Fung Eva Lai Wah, Sung Rita Yn Tz, Nelson Edmund Anthony Severn, Poon Wai Sang
Department of Paediatrics, Faculty of Medicine, 6/F Clinical Science Building, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
Pediatr Int. 2002 Feb;44(1):37-42. doi: 10.1046/j.1442-200x.2002.01500.x.
In the published reports of the developed society, subdural hematoma and/or retinal hemorrhages, in the absence of documented history of major trauma, should be considered diagnostic of child abuse. Many people used the above criteria for diagnosis, but subsequently found that retinal hemorrhages were more common in non-accidental injuries (NAI). To what extent is the proposed pathognomonic association between unexplained subdural hematoma/retinal hemorrhages and child abuse a self-fulfilling prophecy?
Clinical details of nine children under 2 years with unexplained subdural hematoma admitted to Prince of Wales Hospital between 1995 and 1998 were reviewed.
Four had no other physical signs of injury, five had retinal hemorrhages and one had multiple bruises over the body. Following multidisciplinary case conferences for seven children, a diagnosis of NAI was concluded in four cases, but in no case could the abuser be definitely identified. Clinical outcome was poor with seven children showing either profound disability (n = 5) or evidence of developmental delay (n = 2).
In this series, NAI were not established in three of the seven cases. Did we underdiagnose child abuse in these cases? Despite a magnitude of opinion to the contrary, the issue of whether "trivial" head injury can cause subdural hemorrhages and/or retinal hemorrhages is yet unresolved. Clearly much more information on this very sensitive and serious issue is required and these data should be collected with an open mind.
在发达国家已发表的报告中，在没有重大创伤记录史的情况下，硬膜下血肿和/或视网膜出血应被视为虐待儿童的诊断依据。许多人使用上述标准进行诊断，但随后发现视网膜出血在非意外损伤（NAI）中更为常见。那么，不明原因的硬膜下血肿/视网膜出血与虐待儿童之间所谓的特征性关联在多大程度上是一种自我实现的预言呢？
回顾了1995年至1998年间入住威尔士亲王医院的9名2岁以下不明原因硬膜下血肿患儿的临床细节。
4名患儿没有其他身体损伤迹象，5名有视网膜出血，1名全身有多处瘀伤。在对7名患儿进行多学科病例讨论后，4例诊断为NAI，但无一例能明确确定施虐者。临床结局较差，7名患儿中有5名出现严重残疾，2名有发育迟缓迹象。
在本系列研究中，7例中有3例未确诊为NAI。我们在这些病例中是否漏诊了虐待儿童的情况呢？尽管有很多相反的观点，但“轻微”头部损伤是否会导致硬膜下血肿和/或视网膜出血的问题仍未解决。显然，关于这个非常敏感和严重的问题需要更多信息，并且应该以开放的心态收集这些数据。
