Odds of abuse associated with retinal hemorrhages in children suspected of child abuse

Abstract

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 under 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 under age 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 under age 6 months. Increasing retinal hemorrhage severity is correlated with increasing likelihood of abuse.

The Evaluation of Suspected Child Physical Abuse

“…69,132 Compared with children with severe accidental trauma, children with AHT are more likely to have subdural hemorrhage, retinal hemorrhages, and associated cutaneous, skeletal, and visceral injuries. 97,[133][134][135][136] Inflicted injuries tend to occur in younger patients and result in higher mortality and longer hospital stays than does accidental head trauma. 97,129,137 Infants with intracranial injuries may have no neurologic symptoms and are sometimes identified during a medical evaluation for other suspicious injuries.…”

“…143 The extent and severity of retinal hemorrhages are also greater in abuse victims and correlate with the severity of acute neurologic symptoms. 136 Conditions that may be confused with AHT include accidental trauma; metabolic, genetic, and other diseases that are associated with vasculitis, coagulation defects, or cerebral atrophy; and primary coagulopathies. 149 Although most household trauma results in minor or no injury, on rare occasion, severe or fatal head injury has been reported.…”

A case for an in utero etiology of chronic SDH/effusion of infancy (letter)

“…Although this has been documented in literature, it is a rare finding with, in most case reports, serious outcomes either during pregnancy or after shortly after birth. [3][4][5][6] This report, however, explores no differential diagnosis for the macrocrania. One common clinical differential diagnosis for macrocrania, which also can be diagnosed prenatally, is benign enlargement of the subarachnoid space.…”

“…The author, who acknowledges serving as an expert witness in previous child abuse cases, certainly must appreciate that retinal hemorrhages are highly associated with inflicted brain injury in this age group. [2][3][4][5] Given this well-recognized association, the absence of other examinations to evaluate for additional injury in this patient is perplexing. The diagnostic workup for infants with abnormalities that could be caused by physical abuse usually includes a skeletal survey.…”

The Eye Examination in the Evaluation of Child Abuse

“…[15][16][17] Although retinal hemorrhages in AHT can be unilateral or bilateral and vary in degree, the severity of retinal hemorrhage often parallels the severity of brain injury. 18,19 Because intraretinal hemorrhages may resolve quickly, a retinal examination is not a substitute for brain imaging when screening physically abused infants who have no neurologic symptoms for AHT. 20 The ophthalmologist is in a unique position to detail the hemorrhagic retinopathy.…”