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Epidemiology of minor blunt head trauma in infants younger than 3 months

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Abstract

Specific knowledge of the features of minor head trauma in infants is necessary to develop appropriate preventive strategies and adjust clinical management in pediatric emergency departments (PEDs). The aim of this study is to describe the epidemiology of minor blunt head trauma in infants < 3 months who present to PEDs. We performed a prospective study of infants evaluated in any of 13 Spanish PEDs within 24 h of a minor head trauma (Glasgow Coma Scale scores of 14–15) between May 2017 and November 2020. Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 1,150,255 visits recorded, 21,981 children (1.9%) sustained a head injury, 386 of whom (0.03%) were under 3 months old. Among the 369 patients who met the inclusion criteria (0.03%), 206 (56.3%) were male. The main causes of trauma were fall-related (298; 80.8%), either from furniture (138/298; 46.3%), strollers (92/298; 30.9%), or a caregiver’s arms (61/298; 20.5%). Most infants were asymptomatic (317; 85.9%) and showed no signs of injury on physical exam (210; 56.9%). Imaging studies were performed in 195 patients (52.8%): 37 (10.0%) underwent computed tomography (CT) scan, 162 (43.9%) X-ray, and 22 (6.0%) ultrasound. A clinically important traumatic brain injury (ciTBI) occurred in 1 infant (0.3% overall; 95% CI, 0–1.5), TBI was evidenced on CT scan in 12 (3.3% overall; 95% CI, 1.7–5.7), and 20 infants had an isolated skull fracture (5.5% overall; 95% CI, 3.4–8.3). All outcomes were caused by falls onto hard surfaces.

Conclusion: Most head injuries in infants younger than 3 months are benign, and the rate of ciTBI is low. Prevention strategies should focus on falls onto hard surfaces from furniture, strollers, and caregivers’ arms. Optimizing imaging studies should be a priority in this population.

What is Known:

• Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination.

• A low threshold for CT scan is recommended in this population.

What is New:

• Most cases of blunt head trauma in infants younger than 3 months have good outcomes, and the rate of clinically important traumatic brain injury is low.

• Optimizing imaging studies should be a priority in this population, avoiding X-ray examinations and reducing unnecessary CT scans.

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Abbreviations

ciTBI:

Clinically important traumatic brain injury

CT:

Computed tomography

GCS:

Glasgow Coma Scale

IQR:

Interquartile range

PED:

Pediatric emergency department

TBI:

Traumatic brain injury

References

  1. Taylor CA, Bell JM, Breiding MJ, Xu L (2017) Traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2007 and 2013. MMWR Surveill Summ 66:1–16. https://doi.org/10.15585/mmwr.ss6609a1

    Article  PubMed  PubMed Central  Google Scholar 

  2. Quayle KS, Powell EC, Mahajan P, Hoyle JD Jr, Nadel FM, Badawy MK, Schunk JE, Stanley RM, Miskin M, Atabaki SM, Dayan PS, Holmes JF, Kuppermann N (2014) Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med 371:1945–1947. https://doi.org/10.1056/NEJMc1407902

    Article  PubMed  Google Scholar 

  3. Koepsell TD, Rivara FP, Vavilala MS, Wang J, Temkin N, Jaffe KM, Durbin DR (2011) Incidence and descriptive epidemiologic features of traumatic brain injury in King County Washington. Pediatrics 946–54.https://doi.org/10.1542/peds.2010-2259

  4. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN) (2009) Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374:1160–1170. https://doi.org/10.1016/S0140-6736(09)61558-0.Erratum.In:Lancet.2014383:308

    Article  Google Scholar 

  5. Dayan PS, Holmes JF, Schutzman S, Schunk J, Lichenstein R, Foerster LA, Hoyle J Jr, Atabaki S, Miskin M, Wisner D, Zuspan S, Kuppermann N; Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN) (2014) Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med 64:153–162. https://doi.org/10.1016/j.annemergmed.2014.02.003

    Article  Google Scholar 

  6. Powell EC, Atabaki SM, Wootton-Gorges S, Wisner D, Mahajan P, Glass T, Miskin M, Stanley RM, Jacobs E, Dayan PS, Holmes JF, Kuppermann N (2015) Isolated linear skull fractures in children with blunt head trauma. Pediatrics 135:e851–e857. https://doi.org/10.1542/peds.2014-2858

