Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma

Objective. To describe the clinical fea- tures that distinguish accidental from abusive head in- jury 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, chil- dren 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. Outcome Measures. 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 vitre- ous hemorrhage; abnormal mental status on presenta- tion; seizures; scalp hematomas; need for anticonvul- sants; and operative procedures such as subdural tap, craniotomy, ventriculostomy, tracheostomy, and gastros- tomy. Results. Eighty-seven children were prospectively enrolled. Fifteen children were classified as having abu- sive head injury, and 72 were classified as having acci- dental head injury. Five children, all in the accidental head injury group, were excluded from statistical analy- sis, because they did not have a dilated ophthalmoscopic examination during their hospitalization. Thus 82 chil- dren 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 abnor- mal 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 pre- retinal 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 chil- dren <24 months of age. Pediatrics 2004;114:165-168; abusive head trauma, retinal hemorrhages, seizures, ab- normal mental status, scalp hematoma.