What to do if a baby suffers a head injury?

Management of Head Injury in a Baby

Immediately assess the baby using PECARN criteria to determine risk level and need for CT imaging, as this validated approach minimizes unnecessary radiation while identifying clinically important injuries. 1

Initial Risk Stratification

For infants under 2 years of age, categorize risk based on specific clinical findings:

Very Low Risk (No CT needed)

• Glasgow Coma Scale (GCS) = 15 1, 2
• No palpable skull fracture 1
• No loss of consciousness >5 seconds 1
• Normal behavior per parent 1
• No altered mental status 1
• No severe mechanism of injury 1
• Nonfrontal scalp hematoma only (frontal hematomas are lower risk) 1

If the baby meets ALL these criteria, the risk of clinically important injury is <0.2%, and observation at home with detailed discharge instructions is appropriate. 3

High Risk (Immediate CT required)

• GCS ≤14 1, 2
• Any signs of altered mental status 1, 2
• Any palpable skull fracture 1, 2
• Signs of basilar skull fracture 4

These features carry a 4.4% risk of clinically important injury requiring immediate non-contrast head CT. 1

Intermediate Risk (Consider CT or observation)

• GCS = 15 with normal mental status BUT 1
• Loss of consciousness >5 seconds 1
• Severe mechanism of injury (high-speed motor vehicle accident, fall from significant height) 1
• Not acting normally per parent 1
• Severe headache 4

This category carries a 0.9% risk of clinically important injury. 1

Critical Imaging Decisions

Use non-contrast CT as first-line imaging for any high-risk patient due to rapid acquisition, excellent sensitivity for acute hemorrhage and fractures, and no sedation requirement. 1, 2

• Skull radiographs should NOT be used as they miss up to 50% of intracranial injuries and cannot evaluate brain parenchyma 1
• MRI is more sensitive than CT but impractical acutely due to exam length and sedation needs in young children 1
• Maintain a particularly low threshold for neuroimaging in infants <1 year old with any concerning findings 1

Important caveat: Even infants meeting low-risk PECARN criteria remain at 5.1% risk for traumatic brain injury on CT, suggesting the need for cautious clinical observation in this age group. 3

Immediate Management Protocol

First 24-48 Hours

• Complete physical and cognitive rest 2
• Avoid strict prolonged rest beyond 48 hours as this may be detrimental to recovery 2

Pain Management

• Use acetaminophen cautiously for headache if needed 2
• Avoid NSAIDs and aspirin in the immediate post-injury period due to theoretical risk of potentiating intracranial bleeding 2

Red Flags Requiring Emergency Evaluation

Instruct caregivers to seek immediate medical attention if the baby develops:

• Persistent or worsening vomiting 1, 2
• Increasing drowsiness or difficulty waking 1, 2
• Seizure activity 1, 2
• Worsening headache (if child can communicate) 1
• Excessive irritability or behavior changes 2
• Unsteady walking or coordination problems 2
• Unequal pupil size 1, 2
• Visual changes 2

Special Considerations for Infants

Toddlers and infants cannot reliably report symptoms, requiring heavy reliance on parental observation of behavior changes, which necessitates maintaining a higher index of suspicion. 2

Always consider non-accidental trauma in infants <1 year with any concerning findings, unexplained injuries, or inconsistent history, as abusive head trauma carries disproportionately high mortality. 1, 5

• Subdural hematoma is the most common intracranial abnormality in abusive head trauma 4
• If abuse is suspected, obtain immediate non-contrast head CT and consider MRI for additional evaluation 4

Recovery Expectations

• Most children recover within 7-10 days, though some may take weeks to months 2
• Approximately 80-90% recover within one month 2
• Pediatric patients generally have longer recovery than older children 2

Return to Activities

For infants and toddlers, start with quiet play activities once asymptomatic at rest, followed by light physical activity only when completely asymptomatic with exertion. 2

• Never allow return to high-risk activities (playground climbing, running, rough play) while any symptoms persist 2

Discharge Instructions for Low-Risk Patients

Provide written instructions including:

• Warning signs of serious injury requiring immediate return 4
• Description of expected symptom course 4
• Instructions for monitoring postconcussive symptoms 4
• Guidance on cognitive and physical rest 4
• Clear follow-up instructions 4