Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma

Child Physical Abuse Fundamentals in the Child Abuse Pediatrics Curriculum for Physicians (CAP-CuP)

Introduction

Child abuse is a highly prevalent yet undertaught condition in medical education. Many physicians feel underprepared to navigate conversations about mandatory reporting.

Methods

We developed an interactive module for teaching pediatric clinicians about sentinel injuries and mandatory reporting. We evaluated the content by seeking qualitative and quantitative feedback from a large audience at a pediatric continuing medical education (CME) conference and then studied its educational impact using a pre- and postmodule assessment with residents from three specialties. Based upon audience and expert feedback, the content was then divided into two parts, with an expanded section on disproportionality in part one and popcorn-style role-play in part two.

Results

In the CME audience, 98% of participants (85 of 87) rated the content and presentation skills as excellent or very good. In the resident presentations, there were 34 resident participants from three specialties: 24 from a combined audience of pediatric and emergency medicine residents and 10 from an audience of family medicine residents. Median confidence level increased in the pediatric and emergency medicine audience from 4 to 7 and in the family medicine audience from 5 to 7 on a 10-point scale. The median knowledge scores increased in both groups as well, from 75% to 100% and 25% to 100%, respectively.

Discussion

This child physical abuse fundamentals module has been presented to a wide range of physician audiences with positive qualitative and quantitative feedback. It is offered here in an expanded two-part workshop that allows for intentional practice of the information taught.

Subconjunctival Hemorrhages Are Rare Among Infants With Cough and Gastrointestinal Conditions

OBJECTIVE

Subconjunctival hemorrhages (SCHs) are uncommon injuries in young children beyond the neonatal period and have been associated with abuse. In otherwise well infants, they are sometimes attributed to commonly observed symptoms that invoke Valsalva maneuvers, such as cough, vomiting, and constipation. Our study aims to ascertain the prevalence of SCH among children presenting to emergency care with cough, vomiting, and constipation.

METHODS

We conducted a cross-sectional secondary analysis of a prospectively collected dataset of children aged 1 month to 3 years presenting to a tertiary pediatric emergency department (ED). Children with and without SCH were identified at the time of their examination by ED providers. Children were assigned to Valsalva symptom groups of cough, vomiting, and/or constipation based on review of the ICD-10 codes associated with the ED encounter. Descriptive statistics and prevalence were calculated for each group. Chi-square testing of proportions was used to compare the prevalence of SCH based on the presence or absence of the 3 symptoms of interest.

RESULTS

Four thousand seven hundred seventeen qualifying ED encounters were captured, with 2 total cases of SCH identified (0.4 per 1000). SCHs were uncommonly observed in patients with cough (0.5 per 1000), vomiting (0 per 1000), and constipation (0 per 1000). We found no significant differences in the prevalence of SCH based on the presence or absence of cough ( P = 0.87), vomiting ( P = 0.52), or constipation ( P = 0.82).

CONCLUSION

SCH is an uncommon finding in children under 3 years and is similarly uncommon among children with cough, vomiting, or constipation. It should not be attributed to uncomplicated presentations of cough, vomiting, or constipation, and alternative diagnoses, including abuse, should be carefully considered in the differential diagnosis of SCH.

Ophthalmologic findings in abusive head trauma

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.

Identifying inflicted injuries in infants and young children

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Orofacial manifestations of child maltreatment: A review

The recognition and reporting of child abuse and neglect continues to be a challenge in the healthcare setting. All healthcare providers, including dentists, should be aware of the high prevalence of orofacial injuries and conditions that are concerning for abuse and neglect. Sentinel injuries may appear trivial and do not require medical attention, but are unlikely caused by accidental mechanisms and, if not properly identified, often precede more severe abusive injuries. Concerning orofacial findings can manifest as bruising, eye injuries, intraoral injuries, pharyngeal perforations, facial bone fractures, and sexually transmitted infections. Abusive caregivers are likely to give inadequate explanations or no history at all to explain concerning findings. Medical providers' failure to make mandated reports about their concerns to the appropriate agencies can have significant long-term impacts on the physical and psychological well-being of children.

