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INTRODUCTION — Head trauma occurs commonly in childhood. Most head trauma in children is minor and not associated with brain injury or long-term sequelae. However, a small number of children who appear to be at low risk may have an intracranial injury.
The goal of the evaluation of children with minor head trauma is to identify those with traumatic brain injury (TBI) and prevent deterioration and secondary injury, while limiting unnecessary radiographic procedures. Imaging, usually with computed tomography (CT), is highly sensitive for identifying brain injury requiring acute intervention. However, clinical predictors for intracranial injury are often nonspecific, particularly in young children.
The epidemiology of head trauma in infants and children, the incidence of TBI, clinical features of head-injured children with and without brain injury, and the evaluation and management of infants and children with mild head trauma are presented here. Severe TBI in children and adolescents, concussion and mild head trauma in adolescents, and inflicted head trauma in children are reviewed separately. (See "Initial approach to severe traumatic brain injury in children" and "Concussion and mild traumatic brain injury" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)
Minor head trauma
Children younger than two years of age — Minor head trauma is generally defined separately in children younger than two years of age for the following reasons [1,2]:
Experts define minor head trauma in this age group as a history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or child who is alert or awakens to voice or light touch .
Children two years of age and older — The definition of minor head trauma for children two years of age and older has often been based on the Glasgow Coma Scale (GCS). Some have defined minor head trauma as a GCS score of 15, whereas others have included children with scores ≥13 (table 1) [3,4]. However, the rate of traumatic brain injury in children with a GCS of 13 is as high as 20 percent.
Thus, for the purposes of this discussion, we define minor head trauma in previously healthy children two years of age and older as follows:
Children who meet this definition of minor head trauma have a GCS score of 15.
Mild traumatic brain injury — Mild traumatic brain injury (TBI) is generally associated with symptoms such as a brief loss of consciousness, disorientation, or vomiting. (See 'Clinical features' below.) Like minor head trauma, patients with mild TBI usually have GCS scores of 13 to 15, measured approximately 30 minutes after the injury. In comparison, patients with moderate TBI generally have initial GCS scores between 9 and 12, whereas those with severe injury have GCS scores ≤8 .
Concussion is often used as a synonym for mild TBI. (See "Concussion and mild traumatic brain injury", section on 'Definitions'.)
Concussion — Concussion has been defined by the American Academy of Neurology as any traumatically induced disturbance of neurological function and mental state, occurring with or without actual loss of consciousness.
Subsequent clinical manifestations following a mild concussion may be as subtle as headache or vomiting. Other more severely affected children may have significant but self-limited symptoms including loss of consciousness, amnesia, and altered mental status. The onset of impairment is rapid, but usually short-lived, and generally resolves spontaneously. The presence of an abnormality consistent with intracranial injury on CT scan precludes the diagnosis of a simple concussion. However, a CT is not necessary to make the diagnosis of concussion.
A detailed discussion of the clinical features of concussion and the grading of concussive injury is found elsewhere. (See "Concussion and mild traumatic brain injury", section on 'Clinical features' and "Concussion and mild traumatic brain injury", section on 'Sequelae'.)
EPIDEMIOLOGY — Head trauma occurs commonly in children. Among children 0 to 14 years of age, traumatic brain injury (TBI) accounted for approximately 435,000 emergency department visits and 37,000 hospitalizations annually between 1995 and 2001 . In developed countries, TBI is the most common cause of death and disability in childhood . Approximately 3000 children die each year of head injuries in the United States [8,9].
Most children with head trauma are young, male, and have a mild injury. This was demonstrated in a large prospective series that described minor head trauma in children in the United Kingdom . Fifty-five percent of children were younger than five years of age, with 28 percent younger than two years of age. Boys accounted for 65 percent of patients, and 98 percent of children had Glasgow Coma Scale (GCS) scores of 15. Other series of children with head trauma have reported lower GCS scores, but many of these describe selected populations, such as children with head injury who had neuroimaging performed [11,12].
MECHANISM — Falls are the most common mechanism of injury for children sustaining minor head trauma, followed by motor vehicle crashes, pedestrian and bicycle accidents, projectiles, assaults, sports-related trauma, and abuse [10,13]. These mechanisms cause isolated head trauma in the majority of patients .
Infants sustain more falls and are at increased risk for inflicted injury. It is of utmost importance to identify children who have sustained an inflicted head injury, even if the injury is minor. Children who remain in the care of the alleged perpetrator are at significant risk for being injured again. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Eye findings in children with abusive head trauma (AHT)".)
