Paediatric
Retinal Haemorrhages in Infancy (Abusive Head Trauma Considerations)
Also known as: retinal haemorrhage infant, retinal haemorrhages child, abusive head trauma, non-accidental injury eye, NAI eye, shaken baby, inflicted head injury, child protection eye findings
Filed as: Emergency
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
Retinal haemorrhages in an infant or young child are a same-day finding, never an observation. The differential spans coagulopathy, leukaemia and other systemic disease, severe accidental trauma, residual birth haemorrhages in the first weeks of life, and abusive head trauma — and separating these is the job of a paediatric team with fundoscopy under controlled conditions, laboratory work-up and skeletal survey, not of a single practitioner in a consulting room. The optometrist's role is exact and limited: recognise, document objectively (number, layers, laterality, extent — with imaging where available), arrange same-day paediatric assessment, and follow local child-safety escalation pathways. This record describes findings and the obligations they create; it does not conclude causation, and nothing in it replaces the jurisdiction's own reporting framework.
Recognition
Symptoms: what patients report
- Often none referable to the eye — the haemorrhages are found on examination of an unwell, irritable, drowsy or seizing infant.
- Carer-reported poor feeding, vomiting, or reduced responsiveness in an infant.
- A history offered for injury that is absent, changing, or developmentally implausible for the child's age.
- Visual inattention in a previously fixing infant.
Signs: what the examination shows
- Retinal haemorrhages — counted, and described by layer (preretinal, intraretinal, subretinal), laterality, and extent (posterior pole only vs extending to the ora serrata).
- Too-numerous-to-count, multilayered haemorrhages extending to the periphery — a pattern with a narrow differential in infancy.
- Traumatic retinoschisis or perimacular retinal folds in an infant.
- Associated neurological signs: reduced conscious state, seizures, apnoeas, a tense fontanelle.
- Associated external findings, which may be absent — a normal external examination does not exclude intracranial injury.
- Vitreous haemorrhage in an infant without a coagulopathy or an ocular explanation.
- Bruising in the sites of the validated bruising rule — and two of them are inside this examination: eyelid and subconjunctiva, alongside torso, ear, neck, frenulum, angle of the jaw and fleshy cheek — or any bruising at all in an infant under about five months, or patterned bruising. In a child under four, any one of these supports further evaluation rather than reassurance (TEN-4-FACESp; 95.6% sensitive, 87.1% specific, Pierce 2021).
What OptoGuide™ covers for retinal haemorrhages in infancy (abusive head trauma considerations)
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked Australian therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- The Eye Examination in the Evaluation of Child Abuse — AAP policy statement, Pediatrics 2018
- Eye Emergency Manual — NSW Agency for Clinical Innovation
- Pierce MC et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics (TEN-4-FACESp). JAMA Netw Open 2021;4(4):e215832
- Sheets LK et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013;131(4):701-7
- Abusive Head Trauma in Infants and Children: Technical Report. Narang SK, Haney S, Duhaime AC, et al. Pediatrics. 2025;155(3):e2024070457.
- Prevalence of Retinal Hemorrhages in Critically Ill Children. Agrawal S, Peters MJ, Adams GG, Pierce CM. Pediatrics. 2012;129(6):e1388-96.
- The Eye Examination in the Evaluation of Child Abuse. Christian CW, Levin AV, COUNCIL ON CHILD ABUSE AND NEGLECT, et al. Pediatrics. 2018;142(2):e20181411.