Defining Sentinel Injuries of Suspected Child Abuse by Age Using International Classification of Diseases-10: A Delphi Study

OBJECTIVE

To address child abuse effectively requires accurate assessment of the magnitude of the problem. Although it is difficult to assess the scale of child abuse cases nationwide, it can be estimated through the incidence of sentinel injuries, which are defined as minor but unusual injuries such as bruises or wounds in children of precruising age. Therefore, this study aimed to define disease codes for sentinel injuries by age as a preliminary study to elucidate the incidence of sentinel injuries among patients who visited hospitals nationwide.

METHOD

This study was designed using the Delphi method with a structured questionnaire. An extensive literature review was conducted to develop the questionnaire. The 9 participants selected as experts in child abuse were all experienced pediatric emergency medicine specialists working at pediatric emergency medicine training hospitals in South Korea, and 8 participants responded to the first survey. The Delphi method comprised 3 rounds of online surveys using Google Forms and Excel sheet questionnaire via e-mail. Only questions that achieved consensus were selected and assigned a sentinel injury disease code.

RESULTS

In total, 105 questions regarding the definition of sentinel injury disease codes were surveyed as to whether they should be included as sentinel injuries, categorized by type (bruises, burns, open wounds/lacerations, and others) and anatomical location. Among them, 5 (62.5%) or more participants agreed on 92 items.

CONCLUSIONS

Using the Delphi method, we defined disease codes for sentinel injuries in children aged younger than 12 months, possibly enabling assessment of the incidence of child abuse based on national data. Future research is needed to validate this result and investigate the incidence of sentinel injuries using the defined disease codes and to determine their association with actual cases of child abuse.

Impact of standardization on racial and socioeconomic disparities in non-accidental trauma evaluations in infants in a pediatric emergency department

BACKGROUND

Studies have illustrated racial and socioeconomic disparities in evaluation of non-accidental trauma (NAT). We aimed to investigate how implementation of a standardized NAT guideline in a pediatric emergency department (PED) impacted racial and socioeconomic disparities in NAT evaluation.

RESULTS

1199 patients (541 pre- and 658 post-guideline) were included for analysis. Pre-guideline, patients with governmental insurance were more likely than those with commercial insurance to have a social work (SW) consult completed (57.4% vs. 34.7%, p < 0.001) and a Child Protective Services (CPS) report filed (33.4% vs. 13.8%, p < 0.001). Post-guideline, these disparities were still present. There were no differences in race, ethnicity, insurance type, or social deprivation index (SDI) in rates of complete NAT evaluations pre- or post-guideline implementation. Overall adherence to all guideline elements increased from 19.0% before guideline implementation to 53.2% after (p < 0.001).

CONCLUSION

Implementation of a standardized NAT guideline led to significant increase in complete NAT evaluations. Guideline implementation was not associated with elimination of pre-existing disparities in SW consults or CPS reporting between insurance groups.

Prevalence and Causes of Subconjunctival Hemorrhage in Children

OBJECTIVE

Subconjunctival hemorrhage (SCH) is a reported sign of occult abusive injury, but there are limited published data about SCH during childhood. We sought to determine the prevalence and causes of SCH in children.

METHODS

This is a retrospective cross-sectional study of children seen by pediatric ophthalmologists in an outpatient setting over 4 years. Primary outcomes were prevalence and causes of SCH, based on history, physical ocular and nonocular findings, and laboratory and imaging studies. Subconjunctival hemorrhage prevalence was determined including and excluding eye surgery to reduce bias in the prevalence estimate.

RESULTS

We studied 33,990 children, who underwent 86,277 examinations (median age, 5 years; range, 2 days to 18 years; 9282 younger than 2 years, 13,447 age 2-7 years, 11,261 age 8-18 years). There were 949 cases of SCH (1.1%; 95% confidence interval, 1.0-1.2). When surgery was excluded, there were 313 cases (prevalence, 0.4%; 95% confidence interval, 0.3-0.4), of which 261 (83%) were due to trauma; 40 (13%) ocular surface inflammation, including infectious conjunctivitis; 7 (2%) orbital or conjunctival lesion; 3 (1%) vessel rupture from choking or cough; and 2 (1%) coagulopathy related. Across all ages, including less than 2 years, trauma and inflammation together accounted for 94% to 97% of all cases of SCH.

CONCLUSIONS

Subconjunctival hemorrhage is uncommon in children. The great majority of cases are due to trauma. All children with SCH, including infants and young children, should be closely examined to identify other ocular or nonocular signs of trauma.

