Young children aged 0–4 years have the most emergency department (ED) visits for traumatic brain injury (TBI) among all pediatric age groups; falls are the leading cause of injury (1). Infants are more likely than other age groups to sustain a fractured skull injury after a fall due to their lower structural rigidity and presence of sutures (2-4). Although falls may be the initial parent explanation for the ED visit, that report may not always be accurate (5). Examining the circumstances of these head injuries, especially in infants and young children who are unable to provide a report of what happened, is important (6,7). A previous study that examined fall-related TBI ED visits in young children (aged 0–4 years) and the actions associated with the falls, found that most were 1 year or younger (59.7%) and were treated and released from the ED (93%) (5). Most children were classified as having had an internal injury to the head (87.7%) or concussion (9.6%); however, a small percentage of children were diagnosed with a fractured skull (2.7%), potentially indicating a more severe injury. Among children between the ages of 0 and 4 years, the circumstances leading up to the fall were most often associated with actions of the child (87.5%), for example, running, jumping, and tripping. Only 12.5% were caused by the actions of others. However, actions by others were the leading cause of fall-related TBI ED visits (59.7%) for children younger than 1 year. Most of the injuries in the age group from 0 to 4 years occurred in the home. The data source used for this study did not allow for examining fall biomechanics, such as fall height, or clinical features, such as additional injuries, as contributors to injury severity (8).

Head injuries in young infants (aged 0–4 months) are likely related to actions by others because infants at this age are in a developmental stage of motor development with limited self-movement. Clinical diagnosis of intentional and unintentional head injuries is influenced by several factors that include presence of a skull fracture, age, mechanism of injury, presence of seizures, retinal hemorrhage, and other fractures, such as ribs and long bone fractures (9-13). The presence of skull fractures in young infants is one of the most common diagnoses of abusive head trauma (AHT) in children younger than 3 years and can be a predictor of an intentional injury that requires further examination at the time of evaluation (10, 11, 13). Although falls are the most common injury mechanism reported for young children who report to the ED, the circumstances around the fall are not always reported (1,8). Recent research indicated that when no mechanism of injury is reported by the caregiver, there is an association with AHT (10). Therefore, understanding the circumstances of fall-related fractured skulls can offer insights into why such actions may contribute to injuries in this age group.

The biomechanics of injury-related severity and complexity in young children is related to fall height and surface of impact (2,3,4,14). In a recent study that evaluated stress indicators in witnessed infant falls, findings indicated a lower probability of a fractured skull in infants from a 0.3-m distance, particularly when a carpeted surface was involved and a higher probability of a fractured skull in infants from a 0.9-m distance fall for concrete impact (86–100%) (4). This study highlights the importance of biomechanical parameters to predict skull fracture in infants. In a study examining head kinematics during shaking associated with AHT in animal models, peak accelerations occurred when the animal’s head hit the torso and produced high-acceleration magnitudes (15). These studies highlight the importance of biomechanical parameters, fall heights, and type of impact surfaces or floorings to predict the probability of skull fracture occurrence in infants and illustrate the importance of understanding the circumstances surrounding the injury when an infant is receiving a medical evaluation.

The purpose of this study was to examine adult actions and products associated with infant falls among a large nationally representative sample. Better insight into circumstances and actions related to these injuries could aid in preventing future fall-related fractured skulls among infants. Findings can also inform health care providers about what to examine when evaluating infants in this age group and can focus communication on prevention efforts. It can also provide insight into whether the injury was unintentional or intentional. The purpose of this study was to examine actions and products associated with nonfatal ED visits for unintentional fall-related fractured skulls among infants aged 0–4 months.

This study examined a nationally representative database between 2001 and 2017 to better understand caregiver actions and products related to fall-related fractured skulls in infants aged 0–4 months, an age when they are beginning to gain ability to move in their environment. Findings indicate that most injuries occurred in the home and that most infants with fractured skulls were hospitalized. The primary actions leading to these falls were placing an infant on a surface, followed by dropping and then carrying an infant. Floor surfaces were the leading product related to the fall. This study aligns with findings from a previous study that reported actions by others were the primary cause of TBI-related falls, resulting in an ED visit for children younger than 1 year (8). When young infants present to the health care setting for care with a TBI, clinical screening and a comprehensive examination that includes an understanding of the biomechanics of the injury (i.e., fall height and impact surface) can also provide insight into the circumstances of fall-related skull fractures in infants, safe practices, and fall prevention education.

