Head trauma in children younger than 2 years: are there predictors for complications?
OBJECTIVE
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.


METHODS
Retrospective medical record review.


METHODS
Tertiary pediatric emergency department.


METHODS
Case series of 278 children aged younger than 24 months evaluated for head injury.


METHODS
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.
Gruskin
K D
KD
Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, Mass 02115, USA.
Schutzman
S A
SA
D000058:Accidental Falls / Q000706:statistics & numerical data; D001930:Brain Injuries / Q000150:complications / Q000000981:diagnostic imaging / Q000453:epidemiology*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007223:Infant; D016015:Logistic Models; D012189:Retrospective Studies; D012307:Risk Factors; D012535:Scalp / Q000293:injuries; D012680:Sensitivity and Specificity; D012887:Skull Fractures / Q000150:complications / Q000000981:diagnostic imaging / Q000453:epidemiology*; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014474:Unconsciousness / Q000453:epidemiology