fletcher factor deficiency was used until Fletcher factor was later identified as plasma prekallikrein. A prekallikrein deficiency is inherited as an autosomal recessive trait. The purpose of this article is to provide a basic review for nurses on hemostasis, identify the 6 causes of a prolonged PTT with a normal or slightly prolonged PT, and to present 2 recently diagnosed adult cases, not previously reported in the medical literature.

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.

Evaluation for bleeding disorders in suspected child abuse

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding concerning for abuse requires an evaluation for bleeding disorders. In some instances, however, bleeding disorders can present in a manner similar to child abuse. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of the laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma, and retinal hemorrhages

External hydrocephalus has been associated with subdural hematomas in infancy, and the hematomas have been noted to be secondary to minor trauma or have even been described as spontaneous. The author reports the case of an infant with external hydrocephalus who developed retinal as well as subdural hemorrhages after sustaining a minor head injury. Although retinal hemorrhage in infancy has been considered virtually pathognomonic of child abuse, in the setting of external hydrocephalus a more cautious interpretation may be appropriate.

Challenges in the evaluation for possible abuse: presentations of congenital bleeding disorders in childhood

OBJECTIVES

To describe children with congenital bleeding disorders that present in a manner that may be concerning for non-accidental trauma (NAT), and to evaluate associations with disease and demographic characteristics.

METHODS

Ten year retrospective chart review of subjects at a Hemophilia Treatment Center. Demographic, historical, and disease characteristics were collected. Findings were compared to a priori criteria for bleeding/bruising that is concerning for abuse.

RESULTS

Twenty-nine (15.3%) of the 189 children in the study had an initial presentation that was concerning for NAT. Of those 29, 75.9% were <5 years of age, 44.8% had von Willebrand disease (vWD), 51.8% had hemophilia, and 48.3% had a family history of a named bleeding disorder. Children from 9 months through 5 years of age were more likely than older children to present with findings concerning for abuse (OR 3.32, 1.21-9.10). No association was detected between presentation concerning for abuse and gender (OR 1.51, 0.6-3.77). Hemophilia was no more likely than vWD to present in a manner that was concerning for abuse (OR 0.7, 0.31-1.58). No children presented with patterned bruising.

CONCLUSIONS

Children with bleeding disorders may present with bruising/bleeding that is clinically highly suggestive of NAT.

PRACTICE IMPLICATIONS

Infants and young mobile children who have non-patterned bruising or bleeding as the only symptom concerning for abuse require an evaluation that includes testing for hemophilia and vWD. Children who have laboratory testing that indicates the presence of a bleeding disorder, but have clinical findings concerning for abuse, may benefit from a collaborative evaluation including a pediatric hematologist and a child abuse pediatrician.

Bruising and bleeding in infants and children - a practical approach

Bruising and bleeding are commonly seen in children and are usually associated with minor injury and trauma. However, in two groups of children the bruising may be more significant than expected: those with an underlying haemostatic abnormality, such as an inherited bleeding disorder, or those who have been subjected to non-accidental injury (NAI). Diagnosing inherited bleeding disorders in children is fraught with difficulty, from venous access to interpretation of results; the possibility of NAI should be borne in mind, even in those children with proven significant bleeding disorders when the severity of the injury and the history are non-compatible. We describe the investigation of the haemostatic system in children with bruising and/or bleeding with emphasis on the key haemostatic disorders that need to be excluded.

Main clinical manifestations of a bleeding diathesis: an often disregarded aspect of medical and surgical history taking

A suitable clinical evaluation of a bleeding diathesis is often forgone. The young doctor is often unprepared to describe in an accurate way the different types of bleeding. An adequate classification and adequate clinical information about a bleeding diathesis are instead of paramount importance. Bleeding may be cutaneous, mucous, articular, muscular, parenchymal, intracavitary, orificial. Each of these sites and forms may have diagnostic implications. An accurate description of the several forms of cutaneous bleeding (petechiae, purpuric spots, ecchymosis, haematomas, etc.) is needed for referrals and for controls. The correct evaluation of cutaneous bleeding manifestations of children (battered child syndrome) is absolutely important for clinical and medico-legal purposes. The same is true for the battering syndrome seen in women abused by their spouses. The grading of haemarthrosis in haemophilia patients is important for the follow-up. A proper description of haematuria is essential in suggesting the probable site of bleeding (kidney or bladder or urethra). A proper evaluation of bleeding may give also useful information on the general health status of the patients (presence of anaemia, poor nutrition, renal insufficiency, etc.). The combination of bleeding and thrombosis in the same patient is also a clinical challenge. The relationship between haemorrhage and thrombosis may be sequential or concomitant. Sequential thrombosis may occur in a patient confined in bed for a brain haemorrhage. Concomitant thrombosis and bleeding occur in DIC and in patients with thrombosis being treated with anticoagulants. Finally, it should be kept in mind that a proper evaluation of the bleeding diathesis of a given patient may help the caring doctor in ordering appropriate laboratory tests (e.g. a platelet count for petechiae, a PTT for a patient with haemarthrosis, etc.).

The bleeding child; is it NAI?

