du Toit-Prinsloo, Lorraine MBChB; DipForMed(SA)Path; FCForPath(SA); MMed(Path)(Forens); Saayman, Gert MBChB; MMed(Med)(Forens); FCForPath
Injury is one of the leading causes of mortality and morbidity in children. Feickert et al1 (1977–1994) reported on a study conducted in Germany that “the mortality of children caused by trauma and head injuries is second only to congenital disease in developed countries.” On the other hand, Adesunkanmi et al2 reported a study from Nigeria (for the period 1992–1995), stating that most deaths in infants were because of infectious disease processes, but with trauma deaths (especially because of road traffic accidents as the external cause/circumstance of death) being the second most common cause of death. This difference between developed and developing countries has however been changing, with the World Health Organization (WHO) World Report On Child Injury Prevention (2004 data), indicating that also in developing countries, an increasing number of children are now dying from injury and that head injuries are the single most common type of fatal injury sustained by children.3 Danseco et al4 (1987–1994) reported (from Maryland) that injury rates increase with age and recorded higher nonfatal injuries among the 5-year-old to 9-year-old children, yet the rate for fatal injuries was higher among children aged 0 to 4 years.
John et al5 reviewed fatal pediatric head injuries over a 20-year period in Auckland. This study included all children up to 15 years of age who were admitted to the Coronial Service from 1991 to 2010. One hundred sixty-seven cases were identified and divided into accidental and nonaccidental causes of head injury. In the 126 cases of accidental head injury, the majority were because of motor vehicle accidents (including pedestrian accidents) (71%), with 9% caused by falls and 4% caused by blunt force trauma.5 Tabish et al6 reported that in India, the most common cause of head injury was falls (68.2%), followed by transportation accidents (28%), assault (2%), and injuries because of flying objects (2%). Head injury as a result of falls was stated to be the third leading cause of death in children aged 1 to 4 years, according to a study done by Hall et al7 from Chicago.
There appears to be minimal recent published literature on the fatal head injuries in the pediatric population. More current publications report on general trauma in children. Bratu et al8 (from Canada) reported specifically on pediatric trauma in the Aboriginal children. In the latter study, which was conducted from 1996 to 2010 (in all fatal traumatic deaths in children under 18 years), the Aboriginal children were over represented (30.9% of fatalities) with the most fatalities because of road traffic accidents.8 Head and cervical spine injuries were present in 69% of children.8 Pearson et al9 from Scotland reviewed fatal injuries in children under 14 years for 2002 to 2006. Their findings included that pedestrian and road traffic fatalities in the 0-year-old to 4-year-old age group accounted for 11% and 9% of injuries respectively.9
The possibility of nonaccidental causes (i.e., inflicted injury) of head injury should always be considered because this has been shown to be an important cause of death.10 John et al5 (1991–210) reported that there were 37 cases of inflicted injury among the total of 167 fatal cases reviewed in New Zealand. In the latter study, children who sustained inflicted injury were younger than the children who sustained accidental head injuries.5 There is an ongoing debate as to the validity and premises used for differentiating between inflicted (nonaccidental) injury and accidental head injuries. Goldstein et al11 stated that inflicted head injury should be considered when 1 of 3 parameters are present: inconsistency between the history and the clinical examination, retinal hemorrhages, or parental risk factors. More recently, Minns et al12 (Scotland, 2012) conducted a prospective study on children with retinal hemorrhages and concluded that “a young age and a high dot-blot count are strong predictors of inflicted traumatic brain injury.” Controversy continues to surround the pathogenesis and nature of injuries associated with the “shaken baby syndrome.”13 Scheimberg et al14 suggest that a more appropriate term would be the one initially described by Guthkelch, being that of “retinodural hemorrhage of infancy” and that more research is needed to fully understand the anatomy and physiology of the dura in infancy.
There appears to have been only one published report on severe head injury in children in South Africa, provided by Semple et al.15 This study included 102 children younger than 14 years of age who had been admitted to the Red Cross Memorial Children’s Hospital (Cape Town) and who presented with a Glasgow Coma Scale of less than 8.15 There were 57 male and 45 female patients, and the majority of the head injuries were the result of transportation-related accidents (83% of victims were pedestrians).15 Falls accounted for 11% of the cases. The author then emphasized that head injury in children in South Africa can be described as “a silent or forgotten epidemic”.15
According to the official South African governmental statistics agency (StatsSA), the leading cause of death in infants (in the postneonatal group) and in children aged 1 to 4 years in 2011 was intestinal infection (14.1% and 17.6%, respectively).16 Nonnatural causes accounted for 2.7% of deaths in infants and 12% of deaths in children between 1 and 4 years.16 In another publication from Statistics South Africa which reviewed road traffic accident deaths for the period 2002 to 2006, the age-specific accident rate in the children aged 0 to 14 years was stated as 3.89 per 100,000.17 It may be postulated that there is greater accuracy of statistics pertaining to cases of nonnatural death because these deaths are routinely subjected to (medicolegal) autopsy, whereas statistics regarding natural causes of death may be less reliable because these depend almost exclusively on clinical diagnoses supplied on death notification forms.