PATHOPHYSIOLOGY — Brain injury can occur following a minor head trauma because rotational acceleration-deceleration of the head generates shearing forces that cause mechanical disruption of nerve fibers, resulting in diffuse axonal injury. This process has been described in association with severe brain injury and occurs in mild traumatic brain injury (TBI) as well. Whether or not this pattern of injury differs in the developing brain is uncertain . (See "Concussion and mild traumatic brain injury", section on 'Pathophysiology'.)
The type of mechanical forces applied to the brain may determine, to some extent, the nature of the resultant injury [15,16].
Mild TBI usually occurs with head trauma due to contact and/or acceleration/deceleration forces.
INCIDENCE OF INTRACRANIAL INJURY — The true incidence of intracranial injury following minor head trauma is unknown. Most studies providing incidence data are from selected populations in which children with moderate to severe injury are overrepresented (for example, including only children who have had computed tomography (CT) or primarily children with nontrivial trauma) [11,12,17,18]. Consequently, the risk of intracranial injury in these series may be overestimated.
Estimates of the incidence of intracranial injury following head trauma from selected populations are summarized as follows:
Data from two European populations suggest that the incidence of intracranial injury after minor head trauma is much lower (0.6 to 1.2 percent). However, only 2 to 3 percent of patients in these studies underwent neuroimaging [26,27].
Patients with shunts or bleeding disorders — Although the threshold for obtaining neuroimaging after minor head trauma in patients with ventricular shunts or bleeding disorders is lower for many clinicians, it is not clear that serious intracranial injury after minor head trauma actually occurs more frequently than in normal children. As an example, in planned secondary analyses of a large multicenter observational study of children with minor head injury, approximately 1 percent of children with either ventricular shunts (98 children) or bleeding disorders (230 children) had a clinically important injury (eg, head injury resulting in death, neurosurgery, intubation >24 hours, or hospital admission >2 nights) compared with 0.9 percent of the approximately 40,000 normal children [28,29]. However, with the low numbers of patients in these studies, the true frequency of intracranial injury following minor head trauma in children with bleeding disorders or ventricular shunts could be as high as 4 to 5 percent, respectively. Furthermore, the rate of clinically important intracranial injuries seen in children with bleeding disorders occurred despite significantly fewer severe mechanisms of injury when compared with normal children .
CLINICAL FEATURES — Similar to reports of the incidence of intracranial injury, some studies that describe clinical features following minor head trauma only included children who underwent head CT. Consequently, these data also likely represent children whose injuries were more severe.
Common clinical features — Two large prospective observational studies have identified the following common features associated with minor head trauma in children [13,26]:
Seizures — Among unselected populations of children with head trauma, immediate post-traumatic seizures occurred in ≤0.6 percent [26,27]. In smaller, heterogeneous series, seizures have been reported in approximately 3 to 8 percent of patients [4,17,31].
Skull fractures — Skull fractures are not uncommon following minor head trauma in children, particularly in those younger than two years of age [3,32]. The vast majority of skull fractures are linear. Among children with linear skull fractures, 15 to 30 percent have associated intracranial injuries [1,17,18,25,33,34].
Most children with skull fractures will have overlying scalp hematomas, but most scalp hematomas in older children are not associated with skull fractures. In infants younger than the age of one year, increased scalp hematoma size and location in the parietal or temporal areas suggest a higher incidence of skull fracture. In one prospective series, no child with a frontal hematoma had an intracranial injury . Skull fractures in children are discussed in greater detail separately. (See "Skull fractures in children".)
Other clinical features — Transient cortical defects, such as cortical blindness and acute confusional states, have been reported in association with minor head trauma [35-37]. These deficits are thought to be secondary to vascular hyperreactivity and may be trauma-induced, migraine-equivalent phenomena. There are case reports of stroke following mild head trauma in children [38,39].
EVALUATION — The goal of the evaluation of children with apparently minor head trauma is to identify those with traumatic brain injury (TBI) who may require immediate intervention (as with an epidural hematoma) or close follow-up (as with a concussion), while limiting unnecessary neuroimaging procedures. In addition, children who may have sustained an inflicted injury must be identified. The evaluation of nonaccidental injury is discussed in detail elsewhere. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children".)
Features of the history and physical examination, along with selective neuroimaging, generally identify children who have sustained a brain injury with acute management implications.
