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Unexplained subdural hematoma in young children: is it always child abuse?
Eva Lai Wah Fung1, Rita Yn Tz Sung, Edmund Anthony Severn Nelson
1Department of Paediatrics, Faculty of Medicine, 6/F Clinical Science Building, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong. b300875@mailserv.cuhk.edu.hk
Insights
The link between unexplained subdural hematoma, retinal hemorrhages, and child abuse may be overstated. Further research is needed to determine if minor head trauma can cause these injuries, as diagnoses of non-accidental injury (NAI) were not confirmed in all cases.
Area of Science:
- Pediatrics
- Forensic Medicine
- Ophthalmology
Background:
- Subdural hematoma and retinal hemorrhages in infants without major trauma are often presumed indicative of child abuse.
- Retinal hemorrhages have been observed more frequently in cases of non-accidental injury (NAI).
- The diagnostic criteria for child abuse based on these findings warrant critical re-evaluation.
Purpose of the Study:
- To investigate the diagnostic certainty of non-accidental injury (NAI) in young children presenting with unexplained subdural hematoma.
- To examine the association between subdural hematoma, retinal hemorrhages, and the diagnosis of child abuse.
- To assess the clinical outcomes for children with unexplained subdural hematoma.
Main Methods:
- A retrospective review of clinical data for nine children under two years old with unexplained subdural hematoma.
- Inclusion criteria focused on cases admitted between 1995 and 1998.
- Multidisciplinary case conferences were utilized for diagnosis in seven of the cases.
Main Results:
- Four children had subdural hematoma without other physical signs of injury.
- Five children presented with retinal hemorrhages; one had multiple bruises.
- NAI was concluded in four of seven reviewed cases, but perpetrators were unidentified. Seven children experienced poor outcomes, including profound disability or developmental delay.
Conclusions:
- The diagnosis of NAI was not definitively established in three of the seven reviewed cases, raising questions about potential underdiagnosis.
- The causal link between minor head injury and subdural hematoma/retinal hemorrhages remains unresolved.
- Further open-minded data collection is essential for this sensitive issue.
Background:
In the published reports of the developed society, subdural hematoma and/or retinal hemorrhages, in the absence of documented history of major trauma, should be considered diagnostic of child abuse. Many people used the above criteria for diagnosis, but subsequently found that retinal hemorrhages were more common in non-accidental injuries (NAI). To what extent is the proposed pathognomonic association between unexplained subdural hematoma/retinal hemorrhages and child abuse a self-fulfilling prophecy?
Methods:
Clinical details of nine children under 2 years with unexplained subdural hematoma admitted to Prince of Wales Hospital between 1995 and 1998 were reviewed.
Results:
Four had no other physical signs of injury, five had retinal hemorrhages and one had multiple bruises over the body. Following multidisciplinary case conferences for seven children, a diagnosis of NAI was concluded in four cases, but in no case could the abuser be definitely identified. Clinical outcome was poor with seven children showing either profound disability (n = 5) or evidence of developmental delay (n = 2).
Conclusion:
In this series, NAI were not established in three of the seven cases. Did we underdiagnose child abuse in these cases? Despite a magnitude of opinion to the contrary, the issue of whether "trivial" head injury can cause subdural hemorrhages and/or retinal hemorrhages is yet unresolved. Clearly much more information on this very sensitive and serious issue is required and these data should be collected with an open mind.