A comprehensive search on Pubmed yielded no published articles reporting specifically on fatal head injuries in children in South Africa. The current study was undertaken in an attempt to establish a profile of fatal head injuries in children younger than 5 years, who were admitted to a large urban medicolegal mortuary, situated in Pretoria (the capital city of South Africa), over a 5-year period.
This study comprised a 5-year retrospective descriptive review (January 2004 through December 2008) of all children under the age of 5 years who were admitted to the Pretoria Medico-Legal Laboratory (PMLL) and in whom the attending forensic pathologist/forensic medical officer ultimately formulated the cause of death as having been caused by head injury. All cases where multiple injuries had been sustained and where a head injury was part of the injuries sustained, but not specified in the cause of death, were excluded from the study.
The following data were recorded from the case files, registers and data forms (including the National Nonnatural Injury Surveillance System forms18):
- Demographic details (including race, sex, and age)
- External cause/circumstances of injury (i.e., fall, road traffic accident, blunt force application, gunshot wound, etc.)
- Whether or not the deceased had been hospitalized (including the duration of hospitalization, where applicable)
- Whether or not any surgical procedure was conducted
- The pathological findings pertaining to the scalp, skull and intracranial structures.
Statistical evaluation of data was done using the SPSS (version 17.0) program, in conjunction with the Department of Biostatistics at the Medical Research Council.
Prior approval to conduct the study was obtained from the Research and Ethics Committee of the Faculty of Health Sciences at the University of Pretoria.
A total of 107 cases were identified for inclusion in this study. The number of cases per year varied from 15 to 28. Over the study period, the annual total number of children under the age of 5 years who were admitted to the PMLL varied from 93 to 150 cases (with an average of 125 cases per year). The overall total annual case load (all admissions) at the mortuary varied from 2253 to 2461 (with a cumulative total case load of 11,768). Deaths caused by head injuries in children under the age of 5 years accounted for approximately 16% of children under the age of 5 years who were admitted to the mortuary and comprised an average of approximately 1% of the total annual mortuary admission case load.
There were 60 males (56%) and 47 females (44%). The highest number of fatal head injuries were seen in children under 1 year (24 cases), with 50% of these children being aged between 2 and 4 months (see Fig. 1).
External Cause/Circumstance of Death
The external cause/circumstances of death are depicted in Table 1. The majority of deaths were because of road traffic accidents, being 75 cases (70%). Of these, pedestrian victims accounted for 35 cases (47%) and passenger occupants for 30 cases (40%), whereas in 10 cases (13%), the type of road traffic accident was unknown. Forty-one of these fatally injured children were younger than 3 years (and with half  of this subset being vehicle occupants).
Head injuries caused by falls ranked second, with 11 fatal outcome cases (10%). These included 6 falls (55%) from a height, 4 from a bed (36%), and 1 (9%) from a tree. Ten cases (9%) were the result of blunt force injury (including 4 cases of gates falling on children: 1 case where a wall collapsed on a child, one where a motor vehicle wreck fell on the victim, 1 victim suffering a kick by a horse, and 1 assault). Gunshot wounds accounted for 4 cases (4%) of head injury. Three of the gunshot fatalities were victims of family murders (in 2 separate incidents). There were 4 neonates who sustained fatal birth-related head injuries. Of interest is that only 1 case was admitted to our facility as a possible victim of suspected physical abuse. In this case, the medicolegal autopsy confirmed the presence also of other injuries (of differing ages), in keeping with the diagnosis of nonaccidental injury syndrome.
Cause of Death in Infants Under 1 Year of Age:
The causes of death in the 24 infants who were under 1 year were as follows:
- Road traffic accidents—13 cases (1 pedestrian, 8 occupants, and 4 unspecified cases);
- Falls—3 infants who allegedly fell from a bed;
- Birth-related head trauma—4 cases;
- Other forms of blunt force trauma—2 cases (1 motorized gate which fell on the infant and 1 case where the father allegedly assaulted the infant);
- Unspecified—2 cases.
