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Retinal hemorrhages and shaken baby syndrome: an evidence-based review
Brandon M Togioka1, Meghan A Arnold, Melinda A Bathurst
1Center for Pediatric Surgical Trials and Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Insights
Retinal hemorrhages (RH) are key indicators in diagnosing shaken baby syndrome (SBS), a form of non-accidental head injury (NAHI). Bilateral, flame-shaped RH strongly suggest child abuse, even with an accidental injury explanation.
Area of Science:
- Ophthalmology
- Pediatric Medicine
- Forensic Pathology
Background:
- Non-accidental head injury (NAHI) is a significant concern in child abuse cases.
- Shaken baby syndrome (SBS) is a challenging diagnosis within NAHI, often associated with retinal hemorrhages (RH).
Purpose of the Study:
- To identify specific findings and patterns of retinal hemorrhages (RH) indicative of shaken baby syndrome (SBS).
- To review the utility of RH in diagnosing SBS, correlating with intracranial pathology, and prognosticating outcomes.
- To facilitate clinical decision-making in suspected SBS cases.
Main Methods:
- A comprehensive PubMed search was conducted using keywords related to shaken baby syndrome, child abuse, and retinal hemorrhage.
- 66 articles meeting inclusion criteria were analyzed.
- Data were categorized based on the diagnostic, correlative, and prognostic utility of RH in SBS.
Main Results:
- Retinal hemorrhages (RH) occur in 53-80% of abusive head injury cases versus 0-10% in severe accidental trauma.
- Bilateral RH, particularly flame-shaped, are present in 62.5-100% of SBS cases.
- Isolated RH from non-abusive events like convulsions or severe coughing is rare (0-0.7%).
Conclusions:
- Shaken baby syndrome (SBS) diagnosis remains difficult, but ophthalmologic findings are crucial.
- The presence of bilateral, flame-shaped RH, or those extending through all retinal layers, warrants high suspicion of child abuse.
- RH findings are critical for both diagnosis and prognosis in suspected SBS.
Background:
Among the causes of non-accidental head injury (NAHI), shaken baby syndrome (SBS) is difficult to diagnose and is associated with retinal hemorrhages (RH).
Description:
To identify findings and patterns of RH specific to SBS, a PubMed search using the keywords "shaken baby syndrome" or "child abuse" and "retinal hemorrhage" was conducted; 66 articles met the inclusion criteria. The published data address the utility of RH in three categories: 1) in diagnosing SBS; 2) as correlated to intracranial pathology; and 3) in prognosticating SBS. The present review aimed to summarize studies in a way that facilitates clinical decision-making.
Results:
Studies found a 53-80% incidence of RH with abusive head injury and a 0-10% incidence with proven severe accidental trauma. RHs are found bilaterally 62.5-100% of the time in SBS cases, and flame-shaped hemorrhages are the most common. The incidence of RH from convulsions, chest compressions, forceful vomiting, and severe persistent coughing in the absence of another condition known to cause RH is 0.7%, 0-2.3%, 0%, and 0%, respectively.
Conclusion:
SBS remains a difficult cause of NAHI to diagnose. Ophthalmologic examination can provide critical diagnostic and prognostic information in cases of suspected SBS. Child abuse should be highly suspect in children with RH and a parental explanation of accidental head injury, especially if the RHs are found to be bilateral, flame-shaped, or to extend through to all layers of the retina.
