Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries

Background. It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification. Objective. To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury. Design/Methods. Data on children < 48 months of age who sustained a fatal head injury from 1986-2002 were extracted from the Pennsylvania Trauma Outcomes Study. Only those with external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs) with a recorded Glasgow Coma Scale (GCS) on admission were included. The GCS was compared across mechanisms and age groups (0-11, 12-23, 24-35, and 36-47 months). Results. Of the 314 fatally injured children, 37% sustained inflicted injury, 13% sustained a fall, and 49% sustained an MVC. At admission, 6.8% of all children had a GCS score of > 7, and 1.9% presented with a GCS score of > 12 ( lucid). The incidence of admission a GCS score of > 7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of > 7 than those injured in MVCs ( odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of > 7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >= 24 months old, a GCS score of > 7 did not differ by mechanism. In contrast, in those < 24 months old, children who died as a result of inflicted injury were > 10 times more likely to have a GCS score of > 7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9). Conclusions. The data suggest an age- and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: > 12) before death. Furthermore, children < 48 months old sustaining inflicted injury are 3 times more likely to be assessed with a moderate GCS score 7) than those in MVCs. This effect is amplified in the youngest children (< 24 months old): those with inflicted injury were 10 times more likely to present with moderate GCS scores than those in MVCs. In addition, this youngest age group seems to be overrepresented in those who present as lucid (GCS score: > 12 [5 of 6]). It is unclear whether these differences are the result of inadequate tests to evaluate consciousness in younger children or differences in biomechanical mechanisms of inflicted trauma.