An 8 week old infant is brought in by his mom after being found on the ground. According to the mom, she put the baby in a bouncy seat in the middle of the kitchen table and went to take a shower. When she got out of the shower, she heard crying and the dog barking and found that the baby had rolled out of the bouncy seat and landed on the ground. The fall was about 4 feet. After she picked the baby up, he stopped crying. No vomiting, no abnormal behavior. She wanted to be sure the baby was okay, so she brought him in to be checked. Prior to this the baby had been normal, with no rashes, fevers, diarrhea or vomiting. The baby had been eating normal, and had normal bowel movements and normal stools.
PMH: Vaginal delivery, shots up to date, went home with mom from the hospital. Baby has made all of his pediatrician’s appointments.
SH: Mom is a social worker, and brings the baby to day care during the day. She recently returned to work after her maternity leave. Parents are married and have no other children.
PE: Easily consolable 6 wk old held in mom’s arms.
VS: HR 140, RR 40, Temp 98.6F
HEENT: PERRL, fundoscopic exam difficult to be confident no paplidema
Fontanel flat, small scalp hematoma to left parietal area. TM normal, no fluid from ears or nose. No raccoon eyes, no other scalp abnormalities.
Neck: Baby moves head in all directions, no pain or tenderness to cervical spine.
Abd: Soft, normal and non-tender
Ext: Good pulses, normal exam
Neuro: Good eye contact, moves all 4 extremities normally, interactive with toys, normal reflexes, normal sensation. Just starting to hold head independently for a few seconds.
1. What are the indications for CT scanning in infants?
With all the press about the negative consequences of radiation from overzealous use of CT scans, this is an even hotter topic. I’d be interested to hear what criteria others use. There are several guidelines that have been published, and several are available for free on line.
The American Academy of Pediatrics has a guideline, but it starts with 2 y/o children (so it’s not helpful for this child). The entire article and discussion can be accessed free at: “http://aappolicy.aappublications.org/cgi/content/full/pediatrics;104/6/1407“
It’s a complicated algorithm (see this link for just the algorithm: http://aappolicy.aappublications.org/sub-journals/pediatrics/html/content/vol104/issue6/images/large/pe1294063001.jpeg”
Basically it suggests considering CT scanning for kids with:
1. Abnormal neurologic examination
2. Abnormal skull examination
3. History of LOC
This algorithm excludes patients with bleeding diathesis, suspected intentional head trauma, multiple trauma patients, preexisting neurologic disorder, or presence of drugs and alcohol.
In another pediatric study (1), a modification of the NEXUX II found the following predictors suggest need for CT:
1. Abnormal mental status
2. Signs of skull fracture
3. High risk vomiting
4. Scalp hematoma in child < or = 2 years old
5. Severe or progressive headache
This complete article is available for free at: “http://www.annemergmed.com/article/S0196-0644(06)02152-4/fulltext“.
Another pediatric clinical decision rule (2) suggests CT in children meeting the following criteria:
2. Skull defect
3. Sensory deficit
4. Mental status change
5. Bicycle-related injury
6. Age < 2yrs old
7. GCS <15
8. Evidence of a skull fracture
This one is challenging as it suggests to consider CT scans in all children under the age of 2!
In this case, the infant had a scalp hematoma, so a CT was clearly indicated. It revealed a chronic and acute subdural hematoma.
2. What is a rough estimate for the motor development of an infant?
When I was a resident at Cincinnati, I learned a rhyme that always helps me: “Eyes, mouth, head, hands, roll, sit, crawl, stand.” I call it the trick of the month club. Each month a baby should advance to the next milestone.
1. Eyes: First month baby should focus with eyes.
2. Mouth: Second month baby should have social smile.
3. Head: Third month baby should be able to hold head up by him/her self.
4. Hands: Fourth month baby should be able to grasp objects (not pincers using thumb, but grasp with whole hand)
5. Roll: Baby should be able to roll over by the fifth month.
6: Sit: By the sixth month baby should be sitting.
7. Crawl: Babies begin to crawl by the seventh month.
8. Stand: In the eighth month, babies should be able to stand.
This is only a rough estimation, Being off by one month doesn’t worry me. But if a baby is 2 months behind, I would be concerned. For example, if a 5 month old can’t hold his head up, I would be very worried about a developmental problem.
This can also be used to corroborate histories. There is no way a 2 month old would be able to roll over.
One last word of caution, if you try this on your own kids, and find that they are reaching their milestones ahead of schedule, it does not mean they are genius!
3. Should this be reported to child protective services?
This is always a challenge. This mom is a social worker, brought the child in immediately, and was straightforward with the history. On the other hand, there is no way this baby could have rolled off the table, and the baby had 2 injuries in different stages of healing! So yes, I did fill out the paperwork and report the situation to child protective services.
The conversation with the family is always a challenge, and if others have any pearls, I hope you pass it along. The way I approach it is:
“I know you want to be sure your child is safe and healthy. Because of the nature of this injury (2 traumatic injuries in different stages of healing) and because it’s not clear how this baby could have rolled off the table, by law I’m required to report this to child protective services. They will do their own investigation to be sure no one is hurting your baby.”
By not being judgmental, and noting that I’m required by law to report, it somewhat distances me from the reporting. I’ll be interested to hear how others approach this difficult discussion.
In this case, the mom was livid. She was very verbal about how she was insulted, and that reporting this was ridiculous. I was surprised as she was a social worker and should have realized that this referral was indicated.
Ultimately, the baby was admitted to the ICU for observation. He never required any surgery. Additionally, the neurosurgeon thought that the chronic subdural could have been from birth trauma (even though the vaginal delivery was uncomplicated). The child protective services investigation ultimately did not find any cause for concern, and the final theory was that the dog somehow jumped up on the table and knocked the baby off.
In hindsight, I would still report this. I would rather report a few non-abuse cases than miss even one.
1. Sun BC, Hoffman JR, MoweWR. Evaluation of a modified prediction instrument to identify significant pediatric intracranial injury after blunt head trauma. Ann Emerg Med March 2007, 49(3);325-332. Accessed at: “http://www.annemergmed.com/article/S0196-0644(06)02152-4/fulltext“
2. Atabaki SM, Stiell EG, Bazarian JJ, et al. A Clinical decision rule for cranial computed tomography in minor pediatric head trauma. Arch Pediatr Adolesc Med 2008 May;162(5):439-45. Accessed at: “http://www.ncbi.nlm.nih.gov/pubmed/18458190?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum“