Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings

Evidence-Based Screening to Optimize the Yield of Positive Ophthalmologic Examinations in Children Evaluated for Suspected Child Abuse

PURPOSE

To determine nonocular findings associated with significant retinal hemorrhage on dilated fundus examination in cases of suspected child abuse.

METHODS

This was a retrospective chart review from May 2014 to August 2021 at a level-1 trauma center. Two hundred seventy-four patients met the following inclusion criteria: (1) children 36 months and younger; (2) concern for child abuse; and (3) had an ophthalmology consultation. Through univariate and multivariate logistic regression, the study produced a screening algorithm for ophthalmic work-up in child abuse.

RESULTS

One or more abnormal neuroimaging findings had a statistically significant association with retinal hemorrhages and produced the strongest association with a univariate odds ratio of 170 (confidence interval: 10.245 to > 999.999). The multivariate model (P < .0001 with a c-statistic of 0.980) proposes using the following variables for predicting retinal hemorrhage on examination: abnormal neuroimaging, Glasgow Coma Scale score less than 15, altered mental status on examination, seizure activity, vomiting, bruising, scalp hematoma/swelling, and skull fractures.

CONCLUSIONS

This study elucidates clinical and imaging factors that correlate to retinal findings, validating previously studied variables and introducing new variables to be considered. The authors propose an evidence-based screening algorithm to increase the yield of positive dilated examinations and decrease the burden of potentially unnecessary child abuse ophthalmologic examinations. [J Pediatr Ophthalmol Strabismus. 2022;59(5):310-319.].

Predictive value of non-ocular findings for retinal haemorrhage in children evaluated for non-accidental trauma

PURPOSE

To determine non-ocular examination findings in non-accidental trauma (NAT) patients that are associated with retinal haemorrhage and warrant urgent examination by an ophthalmologist.

METHODS

A hospital- and clinic-based retrospective cross-sectional and cohort study of children age 0-12 years who underwent workup for NAT over a span of nine years in a level I trauma and tertiary referral centre. Details of ocular and non-ocular examination and imaging findings at the time of NAT evaluation were collected by chart review. Univariate and logistic regression analysis for association between retinal haemorrhage and non-ocular examination findings was performed.

RESULTS

A total of 557 patients with ophthalmology evaluation and 425 without were included in this study. All ages combined, none of the cutaneous signs of trauma or non-skull fractures were associated with retinal haemorrhage on univariate analysis (p > 0.05). By logistic regression, subdural or extra-axial haemorrhage (OR = 16.2; 95% CI [5.11-51.3]), occipital lobe insult (OR = 6.2; 95% CI [1.77-21.6]) and Glasgow coma score (GCS) <15 (OR = 5.8; 95% CI [1.96-17.4]) were significant predictors of retinal haemorrhage.

CONCLUSION

Subdural or undistinguished extra-axial haemorrhage, GCS <15, and occipital lobe insult are risk factors for the presence of retinal haemorrhage in patients with suspected NAT and their presence warrant urgent dilated fundus examination by an ophthalmologist. The presence of cutaneous trauma or non-skull bone fractures without the aforementioned risk factors does not warrant ophthalmology evaluation.

Analysis of non-retinopathy of prematurity (ROP)-related fundus hemorrhage in preterm infants in China

OBJECTIVE

To determine the incidence of fundus hemorrhage (FH) not associated with retinopathy of prematurity (ROP) during ocular screening and report their clinical features, risk factors, therapies, and prognosis in a large population of premature newborns.

METHODS

The medical records of all preterm newborns admitted to the Department of Ophthalmology, Peking University People's Hospital, Beijing, from January 1, 2016 through August 31, 2021 were retrospectively reviewed. Fundus examinations were carried out by experienced retinal experts. Examination under anesthesia was carried out in newborns with abnormal fundus including vitreous hemorrhage (VH) or retinal hemorrhage (RH) >2 disks' diameter by a Retcam 2 system. A lens-preserving vitrectomy was performed in infants requiring a vitrectomy. A comprehensive medical history was also recorded and analyzed.

RESULTS

During the 5-year period, a total of 7,260 preterm babies were screened. There were 82 (1.13%) newborns and 104 (0.72) eyes with FH, including VH or RH.Twelve (14.63%) newborns (16 eyes, 15.38%) had VH; 56 (68.29%) (74 eyes, 71.15%) had flame-shaped, superficial hemorrhages; six (7.31%) (6 eyes, 5.77%) had small, round, deep hemorrhages (<2 disk diameters in size); and eight (9.76%) (8 eyes, 7.69%) had large, round hemorrhages (>2 disk diameters). In all, there were 10 (12.20%) cases of intracranial hemorrhage. The mode of delivery was not found to be a significant factor in the occurrence of birth-related retinal hemorrhage (P = 0.22).Six newborns (eyes) with large, round retinal hemorrhage at the posterior pole while the macular was not impacted and 11 cases (15 eyes) with vitreous hemorrhage were required to receive close follow-up with average follow-up time of 105 days. A lens-sparing vitreous surgery was conducted in three patients without any complications.

