Childhood head injuries: accidental or inflicted?

To determine the relative incidence of accidental and abusive causes of head injuries in children younger than 6.5 years, to identify the types of craniocerebral damage resulting from reported mechanisms of injury, and to assess the likelihood of injuries being accidental or inflicted.

Retrospective review of medical records of 287 children with head injuries aged 1 week to 6.5 years admitted to a metropolitan children's hospital from January 1986 through December 1991. Those patients with diagnoses of skull fracture; concussion; subarachnoid hemorrhage (SAH); subgaleal, epidural, or subdural hematoma (SDH); parenchymal contusion or laceration; and closed head injury were included. Criteria were used for inclusion in categories of definite abuse or accident.

Accidents accounted for 81% of cases and definite abuse for 19%. The mean age of the accident group was 2.5 years and for the definite abuse group, 0.7 years. Major differences were seen in the incidence of the following: SDH, 10% in the the accident group and 46% in the the definite abuse group; SAH, 8% in accident group and 31% in the definite abuse abuse; and retinal hemorrhages, 2% in the accident group and 33% in the definite abuse group. Associated cutaneous injuries consistent with inflicted injury were seen in 16% of the accident group and 50% of the definite abuse group. Twenty-three percent of those in the accident group were injured in motor vehicle crashes (MVCs), 58% by falls, 2% in play activities, and the rest had insufficient medical record information. In 56% of those in the definite abuse group, there was no history to account for the injuries and no history of MVC. In 17%, a fall was said to have been the mechanism of injury. In 24%, inflicted injury was admitted. Mortality rates were 13% in the definite abuse group and 2% in the accident group. Median hospital stay was 9.5 days for the definite abuse group and 3 days for the accident group. In falls less than 4 feet in the accident group, 8% had SDH, 2% had SAH, and none had retinal hemorrhages; among those in the definite abuse group reportedly falling less than 4 feet, 38% had SDH, 38% had SAH, and 25% had retinal hemorrhages.

A substantial percentage of head injuries requiring hospitalization in children younger than 6.5 years are attributable to inflicted injury. Subdural hematoma, subarachnoid hemorrhage, retinal hemorrhages, and associated cutaneous, skeletal, and visceral injuries are significantly more common in inflicted head injury than in accidental injury.