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PEDIATRICS Vol. 110 No. 3 September 2002, pp. 557-562

Prevalence of Retinal Hemorrhages and Child Abuse in Children Who Present With an Apparent Life-Threatening Event

Raymond D. Pitetti, MD*,§, Frank Maffei, MD, Kenneth Chang, MD||, Robert Hickey, MD*,§, Rachel Berger, MD§ and Mary Clyde Pierce, MD*,{ddagger},§

* Division of Pediatric Emergency Medicine
{ddagger} Child Advocacy
§ Department of Pediatrics, Children’s Hospital of Pittsburgh
|| Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Divisions of Pediatric Critical Care and Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Children’s Hospital at Strong, University of Rochester School of Medicine, Rochester, New York

--> Objective. Child abuse (CA) can present with a spectrum of signs and symptoms. Apparent life-threatening events (ALTEs) may be a subtle presentation of CA. Retinal hemorrhages (RHs) are a well-described finding in some patients with CA. We hypothesized that screening children who present with a chief complaint of an ALTE for RH would detect an otherwise occult presentation of CA.

Methods. Children who were younger than 24 months of age and presented to the emergency department between March 1, 1997, and February 28, 1999, with signs and symptoms consistent with the National Institutes of Health’s definition of an ALTE were studied prospectively. Children were excluded when it was readily apparent on presentation that the child was a victim of CA. Demographic data, a complete blood count with differential, venous blood gas, carboxyhemoglobin level, and urine toxicological screen were collected. A pediatric ophthalmologist performed a dilated funduscopic examination; patients who were found to have RH underwent a noncontrast computerized tomographic scan of the head and skeletal survey to evaluate for occult injury. Evaluations by social services or Children, Youth and Families, the results of all diagnostic tests obtained, and the final discharge diagnosis were recorded. Medical records of all patients were reviewed at 1 year; subsequent visits, hospitalizations, and evaluations by social services or Children, Youth and Families were recorded.

Results. A total of 128 patients presented to the emergency department with an ALTE during the study period. No patients were excluded. Mean age was 2.1 months (median: 1.27; range: 0.07–16.0; standard deviation: 2.1). Fifty-seven (44.5%) were boys; 86 (67.2%) were white, and 36 (27.9%) were black. A total of 26 (20.3%) of 128 patients had a history of an ALTE, 4 (3.4%) of 117 had a family history of an ALTE, and 15 (12.8%) of 117 had a family history of sudden infant death syndrome. Dilated funduscopic examination was performed on 73 (57.0%) of 128 patients; RH was detected in 1 patient (1.4%). Four children, including the patient with RH, underwent an evaluation for suspected abuse; 3 (2.3%) of 128 were determined to have been abused.

Conclusions. RH was detected in 1 (1.4%) of 73 patients in our population of infants with ALTEs and 1 of 3 patients who were victims of CA and presented with an ALTE. CA was detected in 2.3% of patients who presented with an ALTE. The diagnosis of CA should be seriously considered in patients who present with an ALTE. The evaluation of ALTEs should include funduscopic examination as ALTEs and RHs are associated with CA.

Key Words: apnea • apparent life-threatening events • retinal hemorrhages • child abuse

Abbreviations: ALTEs, apparent life-threatening events • CA, child abuse • RH, retinal hemorrhage • ED, emergency department • CT, computed tomography • CPR, cardiopulmonary resuscitation • CYF, Children, Youth and Families • TBI, traumatic brain injury

Received for publication Jul 2, 2001; Accepted Nov 30, 2001.


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