Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases

Abstract

Background: The diagnosis of inflicted head injury (IHI) or accidental trauma (AT) in infants is based on clinical, radiological, and/or ophthalmological findings such as subdural hematoma (SDH), encephalopathy, retinal hemorrhage (RH), and signs of impact. As a consequence, the diagnostic value of these criteria is difficult to assess because of a circularity bias.

Purpose: In order to assess the predictive value of these diagnostic criteria avoiding circularity, we studied prospectively corroborated cases of head injuries in infants, comparing IHI with AT.

Material and methods: We selected 45 cases of confessed IHI and 39 cases of AT having occurred in public places. Patients were systematically evaluated clinically, with computed tomography scanner and ophthalmological evaluation by a trained ophthalmologist. RH was rated as absent, mild, and severe, according to the depth and extent of the RH.

Results: Brain ischemia was found in 26.7% of IHI; the most prominent elements in favor of IHI were SDH, severe RH, and absence of signs of impact; the predictive diagnostic values of these three features were 0.685, 0.961, and 0.830, respectively; however, only severe RH in the absence of ocular impact was specific of IHI. When all three features were combined, the specificity was 100%, but the sensitivity was only 24.4%.

Conclusion: Our study confirms the high diagnostic value of RH, SDH, and signs of impact for the differential diagnosis between AT and IHI. The evaluation of head injuries in infants requires a high level of awareness and thorough and systematic examination by a trained multidisciplinary team.