Characteristics of falls and risk of injury in children younger than 2 years

Evaluating Young Children With Fractures for Child Abuse: Clinical Report

Fractures are common injuries in childhood and can be caused by unintentional injury, medical conditions, and child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, the consequences of incorrectly diagnosing child abuse in a child whose fractures have another etiology are also significant. This report aims to review recent advances in the understanding of fracture specificity, fracture mechanisms, and other medical conditions that predispose infants and children to fracture. This clinical report will aid pediatricians and pediatric care providers in developing an evidence-based differential diagnosis and performing appropriate evaluations when assessing a child with fractures.

Factors associated with trauma recidivism in young children

BACKGROUND

Trauma recidivism is associated with future trauma-associated morbidity and mortality. Previous evidence suggests that socioeconomic factors predict trauma recidivism in older children (10-18 years); however, risk factors in US children 10 years and younger have not been studied. We sought to determine the factors associated with trauma recidivism in young children 10 years and younger.

METHODS

We conducted a retrospective cohort study of pediatric trauma patients 10 years and younger who presented to a single American College of Surgeons-verified Level I pediatric trauma center from July 1, 2017, to June 30, 2021. All patients were evaluated for prior injury during trauma registry entry. Characteristics at the index injury were collected via chart review. Patients were geocoded to assess Social Vulnerability Index. Logistic regression examined factors associated with recidivism. Best subset selection was used to compare multivariable models and identify the most predictive and parsimonious model. Statistical significance was set at p < 0.05.

RESULTS

Of the 3,518 patients who presented in the study period, 169 (4.8%) experienced a prior injury. Seventy-six percent (n = 128) had one prior injury presentation, 18% (n = 31) had two prior presentations, and 5.9% (n = 10) had three or more. Falls were the most common mechanism in recidivists (63% vs. 52%, p = 0.009). Child physical abuse occurred in 6.5% of patients, and 0.9% experienced penetrating injury. The majority (n = 137 [83%]) were discharged home from the emergency department. There was no significant difference in the frequency of penetrating injury and child physical abuse between recidivists and nonrecidivists. Following logistic regression, the most parsimonious model demonstrated that recidivism was associated with comorbidities, age, falls, injury location, nontransfer, and racialization. No significant associations were found with Social Vulnerability Index and insurance status.

CONCLUSION

Medical comorbidities, young age, injury location, and falls were primarily associated with trauma recidivism. Support for parents of young children and those with special health care needs through injury prevention programs could reduce trauma recidivism in this population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Pediatric Unintentional Fall-Related Injuries in a Statewide Trauma Registry

OBJECTIVES

The purpose of the study was to evaluate patterns of fall-related injury through childhood and identify risk factors for more severe fall-related injuries with the goal of informing targeted prevention strategies for different ages.

METHODS

The study population consisted of pediatric patients in the Iowa Trauma Registry from January 1, 2010, to December 31, 2014, who sustained an unintentional fall-related injury (N = 3856 patients). Multinomial logistic regression analysis was used to predict injury severity. Adjusted odds ratios were calculated characterizing the relationship between fall severity and age, sex, race, and fall type.

RESULTS

More males (62%) sustained a fall-related injury during the study period when compared with females (38%; P < 0.0001). Head injuries were the most common type of injury in the younger than 1 year age group (77%), whereas fractures were the predominant injury type in all other age groups, followed by head injuries. Those younger than 1 year (adjusted odds ratio, 4.0; 95% confidence interval, 2.36-6.90) and aged 15 to 18 years (adjusted odds ratio, 1.9; 95% confidence interval, 1.17-3.03) were more likely to have an Injury Severity Score of ≥16 than those aged 10 to 14 years.

CONCLUSIONS

Recommendations and prevention strategies need to focus on specific risk factors to reduce the harm of multilevel falls. As we have shown, patterns of fall injuries presenting to trauma hospitals differ by age, thus suggesting that prevention strategies focus on specific age groups.

Fall-related traumatic brain injury in children ages 0-4 years

INTRODUCTION

Falls are the leading cause of traumatic brain injury (TBI) for children in the 0-4 year age group. There is limited literature pertaining to fall-related TBIs in children age 4 and under and the circumstances surrounding these TBIs. This study provides a national estimate and describes actions and products associated with fall-related TBI in this age group.

METHOD

Data analyzed were from the 2001-2013 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), a nationally representative sample of emergency departments (ED). Case narratives were coded for actions associated with the fall, and product codes were abstracted to determine fall location and product type. All estimates were weighted.

