Bechtel Kirsten, Stoessel Kathleen, Leventhal John M, Ogle Eileen, Teague Barbara, Lavietes Sylvia, Banyas Bruna, Allen Karin, Dziura James, Duncan Charles
Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA.
Pediatrics. 2004 Jul;114(1):165-8. doi: 10.1542/peds.114.1.165.
To describe the clinical features that distinguish accidental from abusive head injury in hospitalized children <24 months of age.
Prospective study of children <24 months of age hospitalized for head injury between August 1, 2000, and October 31, 2002. During hospitalization, children 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.
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 vitreous hemorrhage; abnormal mental status on presentation; seizures; scalp hematomas; need for anticonvulsants; and operative procedures such as subdural tap, craniotomy, ventriculostomy, tracheostomy, and gastrostomy.
Eighty-seven children were prospectively enrolled. Fifteen children were classified as having abusive head injury, and 72 were classified as having accidental head injury. Five children, all in the accidental head injury group, were excluded from statistical analysis, because they did not have a dilated ophthalmoscopic examination during their hospitalization. Thus 82 children 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 abnormal mental status on initial presentation (53% vs 1%). Children with accidental head injury were more likely to have scalp hematomas (6.7% vs 49%).
RHs are seen more often in abusive head injury and often are bilateral and involve the preretinal 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 children <24 months of age.
描述区分24个月以下住院儿童意外性头部损伤与虐待性头部损伤的临床特征。
对2000年8月1日至2002年10月31日期间因头部损伤住院的24个月以下儿童进行前瞻性研究。住院期间，对儿童进行脑部计算机断层扫描、系列神经学检查、散瞳眼底镜眼部检查、由社会工作者进行评估，部分病例还由儿童虐待问题专家进行评估。
主要观察指标是每组发生视网膜出血（RHs）的儿童比例。次要观察指标是每组发生玻璃体积血的儿童比例；就诊时精神状态异常；癫痫发作；头皮血肿；是否需要抗惊厥药物；以及诸如硬膜下穿刺、开颅手术、脑室造瘘术、气管切开术和胃造瘘术等手术操作。
前瞻性纳入87名儿童。15名儿童被归类为患有虐待性头部损伤，72名被归类为患有意外性头部损伤。5名儿童（均在意外性头部损伤组）被排除在统计分析之外，因为他们住院期间未进行散瞳眼底镜检查。因此，82名儿童被纳入统计分析。两组在平均年龄、性别或种族方面无显著差异。RHs在虐待性头部损伤儿童中更常见（60%对10%），且更可能为双侧（40%对1.5%）。视网膜前出血（Pre - RHs）在虐待性头部损伤儿童中更常见（30%对0%）。黄斑前RHs以及延伸至视网膜周边的RHs在虐待性头部损伤儿童中也更常见（分别为20%对0%和27%对0%）。在7名有RHs的意外性头部损伤儿童中，6名有单侧RHs。虐待性头部损伤儿童更可能出现癫痫发作（53%对6%）和初次就诊时精神状态异常（53%对1%）。意外性头部损伤儿童更可能出现头皮血肿（6.7%对49%）。
RHs在虐待性头部损伤中更常见，且常为双侧并累及视网膜前层。虐待性头部损伤儿童更可能出现覆盖黄斑并延伸至视网膜周边的RHs。单侧RHs可见于意外性头部损伤儿童。虐待性头部损伤儿童更可能表现为精神状态异常和癫痫发作，而意外性头部损伤儿童更可能出现头皮血肿。这些特征可能有助于区分24个月以下儿童的意外性与虐待性头部创伤。
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