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Risk for occult head injury in abused children

▸ The leading cause of death in abused children younger than 2 years is head injury. Early detection can prevent mortality and serious morbidity, but there is no established guideline on screening for head injury in neurologically asymptomatic children with evidence of abuse. These authors reviewed hospital records to estimate the incidence of occult head injury in a high-risk sample of children. The children were admitted to an urban children’s hospital between January 1998 and December 2001 with a diagnosis of suspected child abuse, normal neurologic findings, and one of the following high-risk criteria: rib fracture, multiple fractures, facial injury, or age younger than 6 months. Children who had scalp lacerations or histories of neurologic dysfunction, seizures, or respiratory arrest were excluded.

Sixty-five children met the study criteria. The mean age was 6.4 months (range, 0.7-23.9 months), and the median weight was at the 35th percentile for age, with 19% of children below the 5th percentile. Thirty-four percent had rib fracture, 59% had multiple fractures, and 35% had facial injury. All had received skeletal surveys. Of 51 children who also had either a CT scan of the head or an MRI, 19 (37%) had evidence of occult head injury. Of the 19, 74% had skull fractures and 53% had intracranial injuries. Retinal hemorrhages were not evident in 14 of the 19 who underwent ophthalmologic examination.

Comment

▸ Limitations of this study include the small sample size and a possible selection bias regarding risk factors. Current guidelines for the screening of abused children recommend skeletal surveys. These results demonstrate that such children should also be screened for occult head injury, even in the absence of neurologic findings.

Harlan R. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine August 25, 2003

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