Unexplained subdural hematoma in young children: is it always child abuse?
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).


CONCLUSIONS
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.
Fung
Eva Lai Wah
EL
Department 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
Sung
Rita Yn Tz
RY
Nelson
Edmund Anthony Severn
EA
Poon
Wai Sang
WS
D002648:Child; D002649:Child Abuse / Q000175:diagnosis; D002675:Child, Preschool; D005260:Female; D006408:Hematoma, Subdural / Q000209:etiology*; D006801:Humans; D007223:Infant; D008297:Male; D012166:Retinal Hemorrhage / Q000209:etiology; D012189:Retrospective Studies