Severe cough and retinal hemorrhage in infants and young children

doi:10.1016/j.jpeds.2005.12.052

The Journal of Pediatrics

Volume 148, Issue 6, June 2006, Pages 835-836

https://doi.org/10.1016/j.jpeds.2005.12.052 Get rights and content

No retinal hemorrhages were detected in any of 100 consecutive children aged 3 months to 2 years with severe, persistent coughing (0 of 100, 95% CI: 0%- 3%). Therefore, if one finds retinal hemorrhage in infants and young children with cough, child abuse must be excluded.

Section snippets

Methods

The study was approved by the Ethics Review Board of the Assaf Harofeh Medical Center, Israel. All children aged 3 months to 2 years admitted to the Department of Pediatrics, Assaf Harofeh Medical Center, Israel, with severe coughing were eligible for the study. Severe coughing was defined as (1) coughing ≥3 days, (2) reason for referral to the Emergency Department, and (3) hospitalization required. Children were excluded if there was any evidence of child abuse via history, physical

Results

From July 2004 through September 2005, 122 consecutive patients who met the inclusion criteria were asked to participate in the study, and 100 were enrolled in the study. Of the 100, 65 were male. Patient age ranged from 3 to 24 months, with a mean age of 8.88 months (±6.03 months) and a median age of 7 months. The duration of coughing before the ocular examination ranged from 3 to 31 days, with a mean of 8.04 days (±6.8), and a median of 6 days. Clinical diagnoses at discharge are shown in the

Discussion

Early diagnosis of child abuse is crucial to reduce morbidity and mortality rates.1, 2 However, an incorrect diagnosis may cause severe psychological distress to the family, termed “medical abuse” by Kirschner.⁸ Although retinal hemorrhages are a potential manifestation of child abuse, especially for “shaken baby syndrome,” their existence has also been described in other clinical settings.1, 2, 3 Recently, Herr et al³ examined 100 infants with forceful vomiting caused by hypertrophic pyloric

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Cited by (34)

Child maltreatment, abusive head trauma, and the eye
2016, Taylor and Hoyt's Pediatric Ophthalmology and Strabismus, Fifth Edition
Mimics of child abuse: Can choking explain abusive head trauma?
2015, Journal of Forensic and Legal Medicine
Citation Excerpt :
Forceful vomiting in infants from pyloric stenosis does not result in retinal hemorrhages.20 Severe persistent cough in infants has not been associated with retinal hemorrhages.21 Similarly evidence is lacking that pertussis infection results in retinal hemorrhages.22
Choking is one of the alternative explanations of abusive head trauma in children that have been offered in courtroom testimony and in the media. Most of these explanations — including choking — are not scientifically supported.
This article highlights four points. (1) The origins of choking as an explanation for intracranial and retinal hemorrhages are speculative. (2) Choking has been used in high profile court testimony as an explanation for the death of a child thought to have been abused. (3) A case report that proposes choking as an alternative explanation for the death of a child diagnosed with abusive head trauma includes omissions and misrepresentations of facts. (4) There was a decision by the editor of the journal that published the case report that it was not necessary to include all the facts of the case; moreover, the editor indicated that facts are not required when presenting an alternative explanation.
The use of scientifically unsupported alternative explanations for abusive head trauma based on inaccurate and biased information constitutes further victimization of the abused child and represents a travesty of justice.
Valsalva hemorrhagic retinopathy presenting as a rare cause of impaired vision after a general anesthetic - A case report and review of the literature
2015, Journal of Clinical Anesthesia
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Valsalva hemorrhagic retinopathy has also been reported after common medical and surgical interventions including the following: colonoscopy [15], upper endoscopy [16,17], laparoscopy [4,11], laparoscopic cholecystectomy [5], prostate biopsy [50], dental procedures [18,19], lumbar and caudal epidural injection [6-10,12], a seizure [51], choking and an attempted Heimlich maneuver [52], and cardiopulmonary resuscitation (CPR) [53]. Valsalva hemorrhagic retinopathy is generally thought not to occur in children [54,55]; however, there is at least 1 report of retinal hemorrhages in a child who underwent CPR after being admitted for severe dehydration and vomiting, these caused by either the retching and/or CPR [56]. In addition to the difficult intubation and “stormy” anesthetic reported by Duane [13] and in our patient who coughed, 3 cases of VHR have been published after reportedly uneventful general anesthetic administration.
Postoperative visual loss from any cause is potentially catastrophic. We present a case of Valsalva hemorrhagic retinopathy (VHR) as a rare cause of impaired vision after an apparently uneventful general anesthetic. Previously published cases of VHR, anesthetic related and otherwise, are reviewed and the phenomenon discussed. Although VHR is considered to be rare, the events and activities with which it is associated are relatively common, both in everyday life and in the operating room. We suggest that the occurrence of VHR after anesthesia and surgery may be more frequent than previously appreciated and make recommendations for further investigations.
A public hearing. " Shaken baby syndrome: Guidelines on establishing a robust diagnosis and the procedures to be adopted by healthcare and social services staff" Scoping report
2011, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
None of 32 children (mean age: 30 months) hospitalized after an epileptic attack had any RH, despite the need for resuscitation in a few cases [155]. No RH was observed in a series of 100 consecutive children with a persistent cough [66]. No RH was observed in a series of 100 children with vomiting due to pyloric stenosis [77].
Eye injuries in child abuse
2011, Child Abuse and Neglect
Letter to the Editor
2010, Seminars in Pediatric Neurology

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Clinical and laboratory observationSevere cough and retinal hemorrhage in infants and young children

Section snippets

Methods

Results

Discussion

Retinal hemorrhage in the young childa review of etiology, predisposed conditions, and clinical implications

J Emerg Med

Child abuse and neglect

N Engl J Med

Does Valsalva retinopathy occur in infants? An initial investigation in infants with vomiting causes by pyloric stenosis

Pediatrics

Retinal hemorrhage in the newborn following labor induced by oxytocin or dinoprostone

Arch Ophthalmol

Clinical and laboratory observation
Severe cough and retinal hemorrhage in infants and young children