BMJ 1998;317:1558-1561 ( 5 December )

Papers

Subdural haemorrhages in infants: population based study

Editorial by Lloyd

S Jayawant, senior registrar, ^a A Rawlinson, consultant paediatrician, ^a F Gibbon, consultant in paediatric neurology, ^a J Price, consultant paediatrician, ^b J Schulte, consultant paediatrician, ^c P Sharples, consultant in paediatric neurology, ^c J R Sibert, professor, ^a A M Kemp, senior lecturer. ^a

^a Department of Child Health, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Penarth, Vale of Glamorgan CF64 2XX, ^b Department of Child Health, Southmead Hospital, Bristol BS10 5NB, ^c Frenchay Hospital, Bristol BS16 1LE

Correspondence to: Dr Kemp kempam{at}cardiff.ac.uk

Objectives: To identify the incidence, clinical outcome, and associated factors of subdural haemorrhage in children under 2 years of age, and to determine how such cases were investigated and how many were due to child abuse.
Design: Population based case series.
Setting: South Wales and south west England.
Subjects: Children under 2 years of age who had a subdural haemorrhage. We excluded neonates who developed subdural haemorrhage during their stay on a neonatal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention.
Main outcome measures: Incidence and clinical outcome of subdural haemorrhage in infants, the number of cases caused by child abuse, the investigations such children received, and associated risk factors.
Results: Thirty three children (23 boys and 10 girls) were identified with subdural haemorrhage. The incidence was 12.8/100 000 children/year (95% confidence interval 5.4 to 20.2). Twenty eight cases (85%) were under 1 year of age. The incidence of subdural haemorrhage in children under 1 year of age was 21.0/100 000 children/year and was therefore higher than in the older children. The clinical outcome was poor: nine infants died and 15 had profound disability. Only 22 infants had the basic investigations of a full blood count, coagulation screen, computed tomography or magnetic resonance imaging, skeletal survey or bone scan, and ophthalmological examination. In retrospect, 27 cases (82%) were highly suggestive of abuse.
Conclusion: Subdural haemorrhage is common in infancy and carries a poor prognosis; three quarters of such infants die or have profound disability. Most cases are due to child abuse, but in a few the cause is unknown. Some children with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a full multidisciplinary social assessment, an ophthalmic examination, a skeletal survey supplemented with a bone scan or a skeletal survey repeated at around 10 days, a coagulation screen, and computed tomography or magentic resonance imaging. Previous physical abuse in an infant is a significant risk factor for subdural haemorrhage and must be taken seriously by child protection agencies.

Key messages Subdural haemorrhage in children under 2 years of age is a relatively common occurrence. The majority are due to child abuse The mortality and morbidity of this condition are both high and serious The high probability of child abuse in cases is still not being recognised, and cases are not being investigated fully The clinical investigation of subdural haemorrhage must include a full series of basic investigations Previous child abuse in an infant is a strong risk factor for subdural haemorrhage, and social services must be aware of this in the future care plans for that child and family

---

© BMJ 1998
CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Looking after infants
BMJ 1998 317: 0. [Full Text] [PDF]

Looking after infants
BMJ 1998 317: 0. [Full Text] [PDF]

Clinicians must always exclude child abuse in cases of subdural haemorrhage
BMJ 1998 317: 0. [Full Text]