As we learned from our results, most injuries occurred in the home, a common location of injuries for young children, as noted in other studies (8,20,21). In the home environment, care supervision practices, such as attention, proximity and continuity, and environmental hazards are key determinants of injury risk (1). Parents may lack experience caring for a new baby when first bringing their baby home from the hospital after birth, and lack sleep due to the nature of newborn behavior, which could influence their decisions about where to place or how to carry the infant. However, parent status related to falls (i.e., fatigue) was not indicated in this dataset. A newborn safety bundle, combined with education, is a prevention method that involves wrapping the infant in a sleep sack bundle. It is designed to promote safe sleep and to minimize fall risk and is initiated in the hospital setting. This can be an important first step in parent education about safe sleep and attending to the infant (22). Home safety interventions are most commonly provided as one-to-one, face-to-face education and are effective in increasing many safety practices (21,23,24). Evidence shows that such interventions may reduce injury rates, particularly those provided at home (24). Future studies might examine the content of injury prevention messages provided by pediatricians related to infant fall prevention, through both verbal and written instruction during well-check visits. Furthermore, examining the degree of universality of these messages and how often they are repeated across visits may be beneficial.

Falls are frequently a reason young children visit the ED, and although this may be the initial parent explanation for the visit, as indicated in previous studies, their description may not always be complete or accurate (5-7,25-27). Recent research also reports that when no mechanism of injury is reported by the caregiver, there is an association with AHT (10). Based on our examination of caregiver actions, a fall in this young age group warrants further examination of the infant and circumstances of the fall. Although our study focused on unintentional injuries, a fractured skull in this group (where independent mobility is extremely limited) is one of the most common signs of AHT, and child physical abuse is also a mechanism that can cause a fractured skull (5,6, 10,11,24-27). Clinical tools for health care providers, such as PredAHT (Predicting Abusive Head Trauma) can identify AHT symptoms at the time of the health care visit, which can influence a clinician’s probability estimates of the trauma in children younger than 3 years who present with intracranial injuries (28,29). Further examining children helps to determine health history, presence of seizures, retinal hemorrhage, and other orthopedic injuries (9-13).

Injury severity and complexity in young children is related to fall height and surface of impact (2-5,25). Although the current study could not identify fall height in the narratives, findings reported from the biomechanics literature offer insight and can inform a more comprehensive assessment for circumstances related to the fall for medical providers. When examining the biomechanics of children’s falls, research supports that even "short falls" (often defined as <5 ft) may be used as explanations for unintentional injuries that are in reality AHT (7,10).

A recent study found that infants were most likely to fall onto floors, which may also contribute to the likelihood of a skull fracture (4). Infants falling from a 0.3-m distance were less likely to sustain a fractured skull, particularly when the fall occurred on a carpeted surface (4). Studies on the biomechanical aspects of falls illustrate the importance of understanding the circumstances surrounding the injury, including fall height, additional injuries, and type of impact surface when an infant is receiving a medical evaluation (27).

Because of their risk of abusive head trauma, health care professionals examining the infant at the time of injury need to conduct a comprehensive assessment at the time of injury that includes a better understanding of injury circumstances. Pediatric health care professionals in contact with caregivers of young children can provide education about the importance of care supervision practices that promote safety when carrying and placing an infant in the home.

When parents leave the hospital after childbirth, education about attending to and placing infants in a safe space, such as their crib, and how to safely carry an infant to prevent dropping could prevent infant falls. Pediatricians can also educate parents about fall prevention during well visits for young infants. Although there is some information available for parent education, how universal and frequently these messages are communicated and if they are effective for prevention is unclear. There is a lack of evidence-based fall prevention strategies for infants. The fall prevention methods pediatricians and other health care specialists currently discuss with new parents are not well understood and require further investigation to ascertain what information is provided to new parents and caregivers (22,24,30,31).