Fatal Head Injury Caused by Falls
These cases were included on the basis of initial history received at the mortuary, but with no detailed or further evaluation of the history or scenes. Table 2 displays the age of the infants and the height from where the fall occurred.
Neuropathological Autopsy Findings
The most frequent anatomic injury which was recorded in the autopsy reports was that of skull fracture (seen in 80% of sample cases), followed by scalp injury (78%). In most cases, there was concurrent involvement of both the vault and base of skull vault (45 cases [42%]—refer Table 3). The nature of recorded intracranial injuries seen at autopsy is depicted in Figure 2. Epidural hemorrhage was recorded in 5 cases (4.6%—refer Table 4) and subdural hemorrhages in 39 cases (36%—refer Table 5). Subarachnoid hemorrhage was seen in 77 cases (72%). The entire brain was retained in 5 cases (5%) for fixation and neuropathological evaluation, with histological examination being performed in 8 cases (7%).
Most victims died at the scene of injury (51 cases; 48%). Nine cases (8%) were declared dead on arrival at the emergency room, and a further 18 patients (17%) demised in the emergency room. Twenty-nine patients (27%) had hospital admission, with the duration of hospitalization ranging from 3 hours to 14 days. In 15 of the latter cases surgical (cranial) procedures were carried out (trepanation in 8 cases, craniotomies in 6 cases, and fixation of the skull in 1 case).
Mechanism/Mode of Death
The forensic medical practitioner specifically recorded the mechanism (mode) of death in 12 of the 29 victims who had undergone hospitalization. In a further 10 cases in this group, the mechanism/mode of death could be deduced from the post mortem report. Features of raised intracranial pressure were recorded in 17 cases (59%), bronchopneumonia was diagnosed in 4 cases (14%), and aspiration of blood and meningitis were considered to be the mechanism of death in 2 cases (7%) each. In the majority of cases where a specific mechanism of death was not recorded, the child had died at the scene of injury.
Manner of Death
In South Africa, the manner of death is a legal function and is ultimately recorded by the presiding judicial officer at legal proceedings (inquest magistrate, judge, etc.). However, forensic pathologists are routinely asked to comment on the apparent manner of death at the time of conducting the autopsy (for statistical purposes only). The majority of the cases were thus classified by the attending forensic medical practitioner as being accidents (98 cases; 91%). Six cases were recorded as homicides and included 1 case of assault, 4 firearm fatalities, and 1 case of nonaccidental injury syndrome (see Table 6).
The WHO report on child injury prevention states that head injuries are “the single most common—and potentially most severe—type of injury sustained by children.”3 The latter report indicates that intracranial injury (specifically traumatic brain injury) constitutes 16.3% of unintentional injuries sustained by children up to 15 years of age.3 In our study, fatal head injuries in children under 5 years occurred mostly in infants (children less than 1 year of age). This correlates with the previous study done by Semple et al.15 In the study reported by John et al5 in Auckland, the majority of inflicted head injuries were sustained in children under 2 years.
Fatal head injuries in children under 5 years at the PMLL accounted for nearly 1% of the total (admission) case load and comprised 16% of all admissions of children on the under 5 years age group. There was no discernible sex distinction among victims in the present study. In a study by Wang et al,19 it was reported that boys might be more active and may have a higher frequency of participation in different types of activities and that they may be more curious than girls, thus rendering them more susceptible to (head) injuries.
Road traffic accidents were by far the most common external cause/circumstance of death, accounting for 75 cases (70%) of fatal head injury. This correlates with the previous study done by Semple in Cape Town.15 John et al5 (Auckland) also reported the majority of accidental head injuries in children to be the result of road traffic accidents. The WHO report on “Children and road traffic injury” states that in 2004, children accounted for 21% of all road traffic fatalities, most of these occurring in low-income and middle-income countries.20 The latter report stated that as pedestrians in high income countries, children accounted for 5% to 10% of all road traffic deaths and in low income countries, 30% to 40%.20 In our study, more than 50% of children sustaining fatal head injury as a result of a road traffic accident were under 3 years of age, with 50% of them being passengers in vehicles. Legislation in South Africa pertaining to the mandatory use of vehicle restraint mechanisms in children is provided by the National Road Traffic Act 93 of 1996 (in the National Road Traffic Regulations, 2000), where Section 213(1)(b) defines a child as being a person aged from 3 to 14 years. Surprisingly, no provision is made in this legislation for the mandatory use of restraint mechanisms in children under the age of 3 years. Section 213(6) and (7) stipulate that children in motor vehicles should be in a proper child restraint, if the latter is available, otherwise the child should be on the back seat and the normal seat belt should be used as restraint. It would appear that the findings of this study (showing a high incidence of fatal head injuries in children under the age of 3 who were involved in road traffic accidents) warrant urgent review of the legislation. Many international studies (including Lennon et al21 in Australia and Braver et al22 in the United States) have indicated that the proper use of restraints and the seating position of children in motor vehicles can dramatically reduce the mortality rate in these instances. Stricter rules and more stringent application of existing measures are thus called for in South Africa.
