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Ophthalmologist plays important role in recognizing and reporting child abuse
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Shaken baby syndrome is associated with retinal hemorrhage, subdural hematoma and cerebral edema resulting in increased intracranial pressure. It is a sight-threatening and life-threatening triad.
Many children also suffer rib or long bone fractures and damage to the neck and spinal cord; 80% suffer permanent neurological damage, and 30% die.
The ophthalmologist often plays an important role in the diagnosis and legal sequelae associated with this form of physical child abuse, so it is important for all of us to be familiar with its major manifestations and consider the diagnosis when appropriate.
I saw a couple cases of shaken baby syndrome in my residency while working for a year in the county hospitals, but I have not seen a single case since because my practice does not include many infants and children.
Most of these cases are first seen in emergency rooms or by pediatricians and family physicians. Most ophthalmologists who encounter a case are likely to do so while on call for an emergency room or in consultation with a primary care physician. In larger communities, most cases will be routed through a pediatric ophthalmologist and/or a retina specialist. For me, that is a comforting fact, because this is a tragic and difficult diagnosis to manage. Parents almost universally deny purposeful child abuse, and it is very hard to deal with such a difficult social issue. In most larger hospitals and health care institutions, there are teams of trained professionals to whom these patients can be referred, which is ideal because the treatment and legal management are beyond the scope of skills and training of the typical comprehensive ophthalmologist.
For those of us who take emergency room call, it is simply critical to be aware of the syndrome, suggest it as a possible diagnosis when appropriate and, because all these infants will be admitted to the hospital, refer the patient to the institution’s child advocacy team.
A few more thoughts on child abuse. Child abuse is common, afflicting as many as one in four children. The abuse can be physical, sexual, emotional or simple neglect. Some abuse is caused by inappropriate actions by a caregiver or parent, but abuse may also include acts of omission, including not providing adequate shelter, food or a safe, supportive environment. Children most likely to suffer child abuse are those who are born of unwanted pregnancies, especially in the face of poverty and substance abuse, in particular hard drugs such as cocaine, methamphetamine and heroin. Children who are abused are more likely to abuse their children, setting off a vicious multigenerational cycle of destructive behavior. Abused children, in addition to their physical injuries, suffer a form of post-traumatic stress disorder with chronic anxiety and depression.
There are many resources for the ophthalmologist who needs assistance in dealing with a case of suspected child abuse, including Prevent Child Abuse America, the National Children’s Advocacy Center, the National Alliance of Children’s Trust and Prevention Funds, and the National Center on Shaken Baby Syndrome.
It should be remembered that the ophthalmologist has both a medical and a legal responsibility when confronted with suspected child abuse. The laws are designed to protect the physician who appropriately reports such cases to the proper authorities, even when the diagnosis in the end is not confirmed.
The newspapers report daily on terrible cases of child abuse that were suspected by many but reported by no one and ended tragically. So it is incumbent upon those of us who see and treat children to remain aware that child abuse occurs and report our findings or refer appropriately when we are suspicious that child abuse is the etiology of any ocular pathology.