Pediatric short-distance household falls: biomechanics and associated injury severity

A 10-Year National Analysis of Pediatric Elbow Fractures

Elbow fractures comprise 15% of all fractures in children. Our study identifies risk factors and consumer products that contribute to pediatric elbow fractures. The National Electronic Injury Surveillance System was used to collect demographic and consumer product information between 2010 and 2019 for patients younger than 17 years who presented to the emergency department with elbow fractures. Of the 458,433 elbow fractures, the average age of the patients was 7.4 ± 4.1 years and 55.6% were male children. The most common consumer product was sports and recreation equipment, followed by home furnishings. Male patients (P < .0001) and patients 8 years and older (79.2% vs 51.1%, P < .0001) experienced significantly greater rates of injury with sports and recreation equipment. This study evaluates the products associated with pediatric elbow fractures and highlights the importance of safe sports and recreation equipment use and the role of parental counseling in preventing falls from furniture.

Head biomechanics of video recorded falls involving children in a childcare setting

The objective of this study was to characterize head biomechanics of video-recorded falls involving young children in a licensed childcare setting. Children 12 to < 36 months of age were observed using video monitoring during daily activities in a childcare setting (in classrooms and outdoor playground) to capture fall events. Sensors (SIM G) incorporated into headbands worn by the children were used to obtain head accelerations and velocities during falls. The SIM G device was activated when linear acceleration was ≥ 12 g. 174 video-recorded falls activated the SIM G device; these falls involved 31 children (mean age = 21.6 months ± 5.6 SD). Fall heights ranged from 0.1 to 1.2 m. Across falls, max linear head acceleration was 50.2 g, max rotational head acceleration was 5388 rad/s², max linear head velocity was 3.8 m/s and max rotational head velocity was 21.6 rad/s. Falls with head impact had significantly higher biomechanical measures. There was no correlation between head acceleration and fall height. No serious injuries resulted from falls—only 1 child had a minor injury. In conclusion, wearable sensors enabled characterization of head biomechanics during video-recorded falls involving young children in a childcare setting. Falls in this setting did not result in serious injury.

Overturned abusive head trauma and shaken baby syndrome convictions in the United States: Prevalence, legal basis, and medical evidence

BACKGROUND

Media reports and the Innocence Network assert that wrongful Abusive Head Trauma (AHT)/Shaken Baby Syndrome (SBS) convictions pervade the United States (U.S.) criminal justice system. Yet, no empirical evaluation of overturned AHT/SBS convictions has been conducted.

OBJECTIVE

To evaluate the prevalence, legal basis, and characteristics of appellate rulings of AHT/SBS convictions.

PARTICIPANTS AND SETTING

U.S. appellate cases in a legal database, Westlaw.

METHODS

Retrospective review of AHT/SBS convictions that had appellate rulings from January 2008 through December 2018. Multiple search terms ensured all potential AHT/SBS cases were included. A mixed-methods analysis was conducted on overturned AHT/SBS convictions.

RESULTS

We identified a total of 1431 unique AHT/SBS criminal convictions that had appellate rulings since 2008. Of those, 49 convictions (3%) were overturned, and 1382 (97%) were affirmed/upheld. Of those overturned, 20 cases (1% overall) were overturned on medical evidence-related grounds. The most common themes from the medical evidence-related reversals were controversy over the AHT/SBS diagnosis (n = 12) and accidental injury mechanism (n = 11). After being overturned on appeal, upon retrial, 42% of defendants either re-plead guilty to or were convicted again of the same offense.

CONCLUSION(S)

AHT/SBS convictions are rarely overturned on medical evidence-related grounds. When overturned, medical evidence-related themes seldom reflect new scientific or clinical discoveries, but rather are alternative or differing medical opinions from those offered at the original trial. Our data tends to support the concerns of other authors regarding irresponsible communication of medical information in AHT/SBS cases.

The Effect of Impact Angle and Fall Height on Skull Fracture Patterns in Infants

Skull fracture is a common finding for both accidental and abusive head trauma in infants and young children, and may provide important clues as to the energy and directionality of the event leading to the skull fracture. However, little is understood regarding the mechanics of skull fracture in the pediatric skull, and how accidental fall parameters contribute to skull fracture patterns. The objectives of this research were to utilize a newly developed linear elastic fracture mechanics finite element model of infant skull fracture to investigate the effect of impact angle and fall height on the predictions of skull fracture patterns in infants. Nine impact angles of right parietal bone impacts were simulated from three different heights onto a rigid plate. The average ± standard deviation of the distance between the impact location and fracture initiation site was 8.0 ± 5.9 mm. Impact angle significantly affected the fracture initiation site (p < 0.0001) and orientation (p < 0.0001). A 15 deg variation in impact angle changed the initiation site up to 47 mm. The orientation of the fracture pattern was dependent on the impact location and ran either horizontal or vertical toward the ossification center of the bone. Fall height significantly affected the fracture length (p = 0.0356). Specifically, at the same impact angle, a 0.3 m increase in fall height increased the skull fracture length by 21.39 ± 34.26 mm. These data indicate that environmental variability needs to be carefully considered when evaluating infant skull fracture patterns from low-height falls.

