One hundred fifty infants hospitalized with head injury over a 3-year period, 57 (38%) due to child abuse, were studied prospectively at the Departments of Pediatric Neurosurgery, Neuro-ophthalmology, and Legal Medicine, CHRU de Lille, France. Mean age at diagnosis was 5.3 months; 103 (69%) boys and 47 (31%) girls. Head circumference was abnormally high, above 97th percentile, in 28 (18.7%) cases. Of the 57 (38%) cases with trauma due to child abuse, 40 involved shaking and 17 involved beating; male to female preponderance was 3.14. Household accident was the cause of trauma in 55 (36.7%), birth trauma in 21 (14%), and traffic accident in 12 (8%) cases. Perinatal illness (prematurity, long labor etc) found in 54 cases, familial dysfunction such as alcohol or drug abuse in 29, absent signs of impact, and seizures on presentation were significantly correlated with child abuse (p<0.001). The most frequent admission diagnosis was subdural hematoma (SDH) in 73 (49%) cases, skull fracture in 20 (13%), and subarachnoid hemorrhage in 18 (12%). SDH occurred in 81% of child abuse cases compared to 28% with accidental trauma. Child abuse was the cause of 64% of all SDH in this study. Head circumference was not significantly correlated with SDH. Retinal hemorrhage (RE) occurred in 47 (36%) of 129 cases examined (15 newborns were not included because RE may occur with normal delivery). The sensitivity and specificity of RH for child abuse were 75% and 93%, respectively. RE with accidental trauma was always mild, whereas that associated with child abuse was severe. Child abuse was the cause of 90% of severe morbidity and 71% of mortality; 17.5% victims of abuse either died or were in a vegetative state. [1]

COMMENT. Child abuse is a major cause of infant head trauma in this study, and also, the most frequent cause of death and morbidity from trauma. Infants with a histoiy of perinatal illness or a dysfunctional family are at high risk for child abuse. Severe RE is highly suggestive of child abuse. SDH is more prevalent in cases of abuse compared to accidental head trauma in infants. Child abuse and clinical severity on admission are the main factors influencing outcome of infant head trauma. For a review of non-accidental head injury with particular reference to whiplash shaking injury, see [2], and Progress in Pediatric Neurology II PNB Publ, 1994;pp387-391.