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Inflicted versus accidental head injury in critically injured children
B Goldstein1, M M Kelly, D Bruton
1Department of Pediatrics, University of Rochester, School of Medicine, NY.
Insights
Inflicted head injuries in children result in more severe neurologic injury and worse outcomes compared to accidental injuries. A combination of inconsistent history, retinal hemorrhages, or parental risk factors can help identify inflicted head injury cases.
Area of Science:
- Pediatric critical care medicine
- Child neurology
- Forensic pediatrics
Background:
- Inflicted head injury (IHI) is a significant cause of severe head trauma in children.
- Understanding the factors associated with IHI is crucial for early diagnosis and intervention.
- Previous studies have highlighted the severity of IHI but require further investigation into associated risk factors.
Purpose of the Study:
- To determine the incidence of IHI in critically injured children.
- To evaluate the severity of neurologic injury and long-term neurologic outcomes in children with IHI.
- To identify historical, socioeconomic, physical, and radiologic factors associated with IHI.
Main Methods:
- Prospective clinical study conducted in a multidisciplinary pediatric intensive care unit (ICU).
- Inclusion of 40 consecutive cases of severe head injury admitted to the pediatric ICU.
- Data collection included neurologic injury severity (Glasgow Coma Scale) and neurologic outcome (Glasgow Outcome Score).
Main Results:
- 35% (14 of 40) of severe head injuries were inflicted, with 79% due to child abuse and 21% due to neglect.
- Inflicted head injury cases showed significantly worse admission Glasgow Coma Scale scores (7.1 vs. 9.9, p=0.04) and Glasgow Outcome Scores (2 vs. 4, p=0.004) compared to accidental injuries.
- In child abuse cases, the presence of any two of: inconsistent history/physical exam, retinal hemorrhages, or parental risk factors (substance abuse, prior social services, history of abuse/neglect) was associated with IHI.
Conclusions:
- Inflicted head injury in children is associated with more severe neurologic injury and poorer neurologic outcomes than other types of head trauma.
- The combination of two specific risk factors (inconsistent history/exam, retinal hemorrhages, parental risk factors) may serve as a reliable marker for early and definitive diagnosis of IHI in pediatric ICUs.
Objectives:
To assess the frequency of inflicted head injury in critically injured children; the severity of neurologic injury; the neurologic outcome; and the historical, socioeconomic, physical, and radiologic factors associated with inflicted head injury.
Design:
Prospective clinical study.
Setting:
Multidisciplinary pediatric intensive care unit (ICU).
Patients:
Consecutive cases (n = 40) of severe head injury admitted to a pediatric ICU.
Interventions:
None.
Measurements And Main Results:
Fourteen (35%) of 40 cases of head injury were due to inflicted head injury. Eleven (79%) of 14 inflicted head injury cases were due to child abuse and three (21%) were due to neglect. The severity of neurologic injury, as measured by the admission Glasgow Coma Scale, was worse in cases of inflicted head injury (7.1 +/- 0.7 [SE] [inflicted] vs. 9.9 +/- 0.8 [accidental]; p = .04). Glasgow Outcome Scores were worse after inflicted head injury (2 +/- 1 inflicted] vs. 4 +/- 1 [accidental]; p = .004). In victims of child abuse, we found the combination of any two of the following three factors was associated with inflicted head injury: an inconsistent history/physical examination; retinal hemorrhages; or parental risk factors (alcohol or drug abuse, previous social service intervention within the family, or a past history of child abuse or neglect).
Conclusions:
This study confirms that severity of neurologic injury and neurologic outcome in cases of inflicted head injury are worse than in any other type of childhood head injury. We believe that a combination of any two of the above three risk factors may prove to be a reliable marker of inflicted head injury in children admitted to a pediatric ICU and will lead to an early and definitive diagnosis.