What is the management and treatment for pediatric head injuries?

Management and Treatment of Pediatric Head Injuries

The management of pediatric head injuries should follow evidence-based guidelines that stratify care based on injury severity, with mild traumatic brain injury (mTBI) requiring careful assessment using validated clinical decision rules to avoid unnecessary imaging, while severe TBI requires intensive monitoring and tiered therapeutic approaches to manage intracranial pressure and prevent secondary injury. 1

Initial Assessment and Diagnosis

Mild Traumatic Brain Injury (mTBI)

• Health care professionals should not routinely obtain head CT for diagnostic purposes in children with mTBI 1
• Instead, validated clinical decision rules (such as PECARN) should be used to identify children at low risk for intracranial injury (ICI) and those who may warrant head CT 1
• Risk factors that warrant consideration for imaging include:
  • Age younger than 2 years
  • Vomiting
  • Loss of consciousness
  • Severe mechanism of injury
  • Severe or worsening headache
  • Amnesia
  • Nonfrontal scalp hematoma
  • Glasgow Coma Scale (GCS) score less than 15
  • Clinical suspicion for skull fracture 1
• When discussing imaging, healthcare professionals should explain the risks of radiation exposure from CT scans in the context of risk factors for ICI 1

Severe Traumatic Brain Injury

• For severe TBI (GCS 3-8), immediate neuroimaging and intensive monitoring are essential 1
• The Brain Trauma Foundation Guidelines recommend a tiered approach to management with first and second tier interventions for elevated intracranial pressure (ICP) 1
• Continuous ICP monitoring is recommended for patients with severe TBI 1

Treatment Approaches

Headache Management

• For painful headaches after mTBI, nonopioid analgesics (ibuprofen or acetaminophen) should be offered 1
• Families should be counseled about the risks of analgesic overuse, including rebound headache 1
• Children with headaches and acutely worsening symptoms should undergo emergent neuroimaging 1
• Chronic headache after mTBI is likely multifactorial and may require multidisciplinary evaluation and treatment 1
• 3% hypertonic saline is not recommended for acute headache treatment outside research settings 1

Vestibulo-Oculomotor Dysfunction

• Children with persistent vestibulo-oculomotor dysfunction after mTBI may benefit from referral to vestibular rehabilitation programs 1
• Early vestibulo-ocular and cervicovestibular physical therapy may help patients with dizziness or objective examination findings 1

Sleep Management

• Proper sleep hygiene methods should be provided to facilitate recovery from pediatric mTBI 1
• If sleep problems persist despite appropriate sleep hygiene measures, referral to a sleep disorder specialist may be warranted 1

Cognitive Impairment Management

• Healthcare professionals should determine the etiology of cognitive dysfunction within the context of other mTBI symptoms 1
• Treatment for cognitive dysfunction should reflect its presumed etiology 1
• For persisting cognitive problems, formal neuropsychological evaluation may help determine etiology and recommend targeted treatment 1

Return to Activities

• A gradual return to activities approach is recommended following mTBI 1
• Initial rest (24-48 hours) followed by gradual, progressive return to normal activities as tolerated 1
• Return to school should be carefully managed with appropriate accommodations as needed 1
• Return to sports and physical activities should follow a stepwise progression based on symptom resolution 1

Special Considerations

Age-Specific Concerns

• Children under 2 years require special consideration due to:
  • Limited verbal communication abilities
  • Different biomechanics of injury
  • Higher risk of undetected intracranial injury 1, 2
• Adolescents may have different recovery patterns and concerns about return to sports 3

Monitoring for Complications

• Parents/caregivers should be educated about warning signs that require immediate medical attention:
  • Worsening headache
  • Repeated vomiting
  • Increased drowsiness
  • Seizures
  • Unusual behavior changes
  • Difficulty recognizing people or places 1

Prevention of Secondary Injury

• In severe TBI, prevention of secondary injury is critical through:
  • Maintaining adequate cerebral perfusion pressure
  • Preventing hypoxia and hypotension
  • Managing intracranial hypertension
  • Appropriate seizure prophylaxis
  • Optimizing nutrition 1

Common Pitfalls to Avoid

• Overuse of CT imaging in minor head trauma, exposing children to unnecessary radiation 1
• Inadequate monitoring of children with risk factors for deterioration 4
• Premature return to physical activities before complete symptom resolution 1
• Overlooking the possibility of non-accidental trauma in infants and young children 3
• Failing to provide adequate education to families about expected recovery and warning signs 1

By following these evidence-based guidelines, healthcare providers can optimize outcomes for children with head injuries across the spectrum of severity, minimizing both short-term complications and long-term sequelae.