As a paediatric haematologist, the question of whether a child has been abused or whether they might have a bleeding diathesis is a question that I am regularly asked. When I first became a consultant, I would often find that not enough information was available; for example, incomplete histories had been taken or investigations were incomplete and difficult to interpret. This inevitably led to delays in confirming the cause of the bleeding and meant that if parents or carers contested a diagnosis of abuse, excluding a bleeding disorder was extremely difficult. I was also aware that carers of several of my patients with haemophilia or other bleeding disorders had initially been under suspicion of abuse, most usually at the time of the first few presentations. By highlighting important questions in history taking, having a specific haematological screen for children being investigated for bleeding in the context of non-accidental injury, and encouraging discussion of abnormal results with a haematologist, these difficulties can, for the most part, be avoided.

Bruising, coagulation disorder, and physical child abuse

Child protection is a priority, and the medical community has a responsibility to detect cases of abuse and to intervene using the appropriate measures. Bruises are the most common manifestation of physical abuse, although their interpretation can be extremely challenging for paediatricians as the evidence base is limited. As a history of abuse is a strong risk factor for further non-accidental injury, a correct diagnosis is vital. Clearly, the diagnostic process must determine whether an underlying coagulation disorder exists. It is important to realize, however, that the presence of a coagulation deficit does not necessarily exclude abuse. A growing body of evidence suggests that the practice of estimating bruise age is unreliable; therefore, a key factor in diagnosing abuse is the pattern of bruise distribution, which must be linked to the child's history and stage of development. The paediatrician must also consider the combined probabilities of individual bruises being due to abuse. Our scoring system, which uses a Bayesian approach to evaluate these probabilities and assess bruising patterns, is a potentially useful tool for discriminating between abused and non-abused children. We recommend that paediatricians and haematologists should work together to reach a diagnostic consensus that is acceptable in both the clinic and a court of law.

The acute reversal sign: comparison of medical and non-accidental injury patients

OBJECTIVES

(1) To compare the intracranial computed tomography (CT) appearances of patients admitted with various causes of hypoxic ischaemic encephalopathy. Children with known documented accidental trauma were excluded. (2) To compare our results with those in the published literature.

MATERIALS AND METHODS

Seventy-three patients aged between 1 day and 15 years were admitted with clinical features of brain injury and underwent cranial CT. A retrospective review of their medical records and radiology was undertaken. Clinical and radiological data were collected.

RESULTS

On the basis of the combination of the presenting clinical history, progress, outcome, long term follow up and radiology, two groups of patients were identified. Forty-seven children had been the victims of non-accidental injury (NAI). No child in this group had any associated medical condition or any other medical cause for brain injury. All 47 children demonstrated hypoxic ischaemic encephalopathy and had CT signs of cerebral oedema and 'Reversal Sign'. Intracranial haemorrhage was a highly associated feature. Subdural blood was demonstrated in all 47, acute interhemispheric fissure subdural in 42, intracerebral blood in 16 and intraventricular blood in nine. The remaining 26 children were found to have an identifiable 'medical' cause for brain injury. Acute reversal was demonstrated in 21 of this group. Intracranial haemorrhage was uncommon, found in only five and all five had an underlying predisposition to bleeding. No patient in this group demonstrated subdural blood.

CONCLUSION

Non-accidental injury is strongly associated with the finding on CT of intracranial blood, particularly subdural haematoma and interhemispheric fissure bleeding in the presence of hypoxic ischaemic brain injury. The outlook is extremely poor whatever the underlying cause for hypoxic ischaemic brain injury.

The prevalence and distribution of bruising in babies

AIM

To obtain a prevalence rate and determine the distribution of accidental bruising in babies.

METHODS

177 babies aged 6-12 months were examined naked to look for bruises. They were seen in health visitor hearing test clinics and child health surveillance clinics. The site, size, shape, and colour of bruises were recorded on a skin map, and the parent's explanation noted. Any other injury was recorded. Data collection included the baby's age, mobility and weight, demographic details, and health visitor concerns.

RESULTS

Twenty two babies had bruises, giving a prevalence rate of 12%. There was a total of 32 bruises, 15 babies had one bruise. All bruises were found on the front of the body and were located over bony prominences. Twenty five of the bruises were on the face and head, and seven were on the shin. The babies with bruises on the shin were mobile. There was a highly significant increase in bruises with increase in mobility.

CONCLUSIONS

The study has produced a prevalence and distribution of bruising in babies and sets a baseline from which to work when assessing bruises. It also tested out the methodology, which could be used in further research, particularly of younger babies. Clinicians need to assess a baby's level of development when considering whether a bruise is accidental.

Late-form hemorrhagic disease of the newborn: a fatal case report with illustration of investigations that may assist in avoiding the mistaken diagnosis of child abuse

Hemorrhagic disease of the newborn (HDN) is usually a self-limiting hemorrhagic disorder of childhood that occurs as a result of vitamin K deficiency. It may be defined as early or late form depending on the time of onset related to birth. HDN is recognized as one of several bleeding disorders that can mimic the findings of nonaccidental head injury and may lead to a mistaken diagnosis of child abuse. We present a single fatal case of late-onset HDN with illustration of hematologic assays that can be performed to assist the pathologist in making the correct diagnosis of HDN.

