Retinal hemorrhages and accidental household trauma

Abstract

I read with interest the article by Christian et al1Christian CW Taylor AA Hertle RW Dubaime AC Retinal hemorrhages caused by accidental household trauma.J Pediatr. 1999; 135: 125-127Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar reporting retinal hemorrhages in 3 children as a result of accidental “household” trauma. Although I believe the information provided in this article is interesting and useful, I am concerned that this report may confuse health care and legal workers who deal with child abuse cases. The authors stated that “Retinal hemorrhages in young children have almost become diagnostic of child abuse.” This statement is not correct. The diagnosis of child abuse is never made based purely on the presence or absence of retinal hemorrhages. Dealing with cases of suspected child abuse is a very complex issue, requiring input from many professionals, including representatives of various branches of pediatric medicine, social work, and the legal profession. Though no photographs of the retinal hemorrhages were provided, the authors did point out that the retinal hemorrhages seen in their patients were relatively mild and were isolated to the posterior pole. The authors also pointed out that the retinal hemorrhages seen in non-accidental trauma are generally more severe. They tend to involve all layers of the retina, to involve the peripheral retina, and are often bilateral. These important differences between the retinal hemorrhages in accidental trauma as reported by Christian et al and those in victims of non-accidental trauma need to be made crystal clear. The term household trauma used in this report is conspicuous but misleading. The accidents that were described in this report were not typical “household trauma” at all. Instead, they were extremely unusual household injuries with resultant severe head trauma. Two of the children fell from great heights onto a concrete floor. Another was described as having fallen 1 to 2 feet while he was being swung in play by his father, striking his head on the floor. Great velocities can be achieved with this type of play, and it is highly unlikely that the child sustained his injuries by a simple fall from 1 to 2 feet. I am not surprised, therefore, that significant head trauma with retinal hemorrhages was seen after these events. The fact that retinal hemorrhages can occur as a result of accidental trauma involving extreme forces has been reported.2Johnson DL Braun D Friendly D Accidental head trauma and retinal hemorrhage.Neurosurgery. 1993; 33: 231-234Crossref PubMed Google Scholar The mechanisms of injury in this report should not be trivialized. The cases discussed in the report by Christian et al are likely to be used by perpetrators of child abuse for legal defense purposes. These were not commonplace household injuries. Physicians and other professionals who deal with victims of child abuse must fully understand and be ready to explain how these patients differ from victims of child abuse. They must also be ready to counter defense arguments that retinal hemorrhages were the result of trivial trauma, as is often proposed by child abuse perpetrators.