CONCLUSION

Preterm newborns with FH that are not caused by ROP are more likely to have superficial, peripheral hemorrhages. Vaginal delivery compression and forceps may be associated with hemorrhage. A lens-preserving vitrectomy is required and considered safe for dense FH involving the refractive media.

Application of a deep convolutional neural network in the diagnosis of neonatal ocular fundus hemorrhage

There is a disparity between the increasing application of digital retinal imaging to neonatal ocular screening and slowly growing number of pediatric ophthalmologists. Assistant tools that can automatically detect ocular disorders may be needed. In present study, we develop a deep convolutional neural network (DCNN) for automated classification and grading of retinal hemorrhage. We used 48,996 digital fundus images from 3770 newborns with retinal hemorrhage of different severity (grade 1, 2 and 3) and normal controls from a large cross-sectional investigation in China. The DCNN was trained for automated grading of retinal hemorrhage (multiclass classification problem: hemorrhage-free and grades 1, 2 and 3) and then validated for its performance level. The DCNN yielded an accuracy of 97.85 to 99.96%, and the area under the receiver operating characteristic curve was 0.989–1.000 in the binary classification of neonatal retinal hemorrhage (i.e., one classification vs. the others). The overall accuracy with regard to the multiclass classification problem was 97.44%. This is the first study to show that a DCNN can detect and grade neonatal retinal hemorrhage at high performance levels. Artificial intelligence will play more positive roles in ocular healthcare of newborns and children.

Characteristics of shaken baby syndrome in a regional Japanese children's hospital

PURPOSE

To report the characteristics of Japanese shaken baby syndrome (SBS) in a regional Japanese children's hospital and verify previously reported idiosyncratic features that differ from those of SBS in Western countries: (1) a considerably higher frequency of mothers as perpetrators, (2) older ages of abusive parents, and (3) a higher rate of premature infant birth.

METHODS

We reviewed medical charts obtained between 2002 and 2012 at Nagano Children's Hospital, Japan.

RESULTS

Thirty-seven SBS cases with abusive head trauma were found, among which 11 (30 %) of the perpetrators were mothers, 9 (24 %) fathers, 3 (8 %) brothers, and 14 (37 %) involved both parents. A history of premature birth was present in 2 (5 %) of the cases. The mean age of the mother was 32.4 years and that of the father was 31.3 years.

CONCLUSION

The clinical characteristics of Japanese SBS in this study are largely comparable to those seen in Western countries. Compared with the previously reported idiosyncratic features, there was a decreased predominance of mothers as perpetrators of SBS, suggestive of an increasing culpability of fathers. We also noticed that the ratio of premature births was more similar to those seen in Western surveys, while the mean ages of abusive Japanese parents remained older. Such varying results warrant a further nationwide survey.

Incidence of retinal hemorrhages in abusive head trauma

PURPOSE

To evaluate whether a relationship exists between the presence of retinal hemorrhages and confessions and/or identified perpetrators in cases of abusive head trauma.

METHODS

A retrospective chart review was conducted of all abusive head trauma cases. All cases that met criteria for abusive head trauma were placed into one of three categories: perpetrator confessed (category A), perpetrator identified without confession (category B), and no perpetrator identified (category C).

RESULTS

Forty-eight cases met the criteria for abusive head trauma, with 18, 16, and 14 cases in categories A, B, and C, respectively. Retinal hemorrhages were identified in 16 of 18 (88%) cases in category A, 12 of 16 (75%) in category B, and 6 of 14 (43%) in category C. A statistically significant difference regarding the presence of retinal hemorrhages was seen for perpetrator identified (28 of 34 or 82%) compared to no perpetrator identified (6 of 14 or 43%) (P = .034). The difference in retinal hemorrhages was correlated to the higher incidence of acute presentation in the perpetrator identified group (31 of 34 or 91%) compared to that in the perpetrator not identified group (9 of 14 or 64%) (P = .023).

CONCLUSION

The incidence of retinal hemorrhages in abusive head trauma for identified perpetrators, regardless of a confession, is similar. However, there is a statistically significant decrease in the incidence of retinal hemorrhages in abusive head trauma when comparing identified perpetrators to non-identified perpetrators. This decreased incidence of retinal hemorrhages was statistically correlated to a lower incidence of acute presentation in victims of abusive head trauma without an identified perpetrator.[J Pediatr Ophthalmol Strabismus 2013;50(3):169-172.].

Ocular manifestations and prognosis of shaken baby syndrome in two Japanese children's hospitals

PURPOSE

To distinguish the profiles of patients and ophthalmologic features and to describe the prognosis of shaken baby syndrome (SBS) in Japan.