Implications of Increased Weight Status for the Occurrence of Fall-Induced Intracranial Hemorrhage in Children Aged 4 Years or Younger

OBJECTIVES

The aim of this study was to investigate the association between increased weight status (IWS), a weight for age/sex at greater than the 95th percentile, and fall-induced intracranial hemorrhage (ICH) in children aged 4 years or younger.

METHODS

In 7072 children aged 4 years or younger with head injury who visited a tertiary care hospital emergency department in Korea from 2013 through 2015, the presence of fall-induced ICH was reviewed. The association between IWS and ICH was investigated by multivariable logistic regression. We retrospectively validated the Pediatric Emergency Care Applied Research Network rule alone and in combination with IWS for predicting ICH.

RESULTS

Of 7072 children, 547 (7.7%) underwent computed tomography, of whom 451 (6.4%) were enrolled. Of these, 41 (9.1%; estimated event rate, 0.6%) had ICHs, and 26 (5.8%) had IWS. Increased weight status was more common in the children with ICH (P = 0.023). The association between IWS and ICH remained significant after adjustment (odds ratio, 5.24; 95% confidence interval [CI], 1.49-18.46; P = 0.010). The validation of the rule in combination with IWS showed no significant increases in a sensitivity (92.7% [95% CI, 80.1%-98.5%] to 95.7% [95% CI, 83.5%-99.4%]) and negative predictive value (98.2% [95% CI, 94.7%-99.4%] to 98.8% [95% CI, 95.4%-99.8%]).

CONCLUSIONS

Increased weight status is associated with fall-induced ICH in children aged 4 years or younger. Information on weight status could be potentially helpful in predicting ICH in young children with fall-induced head injury.

Injury Biomechanics of a Child’s Head: Problems, Challenges and Possibilities with a New aHEAD Finite Element Model

Traumatic brain injury (TBI) is a major public health problem among children. The predominant causes of TBI in young children are motor vehicle accidents, firearm incidents, falls, and child abuse. The limitation of in vivo studies on the human brain has made the finite element modelling an important tool to study brain injury. Numerical models based on the finite element approach can provide valuable data on biomechanics of brain tissues and help explain many pathological conditions. This work reviews the existing numerical models of a child’s head. However, the existing literature is very limited in reporting proper geometric representation of a small child’s head. Therefore, an advanced 2-year-old child’s head model, named aHEAD 2yo (aHEAD: advanced Head models for safety Enhancement And medical Development), has been developed, which advances the state-of-the-art. The model is one of the first published in the literature, which entirely consists of hexahedral elements for three-dimensional (3D) structures of the head, such as the cerebellum, skull, and cerebrum with detailed geometry of gyri and sulci. It includes cerebrospinal fluid as Smoothed Particle Hydrodynamics (SPH) and a detailed model of pressurized bringing veins. Moreover, the presented review of the literature showed that material models for children are now one of the major limitations. There is also no unambiguous opinion as to the use of separate materials for gray and white matter. Thus, this work examines the impact of various material models for the brain on the biomechanical response of the brain tissues during the mechanical loading described by Hardy et al. The study compares the inhomogeneous models with the separation of gray and white matter against the homogeneous models, i.e., without the gray/white matter separation. The developed model along with its verification aims to establish a further benchmark in finite element head modelling for children and can potentially provide new insights into injury mechanisms.

Incidence and circumstances of pediatric fall-related injuries: Which fall variables matter?

BACKGROUND

This study's purpose was to determine if age, fall height, fall mechanism, landing surface, and landing position are associated with injury severity and hospital outcomes among pediatric fall patients.

METHODS

A retrospective review was conducted of patients aged ≤18 years who sustained fall-related injuries admitted to an American College of Surgeons verified Level 1 trauma center from January 1, 2006 through December 31, 2015.

RESULTS

Patient age, fall mechanism, landing position, and landing surface were associated with the need for surgery. Patient age, fall mechanism, and landing position were also associated with intensive care unit admissions. Fall mechanism was the only variable associated with injury severity. No variables were associated with the need for mechanical ventilation or mortality.

CONCLUSIONS

Patient age, fall mechanism, landing surface, and landing position need to be considered with regard to injury severity and patient outcomes among pediatric fall patients.

Improved safety standards are needed to better protect younger children at playgrounds

Playground-related traumatic brain injuries (TBIs) in children remain a considerable problem world-wide and current safety standards are being questioned due to historical reasons where the injury thresholds had been perpetuated from automobile industry. Here we investigated head injury mechanisms due to falls on playgrounds using a previously developed and validated age-scalable and positionable whole body child model impacted at front, back and side of the head simulating head-first falls from 1.59 meters (m). The results show that a playground material passing the current testing standards (HIC < 1000 and resultant linear acceleration <200 g) resulted in maximum strain in the brain higher than known injury thresholds, thus not offering sufficient protection especially for younger children. The analysis highlights the age dependence of head injuries in children due to playground falls and the youngest have a higher risk of brain injury and skull fracture. Further, the results provide the first biomechanical evidence guiding age-dependent injury thresholds for playground testing standards. The results also have direct implications for novel designs of playground materials for a better protection of children from TBIs. Only making the playground material thicker and more compliant is not sufficient. This study represents the first initiative of using full body human body models of children as a new tool to improve playground testing standards and to better protect the children at playgrounds.

Age, Ethnicity, and Socioeconomic Factors Impacting Infant and Toddler Fall-Related Trauma

OBJECTIVE

To characterize trauma-related falls in infants and toddlers aged 0 to 3 years over a 4-year period and develop a risk stratification model of causes of fall injuries.

METHODS

Data on falls of 0 to 3 year olds from 2009 to 2012 were identified from a Jerusalem tertiary hospital trauma registry (N = 422) and the National Trauma Registry of Israel (N = 4,131).

RESULTS

Almost half of falls occurred during the first year of life, and 57% of the children were Jewish. The majority of the children lived in low socioeconomic environments, both in the Jewish (59.2%) and Arab (97.6%) samples. Most (74%) of the falls resulted in head injury. A classification and regression tree analysis indicated that falls from furniture were the leading cause of injury in 0 to 12 month olds (estimated probability of 37.9%), whereas slipping is the leading cause in 13 to 36 month olds (estimated probability of 38.4%). Age and ethnicity emerged as the leading predictors of the nature of a fall; Injury Severity Score and the child's sex were secondary. Compared with the national data, Jerusalem children had a higher incidence of falls from buildings (9.3%; 2.4%), a higher moderate-severe Injury Severity Score (>16), a higher incidence of traumatic brain injury, and a longer hospital length of stay (P < 0.001).

CONCLUSIONS

The leading determinants of fall injuries in children below the age of 3 years are age, ethnicity, and low socioeconomic status. Future outreach community interventions should target these risk groups and be tailored to their defining characteristics.

Femur loading in feet-first fall experiments using an anthropomorphic test device

BACKGROUND

Femur fractures are a common orthopedic injury in young children. Falls account for a large portion of accidental femur fractures in young children, but there is also a high prevalence of femur fractures in child abuse, with falls often provided as false histories. Objective information regarding fracture potential in short distance fall scenarios may aid in assessing whether a child's injuries are the result of abuse or an accidental fall. Knowledge of femur loading is the first step towards understanding likelihood of fracture in a fall.

OBJECTIVE

Characterize femur loading during feet-first free falls using a surrogate representing a 12-month-old child.

METHODS

The femur and hip joint of a surrogate representing a 12-month-old were modified to improve biofidelity and measure femur loading; 6-axis load cells were integrated into the proximal and distal femur. Femur modification was based upon CT imaging of cadaveric femurs in children 10-14 months of age. Using the modified 12-month-old surrogate, feet-first free falls from 69 cm and 119 cm heights onto padded carpet and linoleum were conducted to assess fall dynamics and determine femur loading. Femur compression, bending moment, shear and torsional moment were measured for each fall.

RESULTS

Fall dynamics differed across fall heights, but did not substantially differ by impact surface type. Significant differences were found in all loading conditions across fall heights, while only compression and bending loads differed between carpet and linoleum surfaces. Maximum compression, bending, torsion and shear occurred in 119 cm falls and were 572 N, 23 N-m, 11 N-m and 281 N, respectively.

CONCLUSIONS

Fall dynamics play an important role in the biomechanical assessment of falls. Fall height was found to influence both fall dynamics and femur loading, while impact surface affected only compression and bending in feet-first falls; fall dynamics did not differ across carpet and linoleum. Improved pediatric thresholds are necessary to predict likelihood of fracture, but morphologically accurate representation of the lower extremity, along with accurate characterization of loading in falls are a crucial first step.