Falls accounted for 11 cases (10%), being the second leading external cause resulting in fatal head injury cases admitted to the PMLL. Hall et al7 (Chicago) reported that falls were the third leading cause of traumatic deaths in children aged 1 to 4 years. The mean age of children who died from accidental falls in the latter study was 2.3 years, and 41% of these falls were considered to have been “minor” falls, with delays in seeking medical attention being present in 38% of cases.7 John et al5 reported from Auckland that falls accounted for 9% of accidental fatal pediatric head injuries and 38% of inflicted pediatric head injuries in their study. All the falls in our study were deemed to have been accidental in nature, but we were not in a position to further corroborate this, and the information regarding height of fall, nature of surface of impact, and versions provided by informants or investigators cannot be validated. Deaths resulting from short falls in children remain a problematic area for forensic pathologists, and the differentiation between accidental and homicidal injury can be very difficult to ascertain. Fujiwara et al23 (Japan, 2001–2005) reviewed the validity of reports provided by caregivers after children sustained short falls. They concluded that children sustaining short falls may indeed present with severe head trauma and that the “validity of caretakers’ report on infant or young child’s head trauma caused by falls is low”.23 Ibrahim et al24 (Philadelphia,2012) reviewed children under the age of 4 years who had sustained accidental head injury in a fall and found that there were age-related differences in the nature of injuries sustained. This study found skull fractures to be more common in infants (79% of cases) than in children aged 1 to 4 years (39%). They also indicated that falls from a low height (≤3 ft) resulted in primary intracranial injury without scalp or skull injury in 6% of infants and 16% of toddlers.24
We identified 6 cases of homicide for inclusion in our study sample: 4 of these fatalities were because of gunshot wounds, with 3 of these coming from 2 homicide-suicide events. Byard et al25 (1968–1998) have reported on children involved in murder-suicide cases, stating that when the father was the perpetrator, they tended to kill the children and the adult in the relationship. One of our homicide cases was the result of inflicted blunt force trauma, with a father striking the victim with a bottle. In 1 case, the circumstance/cause of injury was established as being related to nonaccidental injury syndrome.
South Africa does not have a national registry for recording of injuries to pediatric patients to provide surveillance of individual cases or broader injury patterns.26 A fatal outcome constitutes only a small portion of children who suffer head injuries. The WHO report on child injury prevention indicates that the severity of the problem of head injuries in children may be measured in mortality, hospital admissions, emergency department visits, and days lost from school.3 Data from the Global Childhood Unintentional Injury Surveillance report indicate that nearly 50% of children under 12 years who sustained an unintentional head injury was left with a degree of disability.3 The only specific legislation in South Africa, which currently applies to the monitoring of injuries in children, is found within the Childrens’ Act (Act no. 35 of 2005), which stipulates that child abuse (or suspicion thereof) must be notified to the authorities. There is no legal obligation to record or report other injuries which a child may have sustained, for purposes of implementing individual or collective preventative measures or strategies.
There is a paucity of published research regarding childhood injuries in South Africa, particularly also in respect of the profile and nature of serious head injuries. This study suggests that fatal head injury in children under the age of 5 years constitutes nearly a fifth of children in this age group admitted to medicolegal mortuaries in an urban environment in South Africa. Children under the age of 1 year were seemingly at greatest risk. Road traffic accidents account for most of these deaths, with falls being the second most prevalent circumstance of injury. Half of road traffic fatality cases were pedestrians. Review of existing legislation regarding measures to protect young children from injury in road traffic accidents appears to be indicated. The implementation of mandatory child injury registers may help to extend injury surveillance into clinical domains. Establishing regional or national multidisciplinary child death review programs may also contribute to our understanding of the scope and nature of this problem and may allow for the implementation of interventional programs and measures to minimize the risk of injury to these most vulnerable members of society.
The authors thank Ms. Lieketseng from the Medical Research Council who aided in the initial statistical analysis of the data. The authors also thank Ms. TP Phasha for the drafting of the research protocol.
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