Risk of traumatic brain injuries in infants younger than 3 months with minor blunt head trauma
Abid Z, Kuppermann N, Tancredi DJ, et al. Ann Emerg Med. Published online June 17, 2021. doi:10.1016/j.annemergmed.2021.04.015
Clinical decision instruments such as the Pediatric Emergency Care Applied Research Network (PECARN) Pediatric Head CT Rule have a sensitivity of close to 100% and have the potential to decrease unnecessary CT scanning in children.
Here, the authors aimed to assess the accuracy of the PECARN rule in children <3 months old.
This is a secondary analysis of the public-use data set from the PECARN prospective observational study, which included patients <18 years of age with head trauma <24 hours before presentation and a Glasgow Coma Scale (GCS) score of 14 or 15.
The authors examined only data from infants <3 months of age with outcomes of (1) clinically important traumatic brain injury (TBI), (2) TBI on CT, and (3) skull fracture on CT.
As in the original article, clinically important TBI was defined as death from the TBI, TBI requiring neurosurgical procedures, intubation for at least 24 hours for the TBI, or hospitalization for 2 or more nights because of head trauma and ongoing symptoms associated with TBI on CT.
Of the original 10,904 children <2 years of age, 1,147 (10.5%) were <2 months old, and full data were available for 1,081 infants (94%). No clinical TBI events were present in the 65 excluded cases.
Of the 1,081 children, 514 met the PECARN low-risk criteria, and 567 did not (these low-risk criteria are GCS score <15, other signs of altered mental status, palpable skull fracture, nonfrontal scalp hematoma, loss of consciousness ≥5 seconds, abnormal behavior according to a parent, and severe mechanism of injury).
Among patients who did not meet the PECARN low-risk criteria, the rate of clinically important TBI was 4.2%, the rate of TBI on CT was 21.3%, and the rate of skull fracture was 28%.
Among patients who did meet the PECARN low-risk criteria, the rate of clinically important TBI was 0.2% (one patient), the rate of TBI on CT was 5.1%, and the rate of skull fracture was 4.6%.
The authors provide many details on the 10 patients who were PECARN negative and still had bleeds. Most were <2 months old and had a mechanism of fall <3 feet; approximately half had no signs or symptoms of trauma (eg, no abrasions or lacerations).
Some limitations with this trial are that it does not report the number of CTs obtained as part of a nonaccidental trauma workup rather than because of suspicion of TBI, and that CTs were not obtained for all patients in the study. Both these limitations could have affected the prevalence of TBI in unpredictable ways.
EDITOR’S COMMENTARY: In this retrospective database study of infants <3 months old with head trauma, 1 of 541 patients at low risk according to PECARN criteria had a clinically important TBI, but 9 more had bleeds despite being PECARN negative. Because of a combination of anatomical differences, such as thinner skulls and difficulty in assessing mental status as a result of limited interactivity, this is a high-risk cohort, and we must take more caution in our approach to CT than we do with older infants or kids.