558 - Occult injury identification in children with subconjunctival hemorrhage: a tale of two studies
Monday, April 28, 2025
7:00am – 9:15am HST
Publication Number: 558.6001
Audrey Raut, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Megan M.. Letson, Nationwide Children's Hospital, Columbus, OH, United States; Julia N. Magana, University of California Davis, Sacramento, CA, United States; Doug Lorenz, University of Louisville, Louisville, KY, United States; Karen L. Bertocci, University of Louisville, Louisville, KY, United States; MARY Clyde Pierce, Ann & Robert H. Lurie Children's Hospital of Chicago, EVANSTON, IL, United States
Professor of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago EVANSTON, Illinois, United States
Background: Although infrequent, subconjunctival hemorrhage (SCH) can be a presenting sign of child physical abuse. However, prior studies have shown that children presenting with SCH are less likely to undergo screening for occult trauma than children presenting with other types of injury. Objective: Using data from two different studies of young children, we sought to determine: 1) the incidence of SCH, 2) rates of occult injury evaluation, 3) the presence of occult injuries highly specific for physical abuse, and 4) the frequency of abuse diagnosis. Design/Methods: We analyzed data from two multicenter prospective observational cohort studies of children < 4 years presenting to 7 different pediatric EDs (pEDs): the Bruising Clinical Decision Rule (BCDR) study, and the Fracture Injury Plausibility Model (FxIPM) study. The BCDR study enrolled children determined to have at least one bruise and the FxIPM study enrolled children determined to have at least one long-bone fracture. Cases were classified as abuse, accident, or indeterminate by a multidisciplinary expert panel. From each study, we calculated rates of occult injury screening and identification as well as abuse diagnosis among those with SCH. Results: Of 2161 children in the BCDR study, 34 (2%) had SCH and 22/34 (65%) were < 12 months. Twenty-nine children underwent occult injury evaluation (Table 1). Eleven children (32%) were found to have occult injuries that were highly specific for physical abuse, including rib fractures, CMLs, and liver or pancreatic lacerations (Table 2). In the BCDR study, 32/34 cases (94%) were diagnosed with abuse and 2/34 (6%) with accident. Of 780 children in the FxIPM study, 20 had SCH (3%) and 18/20 (90%) were < 12 months. All 20 children underwent occult injury evaluation (Table 1). Eighteen children (90%) were found to have occult injuries that were highly specific for physical abuse, including rib fractures and CMLs (Table 2). In the FxIPM study, 20/20 cases (100%) were diagnosed with abuse.
Conclusion(s): Together, these two studies underscore the high prevalence of physical abuse among children presenting to the pED with SCH, especially those < 12 months of age. Even though children were infrequently found to have SCH in these two studies, this physical exam finding was strongly associated with internal injuries highly specific for abuse. Thorough occult injury evaluation is critical to ensure timely identification of abusive trauma and potentially prevent recurrent injuries of escalating severity.