History — Historical features that may suggest an increased risk of intracranial injury include the following:
Physical examination — Vital signs and evidence of associated extracranial injury, such as neck or abdominal tenderness, should be noted. In addition, a neurological examination (including mental status) should be performed. The presence of the following specific findings is significant (see "Classification of trauma in children"):
INDICATIONS FOR NEUROIMAGING — As a general rule, children with head trauma who are at risk for intracranial injury should be initially imaged with computed tomography (CT). Head CT identifies essentially all children with intracranial injuries requiring acute intervention . Plain radiography is of little or no added value if a head CT is performed.
Skull radiographs may be indicated when the history of trauma is uncertain (eg, skeletal survey in the evaluation of suspected abuse), to rule out the presence of a foreign body, or, rarely, to screen for fractures in selected asymptomatic patients 3 to 24 months of age with concerning scalp hematomas. However, skull radiographs should only be performed if a radiologist with pediatric expertise is available to provide an interpretation because physicians with pediatric emergency expertise may have limited accuracy in correctly identifying skull fractures in young children . If a screening skull radiograph shows a fracture, then a head CT should be performed. (See "Skull fractures in children", section on 'Radiologic evaluation' and 'Incidence of intracranial injury' above.)
Among children with minor head trauma, the incidence of injuries that require neurosurgical intervention is very low. (See 'Incidence of intracranial injury' above.)
Nevertheless, in the United States, the use of CT for the evaluation of children with head trauma has been increasing. This was demonstrated in a report of a cross-sectional analysis describing children with head trauma identified from a national database of hospital emergency department and outpatient department visits . The use of CT increased from 13 percent to 22 percent from 1995 to 2003, with a peak of 29 percent in 2000.
Since 2003, two large prospective cohort studies in pediatric referral emergency departments in the United States and Canada found that 35 to 53 percent of children with minor head trauma underwent head CT [13,22]. Children evaluated for closed head injury in US general emergency departments are about twice as likely to have head CTs performed as those seen in a pediatric hospital .
The decision to obtain neuroimaging for children with minor head trauma must balance the importance of identifying significant, but rare, injuries with the risks of CT. The estimated lifetime risk of cancer mortality from a head CT is substantially higher for children than for adults because of a longer subsequent lifetime and the greater sensitivity of some developing organs to radiation [43-48]. In addition, some children may require sedation in order to obtain an adequate study. (See "Approach to neuroimaging in children", section on 'Radiation' and "Procedural sedation in children outside of the operating room", section on 'Adverse outcomes'.)
Although children with ventricular shunts and bleeding disorder may have a predisposition to intracranial injury and many clinicians have a lower threshold for performing head CT for these patients, the risk of a clinically important finding after minor head trauma is still only 1 percent. (See 'Patients with shunts or bleeding disorders' above.)
Predictors of intracranial injury — No single clinical feature reliably predicts children with minor head trauma who have an intracranial injury and therefore should receive neuroimaging.
Observational reports from selected populations have consistently described skull fracture, focal neurologic examination, and depressed mental status as significant predictors of children who are at high risk for intracranial injury [19,26,27,49-51].
Variable significance has been reported for seizures, loss of consciousness, amnesia, vomiting, age less than two years, trauma mechanism (eg, bicycle-related injury), scalp bruise or swelling in children <1 year of age, and headache [19,27,49-53].
A multicenter, prospective observational study has derived and validated prediction rules for children at very low risk for clinically important traumatic brain injuries (ciTBI) in a cohort of 42,412 children younger than 18 years of age who had a Glasgow coma score of 14 to 15 and were evaluated within 24 hours of head trauma . The definition of ciTBI included neurosurgery, endotracheal intubation for more than 24 hours, and hospitalization for more than two nights (table 2):
Head CT was obtained in 14,969 patients (35 percent). Twenty-five percent of children younger than two years of age (N = 835) and 20 percent of children 2 to 18 years of age (N = 2438) had a head CT despite having a very low risk for ciTBI based on the prediction rule. These findings, when combined with evidence from prior observational studies [51,54], suggest that the use of low-risk criteria and judicious observation of patients in lieu of head CT can allow the clinician to avoid head CT in a significant number of children undergoing evaluation for minor head trauma without missing clinically important intracranial injury. Furthermore, this decision rule is clear and relatively easy to implement. As an example, in an implementation study of this decision rule in 356 children with minor head injury (46 percent under two years of age), adherence to the rule was 94 percent and provider satisfaction was high . Although the rate of CT was not significantly different before and after implementation of the rule in this study, the baseline rate for head CT was already low (7 percent).
