Correlations of intracranial pathology and cause of head injury with retinal hemorrhage in infants and toddlers: A multicenter, retrospective study by the J-HITs (Japanese Head injury of Infants and Toddlers study) group

26 cm fall caught on video causing subdural hemorrhages and extensive retinal hemorrhages in an 8-month-old infant

Severe, too many to count retinal hemorrhages (RH) in infants have been associated with abusive head trauma, but can occur in short falls. An 8-month-old male fell backward from a height of 26 cm, landing on his buttocks then hitting the back of his head on a vinyl floor. The fall was videotaped. Acute subdural hemorrhages were found along with extensive, too many to count intra-RH in both eyes. Falls from small heights on to the occiput can lead to extensive RH of the type often associated with abusive head trauma.

An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse

Abusive head trauma (AHT) is an extreme form of physical child abuse, a subset of which is shaken baby syndrome (SBS). While traumatic injury in children is most readily observed as marks of contusion on the body, AHT/SBS may result in internal injuries that can put the life of the child in danger. One pivotal sign associated with AHT/SBS that cannot be spotted with the naked eye is retinal injury (RI), an early sign of which is retinal hemorrhage (RH) in cases with rupture of the retinal vasculature. If not addressed, RI can lead to irreversible outcomes, such as visual loss. It is widely assumed that the major cause of RI is acceleration-deceleration forces that are repeatedly imposed on the patient during abusive shaking. Still, due to the controversial nature of this type of injury, few investigations have ever sought to delve into its biomechanical and/or biochemical features using realistic models. As such, our knowledge regarding AHT-/SBS-induced RI is significantly lacking. In this mini-review, we aim to provide an up-to-date account of the traumatology of AHT-/SBS-induced RI, as well as its biomechanical and biochemical features, while focusing on some of the experimental models that have been developed in recent years for studying retinal hemorrhage in the context of AHT/SBS.

Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence

The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine.

A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma

INTRODUCTION

We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT.

METHODS

We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT.

RESULTS

47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT.

CONCLUSIONS

AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT.

TYPE OF STUDY

Observational cohort study.

LEVEL OF EVIDENCE

III.

Clinical and Forensic Investigation Protocols for Diagnosing Abusive Head Trauma: A Literature Review

Abusive head trauma (AHT) represents a very serious global public health problem. Prevention of these episodes is essential to reduce the morbidity and mortality of this phenomenon. All healthcare professionals should be able to recognize the signs of abuse. However, diagnosis is very complex as the signs are often blurred and cannot be recognized with certainty without carrying out adequate instrumental investigations. It has been calculated that approximately one-third of AHT cases remain undetected and require more than one medical visit to be correctly interpreted and diagnosed. On the other hand, the literature has recently also emphasized the problems related to possible false diagnoses of abuse and the numerous family and personal repercussions that follow from this issue. For these reasons, correct and timely recognition is essential to avoid the risk of recurrence of AHT and to start proper forensic investigations, in order to identify the offender or exonerate a suspect. The present work explores the most recent evidence of recent years in the field of AHT diagnostics through a literature review. The purpose of this article is to provide forensic pathologists with clear tools for diagnosis based on the literature. To this end, the review suggests clinical and forensic protocols aimed at the timely diagnosis of AHT in order to prevent abuse from remaining undetected.