A proclaimed accidental fall of an infant-an experimental case reconstruction study

The differentiation between a non-accidental injury and injuries resulting from accidents, such as falls to the ground or onto various objects, is a challenge not only for forensic experts but also for all clinicians caring for children. The forensic-biomechanical analysis of accidents in infants aims at the assessment of the loading characteristics based on the reconstruction of the particular incident. It includes an evidence-based analytical comparison between the actual injuries presented and the injuries that should be expected as a result of the proclaimed accident. With the help of kinematical and dynamical parameters of the described actions and the resulting loading situations, the forensic-biomechanical analysis can assess the plausibility of the proclaimed course of the event and thus contribute to the differentiation between accidental and non-accidental injuries. The quality of such a forensic-biomechanical expert opinion depends on the accuracy and quantity of available data regarding biomechanical tolerance of tissues, organs, and body parts. Case-specific measurements can contribute significantly to the insight of the kinematics and dynamics of the proclaimed event, its feasibility, etc. The present article demonstrates, based on one case report, the potential as well as the limits of such an analysis of proclaimed accidental fall injuries.

Injury from falls in infants under one year

AIM

Falls in infants are a common cause of injury. Compared to older children, infants under age one are likely to have distinctive causation and injury patterns, as they are pre-mobile or have limited independent mobility and falls are more directly the responsibility of the care giver. There is little known about the mechanistic factors, predictors of injury and injury patterns in this age group.

METHODS

We conducted a retrospective review of infants under age one who presented after a fall to a paediatric trauma centre in Sydney, Australia. Circumstances and mechanisms of the fall, injury patterns, burden of investigations and outcomes were analysed.

RESULTS

Over a 3-year period (2011-2013), 916 infants presented following a fall. One hundred and six (11.6%) were admitted and there was one death. Head injury was the most common reason for admission (85%). While there were severe and critical head injuries (Abbreviated Injury Scale 4-5) these were infrequent (2% of presentations). All admitted cases involved a short distance fall. Patients dropped by others were three times more likely to be admitted than infants presenting following other fall types (95% CI 1.9-4.8). Compared to other mechanisms, patients who fell from furniture had significantly longer hospital stays.

CONCLUSIONS

Fall mechanisms involving infants being dropped by adults, and falls from beds or couches carry the highest clinical burden. These mechanisms should be targets for injury prevention and inform the design of safe equipment and environments for babies.

Pediatric skull fractures and intracranial injuries

The determination of plausibility of an injury arising from a fall leading to head trauma is a great challenge especially in young children. The present review is aimed to discuss important developments in the filed of head trauma cases especially in children. We explored various studies pertaining to head trauma injuries in children by exploring mainly PubMed, Google scholar and some library periodicals available in our library. Studies in the recent past explored the head injuries as a result of a low height fall. However, there are great amount of difficulties in assessment of height with certainty that caused head injuries like skull fracture or intracranial injury. Biomechanical thresholds have been estimated for young children for injuries such as skull fracture, but they have not been assessed against the injuries observed in a clinical setting. So, this review discusses current aspects of pediatric head injuries ranging from a minor head injury to a skull fracture. The present review concludes that recording full details of cause of head trauma such as fall height is essential for proper treatment planning and efficient management.

Biomechanical characteristics of head injuries from falls in children younger than 48 months

BACKGROUND

A fall-height threshold is important when evaluating the likelihood of structural head injury or abusive head trauma. This study investigates witnessed falls to correlate the fall characteristics with the extent of injury.

METHOD

Case-control study of children aged ≤48 months who attended one hospital following a fall from <3 m (10 ft), comparing cases who sustained a skull fracture or intracranial injury (ICI) with controls, who had minor head injuries. Characteristics included: the mechanism of injury, surface of impact, site of impact to the head and fall height.

RESULTS

Forty-seven children had a skull fracture or ICI, while 416 children had minor head injuries. The mean fall height for minor head injuries was significantly lower than that causing skull fracture/ICI (p<0.001). No skull fracture/ICI was recorded in children who fell <0.6 m (2 ft), based on the height of the head centre of gravity. Skull fractures/ICI were more likely in children aged ≤12 months (p<0.001) from impacts to the temporal/parietal or occipital region (p<0.001), impacts onto wood (p=0.004) and falls from a carer's arms, particularly when on stairs (p<0.001). No significant difference was reported between the mean fall heights of children who had a simple skull fracture (n=17) versus those who had a complex fracture or ICI (n=30).

