The cause of infant and toddler subdural hemorrhage: A prospective study

Objective. To determine the frequency of child abuse and unintentional inju ry as a cause of infant and toddler subdural hemorrhage (SDH). Methods. A prospective case series of a level I regional trauma center, reg ional children's hospital, and county medical examiner's office assessed co nsecutive children who were less than or equal to 36 months old and had SDH . Children who had previously known hemorrhagic disease, previous neurosurg ical procedure, previously recognized perinatal brain injury, meningitis, r enal dialysis, and severe dehydration were excluded. Concurrent medical, re tinal, skeletal, and social work abuse evaluation were measured. Etiologic assessment using predetermined criteria was conducted. Results. From March 1995 through December 1998, 66 children were admitted w ith SDH. Abuse was confirmed in 39 (59%), unintentional injury in 15 (23%), and indeterminate cause in 12 (18%). The mean age of abused children was 8 .7 +/-8.1 months and of children with unintentional injuries was 19.1 +/- 1 0.0 months. The predominant presenting histories for abusive injury were a minor fall or no mechanism for 33 (84%) of 39 patients. All unintentional i njuries resulted from a motor vehicle accident or other documented major tr auma. Chronic or mixed acute and chronic SDH were found only in abused chil dren (17 [44%] of 39) and in children whose injuries were indeterminate (8 [67%] of 12), not in children who were unintentionally injured (0 [0%] of 1 5). Long bone and/or rib fractures were found in 20 (51%) of 39 abused chil dren but in only 1 unintentionally injured child. Retinal bleeding was pres ent in 28 (72%) of 39 of the abused children. Only 1 of the 3 unintentional ly injured children who had a retinal examination had bleeding, which was o f the type associated with acute increased intracranial pressure. Conclusions. Nearly one fifth of infant and toddler SDH resulted from unint entional trauma. Of those without obvious unintentional trauma, 76% were co rroborated to have been abused. Abused children were younger, more likely t o have chronic SDH, and more likely to have multiple associated injuries. T heir injury history usually was minor or absent.