Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma

Abstract

Study objective: Infants with head trauma often have subtle findings suggestive of traumatic brain injury. Prediction rules for traumatic brain injury among children with minor head trauma have not been specifically evaluated in infants younger than 3 months old. We aimed to determine the risk of clinically important traumatic brain injuries, traumatic brain injuries on computed tomography (CT) images, and skull fractures in infants younger than 3 months of age who did and did not meet the age-specific Pediatric Emergency Care Applied Research Network (PECARN) low-risk criteria for children with minor blunt head trauma.Methods: We conducted a secondary analysis of infants <3 months old in the public use data set from PECARN's prospective observational study of children with minor blunt head trauma. Main outcomes included (1) clinically important traumatic brain injury, (2) traumatic brain injury on CT, and (3) skull fracture on CT.Results: Of 10,904 patients <2 years old, 1,081 (9.9%) with complete data were <3 months old; most (750/1081, 69.6%) sustained falls, and 633/1081 (58.6%) underwent CT scans. Of the 514/1081 (47.5%) infants who met the PECARN low-risk criteria, 1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%), 10/197 (5.1%, 2.5% to 9.1%), and 9/197 (4.6%, 2.1% to 8.5%) had clinically important traumatic brain injuries, traumatic brain injuries on CT, and skull fractures, respectively. Of 567 infants who did not meet the low-risk PECARN criteria, 24/567 (4.2%, 95% CI 2.7% to 6.2%), 94/436 (21.3%, 95% CI 17.6% to 25.5%), and 122/436 (28.0%, 95% CI 23.8% to 32.5%) had clinically important traumatic brain injuries, traumatic brain injuries, and skull fractures, respectively. Conclusion:The PECARN traumatic brain injury low-risk criteria accurately identified infants <3 months old at low risk of clinically important traumatic brain injuries. However, infants at low risk for clinically important traumatic brain injuries remained at risk for traumatic brain injuries on CT, suggesting the need for a cautious approach in these infants. [

Epidemiology Of Minor Blunt Head Trauma In Infants Younger Than 3 Months

“…Fall-related injuries are the most frequent cause of minor blunt head trauma in infants younger than 3 months old, as reported Abid et al (PECARN cohort) [15]. In our series, the most important mechanism of such falls was from furniture, followed by falls from a stroller.…”

“…Therefore, this criterion may not accurately de ne clinically signi cant injury in this age group, since physicians may be more cautious with these young patients and opt to prolong hospitalization merely because they are more di cult to assess clinically. On the other hand, the PECARN study [15] reports more TBI on CT due to the greater number of CT scans performed (58.6%), thus contrasting with the cohort of neonates [16] where only a few had CT scan (5.4%) and with data from our registry (10.0%). Clearly, a higher percentage of TBI can be identi ed if more CT scans are performed, although the key is whether it is necessary to expose more infants to radiation, as these lesions may have no clinical relevance.…”

“…As reported previously [15,16], most head injuries are benign, as between 2.3% and 4.3% and between 1.1% and 9.6% of infants with blunt head trauma present with ciTBI and TBI on CT, respectively. In our series, only 1 patient (0.3%) underwent neurosurgery (ciTBI), 12 (3.3%) were found to have a TBI on CT, and 20 (5.4%) sustained an isolated skull fracture.…”

“…Firstly, ciTBI was more frequent in the Australian and New Zealand cohort [16], primarily due to the outcome criteria of hospitalization for 2 or more days, without being very clear if the admission time was related to the persistence of symptoms. In the PECARN cohort [15], the authors could not ensure that some infants were hospitalized based on age alone. If we include patients admitted for more than 48 hours in our registry, the percentage of ciTBI rises to 2.2%; according to our data, however, prolonged admission in these patients was not related to ongoing signs or symptoms associated with head injury.…”

“…Blunt head trauma is a common injury among children and a major cause of pediatric emergency department (PED) visits [1]. Most of these injuries are minor [Glasgow Coma Scale (GCS) score [14][15] and few develop complications or require neurosurgical intervention [2,3]. Pediatric studies of minor blunt head trauma usually distinguish between children older and younger than 2 years [4].…”