Of all unintentional injuries, falls constitute the most frequent reason for visiting paediatric emergency departments in the United States, generating more than 2 million visits in patients aged less than 19 years in 2013.1

The injuries sustained in falls are among the main causes of death and permanent brain damage secondary to unintentional injuries. The rate of mortality is highest in infants aged less than 1 year and adolescents,2 in who falls are associated with a large number of hospitalizations and a considerable economic and social burden.

Despite the current recommendations of major research groups3 that support watchful waiting in cases of mild fall-related injury, the performance of diagnostic tests in the initial assessment of these patients continues to be a widespread practice in many paediatric emergency departments.

The aim of our study was to describe and analyze fall-related injuries in infants aged less than 1 year, their management in emergency departments, the resources used in its management and the factors associated with an increased use of resources.

We conducted a substudy in the context of a larger study on the epidemiology and risk factors of fall-related injuries in infants aged less than 1 year.4

It was a descriptive multicentre study. We included infants aged less than 1 year that had sought care for a fall in the emergency departments of 8 hospitals members of the Working Group on Unintentional Injuries of the Sociedad Española de Urgencias Pediátricas (Spanish Society of Paediatric Emergency Medicine), between March 1, 2014 and February 28, 2015.

The study was approved by the ethics and clinical research committee of each participating hospital.

Fall is defined as the act or effect of falling until hitting ground or a firm surface that breaks the movement.5

We collected data in a form that was filled out with the families of patients during their stay in the emergency department. The data were entered in an electronic database (Google Drive) that could only be accessed by the principal investigator of the study.

We included epidemiological data (age, mechanism of the fall, height of fall and whether the fall had been witnessed), the circumstances of the arrival to the emergency department (reason for visit, mode of transport and time elapsed since fall) and the management in the emergency department (specialist that cared for patient, type and location of injuries, diagnostic tests, interventions performed, patient destination after discharge from department and final diagnosis).

The data were analyzed with the statistical software SPSS 18.0. We described quantitative variables as median and interquartile range (IQR), and qualitative variables as absolute and relative frequencies; we made inferential analyses of qualitative variables using the χ2 test, using the Bonferroni adjustment for multiple comparisons. In the latter case, we have presented the overall p-values in the tables, and specified in the text the p-values for each pair of categories for which the differences continued to be statistically significant after the correction. We used the Student t-test for the analysis of quantitative variables. We assessed for independent risk factors for the performance of diagnostic tests, the presence of a skull fracture and the need for hospital admission by means of logistic regression. We set the p-value for statistical significance at less than 0.05.

The findings of this study allow us to analyze the emergency management of infants aged less than 1 year that seek care following a fall in paediatric emergency departments, and revealed a persisting tendency to perform skull radiographs and a moderate use of in-hospital resources in their management consisting of the performance of diagnostic tests, observation in emergency department, assessment by other specialists and admission to hospital.

In contrast, the use of out-of-hospital resources was scarce, as most patients sought care on the initiative of their parents and with their own resources, with referral from other health care settings amounting to only 9.5% and ambulance transport to 4.8% of the total. These findings were consistent with the results of a previous study conducted by the Sociedad de Urgencias Pediátricas, in which 96.3% of patients with mild head trauma reached the hospital through private means.6

One salient finding was the promptness with which caregivers sought an evaluation in the emergency department, with a median elapsed time since the fall of 1h, which has also been observed in previous studies.7 This may reflect an increased awareness of parents of the potential severity of fall-related injuries in this age group. Nevertheless, in our study we found that patients that fell from greater heights or whose falls were not witnessed, with mechanisms with a significant potential for injury, did not seek emergency care earlier. We did not find data in the literature regarding these factors.

Kendrick et al. also found no evidence that caregiver awareness of the potential for severe injury is associated with an increased use of preventive measures, and observed that parents of patients that had fallen from furniture were less likely to use safety gates and left infants on raised surfaces more frequently.8

Haney et al.9 also highlighted the absence of effective preventive measures, as 40% of children aged less than 2 years have experienced at least 1 previous fall from a height.

Paediatricians managed most patients, although other specialists were consulted to assess the child in 6.9% of cases, primarily in the area of neurosurgery (26; 2.5%). We did not find any previous studies documenting the need for evaluation by other specialists in children that had experienced a fall.

The proportion of patients that underwent skull radiography and head CT was similar to those reported by some studies,10–12 and slightly higher than that reported in others, especially when it came to skull radiographs.13 These tests were ordered more frequently in patients that presented with haematoma or signs of fracture in the physical examination, in those aged less than 3 months and, in the case of skull radiographs, in those who had fallen from heights of more than 1m. The univariate analysis also found an association with the mechanism of the fall, but this probably does not reflect an actual relationship – as demonstrated by the results of logistic regression – but rather the association of both age and fall height with fall mechanism. García et al. also found a more frequent use of skull radiographs in younger patients.6 We have not found works in the literature analysing the association of the use of diagnostic tests with fall height or fall mechanism.

