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Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH.We performed a 5-year retrospective case-control study of children2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries.Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9-12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6-10.2), high-specificity bruising (OR 2.6, 95% CI 1.3-4.9), and internal abdominal injury (3.5, 95% CI 1.2-9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury.ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.

OBJECTIVEChildren who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.METHODSThe authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.RESULTSOf 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.CONCLUSIONSThe high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.