Occult head injury in high-risk abused children

Abstract

Objective: Head injury is the leading cause of death in abused children under 2 years of age. Evidence for establishing guidelines regarding screening for occult head injury in a neurologically asymptomatic child with other evidence of abuse is lacking. This is particularly important given that many children with acute inflicted head injury have evidence of old injury when they are diagnosed. The primary aim of this study was to estimate the prevalence of occult head injury in a high-risk sample of abused children with normal neurologic examinations. The secondary aim was to describe characteristics of this population.

Methods: Children under 2 years of age admitted to an urban children's hospital between January 1998 and December 2001 with injuries suspicious for child abuse were eligible for this study if they had a normal neurologic examination on admission. Subjects were selected if they met 1 of the following "high-risk" criteria: rib fractures, multiple fractures, facial injury, or age <6 months. Subjects were excluded if they had a history of neurologic dysfunction, seizures, respiratory arrest, or if their initial physical examination revealed scalp injury.

Results: Of the 65 patients who met these criteria, 51 (78.5%) had a head computed tomography or magnetic resonance imaging in addition to skeletal survey. Of these 51 patients, 19 (37.3%, 95% confidence interval 24.2-50.4%) had an occult head injury. Injuries included scalp swelling (74%), skull fracture (74%), and intracranial injury (53%). All except 3 of the head-injured patients had at least a skull fracture or intracranial injury. Skeletal survey alone missed 26% (5/19) of the cases. Head-injured children were younger than non-head-injured children (median age 2.5 vs 5.1 months); all but 1 head-injured child was <1 year of age. Among the head-injured children, 72% came from single parent households, 37% had mothers whose age was <21 years, and 26% had a history of prior child welfare involvement in their families. Ophthalmologic examination was performed in 14 of the 19 cases; no retinal hemorrhages were noted.

Conclusions: Our results support a recommendation for universal screening in neurologically asymptomatic abused children with any of the high-risk criteria used in this study, particularly if that child is under 1 year of age. Ophthalmologic examination is a poor screening method for occult head injury, and one should proceed directly to computed tomography or magnetic resonance imaging. Given the high prevalence of occult head injury detected in this study, further study is warranted to estimate the prevalence of occult head injury in lower risk populations of abused children.