Major Causes of Head Trauma in Children Identified

Larry Hand

November 13, 2014

With prospective data on more than 43,000 head injuries in children younger than 19 years, researchers pinpoint the main causes of head trauma in different age groups, as well as the frequency of traumatic brain injury (TBI).

The new data, published in the November 13 issue of the New England Journal of Medicine, should be used to develop injury-prevention strategies, researchers say.

Kimberly S. Quayle, MD, from the Washington University School of Medicine in St. Louis, Missouri, and colleagues conducted a prospective, multicenter study and analyzed the records of 43,399 pediatric patients who were treated for head injuries at 25 US emergency departments in the Pediatric Emergency Care Applied Research Network between 2004 and 2006. Medscape Medical News reported previously on the group's earlier development of TBI prediction rules for children.

Overall, 98% of the head injuries were mild, as defined by a Glasgow Coma Score (GCS) of 14 or 15; 1% were moderate, with a GCS of 9 to 13; and less than 1% (n = 354) were severe, with a GCS of 8 or lower. Seventy-eight children died.

In the overall population, the most common mechanism of injury was a fall from any distance (27%), followed by a fall while standing, walking, or running (11%); a collision with a stationary object when walking or running (6%); a motor vehicle crash (9%); and a bicycle crash (4%).

Among those injuries caused by a motor vehicle crash or a bicycle crash, a substantial proportion occurred when the child was not using a seat belt (36%) or wearing a helmet (72%).

Children not using the recommended safety device made up a disproportionate fraction of patients diagnosed with TBI. Specifically, 16% of patients in a motor vehicle crash were diagnosed with a TBI, and a slight majority of those (52%) were not using a seat belt at the time. Of those in a bicycle crash, 4% had a TBI, and of those with a TBI, 93% were not wearing a helmet.

The authors found that falls were the most frequent cause for TBI for children younger than 12 years, and assaults, motor vehicle accidents, and sports activities led to the most injuries for adolescents.

Clinicians performed cranial computed tomography (CT) in 37% of the children. They identified TBIs in 7% of the children who underwent CT, plus an additional 3% who had skull fractures without intracranial findings.

The rate of TBI as seen on CT was 5% for children with mild injuries, 27% for children with moderate injuries, and 65% for children with severe injuries.

Subdural hematoma was the most common injury overall, followed by subarachnoid hemorrhage and cerebral contusion. Almost half of the children in the CT group had more than one kind of brain injury.

Neurosurgeons treated 200 of the children in the CT group, and the types of neurosurgical procedures varied greatly.

"This prospective, multicenter study provides more detailed and representative clinical and radiographic information about the spectrum of [TBIs] in children than is available in previous studies of administrative databases or from single institutions," the researchers write.

"Our findings may be useful in the development of future injury-prevention measures and age-stratified targeted interventions, such as campaigns to promote the use of bicycle helmets and automobile restraints."

This research was supported by a grant from the Health Resources and Service Administration/Maternal and Child Health Bureau and the Education and the Emergency Medical Services for Children Program. The authors have disclosed no other relevant financial relationships.

N Engl J Med. 2014;371:1945-1947. Full text

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