Retinal hemorrhages associated with child abuse

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• Marc D. Myers, O.D.

Whether it is referred to as shaken baby syndrome, inflicted traumatic brain injury, or inflicted head trauma, child abuse is the leading cause of death in infancy. It is estimated that the number of physically abused children in the United States increased approximately 42% from 269,700 children in 1986 to 381,700 in 1993. Very young babies (under 6 months old) have the highest risk of suffering damage or death as a result of physical abuse. Severe abuse, in particular subdural hematoma and fracture, is much more common in babies than in older children. Retinal hemorrhages are the most common ocular finding, occurring in 50% to 100% of victims. Studies have not been clear in the past as to the most common patterns associated with an abusive situation. This study seeks to remedy this confusion concerning the prevalence and pattern of retinal hemorrhages in infants to allow eye care providers the opportunity to protect these patients who cannot protect themselves.

Data was gathered retrospectively from 180 charts over a 3.5-year timeframe of patients no older than 15 months who were admitted to a hospital specializing in the care of children. To be included in the statistical analysis, children had to be examined by the hospital's child abuse evaluation team and referred to the department of ophthalmology within 72 hours of presentation. Only 110 charts were included in the study because of completeness of records. Data collected included age, reported mechanism of injury, physical examination, and radiographic, laboratory and subspecialty findings, including ophthalmologic examination details. The hemorrhage grading scale was completed separately in each eye and took into account severity and retinal location. A total of 12 points was possible (6 per eye), and a higher score represented a greater severity.

Based on the evaluation of the abuse team, the children were separated into 2 groups for statistical analysis: definite/probable abuse (n=57) and definite/probable accident (n=53). The presence of retinal hemorrhages across all ages was highly associated with definite or probable abuse versus definite or probable accident. The presence of retinal hemorrhage was 32% for the entire study group. Forty-seven percent of children with definite/probable abuse and 15% of children with definite/probable accident had retinal hemorrhages. The odds ratio in children younger than 6 months (n=81) was 11.7. Retinal hemorrhage severity was higher in abuse versus accident (P < 0.0001) and correlated positively with abuse.

Based on the findings, it is recommended that all children with an intracranial hemorrhage undergo an eye health evaluation to rule out the presence of retinal hemorrhages. Doing so will help other members of the acute care team identify those children who have most likely been abused.