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Minor head trauma in infants and children

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Minor head trauma in infants and children Author Sara Schutzman, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Nov 2013. | This topic last updated: jun 11, 2013. 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".) DEFINITIONS 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]: Clinical assessment is more difficult Infants with intracranial injuries are frequently asymptomatic Skull fractures may occur as the result of minor trauma Inflicted injury occurs more often 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 [2]. 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: Normal mental status at the initial examination
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Section Editors Richard G Bachur, MD Douglas R Nordli, Jr, MD

Deputy Editor James F Wiley, II, MD, MPH

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Minor head trauma in infants and children

No abnormal or focal findings on neurologic examination No physical evidence of skull fracture 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 [5]. 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 [6]. In developed countries, TBI is the most common cause of death and disability in childhood [7]. 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 [10]. 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 [13]. 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 accelerationdeceleration 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 [14]. (See "Concussion and mild traumatic brain injury", section on 'Pathophysiology'.)
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Minor head trauma in infants and children

The type of mechanical forces applied to the brain may determine, to some extent, the nature of the resultant injury [15,16]. Acceleration occurs when a moving object strikes a stationary head. Linear acceleration is considered the least injurious force and typically is associated with superficial contusions or in some cases, subdural hematomas. Deceleration results when a moving head strikes a stationary surface. Sudden deceleration is thought to be responsible for most severe brainstem injuries. Rotation of the brain occurs when the head is struck in an asymmetric manner or an infant is vigorously shaken. Rotational acceleration-deceleration can induce widespread injury. 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: Among children two years of age and older with minor head trauma and a normal neurologic examination, 3 to 7 percent may have an intracranial injury noted on CT scan [11-13,17-19]. Of the overall study populations, approximately 0.1 to 0.6 percent require surgical intervention [17,20-22]. For children younger than two years with minor head trauma and a normal neurologic examination, approximately 3 to 10 percent have an intracranial injury [11-13,17,23]. Many of these younger children have no clinical symptoms of brain injury (19 to 48 percent), although most of these patients have scalp hematomas [13,24,25]. In a prospective series of infants under two years of age, 1 of 14 asymptomatic infants with intracranial injury required surgery [25]. 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 [29]. 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.
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Minor head trauma in infants and children

Common clinical features Two large prospective observational studies have identified the following common features associated with minor head trauma in children [13,26]: Loss of consciousness Loss of consciousness (LOC) occurred in approximately 5 percent of children <2 years of age in both studies. In one study, up to 13 percent of children 2 years of age had some degree of LOC [13]. Documented LOC, particularly for longer than a few seconds, was associated with a somewhat increased risk for clinically important traumatic brain injury [13]. However, the risk of TBI in the setting of brief isolated LOC without any other symptoms or signs of TBI are very low [19]. Headache Headache was a frequent complaint, occurring in up to 45 percent of children. In preverbal children, irritability may be an indication of discomfort, such as headache [13,26]. Vomiting At least one episode of vomiting was reported in approximately 14 percent of patients [13]. Many children who vomit following head trauma do not have intracranial injury. In a case control study comparing children with mild head injury (as defined by discharge to home from the ED) with and without vomiting, predictors of vomiting included a personal history of vomiting, motion sickness, and headache associated with the injury [30]. Nevertheless, a history of any vomiting after head trauma increases the risk of TBI somewhat [13]. 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 [32]. 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 followup (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: High-risk mechanism such as fall from a significant height, any mechanism involving a motor vehicle, penetrating injury, inflicted injury, or unknown mechanism (which may represent inflicted injury) Seizure, confusion, or loss of consciousness
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Minor head trauma in infants and children

Significant headache Vomiting Preexisting conditions that place the child at risk for intracranial hemorrhage, which include arteriovenous malformation, or bleeding disorder 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"): Scalp abnormalities such as hematoma, tenderness, or depression In infants, bulging anterior fontanelle Abnormal mental status Focal neurologic abnormality Signs of basilar skull fracture (periorbital ecchymosis, Battle's sign, hemotympanum (picture 1), CSF otorrhea, or CSF rhinorrhea) 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 [3]. 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 [40]. 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 [41]. 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 [42]. 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'.)
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Minor head trauma in infants and children

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 [13]. The definition of ciTBI included neurosurgery, endotracheal intubation for more than 24 hours, and hospitalization for more than two nights (table 2): In the validation group of 2216 children younger than two years of age, 25 had a ciTBI. The rule had a sensitivity of 100 percent (95% CI 86-100), a specificity of 54 percent (95% CI 53-55), and a negative predictive value of 100 percent (95% CI 99.7-100). The risk of ciTBI was 0.02 percent in children with none of the six clinical predictors present. In the validation group of 6411 children two years of age or older, 63 had a ciTBI. The rule had a sensitivity of 97 percent (95% CI 89-99.6), a specificity of 60 percent (95% CI 58.6-61), and a negative predictive value of 99.9 percent (95% CI 99.8-99.9). Two children with ciTBI were classified as low risk. Neither required neurosurgical intervention. The risk of ciTBI in children with none of the six clinical predictors present was less than 0.05 percent. 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 [55]. 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 [2]. 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: Focal neurologic findings Acute skull fracture, including depressed or basilar fracture Depressed mental status
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Minor head trauma in infants and children

