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The ramifications of failing to diagnose child abuse in any of its iterations are enormous. Most shaken children, the subject of the article by Binenbaum and colleagues1 in this issue of JAMA Ophthalmology, are younger than 2 years and often present with additional findings of central nervous system injury, lethargy (or worse), and other signs of poorly explained trauma. Not every child presents in this fashion. Shaking can occur along a continuum, with some infants showing retinal hemorrhages only, at least at first. Shaking is only one aspect of a constellation of problems the affected infant confronts.
Recent studies have shown that mistreatment by caregivers confers a lifetime of behavioral and neurological difficulties. Brain growth may be impaired2 and the risk of future and more serious central nervous system damage is ever present; the abused child is likely to grow to become an abusive caregiver. Early childhood abuse confers an increased risk for schizophrenia and other psychoses3 and, in general, the abused child lives a life burdened by unhealthy interpersonal relationships. All of these problems assume that the child survives physically intact. The neurological effects of shaking can be lethal and retinal hemorrhages can cause blindness.4
Given the strong association of retinal hemorrhages with abusive shaking, how is it that cases are missed, misdiagnosed, or mishandled? The reasons are myriad and beyond the scope of this Invited Commentary to review in detail. The abused child must confront an overworked and, at times, indifferent social service system. Caregivers’ opinions and excuses for the observed trauma may trump the reality of the physical findings. Abusive caregivers come from all walks of life. In certain ways, physicians can even identify with abusive caregivers and with their stress. However, legion in this litany of excuses is the phenomenon of denial. It is difficult to imagine that an upstanding person could intentionally hurt a child. Most children with retinal hemorrhages are reported to local Child Protective Services; however, what happens after that does not always work in the child’s best interest.
Attorneys are hired to defend abusive parents and prey on everyone’s denial. A fall from a crib or changing table or a sudden stop in the car are proffered as reasons for retinal hemorrhages. Judges may struggle with the disconnect between fact and their own denial and even plaintiff attorneys may not press the case as best they should. The expert witness (ophthalmologist) can lose his or her gumption as he or she is badgered into accepting absurd logic about the child’s condition.
Potential accidental reasons for retinal hemorrhages may be invoked in the process of determining where to place the young child. One excuse is that hemorrhages can be caused by vaccinations.5 We owe the researchers who studied this possible association a debt of gratitude. They studied thousands of children who visited their clinics and received dilated fundus examinations. By evaluating vaccination records of several thousand children seen for pediatric ophthalmology care, the authors found a 0% rate of hemorrhages in children who had been vaccinated in the preceding several weeks. This finding merits reiterating. There were no recently vaccinated children with retinal hemorrhages. However, there were a few children with retinal hemorrhages who also had unambiguous signs of child abuse. The authors have thoroughly debunked the possibility that retinal hemorrhages could ever be the result of vaccinations. In the process, yet another reason to avoid vaccinating your child should be demythologized.
Now, the physician who is thrust into the complex world of child placement, removing children from their caregivers, and medically managing the abused child’s physical problems has another piece of evidence to support his or her opinion that retinal hemorrhages are almost always caused by a shaking type of abuse. Our responsibility to come to the infant’s aid has been bolstered. Confronting the reality of abuse is difficult. One more vestige of doubt about the cause of retinal hemorrhages can be laid to rest.
Corresponding Author: William V. Good, MD, Smith-Kettlewell Eye Research Institute, 2318 Fillmore St, San Francisco, CA 94115 (email@example.com).
Published Online: September 3, 2015. doi:10.1001/jamaophthalmol.2015.3017.
Conflict of Interest Disclosures: None reported.
Good WV. Association of Vaccinations in Young Children and Retinal Hemorrhages. JAMA Ophthalmol. 2015;133(11):1266. doi:10.1001/jamaophthalmol.2015.3017
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