title: Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma.
abstract: OBJECTIVE
  To describe the clinical features that distinguish accidental from abusive head injury in hospitalized children <24 months of age.
  
  
  METHODS
  Prospective study of children <24 months of age hospitalized for head injury between August 1, 2000, and October 31, 2002. During hospitalization, children had computed tomographic scans of the brain, serial neurologic examinations, dilated ophthalmoscopic eye examinations, evaluation by a social worker, and, in some cases, a child abuse specialist.
  
  
  METHODS
  The main outcome measure was the proportion of children in each group with retinal hemorrhages (RHs). Secondary outcome measures were the proportion of children in each group who had vitreous hemorrhage; abnormal mental status on presentation; seizures; scalp hematomas; need for anticonvulsants; and operative procedures such as subdural tap, craniotomy, ventriculostomy, tracheostomy, and gastrostomy.
  
  
  RESULTS
  Eighty-seven children were prospectively enrolled. Fifteen children were classified as having abusive head injury, and 72 were classified as having accidental head injury. Five children, all in the accidental head injury group, were excluded from statistical analysis, because they did not have a dilated ophthalmoscopic examination during their hospitalization. Thus 82 children were included in the statistical analysis. There were no significant differences between the 2 groups with respect to mean age, gender, or ethnicity. RHs were more likely to be seen in children with abusive head injury (60% vs 10%) and were more likely to be bilateral (40% vs 1.5%). Pre-RHs were more likely to be seen in children with abusive head injury (30% vs 0%). Premacular RHs and RHs that extended to the periphery of the retina were also more likely to be seen in children with abusive head injury (20% vs 0% and 27% vs 0%, respectively). Of the 7 children with accidental head injury who had RHs, 6 had unilateral RHs. Children with abusive head injury were more likely to have seizures (53% vs 6%) and an abnormal mental status on initial presentation (53% vs 1%). Children with accidental head injury were more likely to have scalp hematomas (6.7% vs 49%).
  
  
  CONCLUSIONS
  RHs are seen more often in abusive head injury and often are bilateral and involve the preretinal layer. Children with abusive head injury were more likely to have RHs that cover the macula and extend to the periphery of the retina. Unilateral RHs can be seen in children with accidental head injury. Children with abusive head injury were more likely to present with abnormal mental status and seizures, whereas children with accidental head injury were more likely to have scalp hematomas. Such characteristics may be useful to distinguish accidental from abusive head trauma in children <24 months of age.
authors.affiliation: Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA. kirsten.bechtel@yale.edu
authors.forename: Kirsten
authors.initials: K
authors.lastname: Bechtel
authors.forename: Kathleen
authors.initials: K
authors.lastname: Stoessel
authors.forename: John M
authors.initials: JM
authors.lastname: Leventhal
authors.forename: Eileen
authors.initials: E
authors.lastname: Ogle
authors.forename: Barbara
authors.initials: B
authors.lastname: Teague
authors.forename: Sylvia
authors.initials: S
authors.lastname: Lavietes
authors.forename: Bruna
authors.initials: B
authors.lastname: Banyas
authors.forename: Karin
authors.initials: K
authors.lastname: Allen
authors.forename: James
authors.initials: J
authors.lastname: Dziura
authors.forename: Charles
authors.initials: C
authors.lastname: Duncan
mesh_terms: D000059:Accidents; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000209:etiology; D002649:Child Abuse / Q000175:diagnosis*; D006259:Craniocerebral Trauma / Q000209:etiology*; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011446:Prospective Studies; D011859:Radiography; D012166:Retinal Hemorrhage / Q000209:etiology*; D012640:Seizures / Q000209:etiology; D012887:Skull Fractures; D013345:Subarachnoid Hemorrhage