Irritability Bulging fontanel Persistent vomiting Seizure Definite loss of consciousness (especially more than a few seconds and associated with a high-risk mechanism of injury) Suspicion of child abuse Underlying condition predisposing to intracranial injury (see 'History' above) 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: Vomiting Loss of consciousness that is uncertain or very brief (less than a few seconds) History of lethargy or irritability, now resolved Behavioral change reported by caregiver Injury caused by high-risk mechanism of injury (eg, fall more than three to four feet, patient ejection, death of a passenger, rollover, high-impact head injury) Scalp hematoma (particularly nonfrontal) Skull fracture more than 24 hours old (nonacute) Unwitnessed trauma that may be significant 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: Presence of more than one of the intermediate-risk factors noted above Vomiting that is delayed by several hours after injury or occurs multiple times Large nonfrontal scalp hematomas, especially in children younger than 12 months [32] Infants less than three months old with nontrivial trauma 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 [56]. 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 [40]. 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 [13]: Normal mental status
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Minor head trauma in infants and children

No parietal, occipital or temporal scalp hematoma No loss of consciousness No evidence of skull fracture Normal behavior according to the routine caregiver No high-risk mechanism of injury (severe mechanisms: fall >0.9 m (3 feet); head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle) The risk for clinically important traumatic brain injury is less than 0.02 percent in these patients [13]. 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 [49]. 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]: Focal neurologic findings Skull fracture, especially findings of basilar skull fracture Seizure Altered mental status (eg, agitation, lethargy, repetitive questioning, or slow response to verbal questioning) Prolonged loss of consciousness 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: Vomiting Headache Questionable or brief loss of consciousness Injury caused by high-risk mechanism of injury 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]) [58]. 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) [59]. Validated criteria include [13]: Normal mental status No loss of consciousness No vomiting No signs of basilar skull fracture
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Minor head trauma in infants and children