RESULTS

An estimated 139,001 children younger than 5 years were treated annually in EDs for nonfatal, unintentional fall-related TBI injuries (total = 1,807,019 during 2001-2013). Overall, child actions (e.g., running) accounted for the greatest proportion of injuries and actions by others (e.g., carrying) was highest for children younger than 1 year. The majority of falls occurred in the home, and involved surfaces, fixtures, furniture, and baby products.

CONCLUSIONS

Fall-related TBI in young children represents a significant public health burden. The majority of children seen for TBI assessment in EDs were released to home. Prevention efforts that target parent supervision practices and the home environment are indicated. Practical applications: Professionals in contact with parents of young children can remind them to establish a safe home and be attentive to the environment when carrying young children to prevent falls.

Childhood Falls With Occipital Impacts

OBJECTIVES

Falls are commonly reported in children who present with both accidental and inflicted brain injuries. Short falls rarely result in serious or life-threatening injuries. Our purpose is to describe a series of cases of short falls with occipital impact leading to subdural hemorrhage (SDH).

METHODS

We present a series of 8 witnessed accounts of young children diagnosed as having SDHs after striking the back of their heads during a short fall. Child-abuse physicians were surveyed to determine if they had evaluated a child younger than 24 months diagnosed as having SDH, with or without retinal hemorrhages, following a witnessed fall with occipital impact. Submitted cases were analyzed.

RESULTS

The median age of the children was 12.5 months. All fell backward from a standing or seated position onto a hard surface and immediately developed symptoms. There was an average of 4 witnesses per case. Physical examinations were normal; however, the majority of children had enlarged head circumferences. All were previously healthy. Six of 8 children had unilateral convexity SDH. All children had varying degrees of retinal hemorrhage but no retinoschisis. The majority of children had returned to their baseline within 24 hours of hospitalization.

CONCLUSIONS

Although a larger study is needed to identify the full spectrum of injuries, we postulate that, if a history of a fall with an occipital impact is elicited during a trauma workup, accidental injury should be considered.

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.

The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury

Fractures are common injuries in childhood. While most fractures are caused by accidental trauma, inflicted trauma (maltreatment) is a serious and potentially unrecognized cause of fractures, particularly in infants and young children. This practice point identifies the clinical features that prompt concern for inflicted skeletal injury and outlines a management approach based on current literature and published guidelines, including the clinician's duty to report suspicion of child abuse to child welfare authorities. This document does not address isolated skull fractures.

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

Fractures are the second most common abusive injury occurring in young children, particularly those under 2 years of age. The humerus is often affected. To better identify factors discriminating between abusive and non-abusive humerus fractures, this retrospective study examined the characteristics and mechanisms of injuries causing humerus fractures in children less than 18 months of age. 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 vs not abuse). The 97 eligible patients had 100 humerus fractures. The most common fracture location was the distal humerus (65%) and the most common fracture type was supracondylar (48%). Child Protection Teams evaluated 44 patients (45%) and determined that 24 of those had 25 fractures caused by abuse (25% of the total study population).Among children with fractures determined to have been caused by abuse, the most common location was the distal humerus (50%) and the most common types were transverse and oblique (25% each); however, transverse and oblique fractures were also seen in patients whose injuries were determined to have been non-abusive. A younger age, non-ambulatory developmental stage, and the presence of additional injuries were significantly associated with abusive fractures. Caregivers did not provide a mechanism of injury for half of children with abusive fractures, whereas caregivers provided some explanation for all children with non-abusive fractures.

[Falls in less than one year-old infants: Management in the emergency department]

OBJECTIVES

A study was performed in order to describe injuries associated with falls in children aged <1 year who attended the emergency department. The approaches used were examined, as well as the factors associated with the greater use of these approaches, and the management of the patient.

PATIENTS AND METHODS

This was a multicentre, descriptive and analytical study that included all patients aged <1 year who had experienced a fall for which they attended the emergency departments of one of 8 Spanish Hospitals belonging to the "Unintentional Paediatric Injury Working Group" of the Spanish Paediatric Society. A record was made of the data regarding the visit, circumstances before arrival at the hospital, injuries observed, and the diagnostic and therapeutic approaches used.

RESULTS

A total of 1022 patients had experienced falls, that is, 0.35% of the emergencies attended in the study hospitals (95% CI, 0,348-0,352). The most commonly affected part was the head (58%). Cranial radiography was ordered in 31.8% of cases, and was associated with the presence of bruising or signs of fracture on examination (P<.001), falls from heights >100cm (P<.001), and age <3 months (P=.004). Minor head injury was the most common finding (85.6%), followed by fractures, especially cranial fractures (7.1%), which were associated with bruising or signs of fracture on examination (P<.001), and age <3 months (P<.001). Six percent of the patients required admission to hospital. The risk factors for hospital admission in this group were falls from heights >50cm and age <3 months.

