Elsevier

Ophthalmology

Volume 110, Issue 9, September 2003, Pages 1718-1723
Ophthalmology

Original article
Ophthalmologic findings in suspected child abuse victims with subdural hematomas

https://doi.org/10.1016/S0161-6420(03)00581-5Get rights and content

Abstract

Purpose

Shaken baby syndrome consists of intracranial and intraocular hemorrhages in young children in the absence of signs of direct head trauma. Because it has major medicolegal implications, it must be distinguished from accidental trauma. This study aimed to determine the ophthalmologic manifestations and their natural course in child abuse victims and whether ophthalmologic examination can help to distinguish shaken babies from children with accidental impact head trauma.

Design

Prospective comparative observational case series.

Methods

A prospective study was conducted from January 1996 to September 2001 on 241 consecutive infants hospitalized for a subdural hematoma to determine the frequency and the type of ocular abnormalities encountered. At admission, 186 children were highly presumed to have been shaken (group 1), 38 children had signs of direct head trauma without any relevant history of trauma (group 2), some of them having been possibly shaken, whereas 7 children had proven severe accidental head trauma (group 3).

Results

Intraocular hemorrhages were the main finding. Their shape, laterality, and size were not significantly different in groups 1 and 2. However they were significantly more frequent in nonaccidental head trauma than in infants with head impact (77.5% versus 20%). None of the group 3 children had intraocular hemorrhage. Eighty-two percent of intraocular hemorrhages resolved within 4 weeks.

Conclusions

Intraocular hemorrhages are frequent in shaken babies but not specific of this syndrome. When associated with a subdural hematoma, they are strongly suggestive of shaken neglect. They are rare in pediatric accidental head trauma.

Section snippets

Patients and methods

This prospective study consisted of 241 consecutive children younger than 3 years of age admitted for SDH in the Pediatric Neurosurgical Department of the Hôpital Necker-Enfants Malades in Paris from January 1996 through September 2001. Caretakers' histories were recorded searching for direct head trauma or shaken neglect. All children underwent a complete physical and neurologic examination, a computed tomography (CT) scan of the head, and systemic x-rays of the skeleton to detect possible

Results

The median age of the 231 patients at admission was 4.6 months (range, 0.8–29 months); 96.5% of the babies were younger than 1 year. In groups 1, 2, and 3, median ages were, respectively, 4.6 months (range, 0.8–29), 5.5 months (range, 1–18), and 1.5 months (range, 0.9–3.9). There were 165 males and 66 females (gender ratio, 5:2). This ratio was the same in the 3 groups.

Discussion

As far as we are aware, this study is the largest prospective study on ophthalmologic clinical abnormalities in shaken infants. SBS is a form of child abuse whose diagnosis is difficult to establish because a history of shaking events is often unreliable. Both direct head trauma and shaking maneuvers can provoke subdural bleeding. Among shaken babies, some show evidence of additional direct head trauma (fractures of the vault, wounds, or bruises of the scalp).4 It therefore becomes difficult

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    Manuscript no. 220518.

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