Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma.
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.
Bechtel
Kirsten
K
Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA. kirsten.bechtel@yale.edu
Stoessel
Kathleen
K
Leventhal
John M
JM
Ogle
Eileen
E
Teague
Barbara
B
Lavietes
Sylvia
S
Banyas
Bruna
B
Allen
Karin
K
Dziura
James
J
Duncan
Charles
C
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