CONCLUSIONS

Injuries after falls in infants aged <1 year are commonly due to head trauma and frequently require additional diagnostic tests.

[Epidemiology and risk factors in injuries due to fall in infants under one year-old]

OBJECTIVES

To describe the epidemiological characteristics of unintentional injuries due to falls in children under one year and to analyse the risk factors associated with severe injuries.

PATIENTS AND METHODS

This multicentre, observational and cross-sectional study included all children less than one year treated for unintentional fall in the Emergency Departments of 8 Spanish Hospitals, belonging to the «Unintentional Paediatric Injury Workshop» of the Spanish Paediatric Emergency Society, between March 1st, 2014 and February 28th, 2015.

RESULTS

Out of 289,887 emergency department cases, 1,022 were due to unintentional falls. The median age was 8 months and 52.5% were males. Fall injuries were more frequent among children aged 9-12 months (37.6%), and 83.5% occurred at home. The most common mechanism was fall from nursery equipment (69.4%), and 47.8% occurred from a height under 50cm. More than two-thirds (68%) of falls were witnessed, but in half of the cases (329) the caregiver was not in area. Serious injuries were seen in 12% of cases. In this study, a fall height greater than 50cm, falls in the street, from the arms of the carer, and from the stairs were identified as independent risk factors for worse outcomes.

CONCLUSIONS

The most serious injuries occur in children <3 months and from a height of >50cm, though not related to unwitnessed falls. Because the most common serious injury mechanism is the fall from the arms of the carer, from stairs, and falls in the street, these facts should be highlighted in order to avoid morbidity.

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.

Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism?

OBJECTIVES

Nonaccidental trauma (NAT) is most common and most lethal in infants. Falls are the most frequently given explanation for NAT, and head injuries can result from both mechanisms. We hypothesized that infant head injuries from NAT have a distinct injury profile compared to falls.

METHODS

The trauma registry and patient records were reviewed from 2004 to 2008. Infants with at least 1 head computed tomography were included.

RESULTS

Ninety-nine infants were identified. Falls (67 patients) and NAT (21 patients) were the most common mechanism of injury. Falls had lower injury severity scores, 5 versus 17 compared to NAT (P < 0.001). Nonaccidental trauma patients had injuries to face, chest, abdomen, or extremities much more frequently, 62% versus 3% in falls (P < 0.001). Isolated intracranial hemorrhage was higher in NAT (60% vs. 23%, P = 0.002), whereas isolated skull fracture was higher in falls (42% vs. 5%, P = 0.005). Outcomes for NAT showed longer intensive care unit stays (4 days vs. 1 day; P < 0.001), longer hospital stays (7 days vs. 1 day; P < 0.001), and more intracranial operations (9 vs. 1; P < 0.001).

CONCLUSIONS

We recommend that all children younger than 1 year, with an isolated intracranial hemorrhage, have a full NAT work-up. Injury severity score greater than 20, Glasgow Coma Scale less than 13, and extracranial injuries should also increase suspicion of NAT.

Sentinel injuries: subtle findings of physical abuse

Injuries, other than abrasions, are rare in precruising infants. In this population, a history or observation of a sentinel skin injury, intraoral injury, or musculoskeletal injury without a plausible explanation, is concerning for physical abuse. A precruising infant with a sentinel injury should be medically evaluated for occult injury and predisposing medical conditions, as well as reported to authorities for further investigation. Early identification of sentinel injuries and appropriate interventions can prevent further abuse.

Socioeconomic, behavioral, and anthropometric risk factors for traumatic dental injuries in childhood: a cohort study

AIM

To investigate risk factors for the occurrence of traumatic dental injuries (TDI) at 4 years of age.

DESIGN

Prospective cohort study.

METHODS

A birth cohort (n = 500) was recruited from the public healthcare system in São Leopoldo, Brazil. Demographic, socioeconomic, anthropometric, and behavioral variables were collected at 6 months, 1 year, and 4 years of age. Clinical examinations at 4 years of age were carried out by a single examiner using the Andreasen classification. Poisson regression was used to determine risk factors for the occurrence of TDI at 4 years of age.

