Childhood head injuries - Accidental or inflicted?

Objectives: To determine the relative incidence of accidental and abusive c auses of head injuries in children younger than 6.5 years, to identify the types of craniocerebral damage resulting from reported mechanisms of injury , and to assess the likelihood of injuries being accidental or inflicted. Methods: Retrospective review of medical records of 287 children with head injuries aged 1 week to 6.5 years admitted to a metropolitan children's hos pital from January 1986 through December 1991. Those patients with diagnose s of skull fracture; concussion; subarachnoid hemorrhage (SAH); subgaleal, epidural, or subdural hematoma (SDH); parenchymal contusion or laceration; and closed head injury were included. Criteria were used for inclusion in c ategories of definite abuse or accident. Results: Accidents accounted for 81% of cases and definite abuse for 19%. T he mean age of the accident group was 2.5 years and for the definite abuse group, 0.7 years. Major differences were seen in the incidence of the follo wing: SDH, 10% in the the accident group and 46% in the the definite abuse group; SAH, 8% in accident group and 31% in the definite abuse abuse; and r etinal hemorrhages, 2% in the accident group and 33% in the definite abuse group. Associated cutaneous injuries consistent with inflicted injury were seen in 16% of the accident group and 50% of the definite abuse group. Twen ty-three percent of those in the accident group were injured in motor vehic le crashes (MVCs), 58% by falls, 2% in play activities, and the rest had in sufficient medical record information. In 56% of those in the definite abus e group, there was no history to account for the injuries and no history of MVC. In 17%, a fall was said to have been the mechanism of injury. In 24%, inflicted injury was admitted. Mortality rates were 13% in the definite ab use group and 2% in the accident group. Median hospital stay was 9.5 days f or the definite abuse group and 3 days for the accident group. In falls les s than 4 feet in the accident group, 8% had SDH, 2% had SAH, and none had r etinal hemorrhages; among those in the definite abuse group reportedly fall ing less than 4 feet, 38% had SDH, 38% had SAH, and 25% had retinal hemorrh ages. Conclusions: A substantial percentage of head injuries requiring hospitaliz ation in children younger than 6.5 years are attributable to inflicted inju ry. Subdural hematoma, subarachnoid hemorrhage, retinal hemorrhages, and as sociated cutaneous, skeletal, and visceral injuries are significantly more common in inflicted head injury than in accidental injury.