Head Injury from Short Falls in Young Children

In published hospital cohorts of children evaluated after a reported fall, most head injuries were minor, and death from a short fall is rare on a population basis. A review of 177 published articles together with multiple injury databases estimated the annual risk of death from a fall under 1.5 meters in children under 5 at fewer than 0.48 per 1 million children per year, based partly on a California injury database that identified 6 possible fall-related fatalities among 2.5 million young children over five years (Chadwick 2008). That review found no fall deaths reliably reported from day-care centers. A low population-level risk is not the same as an impossible outcome. The California database included six possible fall-related deaths, and the estimate bounds what is plausible rather than ruling out any individual case.

Rarity of death does not mean short falls never cause injury. In a UK multicentre hospital study of 1,775 children under 6 admitted with a head injury attributed to a reported fall, 87% were fully alert on evaluation. Of the 342 children who underwent CT scanning, 32% had an abnormal result, which was 5.9% of the overall cohort (Burrows 2015). Compared with a fall from standing, the odds of skull fracture or intracranial injury were significantly higher for a fall from a person's arms (odds ratio 6.94), from a building component such as a window (odds ratio 6.84), or from an infant or child product (odds ratio 2.75). The authors reported that 12% of children who were fully alert (GCS 15) had an intracranial injury. The authors concluded that most head injuries from falls in this population were minor. Because this was a hospital-based cohort of admitted children, it does not describe every fall occurring in the community.

Injury pattern has also been studied alongside fall history as a way to characterize head injury in infants. A single-center review of 99 infants under 12 months who underwent head CT compared falls (67 cases) with nonaccidental trauma (21 cases). The median injury severity score was 5 for falls and 17 for nonaccidental trauma. Extracranial injuries, meaning injury to the face, chest, abdomen, or extremities alongside the head injury, occurred in 62% of nonaccidental trauma cases compared with 3% of falls. Isolated intracranial hemorrhage without a skull fracture was more frequent in nonaccidental trauma, at 60% versus 23% in falls, while an isolated skull fracture without hemorrhage was more frequent in falls, at 42% versus 5% in nonaccidental trauma. The authors recommended a full nonaccidental-trauma work-up for infants under 1 year presenting with isolated intracranial hemorrhage (Pontarelli 2014). This was a small, single-center, retrospective study with only 21 nonaccidental-trauma cases, and it included only infants who underwent head CT.

What this does and does not mean

A history of a short household fall does not exclude the possibility of serious head injury in a given child, and the low population-level risk of fatal outcome does not decide any individual case. At the same time, this evidence does not support treating every head injury in a young child as inherently suspicious. In these studies, an isolated skull fracture without hemorrhage occurred more often with accidental falls, while isolated intracranial hemorrhage without a fracture, or additional injuries in other body regions, occurred more often with inflicted trauma. None of these studies establishes what happened in a specific case. They describe patterns across groups of children, evaluated with the imaging, histories, and classifications available at each study site, and each carries limitations, including reliance on caregiver-reported histories, hospital-based samples, and small case counts for nonaccidental trauma.

In a case, the relevant questions are narrower. Does the documented injury fit the reported mechanism? How does the pattern, isolated fracture versus isolated hemorrhage, with or without injuries elsewhere, compare with the published pediatric cohorts? Was the child evaluated for other injuries? This literature informs those questions; the answers still depend on the medical record of the specific child.

The studies cited below are indexed in PubMed; DOI links are provided.

References

1. Chadwick DL, Bertocci G, Castillo E, et al. Annual risk of death resulting from short falls among young children: less than 1 in 1 million. Pediatrics. 2008;121(6):1213-1224. doi:10.1542/peds.2007-2281
2. Burrows P, Trefan L, Houston R, et al. Head injury from falls in children younger than 6 years of age. Arch Dis Child. 2015;100(11):1032-1037. doi:10.1136/archdischild-2014-307119
3. Pontarelli EM, Jensen AR, Komlofske KM, Bliss DW. Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism? Pediatr Emerg Care. 2014;30(10):677-679. doi:10.1097/PEC.0000000000000226