Subdural Hemorrhage in Infancy
Subdural Hemorrhage in Infancy
ABSTRACT & COMMENTARY
Synopsis: Subdural hemorrhages are relatively common in infancy and are associated with a poor prognosis—three-quarters of such infants die or have profound disabilities. Most cases are due to child abuse, and caretakers must be cognizant of this fact and undertake appropriate diagnostic investigations and management.
Source: Jayawant S, et al. Subdural haemorrhages in infants: Population based study. BMJ 1998;317:1558-1561.
A series of 33 infants, younger than 2 years of age, with subdural hemorrhages were included in a population-based study from South Wales and southwestern England. The study was performed to identify the incidence, clinical outcome, how these children were investigated, and how many were a result of child abuse. The incidence was estimated to be 12.8/100,000 children. Eighty-five percent (28/33) occurred in infants younger than 1 year of age. Nine infants died and 15 had profound, long-term neurological disability. Only one-third (11/33) of these children had complete basic investigation (social assessment, CBC, coagulation screen, CT or MR imaging, skeletal survey or bone scan, and ophthalmological exam). Eighty-two percent (27/33) of cases were considered highly suggestive of child abuse.
The clinical evaluation of infants with subdural hemorrhages should include a full, multidisciplinary social assessment as well as the studies listed above. Previous physical abuse in an infant is a significant risk factor for subdural hemorrhage and must be taken seriously by child protection agencies.
COMMENT BY JOHN M. LEVENTHAL, MD, FAAP
This article, which provides data from a population-based survey, highlights several important points. First, most subdural hemorrhages in children younger than 2 years of age are due to child abuse. In this study, 27 of 33 cases were definitely or probably due to abuse and one was due to a serious car accident. (Not noted was whether the infant was restrained in a car seat—which might also be considered child neglect if not abuse.). In the remaining five cases, the histories that were provided did not adequately explain the child’s clinical condition. Although Jayawant and colleagues appeared to be keeping an open mind about causality, these five cases also seem likely to be due to abuse.
Second, the evaluations of the children were often incomplete. Jayawant et al advise that five kinds of information be obtained when evaluating children with subdural hemorrhages: 1) a multidisciplinary social assessment; 2) an eye exam by an ophthalmologist; 3) a skeletal survey (and a bone scan or a repeat survey in 10 days—I prefer at least 14 days) to detect acute rib fractures); 4) a coagulation screen (although 27/27 were normal); and 5) a CT or MRI of the head.
The social assessment is the most difficult to complete and often requires the input of both physicians and social workers. A concern about possible child abuse needs to be raised directly with the family, each parent needs to be interviewed, and information needs to be obtained about the parents’ health and mental health, their relationship with each other, and their relationships with the child. Because abusers seldom come right out and say that they have hurt the child, the interviewers need to listen to the histories with an appropriate degree of skepticism and suspicion.
I would add three additional components to the evaluation: 1) a careful review of all medical records to identify previous injuries that may have been suspicious for abuse (e.g., a torn frenulum in an infant); 2) a complete physical exam, looking for old or new bruises; and 3) a referral to child protective services, since physicians in the United States are mandated to report suspected (not just confirmed) abuse.
Third, the failure to make the correct diagnosis of child abuse can have fatal consequences. Four children who died in this series had been abused previously (although Jayawant et al do not provide the clinical details).
Fourth, the outcomes of subdural hemorrhages in infants are poor: in this study, nine children died, and 15 had severe disabilities. The remaining nine children appeared normal, but, clearly, longer-term follow-up is necessary to determine how these children will function in school.
Finally, subdural hemorrhages due to child abuse are not uncommon, with an estimated occurrence of one per 5000 during the first year of life. Obviously, this rate is based on cases that were clinically detected; milder cases might have gone undetected and would not be part of any survey. If the rates of subdurals are about the same in this country, there would be about 800 cases detected per year in children younger than one year of age. This compares to about 1600 new cases of cystic fibrosis per year in the United States.
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