Children younger than two years — Large, multicenter observational studies [14,26,51] support guidelines for evaluation and management that were proposed by expert consensus . These strategies consider high, intermediate, and low-risk criteria for intracranial injury:
Perform imaging — Infants and children younger than two years of age with high risk for intracranial injury or with suspected skull fracture should have head computed tomography (CT) [2,13,56].
High-risk signs or symptoms include the following:
The risk of clinically important traumatic brain injury is 4 percent or higher for patients with one or more of these findings.
Observe or perform imaging — Intermediate-risk patients may be managed with close observation for four to six hours after the injury (with imaging obtained for any worsening condition during this period), or they may be evaluated immediately by head CT.
Intermediate-risk signs or symptoms include the following:
The risk of clinically important traumatic brain injury is approximately 1 percent for a child with at least one of these criteria and 0.3 percent if the sole criteria is a high-risk mechanism for injury [13,57]. Multiple or worsening symptoms or signs likely put the child at greater risk than an isolated finding [13,14,19].
Performing a head CT is suggested for intermediate-risk children under the following circumstances:
If immediate CT is deferred for these patients, we suggest observation for four to six hours to ensure no progression of clinical findings that warrant CT.
Skull radiographs may occasionally be useful to screen for fracture and avoid the risk of radiation and sedation from CT in selected asymptomatic patients 3 to 24 months of age with concerning scalp hematomas . However, skull radiographs should only be performed if a radiologist with pediatric expertise is available to provide an interpretation because physicians with pediatric emergency expertise may have limited accuracy in correctly identifying skull fractures in young children . If a screening skull radiograph shows a fracture, then a head CT should be performed.
Do not perform imaging — Imaging studies should be avoided in children <2 years of age at very low risk for brain injury. These patients should have a normal neurologic examination (including a normal fontanel), no history of seizure, and no persistent vomiting. The clinician should also have no suspicion for abuse. Validated criteria include :
The risk for clinically important traumatic brain injury is less than 0.02 percent in these patients .
Children two years of age and older — Criteria to guide decisions about neuroimaging in children two years of age and older are derived from several large multicenter observational studies [13,19,26] and a metaanalysis of observational studies .
Perform neuroimaging — Children ≥2 years of age with the following signs and symptoms appear to be at the most significant risk for intracranial injury and should have computed tomography of the head performed [13,19,26,49]:
Observe or perform neuroimaging — For children with signs and symptoms that have been variably associated with intracranial injury, close observation for four to six hours after the injury (with imaging obtained for any worsening symptoms or concerns during this period) is an alternative to immediate computed tomography of the head. The clinician should have a lower threshold for imaging for severe, persistent, worsening, or multiple clinical findings. These signs and symptoms include:
The risk of clinically important traumatic brain injury is approximately 1 percent in patients with at least one of these criteria and 0.6 percent if the sole criteria is a high-risk mechanism for injury [13,57]. Multiple or worsening symptoms or signs likely puts the child at greater risk than an isolated finding [13,14,19]. Evidence suggests that observation of patients with these signs and symptoms may decrease the utilization of head CT without missing clinically important traumatic brain injury. As an example, in a multicenter, prospective observational study, children who were observed had a lower rate of head CT use than those who were not (31 versus 35 percent, respectively, difference -4 percent [95% CI -5 to -3 percent]) . The observed patients had a similar rate of clinically important traumatic brain injury (0.8 versus 0.9 percent). In this study, most observed children were older than two years of age.
Do not perform neuroimaging — Imaging studies should be avoided in children ≥2 years of age at very low risk for clinically important brain injury. These patients should have a normal neurologic examination, no physical evidence suggesting a skull fracture, and no preexisting condition that might increase the risk of intracranial hemorrhage (eg, bleeding disorder) . Validated criteria include :
The risk for clinically important traumatic brain injury is less than 0.05 percent in these patients .
MANAGEMENT — Issues involved in the management of children with minor head trauma include need for neurosurgical consultation, disposition, and, for the injured athlete, return to play.
Neurosurgical consultation — Neurosurgical consultation should be obtained in the following situations:
Disposition — Any child who has had a minor head trauma requires observation, whether at home, in the clinician's office, or in the emergency department. Observation in the hospital is indicated in some circumstances.
