Data replace dogma on trauma, abuse in children.

DENVER -- Accepted dogma concerning neurologic evaluation of children with suspected nonaccidental trauma is under challenge from accumulating findings from a number of studies, according to a presentation at a meeting on pediatric neurologic surgery.

A single MRI or CT scan, for example, cannot reliably date or quantify child abuse injuries beyond a few days, Dr. Ann-Christine Duhaime said. Other new findings suggest the need to rethink the significance of retinal hemorrhage or cervical injury in suspected physical abuse cases.

"As usual, progress tells us we know less than we thought we did," said Dr. Duhaime, director of pediatric neurosurgery at Children's Hospital at Dartmouth, Lebanon, N.H.

Recent data show that neither MRI nor CT can reliably count the number of events or time injuries "beyond a few days at best," Dr. Duhaime said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

The old dogma held that blood of different colors seen on a CT or MRI image indicated repeat abuse. "We can no longer say that," Dr. Duhaime said. "It's relevant to your analysis of the etiology of a given child's situation."

As institutions update imaging technology, keep in mind that it may be more difficult to detect skull fractures (Pediatr. Radiol. 2002;32:896-901). "Now the images are done digitally, and I've had a heck of a time finding fractures I was sure were there," Dr. Duhaime said. The "digital images many of us are using are just not as good [as film images]."

Complex, comminuted, or multiple skull fractures--with or without intracranial hemorrhage--signal abuse, Dr. Andrew P. Sirotnak said at the meeting. Another practical point on fractures is that rib fractures are not caused by cardiopulmonary resuscitation. "Rib fractures are markers for abuse, period."

Retinal hemorrhage is a grayer area, although severe bilateral cases are still most likely nonaccidental trauma, Dr. Duhaime said. Accidental trauma also can cause some mild to moderate retinal hemorrhage, according to autopsy reports.

A collection of blood in the retina is evidence of severe trauma and/or abuse, Dr. Sirotnak said. Consult a pediatric ophthalmologist if possible, he suggested, and take photos with a retinal camera to follow resolution.

The images might also be useful as evidence for court proceedings, said Dr. Sirotnak, director of the Kempe Child Protection Team at the Children's Hospital, Denver.

There is controversy around the old idea that shaking and/or angular deceleration injuries cause diffuse axonal injury (DAI), Dr. Duhaime said. Again, accumulating data indicate that DAI is rarely found in these cases (Brain 2001; 124:1290-8). "In the biomechanical world, we have quite good data on what forces are required for diffuse axonal injury. There are good animal models that tell us what it takes to get DAI in a child. Now that the whole DAI thing is in question, we are back to not knowing."

High cervical injuries are likely underreported in severe abuse cases, she said, replacing old dogma that abuse injuries are primarily supratentorial. "Studies on survivors rarely show anything on radiology or MRI. However, [cervical pathology] is often found on autopsies of kids who died from child abuse," Dr. Duhaime added.

BY DAMIAN MCNAMARA

Miami Bureau