CONCLUSIONS

An infant is more likely to sustain a skull fracture/ICI from a fall above a 0.6 m (2 ft) threshold, based on the height of the head centre of gravity, or with a parietal/temporal or occipital impact. These variables should be recorded when evaluating the likelihood of skull fracture/ICI.

Head injury from falls in children younger than 6 years of age

The risk of serious head injury (HI) from a fall in a young child is ill defined. The relationship between the object fallen from and prevalence of intracranial injury (ICI) or skull fracture is described.

METHOD

Cross-sectional study of HIs from falls in children (<6 years) admitted to UK hospitals, analysed according to the object fallen from and associated Glasgow Coma Score (GCS) or alert, voice, pain, unresponsive (AVPU) and CT scan results.

RESULTS

Of 1775 cases ascertained (median age 18 months, 54.7% boys), 87% (1552) had a GCS=15/AVPU=alert. 19.3% (342) had a CT scan: 32% (110/342) were abnormal; equivalent to 5.9% of the overall population, 16.9% (58) had isolated skull fractures and 13.7% (47) had ICI (49% (23/47) had an associated skull fracture). The prevalence of ICI increased with neurological compromise; however, 12% of children with a GCS=15/AVPU=alert had ICI. When compared to falls from standing, falls from a person's arms (233 children (mean age 1 year)) had a significant relative OR for a skull fracture/ICI of 6.94 (95% CI 3.54 to 13.6), falls from a building (eg, window or attic) (mean age 3 years) OR 6.84 (95% CI 2.65 to 17.6) and from an infant or child product (mean age 21 months) OR 2.75 (95% CI 1.36 to 5.65).

CONCLUSIONS

Most HIs from a fall in these children admitted to hospital were minor. Infants, dropped from a carer's arms, those who fell from infant products, a window, wall or from an attic had the greatest chance of ICI or skull fracture. These data inform prevention and the assessment of the likelihood of serious injury when the object fallen from is known.

Biofidelic neck influences head kinematics of parietal and occipital impacts following short falls in infants

Falls are a major cause of traumatic head injury in children. Understanding head kinematics during low height falls is essential for evaluating injury risk and designing mitigating strategies. Typically, these measurements are made with commercial anthropomorphic infant surrogates, but these surrogates are designed based on adult biomechanical data. In this study, we improve upon the state-of-the-art anthropomorphic testing devices by incorporating new infant cadaver neck bending and tensile data. We then measure head kinematics following head-first falls onto 4 impact surfaces from 3 fall heights with occipital and parietal head impact locations. The biofidelic skull compliance and neck properties of the improved infant surrogate significantly influenced the measured kinematic loads, decreasing the measured impact force and peak angular accelerations, lowering the expected injury risk. Occipital and parietal impacts exhibited distinct kinematic responses in primary head rotation direction and the magnitude of the rotational velocities and accelerations, with larger angular velocities as the head rebounded after occipital impacts. Further evaluations of injury risk due to short falls should take into account the impact surface and head impact location, in addition to the fall height.

Understanding forearm fractures in young children: Abuse or not abuse?

This retrospective study describes the characteristics and mechanisms of forearm fractures in children <18 months adding to the evidence-base about forearm fractures. It also examines which features of forearm fractures in young children may help discriminate between abusive and noninflicted injuries. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse versus not abuse). The 135 included patients sustained 216 forearm fractures. Most were buckle (57%) or transverse (26%). Child protection teams evaluated 47 (35%) of the patients and diagnosed 11 (23%) as having fractures caused by abuse. Children with abusive versus non-inflicted injuries had significant differences in age (median age 7 versus 12 months), race, and presence of additional injuries. Children with abusive forearm fractures often presented without an explanation or a changing history for the injury. Children with non-inflicted forearm fractures often presented after a fall. No particular type of forearm fracture was specific for child abuse. Any forearm fracture in a young child should be evaluated with special attention to the details of the history and the presence of other injuries. Young age, additional injuries, and an absent or inconsistent explanation should increase concern that the fracture was caused by child abuse.

Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review

Purpose

Glutaric aciduria type 1 (GA1) is a rare metabolic disorder of glutaryl-CoA-dehydrogenase enzyme deficiency. Children with GA1 are reported to be predisposed to subdural hematoma (SDH) development due to stretching of cortical veins secondary to cerebral atrophy and expansion of CSF spaces. Therefore, GA1 testing is part of the routine work-up in abusive head trauma (AHT). This systematic review addresses the coexistence of GA1 and SDH and the validity of GA1 in the differential diagnosis of AHT.