Subdural haemorrhages in infants: population based study

OBJECTIVES

To identify the incidence, clinical outcome, and associated factors of subdural haemorrhage in children under 2 years of age, and to determine how such cases were investigated and how many were due to child abuse.

DESIGN

Population based case series.

SETTING

South Wales and south west England.

SUBJECTS

Children under 2 years of age who had a subdural haemorrhage. We excluded neonates who developed subdural haemorrhage during their stay on a neonatal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention.

MAIN OUTCOME MEASURES

Incidence and clinical outcome of subdural haemorrhage in infants, the number of cases caused by child abuse, the investigations such children received, and associated risk factors.

RESULTS

Thirty three children (23 boys and 10 girls) were haemorrhage. The incidence was 12.8/100 000 children/year (95% confidence interval 5.4 to 20.2). Twenty eight cases (85%) were under 1 year of age. The incidence of subdural haemorrhage in children under 1 year of age was 21.0/100 000 children/year and was therefore higher than in the older children. The clinical outcome was poor: nine infants died and 15 had profound disability. Only 22 infants had the basic investigations of a full blood count, coagulation screen, computed tomography or magnetic resonance imaging, skeletal survey or bone scan, and ophthalmological examination. In retrospect, 27 cases (82%) were highly suggestive of abuse.

CONCLUSION

Subdural haemorrhage is common in infancy and carries a poor prognosis; three quarters of such infants die or have profound disability. Most cases are due to child abuse, but in a few the cause is unknown. Some children with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a full multidisciplinary social assessment, an ophthalmic examination, a skeletal survey supplemented with a bone scan or a skeletal survey repeated at around 10 days, a coagulation screen, and computed tomography or magentic resonance imaging. Previous physical abuse in an infant is a significant risk factor for subdural haemorrhage and must be taken seriously by child protection agencies.

Two cases of incontinentia pigmenti simulating child abuse

In the United States 1.4 million children were maltreated in 1988, resulting in an estimated 2000 to 5000 deaths. Largely due to the rising awareness and sensitivity to the horrors of child abuse, the number of deaths declined to approximately 1500 in 1993. Guidelines have been published to aid in the identification and management of child maltreatment, and reporting of all suspicious cases is mandated by law. In our zealous efforts to protect children, some families are investigated because of misdiagnosed abnormalities, often cutaneous, leading to the unintentional injury of both patients and their families. In this report, we describe two patients with cutaneous and/or visceral manifestations of incontinentia pigmenti (IP) who were initially thought to be victims of child abuse.

Inflicted injury versus accidental injury

The morbidity and mortality that are associated with child abuse is a serious concern for the practicing pediatrician. If abuse is to be prevented, physicians must become skilled in recognizing factors that place a child at risk for abuse. Early and minor signs of abuse and neglect must be recognized and reported to assure services if more serious abuse and neglect are to be prevented. Instruments that are used to strike children or burn them leave their imprint on the child. Marks on the skin may signal the existence of internal injuries. Nonaccidental injuries may be difficult to distinguish from accidental injuries. Physicians must approach an injury as a symptom requiring a diagnosis of cause. This is best accomplished by careful examination and documentation of each injury. If the injury is not in keeping with the history given or the child's level of development, abuse must be considered as a cause. A suspicion of abuse should result in a report.

Juvenile chronic myelogenous leukemia and neurofibromatosis in infancy presenting as ocular hemorrhage

A patient presenting with intraocular hemorrhage at 4 weeks of life was suspected of having sustained a nonaccidental injury. Juvenile chronic myelogenous leukemia (JCML) was diagnosed, and subsequently the patient developed the signs of neurofibromatosis. There is an association between the two conditions, but the poor prognosis from JCML may mean that evolving neurofibromatosis is overlooked, particularly if a family history of the disease is not obtained.

Constricting bands. Manifestations of possible child abuse. Case reports and a review

Bands around extremities may be from congenital, infectious, accidental, or purposeful causes. The older child may reveal the cause of self-inflicted or caregiver-inflicted banding. Banding in a nonverbal child will challenge the diagnostic acumen of the physician. Bands of unknown cause, or bands that may have been placed purposefully by a caretaker, must be reported as possible child abuse. Failure of the caretaker to seek help for the consequences of a band may suggest that the bands were intentionally placed. This failure may also be construed as medical neglect. Four cases of banding, which were referred to a child abuse program for consultation, are described.

Mistakes in diagnosing non-accidental injury: 10 years' experience

Fifty children who were referred to the child abuse team in Leeds over the 10 years 1976-86 with suspected non-accidental injury were found to have conditions which mimicked non-accidental injury. These included impetigo (nine children) and blue spots (five children). Five children who presented with multiple bruising had haemostatic disorders. Eight children had disorders of the bone. Five children had been previously abused physically. Four showed evidence of neglect. One had evidence of non-accidental injury as well as the condition mimicking abuse. It is emphasised that when child abuse is suspected a sensitive and thorough assessment should be carried out by a paediatrician who is experienced in this.