What are the PECARN (Pediatric Emergency Care Applied Research Network) criteria for a 3-month-old infant?

From the Guidelines

For a 3-month-old infant, the PECARN criteria recommend that a CT scan can be safely forgone if the infant has a GCS of 15 and none of the following: other signs of altered mental status, palpable skull fracture, nonfrontal scalp hematoma, loss of consciousness >5 seconds, severe mechanism of injury, or not acting normally per parents. The PECARN criteria are used to determine which children with head trauma need CT scans, with the goal of reducing unnecessary radiation exposure while identifying clinically important traumatic brain injuries 1. For infants younger than 2 years, including 3-month-olds, the criteria are based on the presence or absence of certain high-risk factors, including altered mental status, palpable skull fracture, or loss of consciousness for 5 seconds or longer 1. The assessment should include a thorough neurological examination, with special attention to fontanelles, which may be bulging if intracranial pressure is elevated. Parents should be educated about warning signs requiring return to care, including vomiting, increased sleepiness, or irritability. The original large prospective trial of more than 14,000 children <2 years of age by Kuppermann et al demonstrated >99% sensitivity and 100% NPV using these decision criteria 1. Subsequent external validation by Babl et al in 2014 derived from over 4,000 children <2 years of age demonstrated 100% sensitivity and 100% NPV for these very low-risk criteria, with an estimated risk of clinically important traumatic brain injury of <0.02% 1. Some key points to consider when applying the PECARN criteria to a 3-month-old infant include:

• A normal mental status and no clinical signs of basilar skull fracture
• No loss of consciousness or vomiting
• No severe injury mechanism or severe headache
• A normal scalp examination, with no evidence of hematoma or other trauma.

From the Research

PECARN Criteria for 3-Month-Old Infants

The PECARN (Pediatric Emergency Care Applied Research Network) criteria are used to identify children with minor head trauma who are at low risk for clinically important traumatic brain injuries (ciTBI). For 3-month-old infants, the criteria are as follows:

• Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination 2.
• A low threshold for CT scan is recommended in this population 2.
• The PECARN rule for infants < 2 years old is an adequate tool with which to identify infants < 3 months old at low risk for clinically important traumatic brain injury 2, 3.

Key Findings

• The PECARN rule accurately identified infants <3 months old at low risk of clinically important traumatic brain injuries, with a sensitivity and negative predictive value of 100% and 99.7%, respectively 2.
• Infants who met the PECARN low-risk criteria had a low risk of ciTBI, TBI on CT, and skull fractures, with rates of 0%, 0.4%, and 0.9%, respectively 2.
• Infants who did not meet the PECARN low-risk criteria had a higher risk of ciTBI, TBI on CT, and skull fractures, with rates of 0.3%, 8.1%, and 13.2%, respectively 2.

Clinical Implications

• The PECARN rule can be used to identify infants < 3 months old who are at low risk for ciTBI and may not require a CT scan 3, 4.
• However, infants at low risk for ciTBI may still be at risk for TBI on CT, and a cautious approach is recommended 3.
• The use of CT scans in infants with minor head trauma should be carefully considered, taking into account the risks of radiation exposure and the potential benefits of imaging 5, 6.