Methods

A systematic literature review, with language restriction, of papers published before 1 Jan 2015, was performed using Pubmed, PsychINFO, and Embase. Inclusion criteria were reported SDHs, hygromas or effusions in GA1 patients up to 18 years of age. Of 1599 publications, 20 publications were included for analysis.

Results

In total 20 cases, 14 boys and 6 girls, were included. In eight cases (40 %) a child abuse work-up was performed, which was negative in all cases. Clinical history revealed the presence of trauma in eight cases (40 %). In only one case neuroradiology revealed no abnormalities related to GA1 according to the authors, although on evaluation we could not exclude AHT.

Conclusion

From this systematic review we conclude that SDHs in 19/20 children with GA1 are accompanied by other brain abnormalities specific for GA1. One case with doubtful circumstances was the exception to this rule.

Pediatric bed fall computer simulation model: parametric sensitivity analysis

Falls from beds and other household furniture are common scenarios that may result in injury and may also be stated to conceal child abuse. Knowledge of the biomechanics associated with short-distance falls may aid clinicians in distinguishing between abusive and accidental injuries. In this study, a validated bed fall computer simulation model of an anthropomorphic test device representing a 12-month-old child was used to investigate the effect of altering fall environment parameters (fall height, impact surface stiffness, initial force used to initiate the fall) and child surrogate parameters (overall mass, head stiffness, neck stiffness, stiffness for other body segments) on fall dynamics and outcomes related to injury potential. The sensitivity of head and neck injury outcome measures to model parameters was determined. Parameters associated with the greatest sensitivity values (fall height, initiating force, and surrogate mass) altered fall dynamics and impact orientation. This suggests that fall dynamics and impact orientation play a key role in head and neck injury potential. With the exception of surrogate mass, injury outcome measures tended to be more sensitive to changes in environmental parameters (bed height, impact surface stiffness, initiating force) than surrogate parameters (head stiffness, neck stiffness, body segment stiffness).

Patterns of accidental craniocerebral injury occurring in early childhood

OBJECTIVE

To describe the range of intracranial injuries encountered in 0-2-year-olds in cases of accidental head injury where the mechanism of trauma was well characterised and to assess the clinical consequences.

DESIGN

A retrospective review of imaging and clinical data.

SETTING

Two tertiary paediatric referral centres.

PATIENTS

All children aged 0-2 undergoing cranial CT as indicated by National Institute for Health and Clinical Excellence guidance for head injury from 2006 to 2011. After exclusion criteria, 149 patients were included.

MAIN OUTCOME MEASURES

Rates of skull fracture, intracranial haemorrhage, parenchymal injuries and ischaemic change per type of mechanism of injury. Rates of neurological sequelae on follow-up.

RESULTS

Skull fractures were demonstrated in 54 (36%) patients of whom 17 (11%) had thin underlying subdural haemorrhage (SDH). Extradural haemorrhage complicated one fracture and two cases of isolated subdural haematomas were seen without skull fracture. Radiologically evident brain parenchymal injuries were present in three patients, all with mechanisms of injury involving high levels of force; severe neurological sequelae were only seen in one patient, who had diffuse hypoxic-ischaemic damage at presentation and whose (accidental) mechanism of injury involved extensive acceleration/deceleration/translational forces.

CONCLUSIONS

Skull fractures and focal SDH are relatively common following minor trauma in this age group but in the vast majority of cases there are no long-term neurological sequelae. Conversely, diffuse brain injury with severe subsequent neurological impairment was only seen in patients with a correspondingly severe mechanism of injury.

Trends in hospitalization rates and severity of injuries from abuse in young children, 1997-2009

OBJECTIVES

To examine trends in incidence of hospitalizations for injury from abuse in young children from 1997 through 2009 and to examine injury severity trends.

METHODS

Cases were identified in the National Inpatient Sample database of the Healthcare Cost and Utilization Project by using International Classification of Diseases, Ninth Revision, Clinical Modification codes for child maltreatment and external cause of injury for assault in children aged 0 through 3 years. Incidence was calculated by age, gender, and region. Trends in incidence of hospitalization and injury severity were calculated over time.

RESULTS

Hospitalization rates for injury from abuse showed no significant change over the study period, ranging from a low of 2.10 per 10, 000 children in 1998 to a high of 3.01 per 10, 000 children in 2005 (P = .755). Children aged <1 had significantly higher hospitalization rates for injury from abuse (6.01 vs 1.12, P <.001) and higher mean injury severity scores compared with children aged 1 to 3 years (12.50, SD = 0.14 vs 8.56, SD = 0.21, P <.001). Injury severity scores increased significantly over the study period.

