Management of Pediatric Minor Head Injury
For this child with mild occipital tenderness after a low-height fall, no loss of consciousness, and no other concerning features, reassurance and observation are appropriate without neuroimaging.
Clinical Decision-Making Framework
Risk Stratification Using Validated Criteria
The three major validated clinical decision rules for mild traumatic brain injury consistently identify low-risk patients who can safely avoid CT imaging 1:
New Orleans Criteria (GCS 15 only): This child lacks all high-risk features including GCS <15 at 2 hours, headache awakening from sleep, vomiting, drug/alcohol intoxication, deficits in short-term memory, physical evidence of trauma above clavicles, and seizure 1
Canadian CT Head Rule (GCS 13-15): No dangerous mechanism (fall from 2 feet does not qualify as dangerous mechanism, which typically requires >3 feet or 5 stairs in children), no vomiting episodes, age not >60 years, and no amnesia for >30 minutes 1
NICE Criteria: Age <65 years, no amnesia for 30 minutes, no posttraumatic seizure 1
When all high-risk criteria are absent, these rules demonstrate 97-100% sensitivity for excluding clinically significant intracranial injury, making CT safely avoidable 1.
Why Imaging is Not Indicated
CT head has a high negative predictive value for neurosurgical intervention in mild TBI, but neuroimaging should be avoided when it will not lead to a change in management 1
Patients are not significantly more likely than the general population to have a significant abnormality when they lack high-risk clinical features 1
The absence of loss of consciousness, combined with only mild tenderness and no scalp hematoma, places this patient in the lowest risk category 1
Skull x-rays have no role in modern head injury evaluation and do not predict intracranial pathology 1
MRI is not indicated for acute mild TBI evaluation and should be reserved for persistent neurologic, cognitive, or behavioral symptoms that develop later 1
Appropriate Management Plan
Immediate Actions
Provide reassurance to the family that serious injury is extremely unlikely given the clinical presentation 1
Educate about postconcussive symptoms that may develop (headache, dizziness, concentration problems, memory issues, irritability) which occur in approximately 28-58% of mild TBI patients but typically resolve within 3-12 months 1
Observation Instructions
Advise parents to monitor for red flag symptoms requiring urgent return: persistent vomiting, severe or worsening headache, confusion, unusual drowsiness, seizures, weakness, numbness, or behavioral changes 1
Contact family the following day to exclude concerning features if not admitted 1
Provide written discharge instructions about warning signs 1
Follow-Up Considerations
Routine follow-up CT is not supported for mild TBI with negative initial clinical assessment 1
Repeat imaging is only indicated if neurologic deterioration occurs 1
If headache persists or worsens beyond expected timeframe, consider alternative diagnoses, but isolated occipital tenderness after minor trauma in a neurologically normal child does not warrant immediate imaging 2
Critical Pitfalls to Avoid
Do not order imaging based solely on parental anxiety without clinical indications, though excessive worry may occasionally justify testing on a case-by-case basis 1
Do not dismiss persistent symptoms that develop later—these may warrant delayed MRI if they represent new-onset, progressive, or worsening neurologic, cognitive, or behavioral problems 1
Do not confuse mild occipital tenderness with true occipital neuralgia, which presents with paroxysmal lancinating pain and would be extremely unusual in this acute traumatic context 3, 4