Subconjunctival bleedings in neonatal calves: a case series report

Background

In animals, only few reports exist about the occurrence and causes of subconjunctival bleedings, especially in newborn calves. Most case reports and studies showed that the major risk factors for subconjunctival bleedings in animals are traumatic events such as birth trauma and traffic accidents, respectively. In neonatal babies, it is suggested that compression of the thorax and abdomen during delivery or forces generated in utero during labor may raise venous pressure to conjunctival vessels and can cause subconjunctival bleedings.

Results

The incidence of bleedings in neonatal Holstein–Friesian calves was 2.4 per cent of 289 neonatal calves examined over a six-year period. In general, two types of subconjunctival bleedings were seen. One was usually in a semilunar fashion immediately outside the limbus of the eye. The other type was a stripe or macule of variable size at different positions of the sclera. The subconjunctival bleedings were not related to gestational time. In all cases, affected calves were born without assistance. Multiparous cows were more often involved in the calves with subconjunctival bleedings. Two calves examined haematologically did not show signs of anemia or thrombocytopenia.

Conclusions

Subconjunctival bleedings in neonatal calves appear not to be incidental findings. Main causes or associated conditions of subconjunctival bleedings were not found.

Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages

OBJECTIVE

The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist.

METHODS

This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls.

RESULTS

Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises.

CONCLUSIONS

These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition

OBJECTIVES

To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated.

METHODS

Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage.

RESULTS

Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%).

CONCLUSIONS

About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

Characteristics That Distinguish Abusive From Nonabusive Causes of Sudden Unexpected Infant Deaths

BACKGROUND

Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department.

METHODS

Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes.

RESULTS

We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30).

CONCLUSIONS

Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.

Occult Injury Screening Among Infants With Subconjunctival Hemorrhage

PURPOSE

To assess the frequency and nature of occult injury screening in infants with subconjunctival hemorrhages (SCH), the incidence of occult injuries in these children, and the factors that may have influenced the decision to screen for additional injury.

METHODS

Infants aged 14 days to 6 months with SCH who presented to two tertiary pediatric centers were identified from a local database (N = 84). A retrospective chart review collected demographics, examination findings, and imaging results. Infants were further stratified into two groups depending on the presence of additional mucocutaneous injuries. The groups were compared with two-sample t testing.

RESULTS

Skeletal surveys were completed in 31% of patients overall, but the rate of screening was significantly higher among patients who presented with SCH and additional mucocutaneous injuries as opposed to SCH alone. However, the presence of additional mucocutaneous injuries was not associated with an increased risk for positive skeletal survey.

CONCLUSIONS

Rates of occult injury screening among infants with SCH were low and were significantly influenced by the presence of additional injuries. When screening was conducted, occult injuries were commonly identified. Future studies should assess the true prevalence of abuse in this population. [J Pediatr Ophthalmol Strabismus. 2021;58(4):213-217.].

What's in a name? Sentinel injuries in abused infants

Infants are at greatest risk of severe and fatal physical abuse yet they sometimes present for medical care multiple times with abusive injuries prior to being diagnosed with abuse and having protective actions taken. Efforts to identify these infants in a timely manner are critical to prevent repeated, escalating abuse and subsequent harm. Increasing the identification and evaluation of sentinel injuries has been highlighted as a strategy for improving timely detection of abuse in infants. Sentinel injuries are visible, minor, poorly explained injuries in young infants that raise concern for abuse. These injuries include cutaneous injuries such as bruising, subconjunctival hemorrhages and intra-oral injuries. Sentinel injuries can signal concurrent clinically occult but more serious injuries or precede more significant trauma from abuse. As such, sentinel injuries offer an opportunity to intervene and protect infants from further harm. A thorough physical exam is critical for detecting sentinel injuries. Imaging with skeletal survey and, when appropriate, neuroimaging are key components of the medical evaluation of sentinel injuries in these high-risk infants.

Providers' Ability to Identify Sentinel Injuries Concerning for Physical Abuse in Infants

OBJECTIVES

The objectives of this study were to assess the ability of pediatric health care providers and social workers to recognize sentinel injuries in infants under 6 months of age and to determine what factors influence their decision to evaluate for physical abuse.