CONCLUSIONS

No significant change in hospitalization rates for injury from abuse among young children was observed from 1997 to 2009. These results coincide with other reports of stable or modestly increasing rates of serious physical abuse or death in young children but not with reports from child welfare data showing declines in physical abuse during the same period. Diverse sources of data may provide important complementary methods to track child abuse.

[Home falls in infants before walking acquisition]

Minor head trauma is frequent among infants and leads to numerous visits to emergency departments for neurological assessment to evaluate the value of cerebral CT scan with the risk for traumatic brain injuries (TBI).

OBJECTIVES

To analyze the epidemiological characteristics of nonwalking infants admitted after falling at home and to analyze associated factors for skull fractures and TBI.

PATIENTS AND METHODS

Between January 2007 and December 2011, all children aged 9 months or younger and admitted after a home fall to the pediatric emergency unit of a tertiary children's hospital were included. The data collected were age, sex, weight and height, body mass index; geographic origin, referral or direct admission, mode of transportation; month, day and time of admission; causes of the fall, alleged fall height, presence of an eyewitness, type of landing surface; Glasgow Coma Scale (GCS) score, application of the head trauma protocol, location and type of injuries, cerebral CT scan results, length of hospital stay, progression, and neglect or abuse situations.

RESULTS

DESCRIPTIVE ANALYSIS: within the study period, 1910 infants were included. Fifty-four percent of children were aged less than 6 months with a slight male prevalence (52%). Falls from parental bed and infant carriers accounted for the most frequent fall circumstances. GCS score on admission was equal to 14 or 15 in 99% of cases. A cerebral CT scan was performed in 34% of children and detected 104 skull fractures and 55 TBI. Infants aged less than 1 month had the highest rate of TBI (8.5%). Eleven percent of patients were hospitalized. A situation of abuse was identified in 51 infants (3%). UNIVARIATE ANALYSIS: Male children and infants aged less than 3 months had a higher risk of skull fractures (P = 0.03 and P = 0.0003, respectively). In the TBI group, children were younger (3.8 ± 2.6 months versus 5.4 ± 2.5 months, P < 0.0001), fell from a higher height (90.2 ± 29.5 cm versus 70.9 ± 28.7 cm, P < 0.0001), were more often admitted on a weekend or day off, and had more skull fractures (54% versus 6%, P < 0.001). MULTIVARIATE ANALYSIS: all variables showing P < 0.2 in the univariate analysis were entered into the model. In the final model, three variables continued to be associated with a risk of TBI: being referred by a physician (OR 4.6 [2.2-9.6], P < 0.0001), being younger than 3 months old (OR 3.1 [1.7-5.7], P = 0.0002), falling from a height greater than 90 cm (OR 3.1 [1.7-5.6], P = 0.0002).

COMMENTS

Before walking acquisition, children are particularly vulnerable and have the highest rate of TBI after a vertical fall. In this age group, the rate of abuse is also higher. Given this double risk, numerous cerebral CT scans are performed (35-40% of the target population). This protocol, however, leads to a low proportion of detected TBI (<10%) compared to the high number of CT scans and an additional risk of irradiation.

CONCLUSION

As no validated predictive score exists and pending the contribution of the S-100B protein assay, the identification of infants at high risk for TBI and justifying neuroimaging is based on the search for predisposing factors and circumstances.

Smoking and medication during pregnancy predict repeated unintentional injuries in early childhood but not single unintentional injuries

This study investigates prospectively the development of single and repeated unintentional injuries from birth to 42 months in a random population sample of new-born children in Quebec (Canada) (N = 1,770). The outcome measures are single unintentional injuries (SUI) and repeated unintentional injuries (RUI). Results showed that the risk factors for SUI differed from the risk factors for RUI. SUI was predicted by mother's antisocial behavior during high school (OR = 1.72) and mother's age at first birth (OR = 1.82) with children from older mothers at higher likelihood of SUI. Also, boys (OR = 1.36) and hyperactive children (OR = 1.06) were at increased risk of SUI. RUI was predicted by maternal smoking during pregnancy (OR = 1.68), medication on prescription (OR = 1.53) and medication without prescription (OR = 1.54). Boys (OR = 2.01), children with a difficult temperament (OR = 1.13) and those with single mothers had higher rates of RUI (OR = 2.05). Maternal perception of impact (OR = 1.15) and maternal feelings of self-efficacy (OR = 0.87; marginally significant) were also associated with RUI. These results show that maternal and child risk factors identified during pregnancy and just after birth can predict SUI as well as RUI in early childhood. However, the only common risk factor for SUI and RUI is the child's sex, with boys being at higher risk than girls. Implications of these findings and suggestions for prevention are discussed.

