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Head trauma in children younger than 2 years: are there predictors for complications?
1Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, Mass 02115, USA.
Insights
Skull fractures (SF) and intracranial injuries (ICA) are common in young children with head trauma, especially those under 12 months. A combination of minor fall height, no neurological symptoms, and normal scalp exam identifies low-risk children.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Radiology
Background:
- Head trauma is a common reason for pediatric emergency department visits.
- Skull fractures (SF) and intracranial injuries (ICA) can occur in young children following head trauma.
- Predicting the presence of SF and ICA in infants and toddlers is challenging.
Purpose of the Study:
- Determine the incidence of SF and ICA in children younger than 2 years with head trauma.
- Evaluate historical features and physical findings for predicting injury type.
- Identify clinical criteria for selective radiographic imaging.
Main Methods:
- Retrospective medical record review of 278 children younger than 24 months.
- Case series design in a tertiary pediatric emergency department.
- Analysis of diagnoses, injury mechanisms, and clinical presentations.
Main Results:
- SF and ICA were diagnosed in 13% of children evaluated for head trauma.
- Children younger than 12 months had a significantly higher incidence (29%) compared to those aged 13-24 months (4%).
- Minor falls (≤3 ft) accounted for some injuries, often occurring in neurologically normal children with no concerning symptoms; scalp abnormalities were more common in injured children.
Conclusions:
- SF and ICA are frequent in young children with head trauma, with infants under 12 months at highest risk.
- Clinical signs and symptoms were poor predictors of SF/ICA.
- A low-risk group was identified: children with falls ≤3 ft, no neurological symptoms, and normal scalp examinations.
Objectives:
To determine the incidence of skull fracture (SF) and intracranial injury (ICA) among children younger than 2 years evaluated in a pediatric emergency department for head trauma; whether historical features and/or physical findings are predictive of injury type; and whether clinical criteria could allow a selective approach to radiographic imaging.
Design:
Retrospective medical record review.
Setting:
Tertiary pediatric emergency department.
Patients:
Case series of 278 children aged younger than 24 months evaluated for head injury.
Main Outcome Measures:
Presence of SF and/or ICA.
Results:
Diagnoses at discharge included 227 minor head injuries, 39 isolated SF, 9 ICA with SF, and 3 isolated ICA. Children younger than 12 months had the highest incidence of SF/ICA (29%) vs 4% for children aged 13 to 24 months (P<.001). Seven percent of complications from SF/ICA resulted from falls 3 ft (0.9 m) or less [corrected]. Incidence of behavioral change, loss of consciousness, emesis, and seizures did not differ significantly between those with minor head injuries and those with SF/ICA. Scalp abnormalities were more common in children with SF/ICA (P<.001). Sixty-two percent of children with isolated SF and 58% of children with ICA had no history of loss of consciousness, emesis, seizure, or behavioral change. Ninety-two percent of children with isolated SF and 75% of children with ICA had normal levels of consciousness and nonfocal neurologic examinations at diagnosis. Among children who fell 3 ft or less (0.9 m) [corrected] and had no loss of consciousness, emesis, seizure, behavioral change, or scalp abnormality, none of 31 (95% confidence interval [CI], 0-0.10) children younger than 24 months and none of 20 (95% CI, 0-0.15) children younger than 12 months had SF/ICA.
Conclusions:
Both SF and ICA are common in children younger than 2 years evaluated for head trauma. Children younger than 12 months are at highest risk. Injuries resulted from relatively minor falls and occurred in alert, neurologically normal children. Clinical signs and symptoms were insensitive predictors of SF/ICA; however, a grouping of features (fall < or = 3 ft [0.9 m], no history of neurologic symptoms, and normal scalp physical examination results) identified a subset of children at low risk for complications.