    Article  PubMed  Google Scholar 

  7. Lee LK, Monroe D, Bachman MC, Glass TF, Mahajan PV, Cooper A, Stanley RM, Miskin M, Dayan PS, Holmes JF, Kuppermann N; Traumatic Brain Injury (TBI) Working Group of Pediatric Emergency Care Applied Research Network (PECARN) (2014) Isolated loss of consciousness in children with minor blunt head trauma. JAMA Pediatr 168:837–843. https://doi.org/10.1001/jamapediatrics.2014.361

    Article  Google Scholar 

  8. Greenes DS, Schutzman SA (1998) Occult intracranial injury in infants. Ann Emerg Med 32:680–686. https://doi.org/10.1016/s0196-0644(98)70067-8

    Article  CAS  PubMed  Google Scholar 

  9. Schutzman SA, Barnes P, Duhaime AC, Greenes D, Homer C, Jaffe D, Lewis RJ, Luerssen TG, Schunk J (2001) Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 107:983–993. https://doi.org/10.1542/peds.107.5.983

    Article  CAS  PubMed  Google Scholar 

  10. Quayle KS, Jaffe DM, Kuppermann N, Kaufman BA, Lee BC, Park TS et al (1997) Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics 99

    Article  CAS  Google Scholar 

  11. Greenes DS, Schutzman SA (1999) Clinical indicators of intracranial injury in head-injured infants. Pediatrics 104:861–867

    Article  CAS  Google Scholar 

  12. Greenes DS, Schutzman SA (2001) Clinical significance of scalp abnormalities in asymptomatic head-injured infants. Pediatr Emerg Care 17:88–92

    Article  CAS  Google Scholar 

  13. Schutzman SA, Barnes P, Duhaime AC, Greenes D, Holmer C, Jaffe D, Lewis RJ et al (2001) Pediatrics 107:983–993

    Article  CAS  Google Scholar 

  14. Schutzman SA, Nigrovic LE, Mannix R (2021) The Infant Scalp Score: a validated tool to stratify risk of traumatic brain injury in infants with isolated scalp hematoma. 28:92–7

  15. Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K (2006) Children’s head injury algorithm for the prediction of important clinical events study group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 91:885–891. https://doi.org/10.1136/adc.2005.083980

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Osmond MH, Klassen TP, Wells GA, Davidson J, Correll R, Boutis K, Joubert G, Gouin S, Khangura S, Turner T, Belanger F, Silver N, Taylor B, Curran J, Stiell IG; Pediatric Emergency Research Canada (PERC) Head Injury Study Group (2018) Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ 190:E816–E822. https://doi.org/10.1503/cmaj.170406

    Article  Google Scholar 

  17. Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, Feigelson HS et al (2013) JAMA Pediatr 167:700–707

    Article  Google Scholar 

  18. Brenner D, Elliston C, Hall E, Berdon W (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176:289–296. https://doi.org/10.2214/ajr.176.2.1760289

    Article  CAS  PubMed  Google Scholar 

  19. Karlsson P, Holmberg E, Lundell M, Mattsson A, Holm LE, Wallgren A (1998) Intracranial tumors after exposure to ionizing radiation during infancy: a pooled analysis of two Swedish cohorts of 28,008 infants with skin hemangioma. Radiat Res 150:357–364

    Article  CAS  Google Scholar 

  20. Brody AS, Frush DP, Huda W, Brent RL (2007) American Academy of Pediatrics Section on Radiology. Radiation risk to children from computed tomography. Pediatrics 120:677–682

    Article  Google Scholar 

  21. Abid Z, Kuppermann N, Tancredi DJ, Dayan PS (2021) Risk of traumatic brain injuries in infants younger than 3 months with minor blunt head trauma. Ann Emerg Med 78:321-330.e1

    Article  Google Scholar 

  22. Eapen N, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA et al (2020) Neonatal head injuries: a prospective Paediatric Research in Emergency Departments International Collaborative cohort study. J Paediatr Child Health 56:764–769

    Article  Google Scholar 

  23. Frush DP, O’Hara SM, Kliewer MA (1998) Pediatric imaging perspective: acute head trauma–is skull radiography useful? J Pediatr 132:553–554

