Subdural haemorrhages in infants: population based study

Objectives. To identify the incidence, clinical outcome, and associated fac tors of subdural haemorrhage in children under 2 years of age, and to deter mine 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 e xcluded neonates developed subdural haemorrhage during their stay on a neon atal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention. Main outcome measures Incidence and clinical outcome of subdural haemorrhag e 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 s ubdural haemorrhage. The incidence was 12.8/100 000 children/year (95% conf idence 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 profo und disability. Only 22 infants had the basic investigations of a full bloo d count, coagulation screen, computed tomography or magnetic resonance imag ing, skeletal survey or bone scan, and ophthalmological examination. In ret rospect, 27 cases (82%) were highly suggestive of abuse. Conclusion Subdural haemorrhage is common in infancy and carries a poor pro gnosis; three quarters of such infants die or have profound disability. Mos t cases are due to child abuse, but in a few the cause is unknown. Some chi ldren with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a ful l multidisciplinary social assessment, an ophthalmic examination, a skeleta l survey supplemented with a bone scan or a skeletal survey repeated at aro und 10 days, a coagulation screen, and computed tomography or magnetic reso nance imaging. Previous physical abuse in an infant is a significant risk f actor for subdural haemorrhage and must be taken seriously by child protect ion agencies.