PEDIATRICS Vol. 116 No. 6 December 2005, pp. 1608 (doi:10.1542/peds.2005-1894)
Initial Neurologic Presentation in Young Children Sustaining Inflicted and Unintentional Fatal Head Injuries
Roger W. Byard, MBBS, MD, FRCPCForensic Science SA and Department of Pathology,
University of Adelaide,
Adelaide, SA 5005, Australia
Terence G. Donald, MBBS, FRCP
Forensic Physician in Pediatrics,
Child Protection Unit,
Women's and Children's Hospital,
Adelaide, SA 5006, Australia
To the Editor.—
The article by Arbogast et al1 deals with the very significant issue of neurologic and behavioral sequelae in infants and young children who sustain fatal, but not necessarily immediately lethal, head injuries. Unfortunately, there are a number of problems with this study and its conclusions. The interpretation of material from retrospective studies that use data as far back as 1986 is difficult, because it is often not possible to determine with any precision how competently the neurologic status of the injured infants was assessed.2 Part of the confusion that has arisen in the literature in this area comes from the lack of well-controlled prospective studies and the legacy of retrospective studies that often depend on second-hand, unverifiable information and therefore raise more questions than answers. Furthermore, it is important to raise the question of the reliability of the diagnostic categorization in this study. The only diagnostic category that can be claimed to be reliable retrospectively is "motor vehicle crashes," because a "fall" is frequently the explanation given to account for a suspicious head injury; the diagnosis of inflicted head injury is still not standardized and continues to be influenced by a range of factors, not the least of which is the level of psychosocial risk in the injured child's family.
Those comments aside, given that the authors comment that the children may have been symptomatic and that some of those with high Glasgow Coma Scale scores may have had clinical signs of head trauma, it is difficult to accept their final comment that their "data suggest that on rare occasion, an infant or toddler can sustain a fatal head injury yet present as lucid to hospital clinicians before death." Although their data may suggest this, it also may not; we simply do not know, and neither do the authors, who on their own admission concede that 1 reason for their results may have been "limitations of the bedside methods used to assess neurologic function." Properly designed and controlled prospective studies are urgently needed, not studies that further confuse the issue with analyses of potentially flawed archival material that will undoubtedly be cited in court as representing the most recent literature.
REFERENCES
- Arbogast KB, Margulies SS, Christian CW. Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries.
Pediatrics. 2005;116
:180
–184
[Abstract/Free Full Text] - Byard RW, Donald T, Hilton JN, Krous HF. Shaking-impact syndrome and lucidity [letter]. Lancet. 2000;355 :758
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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Related articles in Pediatrics:
- Initial Neurologic Presentation in Young Children Sustaining Inflicted and Unintentional Fatal Head Injuries: In Reply
- Kristy B. Arbogast, Susan S. Margulies, and Cindy W. Christian
Pediatrics 2005 116: 1608-1609.[Extract] [Full Text]
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