Subdural haemorrhages in infants

Ben Lloyd
BMJ 1998 317: 1538-1539. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Fujiwara, T., Okuyama, M., Miyasaka, M. (2008). Characteristics That Distinguish Abusive From Nonabusive Head Trauma Among Young Children Who Underwent Head Computed Tomography in Japan. Pediatrics 122: e841-e847 [Abstract] [Full text]  
• Leventhal, J. M., Martin, K. D., Asnes, A. G. (2008). Incidence of Fractures Attributable to Abuse in Young Hospitalized Children: Results From Analysis of a United States Database. Pediatrics 122: 599-604 [Abstract] [Full text]  
• Rooks, V.J., Eaton, J.P., Ruess, L., Petermann, G.W., Keck-Wherley, J., Pedersen, R.C. (2008). Prevalence and Evolution of Intracranial Hemorrhage in Asymptomatic Term Infants. Am. J. Neuroradiol. 29: 1082-1089 [Abstract] [Full text]  
• Chadwick, D. L., Bertocci, G., Castillo, E., Frasier, L., Guenther, E., Hansen, K., Herman, B., Krous, H. F. (2008). Annual Risk of Death Resulting From Short Falls Among Young Children: Less Than 1 in 1 Million. Pediatrics 121: 1213-1224 [Abstract] [Full text]  
• Gordon, M., Prakash, N., Padmakumar, B. (2008). Factor XIII Deficiency: A Differential Diagnosis to Be Considered in Suspected Nonaccidental Injury Presenting With Intracranial Hemorrhage. CLIN PEDIATR 47: 385-387  
• Campbell, K. A., Berger, R. P., Ettaro, L., Roberts, M. S. (2007). Cost-effectiveness of Head Computed Tomography in Infants With Possible Inflicted Traumatic Brain Injury. Pediatrics 120: 295-304 [Abstract] [Full text]  
• Rundblad, G. (2007). Impersonal, General, and Social: The Use of Metonymy Versus Passive Voice in Medical Discourse. Written Communication 24: 250-277 [Abstract]  
• McNeely, P.D., Atkinson, J.D., Saigal, G., O'Gorman, A.M., Farmer, J.-P. (2006). Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse.. Am. J. Neuroradiol. 27: 1725-1728 [Abstract] [Full text]  
• Minns, R A (2005). Subdural haemorrhages, haematomas, and effusions in infancy. Arch. Dis. Child. 90: 883-884 [Full text]  
• Datta, S, Stoodley, N, Jayawant, S, Renowden, S, Kemp, A (2005). Neuroradiological aspects of subdural haemorrhages. Arch. Dis. Child. 90: 947-951 [Abstract] [Full text]  
• Hobbs, C, Childs, A-M, Wynne, J, Livingston, J, Seal, A (2005). Subdural haematoma and effusion in infancy: an epidemiological study. Arch. Dis. Child. 90: 952-955 [Abstract] [Full text]  
• Vorstman, E B A, Anslow, P, Keeling, D M, Haythornthwaite, G, Bilolikar, H, McShane, M T (2003). Brain haemorrhage in five infants with coagulopathy. Arch. Dis. Child. 88: 1119-1121 [Abstract] [Full text]  
• Keenan, H. T., Runyan, D. K., Marshall, S. W., Nocera, M. A., Merten, D. F., Sinal, S. H. (2003). A Population-Based Study of Inflicted Traumatic Brain Injury in Young Children. JAMA 290: 621-626 [Abstract] [Full text]  
• Bannon, M J, Carter, Y H (2003). Paediatricians and child protection: the need for effective education and training. Arch. Dis. Child. 88: 560-562 [Full text]  
• Kemp, A M, Stoodley, N, Cobley, C, Coles, L, Kemp, K W, Geddes, J F (2003). Apnoea and brain swelling in non-accidental head injury * COMMENTARY. Arch. Dis. Child. 88: 472-476 [Abstract] [Full text]  
• Blumenthal, I (2002). Shaken baby syndrome. Postgrad. Med. J. 78: 732-735 [Abstract] [Full text]  
• Hymel, K. P., Jenny, C., Block, R. W. (2002). Intracranial Hemorrhage and Rebleeding in Suspected Victims of Abusive Head Trauma: Addressing the Forensic Controversies. Child Maltreat 7: 329-348 [Abstract]  
• Kemp, A M (2002). Investigating subdural haemorrhage in infants. Arch. Dis. Child. 86: 98-102 [Abstract] [Full text]  
• Feldman, K. W., Bethel, R., Shugerman, R. P., Grossman, D. C., Grady, M. S., Ellenbogen, R. G. (2001). The Cause of Infant and Toddler Subdural Hemorrhage: A Prospective Study. Pediatrics 108: 636-646 [Abstract] [Full text]  
• Hartley, L. M., MRCP, B., Khwaja, O. S., Verity, C. M., FRCPCH, B. (2001). Glutaric Aciduria Type 1 and Nonaccidental Head Injury. Pediatrics 107: 174-175 [Full text]  
• Barber, M A, Sibert, J R (2000). Diagnosing physical child abuse: the way forward. Postgrad. Med. J. 76: 743-749 [Full text]  
• Lloyd, B. (1998). Subdural haemorrhages in infants. BMJ 317: 1538-1539 [Full text]  

Rapid Responses:

Read all Rapid Responses

Subdural haemorrhages in infants: a response

Thomas Beckingsale
bmj.com, 11 Dec 1998 [Full text]

Metabolic disorders: a rare cause of subdural haemorrhage

Johannes Zschocke
bmj.com, 5 Jan 1999 [Full text]

Online poll

Find out more >>