Falls in children birth to 5 years: different mechanisms lead to different injuries

BACKGROUND

Falls are the most common cause of injury-related hospitalization in children younger than 5 years old. Most anticipatory guidance surrounding falls is around falls from windows or stairs; however, falls from furniture also are important causes of morbidity. The purpose of this study was to compare the number of children injured, ages of injured children, and injuries sustained in falls from furniture and falls from stairs in hospitalized children younger than 5 years.

METHODS

All records of individuals from 0 year through 4 years, hospitalized at our institution for a fall from furniture or stairs between January 1, 1996, and December 31, 2006, were retrospectively reviewed. A standard data set was abstracted from each chart. Frequencies were used to characterize the study population. χ and t tests were used to determine differences between groups.

RESULTS

A total of 171 patients were hospitalized for falls from stairs and 318 for falls from furniture. There were no differences between the groups with regard to age, sex, race, type of insurance, length of stay, Injury Severity Score, or total cost. The most common pieces of furniture from which children fell were beds (33.0%), couches (18.9%), and chairs (17.9%). Children who fell from stairs were significantly more likely to have injuries to their head (64.3% vs. 38.1%); those that fell from furniture were more likely to sustain arm injuries (33.3% vs. 9.9%). There were significantly more skull fractures in those that fell from stairs (39.8% vs. 20.1%) and humerus fractures in those that fell from furniture (30.8% vs. 9.4%) (p < 0.001). Falls from furniture increased during the study period, while falls from stairs fell; the difference was not statistically significant, however.

CONCLUSION

Falls from furniture and stairs are important causes of morbidity in children. More children were hospitalized for falls from furniture than from stairs. Falls down stairs are decreasing while falls off furniture are increasing. More anticipatory guidance should be developed and given to families regarding falls from furniture to help prevent these injuries.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Assessment of injury potential in pediatric bed fall experiments using an anthropomorphic test device

Falls from beds and other furniture are common scenarios provided to conceal child abuse but are also common occurrences in young children. A better understanding of injury potential in short-distance falls could aid clinicians in distinguishing abusive from accidental injuries. Therefore, this study investigated biomechanical outcomes related to injury potential in falls from beds and other horizontal surfaces using an anthropomorphic test device representing a 12-month-old child. The potential for head, neck, and extremity injuries and differences due to varying impact surfaces were examined. Linoleum over concrete was associated with the greatest potential for head and neck injury compared to other evaluated surfaces (linoleum over wood, carpet, wood, playground foam). The potential for severe head and extremity injuries was low for most evaluated surfaces. However, results suggest that concussion and humerus fracture may be possible in these falls. More serious head injuries may be possible particularly for falls onto linoleum over concrete. Neck injury potential in pediatric falls should be studied further as limitations in ATD biofidelity and neck injury thresholds based solely on sagittal plane motion reduce accuracy in pediatric neck injury assessment. In future studies, limitations in ATD biofidelity and pediatric injury thresholds should be addressed to improve accuracy in injury potential assessments for pediatric short-distance falls. Additionally, varying initial conditions or pre-fall positioning should be examined for their influence on injury potential.

Paediatric bed fall computer simulation model development and validation

Falls from beds and other household furniture are common scenarios stated to conceal child abuse. Knowledge of the biomechanics associated with short-distance falls may aid clinicians in distinguishing between abusive and accidental injuries. Computer simulation is a useful tool to investigate injury-producing events and to study the effect of altering event parameters on injury risk. In this study, a paediatric bed fall computer simulation model was developed and validated. The simulation was created using Mathematical Dynamic Modeling(®) software with a child restraint air bag interaction (CRABI) 12-month-old anthropomorphic test device (ATD) representing the fall victim. The model was validated using data from physical fall experiments of the same scenario with an instrumented CRABI ATD. Validation was conducted using both observational and statistical comparisons. Future parametric sensitivity studies using this model will lead to an improved understanding of relationships between child (fall victim) parameters, fall environment parameters and injury potential.

Child Abuse and Neglect

It is important for surgeons to be able to accurately assess and diagnose child abuse. While they are generally not the only medical professionals involved in the care of children with suspected abuse, they are highly regarded by hospital and social service staff, and their input regarding the cause of injury is unlikely to be ignored. Appropriate diagnosis of abusive injury can prevent future morbidity and mortality in these vulnerable patients, and can also reduce the trauma to families from false accusations of abuse. A sensitive and open-ended history, thorough physical examination, appropriate diagnostic workup with consideration of child abuse as an underlying cause, appropriate documentation of findings, and determination of safety for discharge can greatly improve an abused child's current and future health and safety.