Initial Neurologic Presentation in Young Children Sustaining Inflicted and Unintentional Fatal Head Injuries

Abstract

ABSTRACT. Background. It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification.Objective. To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury.Design/Methods. Data on children <48 months of age who sustained a fatal head injury from 1986 -2002 were extracted from the Pennsylvania Trauma Outcomes Study. Only those with external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs) with a recorded Glasgow Coma Scale (GCS) on admission were included. The GCS was compared across mechanisms and age groups (0 -11, 12-23, 24 -35, and 36 -47 months).Results. Of the 314 fatally injured children, 37% sustained inflicted injury, 13% sustained a fall, and 49% sustained an MVC. At admission, 6.8% of all children had a GCS score of >7, and 1.9% presented with a GCS score of >12 (lucid). The incidence of admission a GCS score of >7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of >7 than those injured in MVCs (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of >7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >24 months old, a GCS score of >7 did not differ by mechanism. In contrast, in those <24 months old, children who died as a result of inflicted injury were >10 times more likely to have a GCS score of >7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9).Conclusions. The data suggest an age-and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: >12) before death. Furthermore, children <48 months old sustaining inflicted injury are 3 times more likely to be assessed with a moderate GCS score

Shaken baby syndrome: the quest for evidence

“…Whereas axonal tearing results in immediate loss of function and a lucid interval is unlikely, brain swelling takes place with a speed and severity of huge individual variation, which may allow a lucid interval or a period in which cerebral function is gradually impaired. 25,26 This is particularly likely to occur in infants whose skulls still have unfused sutures, and are, therefore, distensible. 27 The alternative hypothesis Geddes had observed that infants with NAHI commonly have a thin bilateral film of subdural blood, sometimes so small that it is missed on scans.…”

Injuries Among Infants Treated in Emergency Departments in the United States, 2001–2004

“…8 Detailed studies of unintentional injuries among infants have focused largely on specific products (eg, bathtub seats, 9 strollers/shopping carts, 10,11 infant carriers, 12 or high chairs 13 ). Other work has focused on a particular cause of injury (eg, falls 14 or burns 15 ) or a particular diagnosis (eg, head injuries 16,17 ).…”

Evaluation of pediatric head trauma in the emergency department

“…The large majority of children had minor head trauma with asymptomatic presentation or with a history of only temporary loss of consciousness. This study emphasizes the practice that CT is rarely necessary in these children, but -and most importantly -only after careful clinical evaluation and a knowledge of the risk factors for intracranial injury [2,5,6,8].…”