RESULTS

A total of 23.7% of the children (80/337) exhibited TDI at 4 years of age. The risk of TDI was 35% lower among children who had been breastfeed for ≥6 months relative risk (RR 0.65; 95% CI 0.43-0.97) and more than twofold higher among those who were bottle fed ≥ three times a day (RR 2.37; 95% CI 1.10-5.11) at 12 months of age. Higher household income in the first year of life and greater height at 4 years of age were significantly associated with the outcome.

CONCLUSIONS

The identification of behavioral, socioeconomic, and anthropometric risk factors for TDI in early childhood can contribute to the elaboration of prevention strategies.

Evaluating children with fractures for child physical abuse

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

[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.

Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures

OBJECTIVE

To measure the yield of a skeletal survey in children ≤ 18 months old presenting with isolated skull fractures without significant intracranial injury.

STUDY DESIGN

A retrospective chart review was conducted on all children ≤ 18 months old presenting with an isolated skull fracture not associated with a motor vehicle crash or shopping cart fall between January 1, 2004 and December 31, 2010. An institutional protocol requires a skeletal survey and social work consult on all such children. We analyzed the association of mechanism of injury, type of skull fracture, and presence of "red flags" with a positive skeletal survey using χ(2) and Fisher exact tests.

RESULTS

Of 175 eligible patients, 150 (86%) underwent a skeletal survey. Of the 9 patients (6%) who had another fracture in addition to the presenting one, only 1 child was older than 6 months. Eight patients with additional fractures had a simple skull fracture (not complex) and 7 patients with other fractures had at least 1 red flag. Regarding skull fractures, the majority of long falls (81%) resulted in a simple skull fracture.

CONCLUSION

The skeletal survey in patients with isolated skull fractures revealed additional fractures in 6% of patients. Thus, a skeletal survey may yield clinically and forensically relevant data in such patients. However, it may be possible to restrict the window for obtaining a skeletal survey to younger infants, particularly those who are premobile.

Leading causes of injury hospitalisation in children aged 0-4 years in New South Wales by injury submechanism: a brief profile by age and sex

AIM

To identify the leading causes of injury in children aged 0-4 years by single year of age using injury submechanisms and present a brief epidemiologic profile of each cause.

METHODS

Hospitalisation data for New South Wales from 1999 to 2009 were used to identify the leading causes of injury for children aged 0-4 years by single year of age. For each leading cause, rates over time and by sex were calculated by single year of age. Associated age and sex risk ratios were estimated.

RESULTS

The leading causes of injury for children aged <1, 1 and 2 years were falls while being carried, burns by hot non-aqueous substances and poisoning by other and unspecified pharmaceutical substances, respectively. Falls involving playground equipment ranked first for children aged 3-4 years. Each leading injury cause exhibited an age pattern that remained stable over time and by sex. Age predicted falls while being carried and both age and sex predicted the remaining leading injury causes, with age and sex interacting to predict burns by hot non-aqueous substances.

CONCLUSIONS

Epidemiologic analysis using single-year age intervals and injury submechanisms results in a clearer picture of injury risk for young children. The findings of this study provide detailed information regarding the leading causes of hospitalised injury in young children by age and sex. Child health-care providers can use this information to focus discussions of child development and injury risk with families of young children and suggest appropriate prevention measures in terms of a child's age and sex.

Finite element model predictions of intracranial hemorrhage from non-impact, rapid head rotations in the piglet

Clinicians are charged with the significant task of distinguishing between accidental and inflicted head trauma. Oftentimes this distinction is straightforward, but many times probabilities of injuries from accidental scenarios are unknown making the differential diagnosis difficult. For example, it is unknown whether intracranial hemorrhage (IH) can occur at a location other than a focal contact site following a low height fall. To create a foundation for predicting regional IH in infants, we sought to identify the biomechanical response and injury threshold best able to predict IH in 3-5 day old piglets. First, finite element (FE) model simulations of in situ animal studies were performed to ascertain the optimal representation of the pia-arachnoid complex, cerebrospinal fluid and cortical vasculature (PCC) for predicting brain strain and brain/skull displacement. Second, rapid head rotations resulting in various degrees of IH were simulated (n=24) to determine the biomechanical predictor and injury threshold most closely correlated with IH. FE models representing the PCC with either spring connectors or solid elements between the brain and skull resulted in peak brain strain and brain/skull displacement similar to measured values in situ. However, when predicting IH, the spring connector representation of the PCC had the best predictive capability for IH with a sensitivity of 80% and a specificity of 85% when ≥ 1% of all spring connectors had at least a peak strain of 0.31 mm/mm. These findings and reported methodology will be used in the development of a human infant FE model to simulate real-world falls and identify injury thresholds for predicting IH in infants.