No severe headache No high-risk mechanism of injury (severe mechanisms: fall >1.5 m (5 feet); head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without a helmet struck by a motorized vehicle) The risk for clinically important traumatic brain injury is less than 0.05 percent in these patients [13]. 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: Brain injury detected by computed tomography (CT) Depressed, basilar, or widely diastatic skull fracture Deteriorating clinical condition 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: Normal mental status and at a baseline level of function Low-risk mechanism of injury No concern for inflicted injury No loss of consciousness or seizure No other apparent injuries No vomiting or only one episode of vomiting occurring shortly after injury No significant headache For the infants <1 year of age, trivial injury without significant nonfrontal hematoma No underlying conditions predisposing to intracranial injury Reliable caretakers who are able to seek care, if indicated 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: Persistent or worsening headaches Vomiting after the initial injury Change in mental status or behavior Unsteady gait or clumsiness/incoordination Seizure 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: There is no suspicion of inflicted injury. The child is easily aroused with light touch and has a normal neurologic examination. The child has returned to baseline level of function and tolerated oral fluids, if there has been vomiting. Caretakers are capable of reliably observing the child and can return for care if indicated.
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Specific instructions have been given regarding the level of observation required, indications for seeking care, and follow-up. There are no extracranial injuries requiring admission. Evidence supporting this approach is as follows: An observational study of 17,962 children evaluated in an emergency department for uncomplicated minor head injuries found that the incidences of delayed diagnosis of an intracranial injury were 0.14 and 0.57 cases per 100,000 children per year for patients with and without worsening level of consciousness, respectively. Not all of the children in this study underwent head CT [60]. A multicenter observational study analyzed 13,543 children who were evaluated in childrens hospital emergency departments for isolated minor head trauma (Glasgow coma scale 14 or 15) and who had normal cranial computed tomography (CT) scan results [61]. Repeat neuroimaging (CT or magnetic resonance imaging) was performed in 2 percent of 11,058 discharged patients and 6 percent of admitted patients. Of these, 0.05 and 0.6 percent of discharged patients and admitted patients, respectively, subsequently had positive findings upon repeat head CT. No patient in either group required neurosurgical intervention. Successful telephone or mail follow-up occurred in 79 percent of the discharged patients. 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: Inability to awaken the child as instructed Persistent or worsening headache Continued vomiting or vomiting that begins/continues four to six hours after injury Change in mental status or behavior Unsteady gait or clumsiness/incoordination Seizure Hospital admission Hospital admission is generally warranted under the following circumstances: Brain injury or depressed or basilar skull fracture, in consultation with a neurosurgeon Persistent, significant alteration in mental status despite normal head CT Unremitting vomiting Suspected inflicted injury Extracranial injury requiring admission Caretakers who are unreliable or unable to return for care 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].
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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 [66]. 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 [74]. Predicting factors that identify children destined to have these neurocognitive sequelae after minor head trauma has been poorly studied. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.)
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Basics topics (see "Patient information: Head injury in children and adolescents (The Basics)" and "Patient information: Concussion in adults (The Basics)" and "Patient information: Skull and facial fractures (The Basics)" and "Patient information: Closed head injury (The Basics)") Beyond the Basics topic (see "Patient information: Head injury in children and adolescents (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Minor head trauma occurs commonly in children. Although associated intracranial injury occurs in a small percentage of those children who have a normal neurologic examination at presentation, it must be recognized in order to prevent deterioration and subsequent morbidity or mortality. In addition, inflicted injury must also be identified because it often results in serious intracranial injury and carries a significant risk of recurrence. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children".) Clinical features Predictors of intracranial injury after minor head trauma include (see 'Predictors of intracranial injury' above): Prolonged LOC Amnesia Vomiting that is delayed by several hours after injury or occurs more than once Seizure Severe headache Suspicion of inflicted head injury GCS score <15 Signs of a depressed or basilar skull fracture or bulging fontanel Focal neurologic examination Nonfrontal scalp hematoma for children <2 years of age Significant mechanism of injury Indications for neuroimaging Neuroimaging with computed tomography (CT) reliably identifies significant intracranial injury. However, there is a small risk of later malignancy with exposure to ionizing radiation. In addition, some children may require sedation in order to perform the study. (See 'Indications for neuroimaging' above.) We recommend that infants and children younger than two years of age have head computed tomography (CT) in the following situations (see 'Perform imaging' above): Focal neurologic findings Acute skull fracture, including depressed or basilar fracture Depressed mental status Irritability Bulging fontanel Persistent vomiting Seizure
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Definite loss of consciousness (especially more than a few seconds and associated with a high-risk mechanism of injury) Suspicion of child abuse Underlying condition predisposing to intracranial injury (see 'History' above) We suggest that infants and children younger than two years of age with the following indications undergo a head CT (see 'Observe or perform imaging' above): Large nonfrontal scalp hematomas, especially in children younger than 12 months Infants less than three months old with nontrivial trauma Vomiting that is delayed by several hours after injury or occurs repeatedly Presence of more than one of the intermediate-risk factors noted below If immediate CT is deferred for patients with these intermediate findings, we suggest observation for four to six hours to ensure no progression of clinical findings that warrant CT. Skull radiographs may be used to screen for a fracture in asymptomatic patients 3 to 24 months of age with concerning scalp hematomas if a radiologist with pediatric expertise is available to provide an emergent reading: CT is indicated if a fracture is present. (See 'Observe or perform imaging' above.) We suggest that infants and children younger than two years of age with any one of the following intermediate-risk criteria may either be observed for four to six hours or have an immediate head CT (see 'Observe or perform imaging' above): Vomiting that occurs only once soon after injury Loss of consciousness that is uncertain or very brief (less than a few seconds) History of lethargy or irritability, now resolved Behavioral change reported by caregiver Skull fracture more than 24 hours old (nonacute) Injury caused by high-risk mechanism of injury (eg, fall more than three to four feet, patient ejection, death of a passenger, rollover, high impact head injury) Unwitnessed trauma that may be significant We recommend that infants and children younger than two years of age with low risk findings for clinically important intracranial injury (table 2) not undergo head CT. These patients should also 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. (See 'Do not perform imaging' above.) We recommend that children two years of age and older have head computed tomography (CT) in the following situations (see 'Perform neuroimaging' above): Focal neurologic findings Skull fracture, especially findings of basilar skull fracture Seizure Prolonged loss of consciousness Altered mental status (eg, agitation, lethargy, repetitive questioning, or slow response to verbal questioning)

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We suggest that children with the following signs and symptoms either be closely observed for four to six hours after the injury (with imaging obtained for any worsening symptoms or concerns during this period) or have immediate head CT: Vomiting Headache Questionable or brief loss of consciousness with no other signs or symptoms Injury caused by high-risk mechanism of injury (severe mechanisms: fall >1.5 m (5 feet) in child age two years and older; head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without a helmet struck by a motorized vehicle) The clinician should have a lower threshold for imaging patients with severe, persistent, or multiple clinical findings. We recommend that neurologically normal children two years of age and older who meet low risk criteria for clinically important intracranial injury (table 2) not undergo head CT. Children who have sustained minor head trauma may be observed at home, in the office, or in the emergency department, depending on their clinical condition. (See 'Home management' above and 'Office or emergency department' above.) We recommend that children with the following indications be admitted to the hospital (Grade 1B): Brain injury or depressed or basilar skull fracture in consultation with a neurosurgeon Persistent, significant alteration in mental status despite normal head CT Suspected inflicted injury Unremitting vomiting Caretakers who are unreliable Caretakers who are unable to follow-up or return for care Extracranial injury requiring admission Careful discharge instructions regarding monitoring, indications to seek care, and follow-up must be given to a reliable caretaker. (See 'Discharge instructions' above.) Children who have sustained a concussion must be carefully evaluated to determine when it is safe for them to return to sports.

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