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The cause of infant and toddler subdural hemorrhage: a prospective study
K W Feldman1, R Bethel, R P Shugerman
1Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA. kfeldman@u.washington.edu
Insights
Child abuse is a leading cause of subdural hemorrhage (SDH) in infants and toddlers. Many cases of SDH without clear unintentional trauma are actually due to abuse, often with subtle injury histories.
Area of Science:
- Pediatrics
- Trauma Surgery
- Child Abuse Forensics
Background:
- Subdural hemorrhage (SDH) in infants and toddlers is a serious condition requiring accurate etiological diagnosis.
- Distinguishing between abusive and unintentional injuries is critical for appropriate medical and legal intervention.
Purpose of the Study:
- To determine the frequency of child abuse versus unintentional injury as causes of subdural hemorrhage (SDH) in young children.
- To characterize the clinical and demographic differences between abused and unintentionally injured children with SDH.
Main Methods:
- A prospective case series was conducted at a regional trauma center, children's hospital, and medical examiner's office.
- Consecutive children aged 36 months or younger with SDH were assessed, excluding those with known confounding medical conditions.
- Comprehensive evaluations included medical, retinal, skeletal, and social work assessments to determine the etiology of SDH.
Main Results:
- Of 66 children with SDH, abuse was confirmed in 59% (39/66), unintentional injury in 23% (15/66), and the cause was indeterminate in 18% (12/66).
- Abused children were significantly younger (mean 8.7 months) than those with unintentional injuries (mean 19.1 months).
- Abused children were more likely to present with chronic SDH, multiple fractures (long bone/rib), and retinal hemorrhages compared to unintentionally injured children.
Conclusions:
- Child abuse is a frequent cause of subdural hemorrhage (SDH) in infants and toddlers, often presenting with subtle or absent injury history.
- A significant proportion of SDH cases without obvious unintentional trauma are attributable to abuse.
- Associated injuries such as fractures and retinal hemorrhages are strong indicators of abusive head trauma in this age group.
Objective:
To determine the frequency of child abuse and unintentional injury as a cause of infant and toddler subdural hemorrhage (SDH).
Methods:
A prospective case series of a level I regional trauma center, regional children's hospital, and county medical examiner's office assessed consecutive children who were
Results:
From March 1995 through December 1998, 66 children were admitted with SDH. Abuse was confirmed in 39 (59%), unintentional injury in 15 (23%), and indeterminate cause in 12 (18%). The mean age of abused children was 8.7 +/- 8.1 months and of children with unintentional injuries was 19.1 +/- 10.0 months. The predominant presenting histories for abusive injury were a minor fall or no mechanism for 33 (84%) of 39 patients. All unintentional injuries resulted from a motor vehicle accident or other documented major trauma. Chronic or mixed acute and chronic SDH were found only in abused children (17 [44%] of 39) and in children whose injuries were indeterminate (8 [67%] of 12), not in children who were unintentionally injured (0 [0%] of 15). Long bone and/or rib fractures were found in 20 (51%) of 39 abused children but in only 1 unintentionally injured child. Retinal bleeding was present in 28 (72%) of 39 of the abused children. Only 1 of the 3 unintentionally injured children who had a retinal examination had bleeding, which was of the type associated with acute increased intracranial pressure.
Conclusions:
Nearly one fifth of infant and toddler SDH resulted from unintentional trauma. Of those without obvious unintentional trauma, 76% were corroborated to have been abused. Abused children were younger, more likely to have chronic SDH, and more likely to have multiple associated injuries. Their injury history usually was minor or absent.
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