title: Prevalence of retinal hemorrhages in critically ill children.
abstract: BACKGROUND
  Retinal hemorrhages (RHs) with encephalopathy and subdural bleeding are considered suggestive of abusive head trauma (AHT). Existing studies describing RH focus on AHT and have potential selection bias. We undertook a prospective observational study to define the prevalence, distribution, and extent of RH in critically ill children.
  
  
  METHODS
  From February 2008 to December 2009, emergency intensive care admissions ≥ 6 weeks of age underwent dilated retinal examination by either a pediatric ophthalmologist or RetCam (retinal photograph) imaging after written informed consent. Patients with suspected or proven AHT, penetrating eye trauma, and elective admissions were excluded.
  
  
  RESULTS
  The prevalence of RH was 15.1% (24/159; 95% confidence interval [CI]: 9.5%-21%); 16/24 (66%) mild, and 2/24 (8%) moderate. Severe multilayered RH were seen in only 6 patients (3.7%), 3 with myeloid leukemia and sepsis, 2 with severe accidental head injury, and 1 with severe coagulopathy secondary to late onset hemorrhagic disease of newborn. There was no detectable impact of age, gender, seizures, coagulopathy or cardiopulmonary resuscitation on prevalence of severe multilayered RH; however, sepsis (odds ratio: 3.2; 95% CI: 1.3-8.0, P = .018) and coagulopathy (odds ratio: 2.8; 95% CI: 1.2-7.0, P = .025) were significantly associated with any RH. Only admission diagnosis was independently associated with severe multilayered RH on logistic regression.
  
  
  CONCLUSIONS
  RHs were seen in critically ill children with a prevalence of 15.1% (24/159); however, most were mild. Severe multilayered RH resembling those described in AHT were rare (6/24) and were only seen in patients with fatal accidental trauma, severe coagulopathy, sepsis with myeloid leukemia, or a combination of these factors.
authors.affiliation: Paediatric and Neonatal Intensive Care Units, Great Ormond Street Hospital for Children, London, United Kingdom. shragrawal@gmail.com
authors.forename: Shruti
authors.initials: S
authors.lastname: Agrawal
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Peters
authors.forename: Gillian G W
authors.initials: GG
authors.lastname: Adams
authors.forename: Christine M
authors.initials: CM
authors.lastname: Pierce
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D015995:Prevalence; D011446:Prospective Studies; D012166:Retinal Hemorrhage / Q000175:diagnosis* / Q000453:epidemiology*; D012307:Risk Factors