METHODS

A statewide collaborative focused on sentinel injuries administered a survey to pediatric health care providers and social workers in the emergency department, urgent care, and primary care. The survey contained 8 case scenarios of infants under 6 months of age with an injury, and respondents were asked if they would consider the injury to be a sentinel injury requiring a physical abuse evaluation. Respondents were then presented with several factors and asked how much each influences the decision to perform a physical abuse evaluation.

RESULTS

A total of 565 providers completed the survey. Providers had moderate interrater reliability on their classification of the cases as sentinel injuries or not (κ = 0.57). Nearly all respondents (97%) recognized genital bruising as a sentinel injury, whereas 77% of respondents recognized intraoral injuries. Agreement was highest among social workers (κ = 0.76) and physicians with categorical pediatrics training and pediatric emergency medicine fellowship (κ = 0.63) and lowest among nurse practitioners (κ = 0.48) and residents (κ = 0.51). Concern over missing the diagnosis of abuse had the greatest influence on the decision to perform a physical abuse evaluation.

CONCLUSIONS

Sentinel injuries are not uniformly recognized as potential signs of child abuse requiring further evaluation by pediatric health care providers. Additional evidence and education are needed regarding sentinel injuries.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics

IMPORTANCE

Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child.

OBJECTIVE

To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020.

EXPOSURES

Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis.

MAIN OUTCOMES AND MEASURES

Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel.

RESULTS

A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp).

CONCLUSIONS AND RELEVANCE

In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.

Suconjunctval hemorrhages

Introduction:Subconjunctival hemorrhage or suffusion is bleeding that occurs between the conjunctiva and episclera. It has a distinctive look and often frightens patients. The causes can be varied. Objective: The research was undertaken in order to determine the characteristics of patients within whomsubconjunctival hemorrhage occur. Methods: Retrospective analysis of patients of the Eye Department of the Health Center in KosovskaMitrovica, during 6 months. Results were analyzed SPSS ver 22, i GraphPad INSTAT software package. Results: The change was observed in 63 patients. Male gender was significantly more frequent. The age of patients was diverse-between 5 and 86 years. The causes and conditions associated with subconjunctival hemorrhages are usually eye trauma, in young,and arterial hypertension in elderly patients. Conclusion: Subconjunctival hemorrhage is a relatively common diagnosis in ophthalmology. The change is benign and spontaneously disappears during one to two weeks. It is important to note that the subconjunctival hemorrhage occur in patients with certain risk factors.

Cumulative visits for care of minor injuries are associated with traumatic brain injury in young children

AIM

To evaluate the association between cumulative visits for care of minor injuries and risk of traumatic brain injuries in children aged ≤36 months.

METHODS

We conducted a retrospective analysis of children born from 2009 to 2012, using a health insurance claims database in Japan. We investigated the total number of visits where children aged 0-36 months presented for treatment of minor injuries such as superficial injuries, fractures, burns and foreign body ingestions. Logistic regression analysis was used to evaluate the association between the cumulative number of visits for treatment of minor injuries and traumatic brain injuries in children aged ≤36 months.

RESULTS

A total of 91 011 children were included in the analysis, 51% of whom were boys. Traumatic brain injuries were identified in 0.7% of these children. Cumulative visits for care of minor injuries among children aged 0-36 months were significantly associated with traumatic brain injuries by 36 months of age, with an odds ratio of 2.12 (95% confidence interval: 1.68-2.68) for multiple visits.

CONCLUSION

Cumulative visits for treatment of minor injuries during the first 36 months of life were associated with increased risk of traumatic brain injuries by 36 months of age.

A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event

In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.

The Eye Examination in the Evaluation of Child Abuse

Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.

Child Abuse and the Eye in an African Population

Purpose

There is a paucity of data on child abuse and the eye in West Africa. Therefore, a need exists to determine the causes and circumstances surrounding these occurrences and their effects on the eye and vision in a pediatric population.

Methods

A 3-year study of consecutive cases of ocular features that presented to an eye clinic following a history suggestive of child abuse along with any associated eye injury was carried out. Socio-demographic characteristics were obtained, as were the presenting and posttreatment visual acuity, and a full clinical eye examination was also done.

