Mild Head Injury in Children: Limit Imaging to High-Risk Cases

Don’t rush to order a CT for a child presenting with mild traumatic brain injury (mTBI), says a new guideline released by the Centers for Disease Control and Prevention (CDC). First assess for a combination of factors indicating that the injury may be severe.

Although emergency departments and clinics see children with blows to the head on a near-daily basis, a lack of consensus on standards of care for evaluation and management have left clinicians on their own to make a host of decisions surrounding diagnosis and resumption of activities.

The CDC guideline, based on an assessment of 25 years of published evidence by a committee of experts, consists of 19 sets of clinical recommendations covering diagnosis, prognosis, management and treatment of pediatric mTBI. It appears in the current issue of JAMA Pediatrics and has been summarized in easy-to-read handouts for parents, coaches and healthcare providers on the CDC website.

“Until now, doctors, coaches and athletic trainers have had to shoot from the hip when dealing with head injury in children,” says Edward Benzel, MD, a neurosurgeon in Cleveland Clinic’s Center for Spine Health who served on the committee that developed the CDC guideline. “This new document, rigorously based on available evidence, provides objective support for common challenges.”

Key takeaways

The CDC guideline committee, including Dr. Benzel (an expert on concussion who has conducted extensive research on helmet safety), has identified the following potentially practice-changing recommendations in the new guideline:

• Don’t routinely image patients to diagnose mTBI. Because of the small but definite risk of brain cancer from radiation, CT neuroimaging should only be used after determining clinically that the patient is at risk for a brain hemorrhage. Risk factors include age less than 2 years, vomiting, loss of consciousness, severe mechanism of injury, severe or worsening headache, amnesia, nonfrontal scalp hematoma, Glasgow Coma Scale score less than 15 and clinical suspicion for skull fracture. Note that brain MRI, single-photon emission CT (SPECT) and skull X-ray are not recommended for acute evaluation of either suspected or diagnosed mTBI.
• Use validated age-appropriate symptom scales to evaluate mTBI. Examples include the Post-Concussion Symptom Scale, Post-Concussion Symptom Inventory and Acute Concussion Evaluation. These help determine severity and set a baseline for future monitoring and need for referral.
• Assess evidence-based risk factors for prolonged recovery. A prior head trauma portends a poor prognosis, which is the basis for advising athletes to not be too quick to return to sports and risk another injury. Other factors associated with delayed recovery include older age (adolescents), Hispanic ethnicity, low socioeconomic status, a neurological or psychiatric disorder, low cognitive ability, and family or social stressors.
• Counsel patients to return gradually to nonsport activities after no more than two to three days of rest. Patients and parents should be given clear verbal and written instructions on returning to full activity, including warning signs that indicate further medical care is needed. Patients should begin light activity and then gradually reintroduce regular activities that do not worsen symptoms.
• Provide athletes with instructions on returning to sports, customized to their symptoms. Athletes should resume activities in a stepwise fashion, starting with a return to regular, nonsport activities, then light aerobic exercise, then sport-specific exercise, then noncontact training drills, then full-contact practice, and finally a full return to sport. A return of symptoms at any point should prompt going back to the previous step.
• Know when to refer. For patients whose symptoms don’t resolve as expected after four to six weeks, refer to a neurologist or clinical psychologist familiar with head injury. Acutely worsening symptoms, chronic headache, vestibulo-ocular dysfunction, worsening sleep problems or cognitive impairment need prompt attention.

Thorough to the extreme

Dr. Benzel feels confident that the committee recommendations are based on thorough evaluation of the best available evidence. He notes that he reviewed about 1,000 papers related to pediatric mTBI and that others on the committee — consisting of dozens of professionals, including neurosurgeons, psychologists, emergency physicians and statisticians — carried similar workloads and engaged in lively discussion.

He identifies one particularly hot issue during the drafting of the guideline: setting the upper age limit for defining pediatric mTBI at 18. Although 18-year-olds are arguably closer to adults than children in terms of brain recovery, the committee wanted the guideline to cover all high school athletes and be easily applicable in a variety of settings.

He also notes that more work is to be done. “The final guidelines are really a call to arms to conduct better research on the issues surrounding diagnosis and management of mild TBI,” he says. “We hope to increase awareness of the importance of head injury in children and the need to quantify clinical outcomes from different scenarios.”