A CLINICAL DECISION-MAKING RULE FOR MILD HEAD INJURY IN CHILDREN LESS THAN THREE YEARS OLD
Public Health Significance: The objective of this study is to establish a clinical decision-making rule for mild head injury in young children, an extremely common type of injury seen in emergency departments. These children appear to respond differently to mild head injuries and face different developmental issues than do older children and management guidelines remain unclear.
Methods: Subjects were 97 children less than three years old with mild head injury (ICD9 codes 800-804 and 850-854) and an initial Glasgow Coma Scale score of 14 or 15, consecutively evaluated at a Level 1 Pediatric Emergency Department. Demographic, injury, symptom and treatment characteristics were abstracted from the medical records.
A classification and regression tree (CART) program was used to identify characteristics that were correlated with intracranial injury (ICI) among children in the study. The information garnered from the tree was used to construct a clinical decision-making rule for the evaluation of very young children with mild head injuries. A cost analysis was done to determine potential cost savings from the new decision-making rule.
Results: Forty-six percent of the children were less than 12 months, 24% were 12-23 months and 30% were 24-35 months old at the time of injury. Three-quarters of all injuries occurred from falls. Almost 25% of the children had evidence of an ICI on the CT scan; more than two-thirds of the ICIs occurred in children less than 12 months old (p=0.03).
We examined multiple CART models to assess the impact of different misclassification penalties and missing data. The main parent node on the final CART model was the presence of vision changes; splits also occurred with the presence of scalp lacerations, vomiting, the child being inconsolable, sex and area of residence.
Minor changes in the way children without ICIs are treated could result in cost savings as much as $90,000 per year.
Conclusion: While similarity exists between decision-making rules for older children and that found for this cohort, very young children have unique characteristics that merit further study and may require a separate decision-making process.
Advisor:Gary M. Marsh, Ph.D.; Thomas J. Songer, Ph.D.; Laura D. Cassidy, Ph.D.; Henri R. Ford, M.D.; Stephen R. Wisniewski, Ph.D.; Evelyn O. Talbot, Dr.P.H.
School:University of Pittsburgh
School Location:USA - Pennsylvania
Source Type:Master's Thesis
Date of Publication:09/27/2007