What is the recommended course of action for an 8-month-old with a head injury?

Management of Head Injury in an 8-Month-Old Infant

For an 8-month-old with a head injury, immediate medical evaluation is essential as infants are at higher risk for intracranial injury and require age-specific assessment and management approaches. 1

Initial Assessment

• Vital Signs: Monitor age-appropriate parameters

  • Mean arterial pressure target: 45-75 mmHg for 3 months-1 year 1
  • Heart rate, respiratory rate, oxygen saturation
  • Blood glucose (infants are prone to hypoglycemia)

• Neurological Assessment:

  • Level of consciousness
  • Pupillary size and reactivity
  • Fontanelle examination (bulging may indicate increased intracranial pressure)
  • Presence of seizures (more common in children under 2 years at 15.7%) 2

Warning Signs Requiring Immediate Medical Attention

• Altered mental status or excessive sleepiness
• Persistent vomiting
• Seizures
• Bulging fontanelle
• Inability to be consoled
• Worsening headache (indicated by excessive crying)
• Progressive neurological symptoms 1

Imaging Considerations

• CT scan should not be used as a routine screening test in pediatric patients 1

• Consider CT scan for:

  • Loss of consciousness >30 seconds
  • Altered mental status
  • Signs of skull fracture
  • Persistent vomiting
  • Severe mechanism of injury
  • Concerning behavior changes 1

• Important caveat: Standard clinical decision rules for head CT may not apply to infants under 6 months, and physicians should have a lower threshold for neuroimaging in this age group 1

Management Based on Severity

Mild TBI (Most Common)

1. Observation:

   • Home observation may be appropriate if:
     • Normal neurological exam
     • No loss of consciousness or brief (<30 seconds)
     • No vomiting or minimal vomiting
     • Normal behavior according to parents
     • No concerning mechanism of injury

2. Activity Management:

   • More restrictive physical and cognitive activity during first several days 1
   • Gradual return to normal activities as tolerated without symptom exacerbation 1

3. Pain Management:

   • Offer non-opioid analgesia (acetaminophen or ibuprofen) for pain 1
   • Avoid opioids for headache management 1

Moderate to Severe TBI

• Immediate transport to pediatric trauma center if available
• Secure airway if GCS ≤8
• Maintain appropriate blood pressure for age
• Age-appropriate equipment should be available for transport 1

Follow-up Care

• Provide clear instructions on monitoring for warning signs
• Schedule follow-up within 24-72 hours for reassessment
• Monitor for development of chronic subdural hematoma, which can occur up to 3 months after initial injury 3
• Ensure proper sleep hygiene to facilitate recovery 1

Parent Education

Parents should be educated about:

• Warning signs requiring return to medical care
• Expected course of symptoms and recovery
• Prevention of further injury
• Management of activity levels
• Return to normal play and activities 1

Common Pitfalls to Avoid

1. Underestimating risk in infants: Infants have less available space around the brain during growth periods, making them more vulnerable to small changes in intracranial volume 1

2. Missing non-accidental injury: Consider child abuse in cases without appropriate history or with suspicious injury patterns 1

3. Inadequate follow-up: Young children may not show immediate deficits but may fail to develop skills as quickly as uninjured peers, necessitating long-term monitoring 4

4. Overlooking evolving injuries: Acute subdural hematomas can evolve into chronic subdural hematomas over weeks to months 3

By following these guidelines, healthcare providers can effectively manage head injuries in 8-month-old infants while minimizing risks and optimizing outcomes.