Published online September 1, 2004
PEDIATRICS Vol. 114 No. 3 September 2004, pp. 633-639 (doi:10.1542/peds.2003-1020-L)
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A Population-Based Comparison of Clinical and Outcome Characteristics of Young Children With Serious Inflicted and Noninflicted Traumatic Brain Injury

Heather T. Keenan, MDCM, MPH*,{ddagger}, Desmond K. Runyan, MD, DrPH*,{ddagger},§, Stephen W. Marshall, PhD{ddagger},||,¶, Mary Alice Nocera, RN, MSN{ddagger} and David F. Merten, MD#

* Department of Social Medicine
{ddagger} Injury Prevention Research Center
§ Department of Pediatrics
|| Department of Epidemiology
Department of Orthopedics
# Department of Radiology, University of North Carolina, Chapel Hill, North Carolina

Objective. Diagnosing inflicted traumatic brain injury (TBI) in young children is difficult in practice. Comparisons of children with inflicted and noninflicted TBI may help to identify markers of inflicted TBI. The objective of this study was to compare inflicted and noninflicted TBI in terms of presenting complaints, clinical features, and hospital outcomes.

Methods. The presenting complaint, clinical finding, hospital course, and outcome of all children who were aged 2 years or younger in North Carolina and were admitted to a pediatric intensive care unit or died with a TBI in 2000 and 2001 were reviewed. Clinical presentation and injury types were compared between children with inflicted and noninflicted TBI. Risk ratios were used to compare clinical and outcome characteristics between the 2 groups. Among survivors, multivariate binomial regression was used to examine the adjusted risk of a poor outcome dependent on injury type.

Results. A total of 80 (52.6%) children had inflicted and 72 (47.3%) children had noninflicted TBI. Children with noninflicted TBI (not in a motor vehicle crash) were more likely to present to the emergency department asymptomatic (44.8% vs 8.3%) and to have a specific history of trauma than children with inflicted TBI. Retinal hemorrhage, metaphyseal fracture, rib fracture, and subdural hemorrhage were more commonly found in children with inflicted compared with noninflicted TBI. Skeletal survey and ophthalmologic examination combined would have missed 8 (10.0%) inflicted TBI cases.

Conclusions. Manner of presentation and injury types are helpful in distinguishing inflicted TBI. Clinicians should not rule out inflicted TBI on the basis of skeletal survey and ophthalmoscopy alone but should proceed to computed tomography and/or magnetic resonance imaging.

Key Words: child abuse • traumatic brain injury • shaken baby syndrome

Abbreviations: TBI, traumatic brain injury • PICU, pediatric intensive care unit • CT, computed tomography • MRI, magnetic resonance imaging • OCME, Office of the Chief Medical Examiner • CPR, cardiopulmonary resuscitation • GCS, Glasgow Coma Score • POPC, Pediatric Outcome Performance Category • RR, risk ratio • MVC, motor vehicle crash • CI, confidence interval

Accepted Mar 11, 2004.


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