In relation to this finding, we ought to note that international guidelines and various studies are increasingly questioning the need for skull radiographs in the initial evaluation of patients with head trauma. In spite of this, it continues to be frequently used in emergency departments for the purpose of ruling out skull fracture, which is significant risk factor for traumatic brain injury in infants. However, radiography has little predictive value in the detection of brain injuries compared to physical examination and clinical manifestations, and there is evidence that intracranial injury may be present in patients with normal radiographic findings.14 Even when radiography detects intracranial injury, only a small percentage of these patients requires neurosurgery.3

Although most of the fall-related injuries in our series were mild, we ought to note that fractures constituted the second most-frequent diagnosis, most of them skull fractures and in infants aged less than 3 months, with no association with the height of the fall. The incidence of skull fractures was similar to those reported in previous studies,6,11,13 although these works did not analyze the association between skull fracture and factors such as fall height, patient age or mechanism of injury.

Our study found a total of 16 patients with intracranial haemorrhage (1.5%), and brain injury in 22% of patients with skull fractures. The percentage of brain injury associated with skull trauma reported by other authors is slightly higher,3 which may be due to the fact that our study only included patients with fall-related injuries, excluding other mechanisms of injury such as motor vehicle accidents. The frequency of intracranial injury observed in our series was similar to the frequencies reported in studies with similar sample frames.11,15

Half of the patients presenting with intracranial haemorrhage were aged less than 3 years, and age was identified as a significant risk factor. Furthermore, 11 of the 16 cases of haemorrhage occurred in patients with parietal bone fractures, a type of skull fracture that was also significantly more frequent in this age group. However, there are other studies that have not found an increased risk of intracranial injury in children aged less than 2 years.6 One possible explanation is that the median age of the patients included in these other studies was greater, and that the authors did not carry out age-stratified analyses in children aged less than 2 years. We have not found any studies that included as many patients aged less than 3 months as ours.

In our series, 14 patients (1.3%) presented with clinically significant injuries (requiring neurosurgery, intubation of more than 24h, hospitalization of more than 48h, admission to the PICU or haemodynamic stabilization); none of them died. Kupperman et al.3 reported a prevalence of 0.9%, with an increased probability of clinically significant injury in the presence of certain prognostic variables. Similar percentages have been reported for Spain at the national level.6

On the other hand, only 12.2% of patients managed for falls were discharged without undergoing any intervention, while 86.7% required clinical observation and 2.9% some form of procedure (major surgery, suturing, immobilization/reduction or haemodynamic stabilization).

Furthermore, 6% (61) of the patients were hospitalised, of which 8 were admitted to an intensive care unit. There is variability in the percentages of hospitalization reported in the literature, with some studies reported rates similar to those in our study,11 and others reporting higher12 or lower13 rates, which may be due to differences in infrastructure and the availability of short-stay observation units. The rate of admission to the PICU was similar to those reported by other authors.6,13

The independent risk factors for hospital admission identified in our study were fall from height of more than 50cm and age less than 3 years. We did not find any studies in the reviewed literature analysing the association of these factors with the risk of hospitalization.

There are limitations to our study, for instance, that we did not consider the association between the clinical presentation and the ordering of diagnostic tests. However, the aim of our study was not to judge whether the use of diagnostic tests was appropriate, but to describe and analyze the actual characteristics and management of fall-related injuries in emergency departments in Spain. Other limitations include the variability that may stem from the different protocols at use in each hospital, the potential for missing data on patients that did not seek emergency care due to the seeming mildness of the manifestations, and the absence of a subsequent followup to analyze patient outcomes and detect events secondary to the fall that may have manifested at a later time.

Thus, we found evidence that while fall-related injuries in infants aged less than 1 year are not usually severe, they continue to be a frequent reason for the performance of diagnostic tests, especially in infants aged less than 3 years and falls from greater heights.

Infants are usually kept under observation in the emergency department, and a small proportion requires assessment by other specialists. Age less than 3 months and falls from heights of more than 50cm were independent risk factors for hospital admission, and management of such cases was associated with an increased use of in-hospital resources.

Infants aged less than 3 months constitute a high-risk group, with a significant incidence of secondary brain injury, so emphasis must be placed on the importance of appropriate preventive measures, striving to improve the knowledge of caregivers on potential fall mechanisms and the strategies that they can use to prevent them.

The authors have no conflict of interests to declare.