A Systematic Review of the Differential Diagnosis of Retinal Haemorrhages in Children with Clinical Features associated with Child Abuse

Abstract

Retinal haemorrhages (RH) in a young child suggest child abuse, yet other causes merit consideration. This systematic review addresses non‐traumatic causes of RH in children with one or more overlapping clinical features of abuse (bruising, fractures, intracranial haemorrhage). Searching 12 databases (1950–2009) identified 338 studies for review by two reviewers. Inclusion criteria included: children < 15 years examined by an ophthalmologist detailing retinal findings, confirmed organic cause and exclusion of abuse. Exclusion criteria included: diagnosed coagulopathy, ocular mass lesion and post‐mortem cases. Twenty included studies identified nine relevant conditions (metabolic diseases, bony dysplasias, bleeding disorders and vascular malformations). Where detailed, the RH were bilateral and involved only one area of the retina (the posterior pole). Among proposed confounders of RH, no child with a cough (100 children) or acute life‐threatening event (184 cases) had RH. Just two of 217 children with seizures had posterior pole RH, one unilateral and one bilateral. One cardiopulmonary resuscitation (CPR) study (43 cases) was included where a child with co‐existent clotting abnormalities had tiny (bilateral dot) RH after 60 minutes’ resuscitation. Child abuse remains the commonest cause of RH in young children, although rarer disorders merit consideration. There are insufficient data to conclude that CPR is a confounder in children with RH. Copyright © 2012 John Wiley & Sons, Ltd.‘Searching 12 databases (1950–2009) identified 338 studies for review’‘There are insufficient data to conclude that CPR is a confounder in children with RH’Key Practitioner Message Retinal Haemorrhages are strongly associated with Abusive Head Trauma, but have been described in certain medical conditions. Neither cough nor ALTE are associated with RH, which have been found in < 3% of children with seizures. There are inadequate data to conclude that CPR is associated with RH. Case series have reported RH in children who also have clinical features that may overlap with physical abuse, namely certain metabolic, vascular, haematologic disorders and bony dysplasias (specifically osteogenesis imperfecta).