    Article  CAS  Google Scholar 

  24. Rozovsky K, Ventureyra ECG, Miller E (2013) Fast-brain MRI in children is quick, without sedation, and radiation-free, but beware of limitations. J Clin Neurosci Off J Neurosurg Soc Australas 20:400–405

    Google Scholar 

  25. Shin SS, Huisman TAGM, Hwang M (2018) Ultrasound imaging for traumatic brain injury. J Ultrasound Med Off J Am Inst Ultrasound Med 37:1857–1867

    Google Scholar 

  26. Rabiner JE, Friedman LM, Khine H, Avner JR, Tsung JW (2013) Accuracy of point-of-care ultrasound for diagnosis of skull fractures in children. Pediatrics 131:e1757-1764

    Article  Google Scholar 

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Acknowledgements

We thank all the patients and families for their participation in this study and the staff members who gathered data from all the involved units. We would like to thank Oliver Shaw for the language review.

Author information

Authors and Affiliations

  1. Pediatric Emergency Department, Hospital Infantil Universitario Niño Jesús, Avenida de Menedez Pelayo 65, 28009, Madrid, Spain

    José Antonio Alonso-Cadenas

  2. Pediatric Emergency Department, Hospital Universitario Gregorio Marañón, Madrid, Spain

    Clara Ferrero García-Loygorri

  3. Pediatric Emergency Department, Hospital Universitario, 12 de Octubre, Madrid, Spain

    Rosa María Calderón Checa

  4. Pediatric Emergency Department, Hospital Materno-Infantil Universitario Málaga, Málaga, Spain

    Isabel Durán Hidalgo

  5. Pediatric Emergency Department, Hospital Universitario Puerta De Hierro, Majadahonda, Spain

    María José Pérez García

  6. Pediatrics Department, Hospital Universitario Severo Ochoa, Leganés, Spain

    Sara Ruiz González

  7. Pediatric Emergency Department, Hospital Universitario La Paz, Madrid, Spain

    Maria De Ceano-Vivas

  8. Pediatric Emergency Department, Hospital Universitario Virgen del Rocío, Seville, Spain

    Pablo Delgado Gómez

  9. Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain

    Miguel Antoñón Rodríguez

  10. Pediatrics Department, Hospital Universitario del Tajo, Aranjuez, Spain

    Rubén Moreno Sánchez

  11. Pediatric Emergency Department, Hospital UniversitarioSant Joan de Déu Barcelona, Esplugues de Llobregat, Spain

    José Martínez Hernando

  12. Pediatrics Department, Hospital Universitario Infanta Leonor, Madrid, Spain

    Cristina Muñoz López

  13. Pediatrics Department, Hospital Universitario Virgen de La Salud, Toledo, Spain

    Irene Ortiz Valentín

  14. Pediatrics Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain

    Raquel Jiménez-García

Authors
  1. José Antonio Alonso-Cadenas
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  2. Clara Ferrero García-Loygorri
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  3. Rosa María Calderón Checa
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  5. María José Pérez García
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  6. Sara Ruiz González
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  7. Maria De Ceano-Vivas
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  8. Pablo Delgado Gómez
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  9. Miguel Antoñón Rodríguez
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  10. Rubén Moreno Sánchez
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  11. José Martínez Hernando
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  12. Cristina Muñoz López
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  13. Irene Ortiz Valentín
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  14. Raquel Jiménez-García
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Contributions

JAA and RJ conceptualized and designed the study, performed data management and statistical analysis, and drafted the manuscript. All co-authors enrolled participants and participated in the collection of data. All co-authors participated and were involved in the critical review of the final manuscript.

Corresponding author

Correspondence to José Antonio Alonso-Cadenas.

Ethics declarations

Ethics approval

The Ethics Committee of the Hospital Infantil Universitario Niño Jesús, Madrid, approved this study (R-0064/16).

Consent to participate

Informed consent was obtained from the parents or legal guardians.

Consent for publication

All authors reviewed and approved the manuscript and agreed to publish this work.

Conflict of interest

The authors declare no competing interests.

Additional information

Communicated by Piet Leroy

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Alonso-Cadenas, J.A., Ferrero García-Loygorri, C., Calderón Checa, R. et al. Epidemiology of minor blunt head trauma in infants younger than 3 months. Eur J Pediatr 181, 2901–2908 (2022). https://doi.org/10.1007/s00431-022-04492-x

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  • DOI: https://doi.org/10.1007/s00431-022-04492-x

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