METHODS

Charts of child abuse cases involving retinal hemorrhage at Kanagawa Children's Medical Center and the National Center for Child Health and Development between January 1997 and December 2007 were retrospectively reviewed. The mean follow-up period was 22.2 months (range, 0-115 months).

RESULTS

Twenty-one boys and 11 girls were identified. The mean age at the initial visit was 7.0 months (range, 4 days to 17 months). Four boys died during hospitalization. Seventeen eyes of ten patients (31%) had vitreous hemorrhage; 16 eyes of eight patients (25%) had a more favorable ocular prognosis with no apparent complications. Eight infants (25%) had been born prematurely. The mean maternal age was 29.9 years, and mothers were the primary perpetrator in 19 cases (59%).

CONCLUSIONS

The clinical features of SBS in Japan are comparable to those in the Western literature. However, we have also found some idiosyncratic features in Japanese SBS cases; the mother is more frequently the perpetrator and abusive parents are older than in the United States, possibly reflecting current trends in Japan toward later marriage.

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.

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: re-examination of diffuse axonal injury as cause of death

The discussion surrounding shaken baby syndrome (SBS) arose from the lack of evidence implicating diffuse axonal injury (DAI) as a cause of death. It was assumed instead that injury to the cervical cord, medulla, and nerve roots played a causal role. The present pathomorphological study examines 18 selected infants (<1-year-old) whose deaths were highly suspicious for SBS, exhibiting the classical SBS triad of acute subdural hemorrhage (SDH), retinal bleeding, and encephalopathy. Gross autopsy and microscopic findings of these infants were compared with those of 19 victims of sudden infant death syndrome (SIDS; control group 1) and of 14 infants who died of disease or injuries/violence not involving the head, neck or eyes (control group 2). Symptoms of mechanical impact to the head were evident in seven of the SBS infants, but in none of the control infants. DAI was not detected in either the SBS or control cases. Localized axonal injury (AI) was regularly present in the brains of the SBS infants surviving longer than 1.5-3.0 h, but only occasionally in the craniocervical junction and within the nerve roots of the upper cervical cord; it was never present in the medulla. Epidural hemorrhage of the cervical cord was seen in four of the ten examined SBS cases, but in none of the control cases. Based on the absence of DAI in the brain and of signs of generalized cervical cord or nerve root injuries, we conclude that the cause of death in the SBS victims was a global cerebral ischemia secondary to SDH, focal vasospasm, trauma-induced transitory respiratory and/or circulatory failure.

Retinal haemorrhages in- head trauma resulting from falls: differential diagnosis with non-accidental trauma in patients younger than 2 years of age

INTRODUCTION

Falls are a common chief complaint among children seeking medical attention in emergency departments and are the leading cause of injuries requiring hospitalisation. Falls are also a frequent excuse to conceal cases of maltreatment in small children. Retinal haemorrhages could be a useful marker for their differential diagnosis.

OBJECTIVE

This study aims to determine the prevalence and characteristics of retinal haemorrhages in children with head trauma resulting from a vertical fall.

MATERIALS AND METHODS

This was a prospective study of children younger than 2 years of age admitted to the hospital with head trauma from a vertical fall. The circumstances of the falls and injuries were analysed. All children were evaluated by an ophthalmologist for retinal haemorrhage.

RESULTS

One hundred fifty-four patients were included. Eighty-three percent of the falls were from a height equal to or less than 120 cm. The most common mechanism of injury was fall from a stroller followed by rolling off the bed. Sixteen children had evidence of intracranial injuries. Three patients had retinal haemorrhages (prevalence 1.9%; 95%CI, 0.4-5.6%), all unilateral, in association with severe epidural haematoma with a midline shift. The detection of retinal haemorrhages could be related to the presence of intracranial injury but not with the circumstances of the fall.

DISCUSSION AND CONCLUSIONS

Any cranial injury from a vertical fall that produces severe epidural bleeding can also cause retinal haemorrhages, mainly unilateral. The finding of diffuse and bilateral retinal haemorrhages or their presence in the absence of this type of intracranial haemorrhage must continue to point out another cause different from the fall as origin of the traumatism, being necessary to exclude non-accidental trauma.

Inflicted childhood neurotrauma

In this article, we review literature related to inflicted childhood neurotrauma (ICN). We discuss the rationale for use of the term "ICN," rather than the more benign, commonly used "shaken baby syndrome." The change in language alters the discourse about a potentially lethal outcome or lifelong problem for survivors. A description of ICN is followed by a discussion of ethical parameters and obligations of those who care for infants and children and professionals who are sentinels to these events such as law enforcement officials, nurses, physicians, and social workers.

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.