Home management — Health care providers are frequently contacted by telephone after a child has sustained minor head trauma. Observation at home without in-person evaluation is reasonable under the following conditions:
Children who have sustained head trauma that meets these criteria may resume normal activity. It is not necessary to awaken them from sleep for monitoring. Caretakers should be instructed to seek medical advice for the following indications:
Office or emergency department — Most children who have had isolated minor head trauma, including those who have had computed tomography (CT) of the head performed that is normal, can be safely discharged following evaluation and a brief period of observation.
The following conditions should be met prior to discharge:
Evidence supporting this approach is as follows:
Thus, children with minor head trauma and a normal level of consciousness at emergency department discharge are unlikely to have intracranial abnormalities upon repeated neuroimaging or to require neurosurgical intervention, especially if they have a normal head CT at initial evaluation.
Discharge instructions — Caretakers of children who have been evaluated for minor head trauma should be given explicit and understandable instructions for monitoring, when to seek medical help, and when to return for follow-up. It is not necessary to awaken most children. Whether it is important to awaken some children to identify the very few who may be experiencing a change in neurologic condition is uncertain, since no data are currently available that address this question. Those who had a concerning mechanism or prolonged symptoms may be awakened from sleep every four or more hours. The child should be able to recognize his or her surroundings and appear alert to the caretaker. Follow-up within 24 hours, at least by telephone, should be arranged for all children who are discharged following a head injury.
Immediate medical attention is required when the following conditions are noted:
Hospital admission — Hospital admission is generally warranted under the following circumstances:
Post-traumatic seizure — Children who have had a brief immediate post-traumatic seizure following minor head trauma and have a normal head CT may not require admission to the hospital. In two observational cohorts describing similar patients, no further seizure activity or neurologic sequelae were noted [31,62].
We suggest that children who have had a brief seizure and who have a normal neurologic examination and head CT be observed for several hours in the office or emergency department. They may be discharged once they meet the criteria described above. (See 'Office or emergency department' above.)
At home, children may be awakened from sleep every four or more hours for monitoring purposes and should have follow-up again in 24 hours, although there is no data to guide specific follow-up recommendations.
Return to play — Children and adolescents who have sustained a concussion may be at greater risk for second impact syndrome than older athletes [63,64]. (See 'Second impact syndrome' below.) In addition, the cumulative effect of mild, repetitive brain injury on the developing brain is uncertain. Conservative guidelines for when a young athlete may return to play are therefore recommended.
Any child who has had loss of consciousness or symptoms of concussion lasting more than 15 minutes as the result of minor head trauma should not participate in sports until asymptomatic for at least one week. Return to play guidelines are discussed in detail elsewhere. (See "Concussion and mild traumatic brain injury", section on 'Sequelae'.)
SEQUELAE — Outcome generally is good for children with minor head trauma with no apparent intracranial injury [59,65]. Short and long-term sequelae that may have implications for children are discussed separately. (See "Concussion and mild traumatic brain injury", section on 'Sequelae'.) Second impact syndrome and postconcussion syndrome are of particular interest.
Second impact syndrome — The second impact syndrome refers to diffuse cerebral swelling that follows a second concussion, which occurs while an athlete is still symptomatic from an earlier concussion. This rare, but often fatal, complication of mild head trauma can usually be prevented by careful assessment before allowing children to resume participation in sports followed by a gradual return to activity once they are asymptomatic. Second impact syndrome and return to play instructions are discussed in detail elsewhere. (See "Concussion and mild traumatic brain injury", section on 'Sequelae'.)
Postconcussion syndrome — The postconcussion syndrome (PCS) is a symptom complex that occurs following mild traumatic brain injury (TBI) that may include headache, dizziness, neuropsychiatric symptoms, and cognitive impairment. The incidence of postconcussion syndrome among children is uncertain, but it is probably lower than in adults. Children who have symptoms that persist beyond several weeks may be referred for evaluation. Postconcussion syndrome is discussed separately. (See "Postconcussion syndrome".)
Short-term functional morbidity, perhaps related to parental concern and social factors, has been reported . These findings emphasize the importance of primary care follow-up for children and families after apparently minor head trauma.
Long-term cognitive and behavioral difficulties have been reported in studies of small populations of children following head injuries of varying severity [67-73]. Cognitive dysfunction among young adults who had mild head trauma in childhood has been reported as well . Predicting factors that identify children destined to have these neurocognitive sequelae after minor head trauma has been poorly studied.
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