Evaluation of infants with subdural hematoma who lack external evidence of abuse.

OBJECTIVE: Advances in radiologic technique have increased the recognition of subdural hematoma. No study to date has addressed the role of child protective investigation into the cause and management of subdural hematoma in children who lack other indicators of abuse.
METHODS: Medical records, radiology studies, and social service notes for all infants and children referred for child abuse investigation who had any form of intracranial hemorrhage were reviewed. The study covered the 12 months of 1997. All referrals were to the Suncoast Child Protection Team (St Petersburg, FL).
RESULTS: There were 19 investigations because of subdural hematoma. Eight children had retinal hemorrhage as well as other major findings of trauma, such as bruises and/or fractures; all 8 were victims of child abuse. Two infants had tiny subdurals adjacent to accidental linear skull fractures. Nine infants were investigated for the possibility of abuse that had no findings of trauma apart from the subdural hematoma. These 9 cases form the basis for this study. The age range was 11 days to 15 months. Inflicted cerebral trauma was the medical diagnosis in 8 of the 9 cases; 1 case had a final diagnosis of possible inflicted injury in a high-risk setting.
CONCLUSIONS: Infants with subdural hematoma but no other findings of abuse present a difficult challenge to child protection workers. Investigation by a medically oriented team can uncover the circumstances of the trauma in most instances and can usefully direct protective efforts. The high incidence of severe sequelae in infants with inflicted cerebral trauma warrants a vigorous approach.