Subdural haematomas and physical abuse in the first two years of life

OBJECTIVE

To analyze our institution's work-up for patients with a diagnosis of subdural haematoma (SDH) in order to determine how many of them are secondary to child abuse, as well as to examine their final functional outcome.

METHODS

Retrospective review of children under 2 years of age diagnosed as having SDH between 1995 and 2005.

RESULTS

A total of 35 cases were identified. Fifteen patients that had underlying conditions that predispose them to bleed were excluded. Among the remaining 20 patients, seizures and head trauma were the main causes for consultation. All patients had a coagulation study and a head computed tomography carried out, 11 of these had a magnetic resonance imaging and 1 had a post-mortem examination. Bilateral SDHs in different stages of evolution was the most common pattern of intracranial haemorrhage. Fourteen infants had a skeletal survey, 4 had a bone scintigraphy and 19 had an ophthalmoscopic examination. Fractures were diagnosed in 7 patients and retinal haemorrhages in 11. The final diagnoses were: 10 shaken baby syndromes, 4 idiopathic SDH, 3 strokes, 2 coagulopathies and 1 accidental head injury. Upon follow-up, 1 patient had died and 9 had sustained permanent disabilities.

CONCLUSIONS

Cases of infantile SDH are usually thoroughly investigated. In spite of this, sometimes it is not possible to determine the SDH aetiology. Nonetheless, shaken baby syndrome remains the most frequent cause of SDH in infants, and it carries a poor prognosis.

When a funduscopic examination is the clue of maltreatment diagnostic

OBJECTIVE

: To report a case of unexpected shaken baby syndrome, the diagnosis of which was possible after an incidental funduscopic examination.

METHODS

: Observational case report. An infant was to be sent back home with an apparent unprovoked seizure diagnosis when a funduscopic examination was made because of an incidental research study changing the diagnostic orientation.

RESULTS

: Extensive bilateral subretinal hemorrhages in the funduscopic examination allowed shaken baby syndrome unexpected diagnosis. A funduscopic examination is not usually included in the first seizure diagnosis management, even when a retinal bleeding could be present and be the clue for its causative diagnosis.

CONCLUSION

: We recommend having in mind the practice of a funduscopic examination in all children with a first apparently unprovoked seizure.

Retinal haemorrhages in premature infants: a pathogenetic alternative diagnosis to child abuse

PURPOSE

To present the occasional observation of retinal haemorrhages in premature babies, as a diagnostic alternative to those observed as part of shaken baby syndrome.

METHODS

We carried out an observational study on 11 infants in whom retinal and/or vitreous haemorrhages had been observed within their first months of life. Ten infants were under surveillance for retinopathy of prematurity (ROP), with gestational ages and birth weights in the ranges of 27--34 weeks and 790--1665 g, respectively. One infant was diagnosed with Zellweger's syndrome and one received substitution therapy for coagulation factor II deficiency. The last child had been delivered at 38 weeks, weighing 2070 g; he died on day 5 from severe brain oedema with incarceration and extensive bilateral fundus bleeding.

RESULTS

Four of the 11 infants had some evidence of ROP, and two later received retinal ablation therapy. Contrary to the quick absorption (<1-2 weeks only) usually seen in most newborn term infants, the ocular bleeding in preterms was generally longstanding. A quick increase in intracranial pressure probably played a role in the lethal case with delivery near term, and one infant received lung physiotherapy for pneumonia at the age of 6 months. Some bleeding appeared to be truly postnatal (i.e. it was observed as a new occurrence during the course of surveillance).

CONCLUSIONS

In the series under study there was no suspicion of child abuse. In term infants, retinal haemorrhages are extremely rare except when due to shaking, but other diseases should be ruled out, coagulopathies in particular. We suggest that prematurity as such is added to the list of possibly underlying causes when retinal bleedings are evaluated in very small infants and shaken baby mechanisms are suspected.

A case of shaken baby syndrome after discharge from the newborn intensive care unit

Preterm infants may be at higher risk of physical abuse after hospital discharge. Nonaccidental or inflicted head neurotrauma is the most common cause of mortality and morbidity in physical-abuse cases, and shaken baby syndrome (SBS) is the most common form of abuse. In the majority of the cases, parents who shake their infant do not intend to harm the infant. This article presents a report of a former preterm infant who presented to the pediatrician's office with a maternal report of an accidental fall. Shaken baby syndrome was suspected based on bilateral subdural hemorrhages of varying ages, which were inconsistent with the history provided. The differential diagnosis and systematic clinical evaluation for SBS are provided, and medical and nursing management is discussed. Patient care, advocacy, and mandatory reporting are reviewed. The newborn intensive care unit caregivers' role in preventing SBS in this high-risk population, including specific parent teaching and anticipatory guidance, is reviewed with an emphasis on teaching all caregivers about the dangers of shaking an infant.