What are the discharge instructions, indications for CT scan, and hospitalization criteria for an infant with a head injury?

Management of Infant Head Injury: Discharge Instructions, CT Indications, and Hospitalization Criteria

Risk Stratification Using PECARN Criteria

For infants with minor head injury, use the validated PECARN criteria to determine whether CT imaging, observation, or safe discharge is appropriate. 1

Very Low Risk Infants (<2 years) - No CT Required

Infants can be safely discharged without CT imaging if they meet ALL of the following criteria: 1

• GCS score of 15
• Normal mental status
• No palpable skull fracture
• No nonfrontal scalp hematoma
• Loss of consciousness ≤5 seconds (or none)
• No severe mechanism of injury
• Acting normally per parents

These infants have <0.02% risk of clinically important traumatic brain injury and do not require hospitalization. 1

Intermediate Risk Infants (<2 years) - CT or Observation

Infants with GCS 15, normal mental status, no palpable skull fracture BUT with any of the following require either CT or careful observation: 1

• Loss of consciousness >5 seconds
• Severe mechanism of injury
• Not acting normally per parent

Risk of significant injury is approximately 0.9%. CT may be considered over observation when: 1

• Parental preference for definitive imaging
• Multiple risk factors present
• Worsening symptoms during observation
• Young age makes observational assessment challenging

High Risk Infants (<2 years) - CT Strongly Recommended

CT imaging is strongly indicated for infants with: 1

• GCS score of 14
• Other signs of altered mental status
• Palpable skull fracture

Risk of clinically significant intracranial injury is approximately 4.4%. 1

Hospitalization Criteria

Infants with negative CT scans and normal neurologic examinations can be safely discharged rather than admitted, with a negative predictive value of 100% for neurologic deterioration requiring surgical intervention. 1 The risk of deterioration with both normal CT and normal examination is extremely low (0.006%). 1

Hospitalization IS required for: 2

• Positive CT findings showing intracranial injury
• Abnormal neurologic examination
• Inability to perform adequate observation at home
• Patients on anticoagulation or antiplatelet therapy (these populations were excluded from safe discharge studies) 2

Important caveat: Even infants meeting PECARN low-risk criteria remain at some risk for traumatic brain injuries on CT (5.1%) and skull fractures (4.6%), suggesting a cautious approach is warranted in very young infants. 3

Discharge Instructions - Critical Components

Discharge instructions MUST be provided in both written and verbal form, written at 6th-7th grade reading level, using font size ≥12 points. 1, 4, 2

Return Immediately If:

• Worsening or severe headache 4, 2
• Repeated vomiting (particularly concerning as vomiting is an established predictor of abnormal CT findings) 4, 2
• Confusion or abnormal behavior 2
• Increased sleepiness or loss of consciousness 2
• Memory problems 2
• Focal neurologic deficits 4
• Seizures 4

Postconcussive Symptom Education

All discharged patients must receive education about expected postconcussive symptoms: 2

• Dizziness and balance problems
• Nausea
• Vision problems
• Sensitivity to noise and light
• Depression, mood swings, anxiety, irritability
• Sleep disturbances

Critical Timing Consideration

18% of patients who deteriorate after head injury do so between days 2-7, making delayed onset of symptoms particularly concerning. 4 Parents must understand that symptoms appearing days after injury warrant immediate re-evaluation.

Home Observation Recommendations

Frequent waking or pupil assessment at home is NOT recommended for infants with negative CT scans, as evidence demonstrates extremely low risk for delayed deterioration. 2

However, reliable caretakers and proper discharge instructions are essential for safe home observation. 5 The vast majority of minor head injuries in infants can be safely observed at home when these conditions are met. 5

Special Considerations for Very Young Infants

For infants <3 months old, exercise additional caution even when PECARN low-risk criteria are met, as this age group has limited validation data and subtle findings may be difficult to detect. 6, 3 When no imaging is performed, this decision should be fully explained to parents before selecting home observation. 6

Telephone follow-up checking on patient status is useful for both patients and physicians. 6