Results

Fifty-six children with 56 affected eyes were examined. The male to female ratio was 1.8 : 1; the mean age was 8.25 ± 3.5 years; and the subjects were predominately primary school children 30 (53.6%). The most common ocular disorders were conjunctiva hyperemia (46.4%), corneal abrasion/ulcer (25.4%), hyphema/uveitis (42.9%), retinal detachment (7.1%), sclera rupture (7.1%), and globe perforation (21.4%). The intraocular pressure was raised in 17.9% of participants. Presenting versus posttreatment visual acuities showed normal vision in four (7.1%) vs. eighteen (32.1%), visual impairment in 12 (21.4%) vs. six (10.7%), severe visual impairment in 20 (35.7%) vs. 12 (21.4%), and blindness in 12 (21.4%) vs. 14 (25%), p < 0.001. The most common injurious agents were canes (25.0%) and sticks (17.9%). The people who inflicted the injuries were parents/relatives (uncles) in 35.7% of cases and the children themselves (accidents) in 21.4% of cases. Circumstances predisposing participants to eye injuries were child labor in 39.3% and beatings in 25.0%. Complications were cataracts (25.0%), corneal opacity (39.3%), and retinal detachment (7.1%).

Conclusions

Injuries commonly resulted from canes and sticks used during beatings, as well as from child labor, corporal punishment, accidents, and assaults. Legislation and laws need to be enacted to prevent negative psychosocial and economic impacts on the child, family and country as a whole.

Characteristics of non-vitreoretinal ocular injury in child maltreatment: a systematic review

PurposeTo identify the spectrum of non-vitreoretinal ocular injury due to child maltreatment.MethodsAll language search of MEDLINE, PsychINFO, EMBASE, AMED, Web of Science, and CINAHL databases, 1950-2015, was conducted.

INCLUSION CRITERIA

explicit confirmation of injury aetiology, age <18 years, examination conducted by an ophthalmologist. Exclusion: post-mortem data, organic diseases, review articles. Standardised critical appraisal and narrative synthesis was conducted of included publications by two independent reviewers.ResultsOf 1492 studies identified, 153 full texts were assessed, 49 underwent full review, resulting in five included studies: three case series and two case reports. The 26 included cases describe a wide variety of ocular, facial and skeletal injuries occurring as a consequence of child maltreatment. Ocular signs included periorbital oedema, chemosis, injection, abrasion, hyphaema, and cataract. Of interest all children that had suffered physical abuse with ocular injury had subconjunctival haemorrhages. Children presenting with abusive ocular injuries had a mean age of 13.9 months (range 1-68), while those who suffered violent corporal punishment were considerably older (mean 96 months). All cases, apart from severe corporal punishment, underwent screening for occult fractures, but neuroimaging only apparent in 2/5 eligible cases.ConclusionAlthough, the face is the most common site of abusive injury, there is a paucity of high-quality data on non-vitreoretinal ocular abusive injury. Thus, while subconjunctival haemorrhages are a potential sentinel injury of maltreatment, and may warrant further evaluation, the lack of large-scale published data limits our ability to highlight further specific characteristics of non-vitreoretinal ocular injury indicative of child abuse.

Differentiating Urgent and Emergent Causes of Acute Red Eye for the Emergency Physician

Patients commonly present with an acute red eye to the emergency department (ED). It is important to distinguish between benign and sight-threatening diagnoses. Here we provide a comprehensive overview on the acute red eye in the ED.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Effective Radiation Dose in a Skeletal Survey Performed for Suspected Child Abuse

Effective dose of a skeletal survey in infants using digital radiography was estimated to be 0.2 mSv using Monte Carlo simulation. Radiation risk from this procedure is, therefore, low. Radiation concern should not be an overriding factor when deciding whether skeletal survey is needed in cases of possible physical abuse.

Testing for Abuse in Children With Sentinel Injuries

OBJECTIVE

Child physical abuse is commonly missed, putting abused children at risk for repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children's hospitals with these putative sentinel injuries.

METHODS

This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries.

RESULTS

Among all visits for children <24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children <12 months old with burns to 56.1% for children <24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries.

CONCLUSIONS

Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.

Subconjunctival hemorrhage: risk factors and potential indicators

Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly, systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common. In patients in whom subconjunctival hemorrhage is recurrent or persistent, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted.