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PAPERS: S Jayawant, A Rawlinson, F Gibbon, J Price, J Schulte, P Sharples, J R Sibert, and A M Kemp Subdural haemorrhages in infants: population based study BMJ 1998; 317: 1558-1561 [Abstract] [Full text]

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Subdural haemorrhages in infants: a response

Thomas Beckingsale   (11 December 1998)

Metabolic disorders: a rare cause of subdural haemorrhage

Johannes Zschocke   (5 January 1999)

Subdural haemorrhages in infants: a response 11 December 1998
Thomas Beckingsale, medical student newcastle university medical school Send response to journal: Re: Subdural haemorrhages in infants: a response	Sir- Jayawant et al's [1] findings that almost 82% of cases of subdural haemorrhage in infants were linked with probable child abuse has profound implications for clinical practice. However, we wonder if there are dangers of generalising the findings from this selected case series too widely. The selection criteria for cases were very restricted and only cases treated at tertiary neurosurgical centres were included. The exclusion of cases in neonates and post neurosurgery seems entirely appropriate. Cases following infection were also excluded, although the type and site of infections meriting exclusion were not defined. We wonder what the incidence is of post-infective haemorrahage,or of more minor cases which are treated outside tertiary centres (presumably this may increase as CT/MRI scanning bacomes more accessible). Unless the criteria for post-infective subdural haemorrhages are made more explicit and similar studies are carried out to find the link between child abuse in more minor cases of subdural haemorrhage, is there a danger of extrapolating the findings and the low threshold of suspicion for child abuse too widely? Also, the quoted percentages of infants who receive computed tomography are based on the total numbers of children, including those who presented dead. The suggestion seems to be that all children, including deceased infants, should receive a full set of tests. While this may be appropriate, it presents implications for clinical practice in what is clearly a traumatic situation. Further discussion on this matter seems necessary. Thomas Beckingsale, Nicholas Ohly, Stephen Land 3rd year medical students, University of Newcastle Richard Edwards, Lecturer in Public Health Medicine, University of Newcastle [1] Jayawant, S, et al. Subdural haemorrhages in infants: population based study. BMJ 1998;317:1558-61
Metabolic disorders: a rare cause of subdural haemorrhage 5 January 1999
Johannes Zschocke, Clinical Fellow in Metabolic Paediatrics Univ. Children's Hospital, Marburg, Germany Send response to journal: Re: Metabolic disorders: a rare cause of subdural haemorrhage	Dear Editor, We were interested to read the paper by Jayawant and colleagues on subdural haemorrhages in infants (1), however, we were surprised that neither the authors nor the accompanying editorial (2) considered the possibility of metabolic disorders in their differential diagnosis. It is now well established that subdural haematomata after minor head trauma may be caused by disorders such as glutaric aciduria type I (GA1). We personally experienced four children with GA1 who after mild head trauma suffered intracranial bleeds, in one case even retinal haemorrhages. One child had had apparently normal development in the first months of life but during the episode suffered an acute encephalopathic crisis that left her with the typical severe dystonic movement disorder resembling cerebral palsy (3). The parents were accused of child abuse, and the correct diagnosis was only made four years after the event. Several other children with GA1 and subdural haematomata have been reported in the literature (4,5). Careful evaluation of neuroradiological findings and a good metabolic work-up including the analysis of urinary organic acids should be part of routine investigations in children with subdural haemorrhages, without delaying the evaluation of possible child abuse. Johannes Zschocke, Clinical Fellow in Metabolic Paediatrics Georg F. Hoffmann, Professor of Paediatrics, Universitäts-Kinderklinik, Deutschhausstr. 12, 35033 Marburg, Germany Ania C. Muntau, Paediatrician, Dr. von Haunersches Kinderspital, University of Munich, Lindwurmstr. 4, D-80337 Munich, Germany References 1 Jayawant S, Rawlinson A, Gibbon F, Price J, Schulte J, Sharples P, Sibert JR, Kemp AM. Subdural haemorrhages in infants: population based study. BMJ 1998;317:1558-1561. 2 Lloyd B. Subdural haemorrhages in infants: almost all are due to abuse but abuse is often not recognised. Editorial. BMJ 1998;317:1538-1539 3 Muntau AC, Röschinger W, Pfluger T, Endres A, Hoffmann GF. Glutaric aciduria type I: two cases of misdiagnosis as battered child syndrome and the importance of presymptomatic diagnosis and treatment. Monatsschr Kinderheilkd 1997;145:646-651 4 Osaka H, Kimura S, Nezu A, Yamazaki S, Saitoh K, Yamaguchi S. Chronic subdural hematoma as an initial manifestation of glutaric aciduria type I. Brain Dev 1993;15: 125-127. 5 Drigo P, Burlina AB, Battistella PA. Subdural hematoma and glutaric aciduria type I. Brain Dev 1993;15:460-461.